Print Inspection: UO2P

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 03/08/2023.  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 the facility failed to provide assistance with bathing and washing hair. Findings include:

During an onsite interview on 03/08/2023, Staff #1 (S1) stated that residents are only given one shower a week and the other shower listed is only for emergencies or incontinence issues.

A review of Resident #1-2 (R1 and R2) service plans, progress notes, ABST services breakdown, and shower schedule. R1 and R2 service plans state that they are given two showers weekly, but they are only scheduled on the shower sheet once a week.

On 03/08/2023, these findings were reviewed and acknowledged by S1.

Plan of Correction: S1 stated that they will change the service plan wording to reflect their current services.

Based on interview and record review it was confirmed the facility failed to have a service plan the reflects the resident's needs and the service plan be completed following quarterly evaluations. Findings include:

During an onsite interview on 03/08/2023, Staff #1 (S1) stated that residents are only given one shower a week and the other shower listed is only for emergencies  or incontinence issues. S1 stated that she was currently working on updated all the residents '  service plans in memory care.

During an unannounced site visit on 03/08/2023, Compliance Specialist (CS) observed S1 attempting to update all residents service plans.

A review of Resident #1-2 (R1 and R2) service plans, progress notes, ABST services breakdown, shower schedule, and the service plan binder. The service plan binder showed all 8 residents service plans provided were dated 11/04/2022 indicating they should have all been updated on 02/04/2023. R1 and R2 service plans state that they are given two showers weekly, but they are only scheduled on the shower sheet once a week.

On 03/08/2023, these findings were reviewed and acknowledged by S1.

Plan of Correction: S1 stated that they will change the service plan wording to reflect their current services and will finish updating the service plans during CS site visit and will schedule quarterly evaluation meetings with POA and resident to finalize.

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

During an interview on 03/08/2023, Staff #1 (S1) stated that there was 1 Caregiver (CG) on memory care, 1 CG on the assisted living side and 1 Med Tech (MT) that works on both sides of the building.

During an unannounced site visit on 03/08/2023, Compliance Specialist (CS) observed 1 Caregiver (CG) and 1 shared Med Tech (MT) working during the day shift.

A review of the facility ' s posted staffing plan, service plan binder, Residents #1-2 (R1 and R2) service plan, the last 30 days progress notes, breakdown of care indicated in the ABST, ABST, shower sheets and shower schedule. The facility ' s ABST tool does not have all 22 activities of daily living (ADL's) outlined individually for each resident and an amount of staff time needed to provide care. The facility was using a uniform discloser statement last updated in 2021 as their posted staffing plan. The service plan binder shows all 8 residents service plans are out of date and not updated quarterly. The shower schedule shows all residents are only scheduled for one shower a week when R1 and R2 service plan states they should be provided two showers a week. The shower sheets show only one shower has been provided.

On 03/08/2023, these findings were reviewed and acknowledged by S1.