Print Inspection: NZOL

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 11/01/2022.  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 determined the facility failed to implement a service planning team.

Findings include:

In an interview with Witness #1 (W1) on 11/01/2022 it was stated: The facility does not notify me of care conferences. I have heard from family members they are also not aware when care conferences are being held.

On 11/01/2022 Compliance Specialist (CS) reviewed Resident #1-Resident #3's progress notes for the months of September and October. R1-R3's progress notes state care plans were updated; however, no mention of care conferences being held and who was invited/in attendance.

On 11/01/2022 these findings were shared with S1 and S2 who were in agreement.

Facility Plan of Correction: S1 states care conferences will be held, all appropriate parties will be invited and documentation will be completed in the form of a progress note.

Based on interview, observation, and record review, it was confirmed the facility failed to ensure the implementation of services.  Findings include:

Compliance Specialist (CS) reviewed Resident #2 (R2) Service Plan which states laundry is to be done two times per week.  

CS was not able to observe any caregiving task sheets while onsite on 11/01/2022 as they were not filled out. CS looked in the 24 hour binder as far back as September 1st, 2022.   

During an interview with R2, s/he stated that their laundry is done only one time per week. S/he stated that s/he has to ask staff to wash clothes for them or it doesn ' t get done.

The above findings were discussed with Staff #1 and Staff #2 who were in agreement.

Facility Plan of Correction: S1 and S2 state retraining will occur for caregivers to ask residents if their laundry is ready for pickup. S2 also stated the facility will look into moving this task to noc shift.

Based on interview, observation and record review, it has been confirmed that the facility failed to have sufficient staff to meet the scheduled and unscheduled needs of residents. Findings include but are not limited to:

During an unannounced site visit on 11/01/2022, Compliance Specialist (CS) reviewed call light logs for 10/02/2022 for all facility residents, which revealed multiple instances of call light response times exceeding 15 minutes.

CS interviewed Staff #1, Staff #2, Staff #4, Resident #1, Resident #2 and Witness #1 (S1, S2, S4, R1, R2 and W1) separately. The following was stated:

-We are looking into contracting with agencies again.

-There is often only one caregiver for the entire facility.

-Staffing is at a crisis level.

-If there were a fire, I would be concerned evacuating with this level of staff members.

-Medications are late due to staffing issues, sometimes showers are missed.

-Laundry is not always done. I have to remind staff to help or it doesn ' t get done.

-Due to not being enough caregivers, Med Techs help with care needs and then medications are sometimes late.

CS reviewed Staff Schedules for September and October 2022, which revealed the facility is not staffing to their posted staffing plan. CS reviewed the facilities Acuity Based Staffing Tool (ABST); which revealed the facility is not staffing to the levels required per the facilities ABST.

CS observed 2 caregivers and 1 med tech to be present on shift.

The above information was shared with S1 and S2 on 11/01/2022.

Facility Plan of Correction: S1 and S2 state they are continuing to hire caregivers. They have put out ads and are attending job fairs. S2 states utilizing an agency is the next step and will start that process ASAP.

Based on interview and record review, it has been confirmed that the facility failed to adopt and implement an Acuity Based Staffing Tool (ABST) as required by rule. Findings include but are not limited to the following:

During an unannounced site visit on 11/01/2022, Compliance Specialist (CS) reviewed Resident #1-Resident #3 ' s service plans against the facilities ABST.

CS interviewed Staff #1, Staff #2, Staff #4, Resident #1, Resident #2 and Witness #1 (S1, S2, S4, R1, R2 and W1) separately. The following was stated:

-We are looking into contracting with agencies again.

-There is often only one caregiver for the entire facility

-Staffing is at a crisis level.

-Medications are late due to staffing issues, sometimes showers are missed.

-Laundry is not always done. I have to remind staff to help or it doesn ' t get done.

-Due to not being enough caregivers, Med Techs help with care needs and then medications are sometimes late.

CS reviewed the facilities staffing schedules for August, September and October, which revealed the facility is not scheduling staffing levels based on the plan created by the facilities ABST.

The above was shared with S1 and S2.

Facility Plan of Correction: S1 and S2 state they are continuing to hire caregivers. They have put out ads and are attending job fairs. S2 states utilizing an agency is the next step and will start that process ASAP.