Print Inspection: DDJR

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 8/4/2022.  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 interviews and records review it was confirmed the facility failed to have sufficient staff to meet the scheduled and unscheduled needs of the residents. Findings include, but is not limited to:

Separate interviews 8/4/2022 with Staff# 1-3 (S1-S3) include:

  * S1 states that there has been call ins from staff, but that management and nursing staff have covered those shifts. No concerns reported to S1 regarding not having time to complete assigned tasks. The facility expected response time for call lights is 7-15 minutes.

  * S2 & S3 states that "they have not had difficulty completing daily care needs or tasks related to resident care"

Facility records reviewed 8/4/2022 of facility call log, posted staffing plan, R1 assessment, service plan and home health therapy notes.

 * Call log 8/1/22-8/4/22 indicated multiple occurrences in which wait times exceeded 20 minutes including waits up to 23-66 minutes.

 * R1 therapy notes 6/30/22-7/20/22, assessment completed 7/30/22 and care plan have R1using adaptive equipment with transferring and is a one person assist with all care needs.

 * Posted staffing plan on day and evening shifts are to 2 caregivers (CG), 1 medication technician (MT), and on night shift are to be 1 CG and 1 MT.

 * Facility schedule 7/29/2022-8/3/2022 has 3 CG ' s and 1.5 MT during day shift, 2 CG ' s and 1 MT evening shift and 1 CG and 1 MT during night shifts.

Findings reviewed with and acknowledged on 8/4/2022 with S1.

Facility Plan of Correction:

Executive Director will review call logs to investigate long response times for call lights.   

Based on interview and records review it was confirmed the facility failed to complete service plans quarterly. Findings include, but is not limited to:

Interview with Staff# 1 (S1) on 8/4/2022 states that current system facility has in place for assessment and reviews only show when it was last updated. It does not show if it was for a review for significant change or quarterly review. There is no signature page to show who was involved with the review/update or if the resident/family was involved with the process. Unless it is narrated in progress notes there is no way of knowing what the changes if any were or who attended and reviewed the care plan.

Facility record reviewed of Resident #1-3 (R1- R3) most recent care plans and progress notes.

 * Care Plans have only a date of when last updated. There was no signature page or dates to show that the resident or family was in attendance or agreed with any updates.

 * R1 & R2 Progress notes do not have narrations about care plan review, changes made or who may have attended.

Findings reviewed with and acknowledged with S1 8/4/2022

Facility Plan of Correction:

Administrator states that as of 8/4/2022 they will create a signature page and binder for all service plan reviews, which will include who was contacted, who attended, date and reason for a change or review.

Based on facility records review and interview it was confirmed that facility failed to update Acuity-Based Staffing Tool before a resident moves in. Findings include, but is not limited to:

Records review on 8/4/2020 of facility Acuity-Based Staffing Tool (ABST) of current census listed and Resident # 2, 5 & 6 (R2, R5 & R6) needs.

 * Resident R5 was moved out of facility and was still in the ABST

 * New move in was not listed in ABST

 * Times and frequencies did not match service plans.

Interview on 8/4/2022 with Staff#1 (S1) states that the times and frequencies with R2, R5 & R6 reviewed in ABST were not accurate. R5 was no longer in their facility and new resident was not listed in ABST.

Findings were reviewed and acknowledged with S1 on 8/4/2022.

Facility Plan of Correction:

Executive Director reports that they were not familiar with the ABST system and that the inputting of times, frequencies and updates of residents was completed by others. As of 8/4/2022 states that they will be going through ABST to review each resident and care need to update as needed to match service plan and needs.