Print Inspection: LPBE

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 9/30/2022.  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 immediately notify the local Department office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. Findings include:

In review of the facility ' s policy and procedures for reporting to APS and an incident report dated 09/16/22 for Resident #3, it was determined that the facility did not provide adequate information when reporting to APS. Staff #3 called and left a voicemail reporting that there was an incident on 09/16/22, however, they did not provide the correct resident ' s name, what the incident was, or if any injuries occurred.

The above information was shared with Staff #1 on 09/30/22, who was in agreement.

In interviews on 09/30/22, Staff #1 stated that they recently had an incident where Staff #3 reported an incident to APS in a voicemail on 09/16/22 and then was out of the facility sick for 5 days. The voicemail they left did not include the correct resident name or information specific about the incident.

Plan of correction:

Re-training to staff regarding APS reporting requirements and what information needs to be provided. Communication and documentation of the report should be noted so that if the person who reported is out, the rest of the staff know what is going on.

Based on interview and record review, it was confirmed that the facility failed to ensure that the service plans are getting updated quarterly. Findings include:

In review of Resident #1-2s Service Plans on 09/30/22, it was determined that they are not being updated quarterly. Resident #1s service plan was last revised on 12/29/21 and Resident #2s service plan was last revised on 08/26/22 however, before that date it was revised 05/15/21.

Interviews with Staff #1-2 stated that the facility is behind on their quarterly updates. It was difficult to coordinate care planning during covid. If a resident has any changes, they have been updated in a temporary service plan (TSP), although they are not current on the actual quarterly updates. They currently use PCC which has not been correctly tracking the service plans that are due to be updated. The nurse has a list and was keeping track. Staff #1 states there are more residents that need updated service plans and they are working on it.

Plan of correction:

Determine how many residents need quarterly updates. The ED, RN, and RCC will immediately get started on updates. This could take an estimated 6 weeks.