Print Inspection: I572

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 12/07/2022.  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:   

During onsite interviews on 12/7/2022, Resident #1 (R1) stated that multiple times they did not receive their scheduled showers. Staff #4 (S4) stated there are days when residents' needs are missed, showers being one of those needs.   

A review of the Acuity Based Staffing Tool (ABST), R1 ' s service plan dated 10/7/2022, progress notes and the shower schedule communication log dated 10/23/2022-11/30/2022. These items demonstrated the shower schedule showed 10 times where staff stated a shower was not provided because they do not have time, 1 time stating they did not do shower due to short staffing and 2 times stating the call lights were high and were unable to provide shower. R1 missed their showers on 11/2/2022, 11/4/2022, and 11/18/2022. R1 ' s service plan, shower schedule, and ABST hours indicate they are to receive showers 3 times a week.   

On 12/7/2022, these findings were reviewed with and acknowledged by Staff #1 (S1).  

Plan of Correction: S1 stated the facility will be implementing new shower monitoring system per company policy once the new system is set up. The new system was being set up the day of the site visit.

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

During separate interviews on 12/7/2022, Resident #1 (R1) stated that the facility has been short staffed, and the biggest issues are swing shift and the weekends. R1 stated that multiple times they did not receive showers due to the facility not having enough staff to provide them with assistance. Staff #4 (S4) stated that there have been times the facility is understaffed, and needs are missed.   

During an unannounced site visit on 12/7/2022, Compliance Specialist (CS) observed 7 Caregivers (CG) and 2 Med Techs (MT) working for day shift.  

A review of the facility posted staffing plan, Acuity Based Staffing Tool (ABST), staff schedule for November and December 2022, the employee timecards for swing shift on 12/2/2022, R1's service plan, progress notes and the shower schedule communication log dated 10/23/2022-11/30/2022. The posted staffing plan and the ABST stated for day shift the facility needs 8 CG and 2 MT, swing shift 7 CG and 2MT, and NOC shift 3CG and 1MT. The timecards for swing shift indicated on 12/2/2022 there was 4CG and 3MT working. The shower schedule showed 10 times where staff stated a shower was not provided because they do not have time, 1 time stating they did not do shower due to short staffing and 2 times stating the call lights were high and were unable to provide shower. R1 missed their showers on 11/2/2022, 11/4/2022, and 11/18/2022. R1 service plan, shower schedule, and ABST indicate they are to receive showers 3 times a week.   

On 12/7/2022, these findings were reviewed and acknowledged by S1.  

Plan of Correction: S1 has obtained multiple Agency Contracts and is working with Corporate Recruiter to obtain adequate staff.

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

During separate onsite interviews on 12/7/2022, Resident #1 (R1) stated that multiple times they did not receive showers due to the facility not having enough staff to provide them with assistance. Staff #4 (S4) stated that there have been times the facility is understaffed, and needs are missed.  

During an unannounced site visit on 12/7/2022, Compliance Specialist (CS) observed 7 Caregivers (CG) and 2 Med Techs (MT).  

A review of the facility posted staffing plan, Acuity Based Staffing Tool (ABST), Staff schedule for November and December 2022, the employee timecards for swing shift on 12/2/2022, R1 service plan, progress notes and the shower schedule communication log dated 10/23/2022-11/30/2022. The posted staffing plan and the ABST state for day shift the facility needs 8 CG and 2 MT, swing shift 7 CG and 2MT, and NOC shift 3CG and 1MT. The timecards for swing shift indicated on 12/2/2022 there was 4CG and 3MT working. The shower schedule shows 10 times where staff stated a shower was not provided because they do not have time, 1 time stating they did not do shower due to short staffing and 2 times stating the call lights were high and were unable to provide shower. R1 missed their showers on 11/2/2022, 11/4/2022, and 11/18/2022. R1 ' s service plan, shower schedule, and ABST hours indicate they are to receive showers 3 times a week.   

On 12/7/2022, these findings were reviewed and acknowledged by S1.  

Plan of Correction: S1 stated as of 12/8/2022 the ABST tool will be updated at time of every service plan change, new move in or discharge. Arranged staffing plan with policy analyst and will continue to obtain staff to meet the staffing levels. Implementing new shower monitoring system per company policy.