Print Inspection: F459

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 02/01/22.  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, conducted during a site visit on 10/21/24, the facility's failure to carry out medication and treatment orders as prescribed was substantiated for 1 of 2 sampled residents (# 8). Findings include, but are not limited to:

Resident 8's MAR, dated 04/01/24 through 04/30/24, did not indicate whether or not s/he had received his/her 7:00 am dose of Humulin 70/30 (insulin) on 04/28/24.

An incident report, dated 05/01/24, indicated Resident 8 had not received a dose of his/her insulin on 04/28/24.

Staff (Liza, RN) stated there had been a system error and the med tach responsible had not administered the medication to Resident 8.

The facility's failure to carry out medication and treatment orders as prescribed was substantiated.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2 (Incoming Executive Director), Staff 3 (Regional Director of Operations), and Staff 4 (Campus Director).

Verbal plan of correction: the facility had self-reported the incident and conducted bi-weekly med tech trainings, including observed med passes.

Based on interview and record review, conducted during a site visit on 10/21/24 the facility ' s failure to carry out medication orders as prescribed was substantiated for 1 of 1 sampled resident (# 6). Findings include, but are not limited to:

An incident report, dated 08/22/24, indicated Resident 6 had received another resident's medication due to an error made by the med tech.

Staff 6 (LPN) stated s/he recalled the incident.

The facility's failure to carry out medication orders as prescribed was substantiated.

The preliminary findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2 (Incoming Executive Director), Staff 3 (Regional Director of Operations), and Staff 4 (Campus Director).

Verbal plan of correction: the facility had self-reported the incident and conducted bi-weekly med tech trainings, including observed med passes.

Based on observation, interview, and record review, conducted during a site visit on 10/21/24, it was confirmed the facility failed to develop and maintain an acuity-based staffing tool (ABST) for 2 of 3 sampled residents (#s 3 and 14). Findings include, but are not limited to:

The facility implemented an ABST called Blue Step. It was not approved by the Department at the time of the investigation, but had been submitted for review. All residents were entered into the tool, Residents 3, 6, and 14's ABST were reviewed and updated at required times. Their respective service plans and ABST profiles accurately captured care needs and were reflected in the ABST evaluation. The facility's posted staffing time accounted for the total ABST care time and incorporated unscheduled needs, fire life safety, multi-person transfer and care, segregated areas, high acuity, behavioral needs, and universal worker task time. The facility was consistently staffing to the posted staffing plan.

The facility's posted staffing plan indicated for day and swing shifts, there were six Caregivers (CGs) and two Med Techs (MTs). For night shift, there were five CGs and one MT.

The facility staffing schedule, dated 10/01/24 through 10/31/24 indicated from 10/14/24 through 10/21/24, the facility staffed MTs according to their posted staffing plan 100% of the time and the facility staffed CGs according to their posted staffing plan 98% of the time.

On 10/21/24, during day and swing shifts, there were two MTs, and six CGs working the floor.

Staff 10 (CG) stated the facility was staffed most of the time. S/He doesn't leave his/her hall until his/her relief shows up. S/He worked swing and night shift the other day because of call offs. Most of the staff stayed to cover the next shift if there were issues with coverage.

During an interview regarding Resident 3's care needs, Staff 12 stated s/he required standby assistance for showers and required the assistance of two staff members. S/He required the assistance of two staff members for toileting and changing briefs. With transferring, Resident 3 sometimes required two staff members, but s/he could stand up on his/her own and assisted with care. S/He required assistance with eating for the entire meal and was on a cut up diet. Before, Resident 3 was on a regular diet, but was choking on food.

During an interview regarding Resident 6's care needs, Staff 11 stated in the morning, care staff changed his/her briefs and provided cleaning care for him/her. Resident 6 sometimes required the assistance of two staff members. S/He could stand on his/her own and could assist with his/her care. Normally one staff member helped him/her with transferring. If s/he had a "bad day" and his/her legs were weak, two staff members helped with transferring. Hospice bathed Resident 6, but facility staff cleaned him/her if s/he had a toileting accident. When there was an emergency needing medication, they called hospice. Otherwise, facility MTs administered medication to Resident 6.

During an interview regarding Resident 14's care needs, Staff 11 (CG) stated at 6:00 am, care staff changed his/her briefs and clothing, when they showered Resident 14, s/he required the assistance of two staff members, s/he required the assistance of two staff members to transfer, and required assistance with eating. Resident 14 was on a pureed diet, and MTs administered his/her medications.

Residents scheduled and unscheduled needs were not being consistently met for 2 of 3 sampled residents (#s 3 and 14). Residents 3 and 14 were missing scheduled showers.

The facility's shower schedule (undated) indicated Resident 3 was to receive showers twice weekly on Sundays and Wednesdays and Resident 14 was to receive showers twice weekly on Mondays and Fridays.

Resident 3's shower sheets indicated s/he received three showers between 09/21/24 and 10/20/24.

Resident 14's shower sheets indicated s/he received six showers between 09/23/24 and 10/14/24.

Residents 3, 6, and 14 were not available for interview.

It was confirmed the facility failed to develop and maintain an ABST for Residents 3 and 14.

The preliminary findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2 (Incoming Executive Director), Staff 3 (Regional Director of Operations), and Staff 4 (Campus Director).