Print Inspection: WZVZ

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 01/12/2023.  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 record review and interview, it was confirmed that the facility failed to promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent reoccurrences of abuse. Findings include but not limited to:

A review of Resident #1-Resident #4 (R1-R4) 12/1/22-1/12/23 progress notes, incident reports #1648, 1671, Temporary Service Plans (TSP), R4 service plan and untitled documents dated 11/21/22, 11/25/22, and 12/28/22 revealed:

On 11/21/2022 R2 injured R4 in a resident to resident altercation.

On 11/25/22 R2 injured R1 in a resident to resident altercation.

On 12/12/22 R2 injured R4 in a resident resident to altercation. Incident report # 1648 created but lacks admin review. No TSPs were available or provided.

On 12/13/22 R2 was put on alert for a physical altercation. No TSP was available.

On 12/28/2022 R2 injured R3 in a resident to resident altercation. RN did post-

incident assessment on 12/29/22. Admin reviewed tapes and provided

narration in untitled document date 12/28/22. No other investigation. A TSP for

R3's skin was created.

On 1/6/2022 two TSPs were created for R2's medications.

CS requested investigations for 12/12/22 and 12/28/22 incidents and only incident reports and a narration of what was revealed by camera for 12/28/22 incident were provided. Incident reports do not include witness statements, resident interviews and follow up, and were not all reviewed by ED.

A review of the facility's Abuse Reporting and Investigation Policy revealed that incident reports are to be filled out with:

a. time, date, place and individuals present

b. description of the event as reported

c. response of staff at time of incident

d. follow up action

e. administrator's review

A review of the facility's Fall and Injury Fall Policy revealed that a resident should be put on alert and a TSP should be created.

During separate interviews, Staff #1 (S1), Staff #6 (S6) and Staff #7 (S7) stated:

*In the event of  a resident to resident incident, the Medication Technician (MT) should separate residents, make a progress note, start an incident report, notify family, nurse and Executive Director and a TSP should be created by a nurse or a Resident Care Coordinator.

*The facility has gone through significant changes recently with the elimination of the Resident Care Coordinator (RCC) positions.

*Two nurses were out for extended leave during these incidences.

*The facility has a new administrator.

*There are big holes in care and jobs.

*R2's aggressive outbursts are unpredictable and can not be prevented.

*R2's aggression escalated when they were moved into a shared room in a busy part of the building.

These findings were reviewed with S1 on 01/13/2023.

Plan of Correction: CS provided abuse investigation and reporting guide to facility via email. Facility to in-service all staff on reporting and investigation requirements by 1/12/23. Registered Nurse (RN), Licensed Practical Nurse (LPN) and Executive Director (ED) to investigate all incidences within 24 hours.

Based on observation, record review and interview, it was confirmed that the facility failed to update service plans quarterly. Findings include but not limited to:

During an unannounced site visit on 01/12/2023, Compliance Specialist (CS) observed and looked through four separate binders containing service plans.

A review of Resident #2 (R2)'s service plan contained within the binder was last revised and reviewed on 06/09/2022.

During separate interviews, Staff #8 (S8) and Staff #1 (S1) stated:

*The facility has gone through significant changes recently with the elimination of the Resident Care Coordinator (RCC) positions.

*Two nurses were out for extended leave recently.

*The facility has a new administrator.

*They were not surprised that service plans were not being updated.

*They thought that a previous RCC or nurse had at least met with R2's family.

No documentation was found or provided for a meeting with R2's family.

These findings were reviewed with S1 on 01/13/2023.

Plan of Correction: Facility to audit all service plans by 1/20/2022. All service plans to be updated and completed by end of February 2023.

Based on record review and interview it was confirmed that the facility failed to implement a service plan reflective of resident's needs.

A review of Resident #1-Resident #4 (R1-R4) 12/1/22-1/12/23 progress notes, incident reports #1648, 1671, untitled documents dated 11/21/22, 11/25/22, and 12/28/22 revealed:

On 11/21/2022 R2 injured R4 in a resident to resident altercation.

On 11/25/22 R2 injured R1 in a resident to resident altercation.

On 12/12/22 R2 injured R4 in a resident resident to altercation. Incident report # 1648 created but lacks admin review. No TSPs were available or provided.

On 12/13/22 R2 was put on alert for a physical altercation. No TSP was available.

On 12/28/2022 R2 injured R3 in a resident to resident altercation. RN did post-incident assessment on 12/29/22. Admin reviewed tapes and provided narration in untitled document date 12/28/22. No other investigation. A TSP for R3's was skin created.

On 1/6/2022 two TSPs were created for R2's medications.

R2's service plan as available in service planning binder dated 6/29/2022  does not include information related to resident's aggressive behaviors. There are no TSPs available that include prevention of aggressive behaviors.

During interview, Staff #8 stated that R2 was previously in a private room in a different area of the facility that was quieter but was move into a shared room due to a payor change. S8 stated they believe R2's behaviors increased after the move.

These findings were reviewed with Staff #1 (S1) on 1/12/2023.

Plan of Correction: Audit all service plans by 1/20/2022. All service plans to be updated and completed by end of February 2023.

Based on observation, interview and record review, it was confirmed that the facility failed to comply with masking requirements. Findings include but not limited to:

During an unannounced site visit on 1/12/2023, Compliance Specialist (CS) observed two staff members in an office without masks. CS saw a third staff member using a copy machine in a shared office using their sweater to cover their face. A fourth staff member was in a group of residents with their mask around their chin and not covering their mouth and nose.

During interview Staff #1 stated that masks are required for all staff in the facility unless they are alone in an office with the door closed.

A review of the facility's Face Mask Policy stated "Mask to be warn in neighborhoods unless eating, in closed rooms/offices by yourself, sleeping, under the age of 5"

These findings were reviewed with S1 on 1/12/2023.

Plan of Correction: Facility to in-service and provide policy at next all staff meeting on 1/25/2023.

Based on observation, interview and record review, it was confirmed that the facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include but not limited to:

During an unannounced site visit on 1/12/2023 Compliance Specialist (CS) observed breakfast trays in carts at 1000 that had not yet been served to residents. CS observed four caregivers (CG) working and two Medications Techs (MT).

During separate interviews Staff #1 (S1), Staff #4 (S4) and Staff #7 (S7) stated:

*The facility needs seven caregivers during day shift.

*Two CGs called out.

*Breakfast was running late because of short staff.

*It is difficult to help the residents when they don't have at least six CGs.

A review of the facility's posted staffing plan and Uniform Disclosure Statement (UDS) indicated the need for seven CGs during day shift. A review of the facility's staff schedule for January 2023 revealed only six CGs were scheduled on 1/12/2023.

These findings were reviewed on 1/12/2023 with S1.

Plan of Correction: ED to implement use of ABST tool immediately and believes all residents can be entered into a tool by end of January 2023 to establish staffing standards.

Based on interview and record review it was confirmed that the facility failed to fully implement an Acuity-Based Staffing Tool. Findings include but not limited to:

During an unannounced site visit on 1/12/2023, Compliance Specialist (CS) requested documentation on how the facility determines its staffing levels. CS was provided the staffing plan contained within the Uniform Disclosure Statement (UDS).

During separate interviews, Staff #1 (S1) and Staff #7 (S7) stated that the facility is not using an ABST and they were not familiar with what an ABST is.

These findings were reviewed with S1 on 1/12/2023 who was in agreement.

Plan of Correction: Facility to implement use of ABST immediately and will have all residents entered into a tool by end of January 2023.