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 12/05/2022. 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, observation and record review, it was confirmed that the facility failed to exercise reasonable precautions against any condition that may threaten the health, safety, or welfare of residents. Findings include:
In separate interviews with Staff #1-3 on 12/05/22, they stated that some staff are working after they test positive for Covid. Staff #2-3 stated that they will come to work sick or with symptoms, unless they have a fever. Staff #1 stated that staff will be sent home if they have a fever over 100 degrees and most staff will call in if they are sick. Staff #1 stated they did have a staff member test positive when they got to work and they were allowed to work their shift because they were under the impression that positive staff could work with positive residents.
During walkthrough on 12/05/22, CS observed two staff members that were coughing and sounded congested when interviewing them.
CS reviewed screening questions for employees. The questions do ask about symptoms, recent exposure or testing for covid, and does take a temperature.
The above information was shared with Staff #1 on 12/05/22 and via email on 12/08/22.
Based on interview, observation and record review, it was confirmed that the facility failed to establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. Findings include:
In separate interviews with Staff #1-3 on 12/05/22, they stated that the staff are wearing their masks in the facility and in resident rooms. They stated that they are doing the covid screening when they get to work, however, they still work with symptoms, when they are sick, and if they have a positive Covid test. Staff #1 states that they get an alert if they answer yes to any of the screening questions and they will get a covid test. Staff #1 also stated that a staff member did test positive for Covid and continued to work because they were under the impression that positive staff can still work with covid positive residents.
Compliance Specialist (CS) observed staff to be wearing their masks in the building around residents and in resident rooms. CS did observed staff that were coughing in the hallways and during interview on 12/05/22. CS observed a staff member take off their mask in the RCC/Nurses office with other staff members in the room and was coughing. In an email dated 12/5/22 from local public health, it reports that the facility has not been officially reporting or updating them regarding positive cases during the outbreak since their initial report on 11/08/22 and had not responded back to public health when they reached out.
CS reviewed the facility's policy and procedures for infection control practices. CS requested verification from the local public health department giving permission for the facility to allow staff to work with symptoms or a positive Covid test, however, this information was not available or approved by the department.
The above information was shared with Staff #1 on 12/05/22 and via email on 12/08/22.
Based on interview and record review, it was confirmed that the facility failed to fully implement and update an acuity-based staffing tool (ABST). Findings include:
Compliance Specialist (CS) reviewed the posted staffing plan that states " daily staffing levels are maintained for each shift by ABST " . CS reviewed the Uniform Disclosure Statement (UDS) that shows number of staff per shift. Shift Hours 6am-2pm Direct Care Staff 3-4 Medication Aid 2, 2pm-10pm Direct Care Staff 3-4 Medication Aid 2 and 10pm-6am Direct Care Staff 1-2 Medication Aid 1.0. CS reviewed the staff schedule from 11/01/22-12/05/22. On 12/05/22 S1 stated current staffing for 12/05/22 was day and evening shift 3 RA's (resident aids/caregivers), 2 Med-techs and NOC shift 1 RA and 1 Med-Tech. On 12/05/22 S1 stated current census was 68. CS reviewed ABST for 12/05/22 which shows the following: ABST reflects that not all residents are currently entered into tool. ABST reflects AM/day shift includes 51 residents (AM total care hours 34.65 and require a total of 5 caregivers/med-techs), PM/evening shift 43 (PM total care hours 32.4 and require a total of 5 caregivers/med-techs) and Graveyard shift 50 (Graveyard total care hours 12.97 and require a total of 2 caregivers/med-techs) out of current census 68 that require assistance with all activities of daily living (ADL) scheduled and unscheduled care needs. ABST does not represent or included all 22 ADL's for scheduled and unscheduled daily care needs for each of the 51 residents entered into tool. Review of residents #1-3 reflects that not all residents care needs are reflected in ABST acuity therefore staffing hours are not calculated to reflect current resident care needs. R1's service plan (SP) shows the resident is a two-person assist in all transfers and showers (2x weekly) every time the assistance is performed; ABST acuity is only reflective of one care staff not two. R1's SP states staff is required to check on resident 16x daily for bowel incontinence and Cather care and, requires unscheduled care needs for monitoring and assistance with assistive devices daily this is not reflective in ABST ADL ' s or calculated staffing. In R1's SP these care needs are listed as PRN not daily assistance being provided by staff.
In separate interviews with Staff #1, they stated they thought the system issues were getting fixed and did know that all residents were not pulled over into ABST. They stated corporate is having an Oregon statewide meeting on 12/06/22 to go over ABST with all facility management.
On 12/05/22, these findings were reviewed with and acknowledged by S1.