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 04/20/2023 and 04/25/2023.  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 that the facility failed to be responsible for the supervision, training, and overall conduct of staff when staff are acting within the scope of his or her employment duties. Findings include the following:

In separate interviews with Staff #6 and Staff #13 (S6 & S13) and Witness #4 (W4) the following was stated:

·There is an endless smell of marijuana in the facility. A resident has complained to staff about how unbearable the smell is, staff have reported to the administrator that marijuana could be smelled on certain staff members and nothing has been done.

·Staff smoke weed on their breaks or while they ' re at work.

·There are several staff members that smoke marijuana in the building or are high at work.

During an unannounced site visit on 04/25/2023 Compliance Specialist (CS) observed Staff #14 (S14) standing in the small copy room by the employee timeclock waiting to clock in from their break. CS observed a pungent skunk like odor emanating from the room upon entering. CS observed odor appeared to be attached to S14 as the odor dissipated after S14 left the copy room.

Facility Plan of Correction:

The facility will implement random drug testing in alignment with their policy.

Based on interview and record review it was confirmed that the facility failed to develop and implement a policy on smoking. Findings include the following:

In separate interviews with Staff #6 and Staff #13 (S6 & S13) and Witness #4 (W4) the following was stated:

·There is an endless smell of marijuana in the facility. A resident has complained to staff about how unbearable the smell is, staff have reported to the administrator that marijuana could be smelled on certain staff members and nothing has been done.

·Staff smoke weed on their breaks or while they ' re at work.

·There are several staff members that smoke marijuana in the building or are high at work.

·Multiple staff smoke vape pens on resident floors and blow the smoke down their shirts.

A review of facility Separation Form for Staff #11 (S11) indicates that S11 violated facility 5-10 Smoking in the Workplace policy and posted on the social media site Snap Chat images of themselves smoking in the medication room in front of the med cart.

Facility Plan of Correction:

Facility terminated staff member for violations of facility policies.  

Based on record review and interview it was confirmed that the facility failed to develop and implement a written policy that prohibits the falsification of record. Finding include the following:

In separate interviews with Witness #4 and Witness #6 (W4 & W6) the following was stated:

·The facility has incomplete and falsified training documents.

·Several staff received a training document to sign that management had already signed. The document was already signed by an employee and the signature was whited out.

Compliance Specialist (CS) requested a copy of the facilities policy that prohibits the falsification of records. No policy was provided. CS reviewed Training documents for Staff #5 - #11 (S5 - S11) which revealed three of seven staff filed reviewed contained a training signature page with what appears to be whited out information and dates removed. CS also reviewed facility incident reports which revealed an Internal Incident Report dated 01/11/2023 for Resident #10 (R10) that was created by staff at the time of the incident, and there are no management signatures or follow-up on the form. CS also reviewed an Unusual Incident/ Injury Report that was created for the same incident and has a time stamp of 03/02/2023 and this document contains management signatures that were back dated for the date of the incident, 01/11/2023.

Based on interview and record review it was confirmed that the facility failed to provide services in a manner that protects privacy and dignity. Findings include the following:

During an unannounced site visit on 04/25/2023 in an interview with Staff #2 (S2) it was stated that Staff #11 (S11) was terminated after they posted a video of themselves smoking in the medication room on Snap Chat and there were resident charts with resident information in the background.

CS reviewed facility Separation Form for S11 which indicates that S11 violated facility policy 5-13 Violation on using a Camera Phone on Company property while performing work for Pacifica.

Facility Plan of Correction:

The facility terminated staff member for violation of company policies.

Based on interview and record review it was confirmed that the facility failed to immediately notify the local Department office of any incident of abuse or suspected abuse. Findings include the following:

In an interview with Witness #5 (W5) it was stated that the facility had not sent any facility self-reports to the local Department since August 2022.

During an unannounced site visit on 04/25/2023 Compliance Specialist (CS) reviewed facility incident binder and found multiple instances of reportable events that do not indicate that the facility reported to APS for Resident #1, #5 and an unsampled resident (R1, R5).

