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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 observations, interviews and record review it was confirmed the facility failed to visually observe resident take their medications. Findings include:

Review of facility service plan for Resident # 1 revealed that the resident is unable to administer their own medications and the facility is to assist resident with the administration of all medications.

During tour of facility on 10/06/2022 at 2:25 pm Compliance Specialist observed a paper cup with 4 medications in it on a table in Resident # 1 room.

Review of Resident # 1 Medication Administration Record for the Month of October 2022 revealed that the medications in the paper cup in Resident # 1's room should have been administered at 12:00 pm.

Interview with Staff # 1 and Staff # 2 on 10/06/2022 with both acknowledging that the facility should have visually observed Resident # 1 take their medications.

Facility Correction Plan: Facility will assess resident's ability to self-administer medications, review resident's service plan to accurately reflect resident's ability to self-administer medications, and facility will provide training to med-tech staff to visually observe residents take their medications.

Based on interviews and record review it was confirmed the facility failed to carry out medications as prescribed. Findings include:

Review of facility Incident Self-report form dated 03/02/2022, Facility Medication Incident Report dated 03/02/2022, and Medication Passing Detail form for medications administered 12/10/2021 through 12/17/2021 reveal that the facility failed to administer resident # 1's  medication for 3 days after it was ordered.

Interview with Staff # 1 and Staff # 2 on 10/06/2022 with both acknowledging that the facility failed to administer Resident # 1 their medication for 3 days after it was ordered.

Based on interview and record review it was confirmed that the facility failed to consistently staff to the levels, intensity and qualifications indicated by the tool and failed to address all of the ABST elements. Findings include the following:

During an unannounced site visit on 10/06/2022 Compliance Specialist (CS) reviewed the facilities Acuity Based Staffing Tool (ABST) against the facilities current posted staffing plan and found that the faciltiy is not staffing to the levels indicated by the ABST. The facility ABST also failed to address repositioning in bed or chair and responding to call lights.   

In an interview with Staff #1 (S1) on 10/06/2022 who acknowledged that the posted staffing plan did not meet the staffing levels indicated by the ABST.