Print Inspection: D5MW

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 have effective methods of responding to and resolving resident complaints. Findings include but not limited to:

A review of the facility's Resident Grievance Policy and Procedure stated that resident grievances are documented on the resident grievance form and then forwarded to the administrator who is responsible for the investigation.

During an unannounced site visit on 12/08/2022 R2 requested documentation of any grievances. The facility was unable to provide this documentation.

During interview Resident #2 (R2) revealed multiple grievances that they stated were discussed with Staff #1 (S1). S1 stated the facility did not have a grievance log.

The facility is not following their policy and procedure.

These findings were reviewed with S1 on 12/08/2022.

Plan of Correction: S1 to develop a grievance log within 30 days to track complaints and resolutions.

Based on interview and record review it was confirmed that the facility failed to ensure the preparation, completeness, accuracy and preservation of resident records. Findings include but not limited to:

During an unannounced site visit on 12/08/2022, Compliance Specialist (CS) requested documentation dating back to January of 2022. The facility was unable to produce resident records prior to February 2022.

During interview, Staff #1 (S1) stated that the facility had a change of management in April 2022 and that they do not have immediate access to the previous management company's records.

Plan of Correction: S1 contacted corporate office to request documentation and request access to old system' s records which are stored on a thumb drive that they do not have.

Based on observation, interview and record review, it was confirmed that the facility failed to exercise reasonable precautions against any condition that may threaten the health, safety, or welfare of residents. Findings include but not limited to:

During an unannounced site visit on 12/08/2022, Compliance Specialist (CS) observed Resident #2 (R2)'s room to be cluttered with newspaper, recycling, soda bottles, mobility equipment, food and garbage. The resident's bed was inaccessible as it was covered with newspaper. R2 was seated in a recliner, under a blanket with orange juice soilage.

During interview, R2 stated that they have asked the facility for assistance in cleaning their room, but the one time they offered, R2 was out of the facility and they removed things without permission. During interview, Staff #1 (S1) stated they had removed things while R2 was out, worked on maintenance issues in the apartment and stated that R2 has had an ant problem on occasion.

A review of R2's service plan dated 7/26/2022 revealed that the facility is to assist resident with housekeeping weekly.

These findings were reviewed with S1 on 12/08/2022.

Plan of Correction: S1 to meet with resident to start planning by end of week and schedule care conference with resident and family. Will get resident ' s family involved and likely a third party that used to assist resident with clutter elimination and removal and hope to have resident ' s apartment under control by 2/8/2023.

During an unannounced site visit on 12/08/2022, Compliance Specialist (CS) observed Resident #2 (R2)'s room to be cluttered with newspaper, recycling, soda bottles, mobility equipment, food and garbage. The resident's bed was inaccessible as it was covered with newspaper. R2 was under a blanket with orange juice soilage.

During interview, R2 stated that they have asked the facility for assistance in cleaning their room, but the one time they offered, R2 was out of the facility and they removed things without permission. During interview, Staff #1 (S1) stated they had removed things while R2 was out, worked on maintenance issues in the apartment and stated that R2 has had an ant problem on occasion.

A review of R2's service plan dated 7/26/2022 revealed that the facility is to assist resident with housekeeping weekly.

These findings were reviewed with S1 on 12/08/2022.

Plan of Correction: S1 to meet with R2 to start planning by end of week 12/09/2022 and schedule care conference with resident and family. S1 will get resident ' s family involved and likely a third party that used to assist resident with clutter elimination and removal and hope to have resident ' s apartment under control by 2/8/2023.

Based on observation, interview and record review, it was confirmed that the facility failed to provide household services essential for the health and comfort of the resident. Findings include but not limited to:

During an unannounced site visit on 12/08/2022, Compliance Specialist (CS) observed Resident #2 (R2)'s room to be cluttered with newspaper, recycling, soda bottles, mobility equipment, food and garbage. The resident's bed was inaccessible as it was covered with newspaper. R2 was under a blanket with orange juice soilage.

During interview, R2 stated that they have asked the facility for assistance in cleaning their room, but the one time they offered, R2 was out of the facility and they removed things without permission. During interview, Staff #1 (S1) stated they had removed things while R2 was out, worked on maintenance issues in the apartment and stated that R2 has had an ant problem on occasion.

A review of R2's service plan dated 7/26/2022 revealed that the facility is to assist resident with housekeeping weekly.

These findings were reviewed with S1 on 12/08/2022.

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

During an unannounced site visit on 12/08/2022, Compliance Specialist (CS) reviewed service plans for Resident #2 (R2) and Resident #3 (R3). R2's service plan was last updated on 07/26/2022 and R3's was last updated on 06/10/2022.

During interview Staff #1 (S1) stated that they had recently hired and trained a new Resident Care Coordinator and their goal is to be caught up and current with service plans within 45 days.

Plan of Correction: All service plans and service planning meetings to be current within 45 days of site visit.

Based on observation, interview and record review it was confirmed that the facility failed to carry out medication orders as prescribed.

During an unannounced site visit on 12/08/2022 Compliance Specialist (CS) observed Staff #4 (S4) pass medications to Resident #2 (R2) at 0955.

A review of R2's MAR for December 2022 revealed that R2 does not have medications scheduled for that time, but does have medications scheduled at 0800 were charted as administered.

During interview, S4 stated that R2 prefers one medication prior to breakfast and he brings that at 0800 and then prefers the other medications after they deliver breakfast so S4 returns with the rest of R2's scheduled medications but charted them as given at 0800.

A review of Resident #1 (R1)'s MAR for March and April 2022 revealed several instances where medications were not administered due to "waiting for delivery."

These findings were reviewed with S1 on 12/08/2022.

Plan of Correction: Med Tech meeting on Monday 12/12. ED will provide service on medication ordering process. RCCs will run exception/variance report for missed medications weekly and audit.

Based on record review and interview it was confirmed that the failed to update their ABST quarterly. Findings include but not limited to:

After an unannounced site visit on 12/08/2022, Compliance Specialist (CS) reviewed the facility's ABST which revealed that three of three sampled residents had not had their ABST profiles updated since 06/15/2022.

During a phone interview on 12/08/2022 Staff #1 (S1) stated that their staff is not going into review the ABST if there are no changes to a service plan.

Plan of Correction: Facility has requested Technical Assistance from ABST Policy Analyst and Corrective Action Coordinator.