Based on interview, observation, and record review, it was confirmed the facility failed to submit background checks to the Department. Findings include, but not limited to:

A review of facility records indicated that Staff #1, 7, and #9 were hired on 08/05/2021, 08/12/2021, and 08/12/2021, respectively.

A review of timecards indicated new hire staff have worked in the facility on one or more days since being hired.

During an unannounced inspection on 08/18/2021, the Compliance Specialist (CS) observed S1 and S9 were currently working in the facility.

In an interview on 08/18/2021, Staff #2 stated that he/she is not aware if background checks were submitted because the facility did not have a Qualified Entity Designee (QED) and have used a third party to submit. Staff #8 stated he/she could not locate any records that the background checks were submitted for newly hired staff. S8 stated that he/she became QED last week. S8 stated he/she submitted background checks for S1, S7, and S9 today.

On 08/18/2021, these findings were reviewed with and acknowledged by Staff #1 and Staff #2.

Action(s) Taken or Planned:

QED updated - Background checks being processed.

Action to Prevent Reoccurrence:

Ensure everyone has background conducted prior to on floor training.

Action Evaluation Frequency:

Monthly to ensure all are in compliance.

Responsible Staff (position/title):

Keith Hopkins, Business Office Manager

Jessica Wonderly, MC Administrator

Christine McLaughlin, Executive Director

Allged Compliance Date: 09/20/2021

Based on interview, observation, and record review, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents. Findings include, but are not limited to:

During an unannounced inspection on 08/18/2021, Oregon Department of Human Services infection control guidelines, which were established to protect the facility staff and residents from the spread of COVID-19 and made available to all facilities, were not being followed by the facility. The Compliance Specialist (CS) observed the following:

* The facility had not established adequate storage and disinfection practices for eye protection.

* Face shields and goggles were observed to be stored without measures in place to prevent contamination.

* The facility had not assigned dedicated staff to provide assistance to residents who have tested positive for COVID.

* Residents who tested positive were residing in the same room with residents who tested negative.

* Staff and visitors were observed to enter the facility without being screened by facility staff screener.

In separate interviews on 08/18/2021, Staff #1, #2, #3, and #4  (S1-S4) stated staff have not been provided with infection control trainings when the Executive Order was imposed on 08/10/2021. S1 stated that Staff #6 (S6) tested positive 08/17/2021 at the end of their shift and was not screened at the start of their shift. S1 and S2 stated that a total of 6 residents have tested positive. S3 stated he/she uses resident peri-care wipes to clean their eye protection and S4 stated that he/she uses soap and water to clean their eye protections. Staff #10 stated that staff that have worked on the MCC have been coming to the ALF-side of the facility including the kitchen and have interacted with residents and staff.

There were no records available to indicate infection control trainings were provided to staff.

A review of records indicated that staff are not screened at the beginning of their shift.

On 08/18/2021, these infection control practices were reviewed with and acknowledged by Staff 1 and Staff 2. They acknowledged the need for increased oversight of infection control practices in the building. At the time of the exit conference, the facility was constructing a barrier wall.

Action(s) Taken or Planned:

PPE stations were put in place immediately and proper cleaning procedures were posted with proper cleansing products. (1 minute contact spray). MC unit was made into a COVID isolation unit and Staff was restricted from entering ALF side. A portable toilet and hand washing stations was put into place and separate entrance and exit for MC staff.

Negative residents were moved to private rooms within the MC and Agency staff was brought in to assist. Staff were inserviced, saw demonstrationsa nd performed demonstrations for proper donning and doffing of PPE.

Isolation wall was put up to prvent anyoen from entering or exiting the MC unit other than the outside entry that kept staff separated. Break room and laundry room was closed to ALF staff on first floor allowing MC staff to access from outside entrance.

ALF had temporary break room upstairs and only utilized 2nd floor laundry room. Sanitizer was placed with signage throughout the community and signage was placed in restrooms as a reminder for staff.

Actions to Prevent Reoccurrence:

Continued education and inservices at all staff meetings.

Management will talk with staff not following proper procedure and demonstrate if they are uncertain.

Action Evaluation Frequency:

Management does rounds to ensure that proper procedure is being followed.

Responsible Staff (position/title):

Jessica Wonderly, Memory Care Director