Print Inspection: Z20F

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 02/07/2023.  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 that the facility failed to include the resident in the service planning team. Findings include the following:

During an unannounced site visit on 02/07/2023 Compliance Specialist (CS) reviewed service plans for Resident #1-#3 (R1-R3). One service plan states resident refused to sign until they could meet with their case manager and the other two service plans did not have resident signatures or reasons for resident not signing.

In an interview with Resident #3 (R3) it was stated that the facility had not gone over their care plan with them in over 6 months and the last time they went over it, they believe it was an old care plan.

Based on interview and observation it was confirmed that the facility failed to establish and maintain infection prevention and control protocols. Findings include the following:

During an unannounced site visit on 02/07/2023 Compliance Specialist (CS) rang the front doorbell to gain entry into the facility. There were not any signs on the front door indicating directions for screening in or for COVID-19 symptoms. Front desk staff did not provide any directions for screening nor did CS observe any location for staff or visitors to screen in. CS observed multiple staff throughout the facility with their masks below their noses or worn at their chin including in resident care areas.

In an interview with Staff #1 (S1) it was stated that there was a screening area but had to request screening documents from the front desk in order for CS to screen in at the screening station.

Based on interview and record review it was confirmed that the facility failed to ensure medication and treatment orders were carried out as prescribed. Findings include the following:

During an unannounced site visit on 02/07/2023 Compliance Specialist (CS) reviewed Medication Administration Records (MARs) for Resident #1 and Resident #3 (R1 & R3) for December 2022 to current as well as progress notes. CS found instances of medication not available, scheduled medications not able to be given due to being too close to last administration and an alert charting for receiving the wrong resident ' s medications.

In separate interviews with R1 and R3 the following was stated:

·That the facility is administering medications late.

·The facility is giving the wrong medications or not giving medications at all.

Based on record review, interview and observation it was confirmed that the facility failed to have sufficient staff to meet the scheduled and unscheduled needs of the residents. Findings include the following:

During an unannounced site visit on 02/07/2023 Compliance Specialist (CS) reviewed facility call light logs for Resident #1-#3 (R1-R3) for 02/03-02/05/2023 which revealed instances of multiple calls over 15 minutes on all three residents call light reports, with eight calls exceeding 30 minutes.

In an interview with Staff #1 (S1) it was stated that the facility expectation for call light response is five minutes or less.

CS observed the swing shift come on and day shift leave, one staff member from swing called off and another would be coming in late. CS observed staff rearrange their schedule to try to ensure there was enough coverage for both sections of the facility. The posted staffing plan stated for day and swing shift there will be two med techs, one to two caregivers for A/B wing and six to seven caregivers for C wing and on NOC shift there will be one med tech, one caregiver for A/B wing and four caregivers for C wing. The facility was not staffed at that for swing shift on 02/07/2023.

Based on interview and record review it was confirmed that the facility failed to have a training program that includes methods to determine competency of direct care staff through evaluation, observation or written testing. Findings include the following:

During an unannounced site visit on 02/07/2023 Compliance Specialist reviewed demonstrated competencies for Staff #3-#5 (S3-S5) which revealed one staff had a correctly and thoroughly completed competency checklist. One staff member had completed their checklist over three months past their hire date with no staff signature and the third staffs record revealed no completion dates on the checklist.

In an interview with Resident #3 (R3) it was stated that new care staff were passing medications without proper training.

Findings we shared with Staff #1 who acknowledged findings.