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 11/02/2022. 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 record review and interview it was confirmed that the facility failed to update care plan quarterly. Findings include but not limited to:
A review of the facility's service plan binder revealed that two of the three sampled residents had not had their care plans updated in the previous quarter.
These findings were reviewed with and acknowledged by Staff #2-Staff #5 and Staff #7 on 11/02/2022 who were in agreement.
Plan of correction: Nurse consultant will review binder 11/02/2022 and put updated service plans in the binder or schedule appropriate assessments and meetings.
Based on observation, interview 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 including protocols to prevent the development and transmission of communicable diseases. Findings include but not limited to:
During an unannounced site visit on 11/02/2022, Compliance Specialist (CS) observed a staff member enter the dining room wearing only a surgical mask during an active COVID outbreak. CS also observed Staff #6 (S6) enter a room identified as an isolation room with a COVID + resident inside without donning proper personal protective equipment (PPE) including a gown or gloves. S6 did not perform hand hygiene when exiting the room. CS observed signage outside of this room with isolation precautions and a PPE station that was well-stocked.
During interview, S6 stated they didn't know it they needed additional PPE upon entrance and that they had not yet returned to their cart to perform hand hygiene upon exiting.
A review of the facility's Community Infection Control Policy revised on 12/21/2021 revealed staff are to utilize contact precautions for known or suspected infections that represent an increased risk for contact transmissions.
These findings were reviewed with and acknowledged by Staff #2-Staff #5 and Staff #7 on 11/02/2022 who were in agreement.
Plan of Correction: CS alerted RN and regional team who immediately educated S6. Facility will educate the rest of their shift to shift meeting at 2pm today, and 2pm tomorrow. Nursing to verified signs, products, etc at stations. Spot check and audit 2x/day, every day for first week, and 3x/week for 4 weeks.
Based on record review and interview it was confirmed that the facility failed to carry out medication and treatment orders as prescribed. Findings include but not limited to:
A review of a report dated 10/12/2022 from Red Cross Drug Store revealed 55 medications administrations being missed in the month prior due to "meds not available."
During an interview conducted 10/31/2022 Witness #1 (W1) stated that this facility's medication practices are unsafe and disorganized.
A review of Resident' #1- Resident #3 (R1-R3) MARs conducted onsite on 11/02/2022 for October 2022 revealed at least 13 occasions when a medication was not administered due to not being available in-house.
These findings were reviewed with and acknowledged by Staff #2-Staff #5 and Staff #7 on 11/02/2022 who were in agreement.
Plan of Correction: Facility has another pharmacy audit and RN consultant beginning 11/02/2022. RN consultant to work on Med Tech competencies.
Based on observation, record review and interview, it was confirmed that the facility has failed to provide direct care staff sufficient in number to meet the scheduled and unscheduled needs of the residents
During an unannounced site visit on 11/03/2022 Compliance Specialist observed three caregivers and one med tech working on the floor during day shift. The facility's posted staffing plan stated need for two caregivers and one med tech on day shift.
A review of the facility's ABST revealed a need for 36 hours of care that day shift. A review of the facility's schedule for November 2022 revealed only one med tech and three caregivers were scheduled.
During interview, Staff #2 (S2) stated that the facility needs four caregivers on day shift.
These findings were reviewed with and acknowledged by Staff #2-Staff #5 and Staff #7 on 11/03/2022.
Based on observation, record review and interview, it was confirmed that the facility has failed to fully implement and update an Acuity Based Staffing Tool (ABST). Findings include but not limited to:
During an unannounced site visit on 11/03/2022 Compliance Specialist observed three caregivers and one med tech working on the floor during day shift. The facility's posted staffing plan stated need for two caregivers and one med tech on day shift.
A review of the facility's ABST revealed a need for 36 hours of care that day shift. A review of the facility's schedule for November 2022 revealed only one med tech and three caregivers scheduled. The facility's ABST also revealed that it is not being updated quarterly as required by rule as 20 of 22 residents included had not been updated since 07/07/2022.
During interview, Staff #2 (S2) stated that the facility needs four caregivers on day shift.
These findings were reviewed with and acknowledged by Staff #2-Staff #5 and Staff #7 on 11/03/2022.