Print Inspection: S0JY

Based on interview and record review, conducted during a site visit on 10/03/23, it was confirmed the facility failed to immediately notify the local Department office, or the local AAA, of any incident of abuse or suspected abuse for 1 of 1 sampled residents (#1). Findings include, but are not limited to:

A review of Resident 1's progress notes from 07/21/23 through 07/30/23 revealed the following:

* On 07/21/23, Resident 1 had an injury fall in Resident Room 24 and obtained a skin tear to his/her right elbow; and

* On 07/23/23, bruising was noticed to Resident 1's right eye.

No investigation into Resident 1's eye bruising was available for review.

During interview, Staff 3 (Resident Services Director) stated Resident 1 had several falls, including one on 07/21/23 with bruising to his/her eye developed on 07/23/23. S/he further stated they completed an incident report for the fall on 07/21/23, but did not complete an investigation for the bruising on 07/23/23, nor did they report to the local department office.

The findings were reviewed with and acknowledged by Staff 1 (Executive Director of a sister facility), Staff 2 (LPN), Staff 3 (Resident Services Director), Staff 11 (Operations Specialist) and Staff 12 (RN).

It was confirmed the facility failed to investigate the incident to rule out abuse and notify the local Department office, or the local AAA. of any incident of abuse or suspected abuse.

Verbal plan of correction: Oregon Department of Human Service abuse reporting guide was provided to facility by Compliant Specialist. That had been a major focus for care team since August 2023. They completed re-training for MTs in September 2023 on how to complete the incident reports and time frame requirements. They review all incident reports daily. The facility RN and LPN were also re-trained for completing the investigations and reporting. They now have a process that was being completed in a timely manner.

Based on observation, interview and record review, during an site visit on 10/03/23,  it was confirmed the facility failed to implement service plans that are reflective of resident needs for 4 of 4 sampled residents  (#s 2, 3, 5 and 6) . Findings include, but are not limited to:

1. Resident 2's service plan was dated 03/07/23 and indicated the resident required mechanically soft food and thin liquids. Facility was to offer two full glasses of liquid for each meal.

During the noon meal on 10/03/23, Resident 2 received a pureed meal and one glass of fluids, instead of the two as service planned.

2. Resident 3's service plan dated 06/06/23 revealed the following:

* S/he was to receive finger foods, double portions and extra liquids.

* S/he required assist with brace, prosthesis, sling, other (specify).

During an observation of the lunch meal on 10/03/23, Resident 3 was not given finger foods, was not offered a second portion after eating 100 % of a regular portion meal, and was offered only two sips of water during his meal.

During observations and interview with Resident 3 s/he had a purple foam boot in his/her bedroom, but was not wearing it.

During interview on 10/03/23 Staff 4 (Agency CG) stated Resident 3 was to wear two foam boots to protect his/her feet, but they have only been able to find one for the last week so s/he has not been wearing them.

3. Resident 5's service plan was dated 06/06/23 and had not been updated in the last quarter.

4. Resident 6's service plan indicated s/he was independent with ambulation, but required occasional assistance for long distances.

Resident 6 was observed receiving assistance for wheelchair ambulation during the site visit and was not observed ambulating independently.

The findings were reviewed with and acknowledged by Staff 1 (acting Executive Director), Staff 2 (LPN), Staff 3 (Resident Services Director), Staff 11 (Operations Specialist) and Staff 12 (RN).

It was confirmed the facility failed to implement a service plan that was reflective of resident needs.

Verbal plan of correction: The facility would distribute a form to all departments with updates and changes to be included in service plan for accuracy. All service plans will be updated within 30 days.

Based on interview and record review, conducted during a site visit on 10/03/23, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (#1). Findings include, but not limited to:

Resident 1's August 2023 Medication Administration Records (MARs) and August 2023 progress notes revealed medications not given due to new order-waiting on delivery for Diclofenac Sodium 1% Gel from 08/01/23 to 08/02/23.

In an interview on 10/03/23, Staff 1 (ED) stated, "On 08/01/23 and 08/02/23 Resident 1 did not receive Diclofenac Sodium due to new order waiting on delivery."

