Print Inspection: 1UC1

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 10/6/2022.  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 and record review, it was determined the facility is not implementing a daily program of social and recreational activities.  Findings include but are not limited to:

In an interview on 10/6/2022, Staff #1 (S1) reported h/she was out on medical leave since 8/9/2022 at which time Staff #2 (S2) was employed as Interim Administrator. During S1's absence, facility staffing was reduced and the activities director quit.  S2 was terminated a week ago, S1 is now back to work as Administrator until another replacement can be found and is in the process of hiring new staff to include a full time activity director.

Record review on 10/6/2022 of the facility's activity schedule revealed social and recreational activities for the Memory Care Unit are not scheduled daily, but around the receptionist's work schedule until a replacement is hired. Scheduled activities are 2-3 times per week, not daily.

On 10/6/2022, S1 acknowledged the findings.

Plan of Correction:

S1 has been back to work for three days and is in the process of hiring a full time activity director.  

Based on interview and record review, it was determined the facility is not staffed adequately to respond to call lights within a reasonable amount of time.  Findings include but are not limited to:

In an interview on 10/6/2022, Staff #1 (S1) reported h/she was out on medical leave since 8/9/2022 at which time Staff #2 (S2) was employed as Interim Administrator. During S1's absence, facility staffing was reduced, several caregivers quit along with some of their long term management team and shifts were not being covered.  S2 was terminated a week ago, S1 is now back to work as Administrator until another replacement can be found.

Record review on 10/6/2022 of Resident #1-3's Medication Administration Records and progress notes for Aug-Sept 2022 revealed Medications were not being administered as prescribed.

Record review on 10/6/2022 of the facility's Medication Administration Policy revealed staff were not following procedures for administering scheduled medications within a two hour window.  

In separate interviews on 10/6/2022, Staff #3-5 reported the facility has been severely short staffed over the past two months.  Care staff would call out or not show up for shifts leaving only one caregiver on shift on multiple occasions.  During this time, medications were not administered as scheduled or timely.

On 10/6/2022, S1 acknowledged the findings.

Plan of Correction:

S1 has been back to work for three days, Staffing Agencies are now in place to supplement staffing and they are actively hiring.  

Based on interview and record review, it was determined the facility is not staffed adequately to respond to call lights within a reasonable amount of time.  Findings include but are not limited to:

In an interview on 10/6/2022, Staff #1 (S1) reported h/she was out on medical leave since 8/9/2022 at which time Staff #2 (S2) was employed as Interim Administrator. During S1's absence, facility staffing was reduced, several caregivers quit along with some of their long term management team, and shifts were not being covered.  S2 was terminated a week ago, S1 is now back to work as Administrator until another replacement can be found.

Record review on 10/6/2022 of the facility's call light logs for 9/5-9/10/22 revealed call light response times in excess of 30-90 minutes in length.

In separate interviews on 10/6/2022, Staff #3-5 reported the facility has been severely short staffed while S2 was working as the Interim Administrator.  Staff would call out or not show up for shifts, leaving only one caregiver on shift on multiple occasions.  Staff would try to contact S2 via phone to no avail. During this time, medications were not administered as scheduled or timely.

On 10/6/2022, S1 acknowledged the findings.

Plan of Correction:

S1 has been back to work for three days, Staffing Agencies are now in place to supplement staffing and S1 is actively hiring.  

Based on interview and record review it was determined the facility is not updating their Acuity Based Staffing Tool (ABST).  Findings include but are not limited to:

In an interview on 10/6/2022, Staff #1 (S1) reported the following:

*S1 was out on medical leave since 8/9/2022 at which time Staff #2 (S2) was employed as Interim Administrator.

*Prior to S1's absence, the facility was implementing and updating their ABST tool (DHS tool).

*During S1's absence, facility staffing was reduced, several caregivers quit along with some of their long term management team and shifts were not being covered.  *S2 was terminated a week ago, S1 is now back to work as Administrator until another replacement can be found.

*S1 stated that the ABST has not been updated during h/her absence.

Record review on 10/6/2022 of the facility's ABST data revealed residents who were no longer at the facility were still included in ABST data and new residents admitted since August 2022 had not been entered into the ABST.  

On 10/6/2022, S1 acknowledged the findings.

Plan of Correction:

S1 has been back to work for three days and is in the process of doing a thorough review of resident care needs to ensure the accuracy of their ABST. S1 completed the reconciliation of resident numbers in their ABST in Compliance Specialist's (CS) presence on 10/6/2022.