Print Inspection: ZL3M

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 12/07/2022.  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 observation and interview, it was confirmed that the facility failed to comply with masking requirements. Findings include but not limited to:

During an unannounced site visit on 12/13/2022, Compliance Specialist (CS) observed Staff #4 (S4) sitting with their mask around their chin and mouth and nose uncovered, approximately two to three feet from three residents who were not wearing masks.

These findings were reviewed with and acknowledged by S1 on 12/13/2022 who was in agreement and stated they would follow up with S4 about masking requirements.

Plan of correction: Facility to in-service all staff on masking requirements by 12/16/22.

Based on observation, interview and record review it was confirmed that the facility failed to provide direct care staff sufficient in number to meet the scheduled and unscheduled needs of the residents. Findings include but not limited to:

During an unannounced site visit on 12/13/2022, Compliance Specialist counted two care givers and two med techs working on the floor.

A review of the facility's Acuity-Based Staffing Tool revealed that the facility had 43.22 hours of care needs during the day shift on Tuesdays. A review of the facility's schedule for December 2022 revealed that two med techs and three caregivers were scheduled. A review of Resident #1 (R1)'s call light log 10/1/2022-10/17/2022 revealed 17 instances when it took 20 or more minutes for a caregiver to answer the call light.

During separate interviews, Staff #1 (S1) and Staff #6 (S6) stated that the facility needs three caregivers and two med techs during the day shift. S6 also stated that there was one call-in that day and that another caregiver had to leave during the shift so there were only two med techs and two caregivers working.

During interview Resident #1 (R1) stated that they have had to wait an hour to go to the bathroom.

These findings were reviewed with S1 on 12/13/2022.

Plan of correction: Facility will review their ABST daily during their meeting to confirm they are staffed to the appropriate level and that it is reflective of residents they have in their building. Executive Director to be notified by staff regarding any call-ins to confirm that staffing needs are met.

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

During an unannounced site visit on 12/13/2022, Compliance Specialist counted two care givers and two med techs working on the floor.

A review of the facility's Acuity-Based Staffing Tool revealed that the facility had 43.22 hours of care needs during the day shift on Tuesdays. A review of the facility's schedule for December 2022 revealed that two med techs and three caregivers were scheduled, which equates to 35 hours/day shift on 12/13/2022.

During separate interviews, Staff #1 (S1) and Staff #6 (S6) stated that the facility needs three caregivers and two medtechs during the day shift. S6 also stated that there was one call-in that day and that another caregiver had to leave during the shift so there were only two med techs and two caregivers working.

These findings were reviewed with S1 on 12/13/2022.

Plan of correction: Facility will review their ABST daily during their meeting to confirm they are staffed to the appropriate level and that it is reflective of residents they have in their building. Executive Director to be notified by staff regarding any call-ins to confirm that staffing needs are met.

Based on observation and interview it was confirmed that the facility failed to prevent the entry of rodents. Findings include but not limited to:

During an unannounced site visit on 12/13/2022, Compliance Specialist (CS) observed rodent droppings in Resident #1 (R1)'s room.

During interview R1 stated that they have had a mouse living in their apartment for sometime and that they can hear it running back and forth in their room at night. R1 also stated that the mouse chewed through the cord of their power wheelchair.

These findings were reviewed with Staff #1 on 12/13/2022 who was in agreement.

Plan of Correction: Daily vacuuming and housekeeping to be performed in resident room. Facility to call pest control company to schedule appointment on 12/13/22.