The findings were reviewed with and acknowledged by Staff 1 (Executive Director of a sister facility), Staff 2 (LPN), Staff 3 (Resident Services Director), Staff 11 (Operations Specialist) and Staff 12 (RN).

It was confirmed the facility failed to carry out medication orders as prescribed.

Plan of correction: The facility now runs an exception report every morning to see if any medications have been missed and follow-up immediately on those. They have completed a training with MTs to document their follow-ups.

Based on observation, interview and record review, during a site visit conducted on 10/03/23, it was confirmed the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs for 2 of 2 sampled residents (#s 6 and 7). Findings include, but are not limited to:

a. During the site visit on 10/03/23, the facility's posted staffing plan indicated the need for the following staff:

Day: 1 MT, 3 CG

Evening: 1 MT, 3 CG

Night: 1 MT, 2 CG

Interviews with Staff 1 (Acting Executive Director), Staff 2 (LPN) and Staff 3 (Resident Services Director) indicated the facility needed the following staff:

Day: 2 MT, 5 CG

Evening: 2 MT, 4.5 CG

Night: 1 MT, 2  CG

Interviews with staff also revealed the facility had ten residents who required assistance of two people for transfers.

During a joint interview on 10/03/23, Staff 1, Staff 2 and Staff 3 were not able to explain how the facility would evacuate the ten residents who required assistance of two people for transfers in the event of a fire or other emergency on night shift.

In separate interviews on 10/03/23, Staff 2 and Staff 3  stated, "We did not know we could audit call lights." Staff 3 stated, "Back in July 2023 a family member complained that the call light response times had taken a long time. After that complaint, we did an in service with staff but did not know we could check what the actual response time was." Staff 13 (Maintenance) stated, "I am able to run the call light response report, it is not completed weekly, only when I am asked to."

Compliance Specialist was unable to obtain call light logs for July 2023. A review of the call light logs for 09/24/23-09/30/23 indicated over 80 of the response times exceeded 30 minutes.

b. A review of Resident 7's progress notes on 07/08/23 at 1:59 PM, indicated resident had a non-injury fall and a MT had to ask care staff four times to transfer the resident off the floor and onto his/her wheelchair. Resident 7's service plan dated 06/01/23, indicated for transfers and falls that the resident will recieve assistance as needed.

A review of Resident 6's August 2023 MAR revealed on 08/05/23, 08/06/23 08/14/23 08/20/23 alert charting for COVID outbreak monitoring was not completed due to "short staff".

It was confirmed the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident.

On 10/03/23, the findings were reviewed with and acknowledged by Staff 1, Staff 2, Staff 3, Staff 11 (Operations Specialist) and Staff 12 (RN).

Verbal plan of correction: The facility was hiring and had posted on all major job boards. The administration have been interviewing, added a hire-on bonus, referral bonuses, and shift differential was available for night shift. Staff 3 has been doing the scheduling. The facility would be adding a CG to the night shift. The maintenance director will bring the call light logs to the daily stand meeting. The administration has requested a capital expenditure for walkie talkie to be combined with call lights.

Based on observation, interview and record review, conducted during a site visit on 10/03/23, it was confirmed the facility failed to fully implement and update an ABST for 3 of 3 sampled residents (#s 3, 5 and 6). Findings include, but are not limited to:

During the site visit on 10/03/23, the facility's posted staffing plan indicated the need for the following staff:

Day: 1 MT, 3 CGs;

Evening: 1 MT, 3 CGs; and

Night: 1 MT, 2 CGs.

The facility's ABST indicated the need for the following:

Day: 37.18 hours (4.95 staff);

Evening: 32.98 hours (4.39 staff); and

Night: 12.93 hours (1.724 staff).

Observations, interviews with staff, and review of the resident's records noted ABST entries were not reflective of the residents current care needs in the following areas:

1. Resident 3:

Bowel and bladder management;

Transferring in and out of bed or chair;

Escorting to/from meals; and

Supervising, cueing or supporting while eating.

2. Resident 5:

Transferring in and out of bed or chair.

