Print Inspection: ZM46

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 12/01/2022.  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 interview and observation it was confirmed the facility failed to have medical and other records kept confidential except as otherwise provided by law. Findings include:    

During an onsite interview on 12/1/2022, Staff #5 (S5) stated that it is typical for the facility to post service plans on a cork board outside the medication room for staff to read and acknowledge the new or updated service plans. S5 stated that this is not a new process and has been done for some time now.  

During an unannounced site visit on 12/1/2022, Compliance Specialist (CS) observed 5 service plans on a cork board near the medication room out in the open for anyone to see and read.   

On 12/1/2022, these findings were reviewed and acknowledged by S1.  

Plan of Correction: S1 stated they will remove the service plans after CS leaves and put them in an area of only staff to obtain.

Based on interview, observation, and record review it was confirmed that the facility failure to have awake qualified direct care staff sufficient in number to meet the scheduled and unscheduled needs of residents. Findings include:   

During separate interviews on 12/1/2022, Staff #4 (S4) stated that their current staffing levels are 2 Med Tech (MT) and 4 Caregivers (CG) for day and swing shift and 1 MT and 2 CG for NOC shift. Resident #2 (R2) stated that call light response times are long.  

During an unannounced site visit on 12/1/2022, Compliance Specialist (CS) observed 2 MT and 3 CG working.   

A review of the staff schedule for October and November 2022, the posted staffing plan, facility ' s Acuity Based Staffing Tool (ABST), call light logs for 11/20/2022-11/24/2022, shower schedule for 11/28/2022-12/4/2022, and service plan and progress notes for Residents #1-3 (R1, R2 and R3). The call light logs indicate 11 occurrences in a four-day time frame where the call lights exceeded the facility ' s 15-minute response time. The longest wait time being 46 minutes. The posted staffing plan stated 1 MT and 3 CG for day and swing shift and 1 MT and 1 CG on NOC shift. The ABST tool has inaccurate numbers stating that on day shift for each day the facility needing 303.5 hours of care resulting in 40 caregivers needed. The staff schedule for October shows multiple occurrences where the facility is understaffing per their indicated staffing levels.  

On 12/1/2022, these findings were reviewed and acknowledged by Staff #1 (S1).  

Plan of Correction: Facility retrain and remind staff at change of shift regarding call light response times. Regular auditing of the call light logs to ensure staff are responding timely.

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 separate interviews on 12/1/2022, Staff #4 (S4) stated that their current staffing levels are 2 Med Tech (MT) and 4 Caregivers (CG) for day and swing shift and 1 MT and 2 CG for NOC shift. Staff #1 (S1) and S4 were unable to express how they use their Acuity Based Staffing Tool (ABST) to generate their current staffing levels based on the amount of caregiving time indicated in the tool. Resident #2 (R2) stated that call light response times are long.  

During an unannounced site visit on 12/1/2022, Compliance Specialist (CS) observed 2 MT and 3 CG working.   

A review of the staff schedule for October and November 2022, the posted staffing plan dated 8/15/2019, facility ' s Acuity Based Staffing Tool (ABST), call light logs for 11/20/2022-11/24/2022, shower schedule for 11/28/2022-12/4/2022, and service plan and progress notes for Residents #1-3 (R1, R2 and R3). The call light logs indicate 11 occurrences in a four-day time frame where the call lights exceeded the facility ' s 15-minute response time. The longest wait time being 46 minutes. The posted staffing plan stated 1 MT and 3 CG for day and swing shift and 1 MT and 1 CG on NOC shift. The staffing plan had not been updated since 2019. The ABST tool has inaccurate numbers stating that on day shift for each day the facility needing 303.5 hours of care resulting in 40 caregivers needed. The ABST for Resident #3 (R3) stated that the resident does not need any assistance with showers and bathing. Review of R3 service plan and the shower schedule showed that R3 receives assistance with showers 3 times a week. The staff schedule for October shows multiple occurrences where the facility was understaffing per their indicated staffing levels.   

On 12/1/2022, these findings were reviewed and acknowledged by S1.    

Plan of Correction: The facility will reevaluate their ABST to reflect to correct hours of care provided to the residents and correct time needed for residents' current needs. They will change their posted staffing plan as needed once the hours are changed and staff accordingly.

Based on interview and record review it was determined that the facility failed to keep clean and in good repair all interior and exterior materials and surfaces, and all equipment necessary for the health, safety, and comfort of the resident. Findings include:   

During separate interviews on 12/1/2022, Staff #1-3 (S1, S2 and S3) stated that the dishwasher and disposal were down for a few days, however the facility did call a company to fix the equipment. S2 stated that there is a practical to use the triple sinks for washing dishes. The triple sinks have the soap and sanitation chemicals needed to ensure dishes are clean when washing dishes by hand. S2 stated the memory care side also has a dishwasher and that they are able to wash the dishes there if needed.  

A review of the receipt for Roto-Rooters stated that on 11/11/2022 the dishwasher and disposal were repaired.    

On 12/1/2022, these findings were reviewed and acknowledged by S1.  

Plan of correction: Both the dishwasher and garbage disposal have been fixed and working in good repair since 11/11/2022.