Print Inspection: 526X

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 10/19/2022.  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, observation and document review, it was confirmed the facility is providing three meals per day.  Findings include but are not limited to:

In separate interviews on 10/19/2022, Staff #1,2 and 5 reported the following:

·The facility has been short staffed due to turnover and illness.

·Residents are receiving their meals, however not as timely for tray delivery due to lack of staffing.

·Residents with Covid receive meals in their rooms, but due to low staffing levels they are not delivered timely.

·If residents are not in their rooms for tray service, the trays are refrigerated in their apartments or are delivered upon request. There is always food available upon request.

·Refusals of meals are documented.

·Residents requesting additional food or beverages are accommodated as quickly as possible after all other residents have been served.

In separate interviews on 10/19/2022, Resident #1-5 reported the following:

·The facility has been short staffed, many of the Residents are sick and are required to stay in their rooms.

·Meals are delivered, but on the upper levels the meals are up to 1-2 hours late.

·If a meal is missed if they are out of the facility or not in their room, they can request it at a later time although it takes a long time to be served and isn ' t always what was on the menu for that day.

·If additional food or beverages are requested, they have to wait a long time to receive them and often have to use their call lights to follow up on the request.

·They have never been told they cannot ask for additional food or beverages, or that they would be charged for it.

During an unannounced site visit on 10/19/2022, Compliance Specialist did a walkthrough of the kitchen and observed the following:

·Kitchen staff preparing for lunch service

·Food being prepared matched the posted menu for the week

·Dry storage, refrigerators and cold storage were fully stocked

Findings were reviewed with and acknowledged by S1 on 10/19/2022.

Based on interview, document review and observation, it was confirmed the facility is not providing personal and other laundry services to residents.  Findings include but are not limited to:

In separate interviews on 10/19/2022, Staff #1-5 (S1-5) stated the following:

·S1-2 stated the facility has had a lot of turn over since new administration took over and with the Covid outbreak affecting residents and staff, there have been a lot of call outs. Tasks are not being done timely.

·S3-5 stated resident needs are not being met when it comes to assistance with showers, toileting, laundry and housekeeping.

In separate interviews on 10/19/2022, Resident #1-5 (R1-5) stated the following:

·The facility has been short staffed and there has been a lot of turn over since new administration took over. Things have gone "downhill."

·Laundry is taking over 2 weeks to be completed.

Document review of R1-5's service plans on 10/19/2022 revealed all five residents are service planned to receive assistance with laundry 1x per week and as needed.

Document review of the facility's Universal Disclosure Agreement (UDS) revealed all residents are to receive assistance with personal laundry and laundering of sheets/towels 1x weekly.

During an unannounced site visit on 10/19/2022, Compliance Specialist observed the following while doing a walkthrough of all three floors:

·Laundry baskets were full and clean laundry had not been put away.

On 10/19/2022, findings were reviewed with and acknowledged by S1.

Facility Plan of Correction:

S1 reports they are actively hiring for all positions to include dedicated housekeeping staff.  

Based on interview and document review it was confirmed the facility is not providing assistance with toileting/bladder management timely.  Findings include but are not limited to:

In an interview on 10/6/2022, Witness #1 reported that the facility is short staffed due to turnover and Covid outbreak.  Resident needs are not being met timely; residents are having to wait long periods of time for assistance with bladder/bowel care.  

In separate interviews on 10/19/2022, Staff #3-6 (S3-6) report that the facility has been short staffed, and they have been unable to meet resident needs timely.  There are days when there are only two care staff on shift for 3 floors, residents are having to wait for assistance with toileting/bladder care.  They are not able to respond to call light requests timely.

In separate interviews on 10/19/2022, Resident #1-5 (R1-5) report having to wait a long time for care staff to respond to their requests for assistance.  R2,4,5 report having to sit in soiled incontinence supplies for long periods of time before receiving assistance. Call lights are not being answered timely.

Document review of facility call light logs dated 10/13-10/18 show call light response times of over 30 minutes, and in some cases up to 90 minutes.

On 10/19/2022, findings were shared with and acknowledged by S1.

Facility Plan of Correction

S1 reports the facility is experiencing extreme staffing shortages and turnover in administration.  They are actively trying to hire and train new employees and are using agency care staff to supplement current staffing shortages.

Based on interview, observation and document review it was confirmed the facility is not staffing sufficiently in number to meet the scheduled and unscheduled needs of the residents.  Findings include but are not limited to:

In separate interviews on 10/19/2022, Staff #1-5 (S1-5) stated the following:

·S1-2 stated the facility has had a lot of turnover since new management took over and with the Covid outbreak affecting residents and staff there have been a lot of call outs.

·There are days they are unable to meet their posted staffing plan, administration tries to fill in as much as possible and staffing agencies are being utilized to supplement shortages.  

·S3-5 stated resident needs are not being met timely when it comes to assistance with showers, toileting, laundry and housekeeping and medications are not always administered as scheduled.

·S3-5 stated they sometimes have to pull care staff from the memory care and vice versa to assist with care needs leaving the other facility short of staff.

·S3-5 stated that there are residents requiring 2 person assist with transfers who are having to wait long periods of time for that assistance.

·S4 stated that s/he is constantly being pulled from her med aide duties to assist with care needs or answer call lights causing medications to be missed or administered late.

In separate interviews on 10/19/2022, Resident #1-5 (R1-5) stated the following:

·The facility has been short staffed and there has been a lot of turn over since new administration took over. Things have gone  " downhill."

·R2,3 report call lights are not being answered timely and they are having to wait 30-60 minutes for a response.

·R2,4-5 report housekeeping and laundry is not being done as scheduled and meals are not being delivered timely.

Document review on 10/19/2022 of the facity's posted staffing plan, Universal Disclosure Statement (UDS) and staffing schedule for October confirm that the facility is not staffing to plan and was not staffed according to plan on the date of the site visit, the ALF was short 2 caregivers due to call outs.  

Document review on 10/19/2022 of facility's call light log for 10/13-10/18/2022 revealed response times ranging from 30-90 minutes.

On 10/19/2022, findings were reviewed with and acknowledged by S1.

Facility Plan of Correction:

S1 reports they are actively hiring to fill management positions and direct care staff.  They are currently using Staffing Agencies to supplement staff.

Based on interview, observation and document review, it was confirmed the facility failed to fully update their ABST.  Findings include:

In an interview on 10/19/22, Staff #1 (S1) stated the following:

·The facility uses the DHS ABST tool.  

·The ABST has been updated to represent the current census of 58 residents however resident needs have not been updated to reflect changes in care needs due to staffing shortages and administration turnover.

·Lack of staffing, increased care needs due to illness and lack of knowledge on how to use the ABST tool has made it difficult to keep up with updating the data.

Document review on 10/19/2022 of Resident #1-3's (R1-3) service plans, temporary service plans, and progress notes for October revealed changes in care needs are not being input into the facility's ABST tool. R2,3 had changes in care needs within the last week because of Covid, S1 was unable to confirm that the increased care needs were updated in the ABST tool. R2,3 ' s service plans had not been updated per quarterly requirements.  

During an unannounced site visit on 10/19/2022, Compliance Specialist (CS) observed the facility's ABST during document review. The dashboard is reflecting the correct census of 58 residents; however, updates in resident needs have not been updated.  

On 10/19/2022, findings were reviewed with and acknowledged by S1.

Facility Plan of Correction:

Staff #1 reports that the facility is actively hiring to fill administrative positions and are in the process of training staff to update the ABST tool.