3. Resident 6:

Transferring in and out of bed or chair;

Escorting to/from meals; and

Medication administration.

Resident 3 and Resident 5's ABST profiles had not been updated in the last quarter.

On 10/03/23, the findings were reviewed with and acknowledged by Staff 1 (Acting Executive Director), Staff 2 (LPN), Staff 3 (Resident Services Director), Staff 11 (Operations Specialist) and Staff 12 (RN).

The facility failed to implement and update an ABST.

Based on interview and record review, conducted during a site visit on 10/03/23, it was determined the facility failed to evaluate the resident's health, medical, behavioral or care needs within a reasonable time, but no later than 24 hours after the resident has been deemed ready for discharge for 1 of 1 sampled resident (#1). Findings include, but are not limited to:

In a phone interview on 10/09/23, Witness 1 (Hospital Care Manager) stated "[Resident 1] was ready to be discharged on 05/15/23, however the facility was not able to readmit because they did not have a nurse available to assess her/him."

In interviews on 10/03/23, Staff 1 (ED), Staff 2 (LPN), Staff 3 (Resident Care Director) all stated there was a delay after the hospital called on 05/15/23 as the Regional Nurse was not able to do the assessment until 05/18/23.

Records revealed Resident 1 returned to the facility on 05/19/23.

On 10/03/23, the findings were reviewed with and acknowledged by Staff 1, Staff 2, Staff 3, Staff 11 (Operations Specialist) and Staff 12 (RN).

It was determined the facility failed to evaluate the resident's health, medical, behavioral or care needs within a reasonable time, but no later than 24 hours after the resident has been deemed ready for discharge.

Plan of correction: The Resident Services Director, RN, LPN, Acting Executive Director, and Operations Specialist are able and willing to assess new residents and they will have someone available every day.

Based on observation, interview, and record review, conducted during a site visit on 10/03/23, it was confirmed the facility failed to have a daily meal program for nutrition and hydration must be provided based upon the resident's preferences and needs for 2 of 2 sampled residents (#s 2 and 3). Findings include, but not limited to:

On 10/03/23, Compliant Specialist observed the following in the kitchen:

·A sign in the kitchen had on it which residents required puree, nectar thickened liquids, cut up foods, mechanically soft, large portions, and resident's allergies;

·Two plates with pureed chicken, pureed vegetables, mashed potatoes, and gravy;

·Multiple pureed options in the freezer; and

·Kielbasa sausage cut up in bite size pieces for all residents.

In an interview on 10/03/23, Staff 15 (Cook) stated, "there are two residents who receive pureed foods. We use a modified bread and dessert, thick and easy mix to help make the pureed foods." When the Complaint Specialist asked what was offered to the residents that required mechanically soft diets, Staff 15 stated," they are given the same food the rest of the residents get."  

a. A review of Resident 2 service plan, dated 03/07/23, noted the resident required mechanically soft and thin liquids. Facility was to offer two full glasses of liquid for each meal.

During the noon meal on 10/03/23, Resident 2 received a pureed meal and one glass of fluids, instead of the two that was service planned.

b. A review of Resident 3's current service plan, noted s/he was to receive finger foods, double portions and extra liquids.

During an observation of the lunch meal on 10/03/23, Resident 3 did not receive finger foods, not was s/he offered a second portion after eating 100 % of a regular portion meal. The resident was offered only two sips of water during the meal.

A hydration pass was not observed at any point on 10/03/23.

On 10/03/23, the findings were reviewed with and acknowledged by Staff 1(Acting ED), Staff 2 (LPN), Staff 3 (Resident Services Director) and 12 (RN).

It was confirmed the facility failed to failed to provide a daily meal program for nutrition and hydration, and based upon the resident ' s preferences and needs available throughout each resident ' s waking hours.

Verbal plan of correction: Facility will complete training with dietary staff and caregiver on GROVE menu system related to mechanical-soft and diet textures. Training with residents who need more assistance to encourage beverages to occur at All -staff meeting on Friday. Facility has a 10am, 3pm, 7pm hydration and snack cart.