Print Inspection: 7Q66

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 12/08/2022.  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 confirmed that the facility failed to provide assistance with bathing and washing hair. Findings include the following:

During an unannounced site visit on 12/08/2022 Compliance Specialist (CS) reviewed a facility grievance form that states resident missed a shower on 11/26/2022. CS reviewed facility Caregiver Assignment Sheet and observed that a newly admitted resident was not listed. CS reviewed service plan for Resident #4 (R4) and found that they require shower assistance once per week.

In separate interviews with Staff #4 and Staff #7 (S4 & S7) the following was stated:

·If R4 gets shower assistance it would be on the assignment sheet.

·I have worked in that house since R4 was admitted, but I have not helped them with a shower, if they get assistance with showers it should be on the assignment sheet.

Facility Plan of Correction:

Facility will update the assignment sheets to ensure they have all residents accounted for.

Based on record review and interview it was confirmed that the facility failed to provide direct care staff sufficient in number to meet the scheduled and unscheduled needs of the residents. Findings include the following:

During an unannounced site visit on 12/08/2022 Compliance Specialist (CS) reviewed the Department imposed licensing condition RCFCD22-00638 amended on 09/18/2022 for their required staffing plan which was listed as six caregivers, two med techs, and one float on day and swing shifts and for NOC shift, four caregivers, and one med tech. A review of facility staff schedules for October, November and December 2022 revealed two dates where facility was not compliant with staffing requirements.

In an interview with Witness #1 (W1) it was stated that that the facility was short staffed one morning and it made it difficult to provide proper care for residents that needed two-person assistance.

Findings were shared with Staff #1 (S1) who was in agreement.

Facility Plan of Correction:

Facility has implemented new systems to ensure that they will have proper staff levels moving forward since their alleged compliance date of 11/23/2022.

Based on record review and interview it was confirmed that the facility failed to fully implement and update an Acuity Based Staffing Tool (ABST). Findings include the following:

During an unannounced site visit on 12/08/2022 Compliance Specialist (CS) reviewed facility ABST, resident specific ABST for Resident #1-#4 (R1-R4) and service plans for R1-R4. CS found that last edit date for one of four residents was 07/18/2022 when their last service plan update was 09/25/2022. CS found several other inconsistencies between resident service plans and ABSTs.

In an interview with Staff #1-#3 (S1-S3) it was stated that they were not aware that when updating resident service plans quarterly they needed to open and save the questions in the ABST to reflect a correct LastEditDate.

Facility Plan of Correction:

Facility will have two nurses review all service plans and update ABST accordingly. Facility also has a meeting set with policy analyst and corrective action coordinators to review facility ABST.