The above findings were shared with Staff #2 and Staff #4 (S2 & S4) who were in agreement.

Facility Plan of Correction:

Staff will review APS reporting and go through their incident binder to report any instances that should have been reported but were not.

Based on interview, observation, and record review it was confirmed that the facility failed to assist with toileting and bladder management. Findings include the following:

In separate interview with Staff #13 and Witness #2 (S13 & W2) the following was stated:

·Staff leave residents unchanged all night and it causes skin breakdown because they are left in wet briefs for long periods of time.

·Residents sit in soiled incontinence supplies for long periods of times causing urinary tract infections and kidney infections when left untreated.

During an unannounced site visit on 04/20/2023 Compliance Specialist (CS) observed Resident #7 (R7) appeared to be completely soiled through all layers of their clothing.

During unannounced site visit on 04/20/2023 and 04/25/2023 CS observed a prevalent urine odor near the 2nd floor elevator.

A review of R7 care plan that was available for care staff was dated 06/13/2022 and it was updated by hand that resident is currently a total assist for toileting and on safety checks. Staff indicated that resident was a 2-hour safety check.

Based on record review and interview it was confirmed that the facility failed to ensure that resident service plans are made readily available to staff as well as failed to ensure changes and entries made to the service plan are dated and initialed. Findings include the following:

During an unannounced site visit on 04/25/2023 Compliance Specialist (CS) reviewed service plan binders that were available to care staff on the first and second floors and found multiple service plan with changes made and not staff initials or dates for changes, including for Resident #7 (R7). Service plans were out of date and the service plan for Resident #5 (R5) was not available or located in the service plan binder.

In separate interviews with Staff #6 and Staff #13 the following was stated:

·Resident care needs have changed quite a bit.

·R7 is on 2-hour safety checks even if care plan doesn't show it.

Based on interview and record review it was confirmed that the facility failed to have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. Findings include the following:

According to Witness #2 (W2) it was stated that Resident #2 (R2) had experienced a UTI and staff were not aware of the residents change of condition. It was also stated that R2 experienced a significant weight gain over six months.

Compliance Specialist (CS) reviewed service plan and progress notes from January 2023 to current for Resident #1 (R1) and R2. CS identified in the progress notes for R1 a short-term change of condition with a physician request for monitoring and intervention that was not alert charted and no follow-up was charted regarding the physician request for intervention. CS also discovered in R2 ' s Medication Administration Records for January 2023 to current a severe weight gain of 9.8% over three months. Residents weight gain was not alert charted or monitored.

See findings in C-tags C0301, C0303 and C0330

Based on interview and observation it was confirmed that the facility failed to ensure medications are kept secure between set-up and administration. Findings include the following:

During an unannounced site visit on 04/20/2023 Compliance Specialist (CS) observed the medication cart in the dining room on the first floor was unattended, upon further review the medication cart was unlocked in an unsecured area with residents nearby and no staff members present.

The above was shared with Staff #2 and Staff #4 (S2 & S4) who acknowledged findings and stated they would work on retraining with the staff working on the med cart that evening.

Based on interview and record review it was confirmed that the facility failed to administer medications as ordered by a physician. Findings include the following:

According to Witness #4 (W4) the facility does not have an effective method for receiving new medication orders and that sometimes if new orders are received over the weekend the staff can ' t administer the medication until staff with the proper authorizations come in to review and input the information causing long delays for residents to receive their medications.

During an unannounced site visit on 04/25/2023 Compliance Specialist (CS) reviewed Medication Administration Records (MARs) for Resident #1- #3 and Resident #5 (R1- R3 & R5) for January 2023 to current which revealed multiple instances of medications not available, conflicting orders entered and several days passing before error is corrected. CS also found eight instances of the incorrect dosage of a PRN medication being given to R1.

Based on interview, record review, and observation it was confirmed that the facility failed to provide sufficient staff to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include the following:

According to Witness #4 (W4) staff consistently no call-no show, come into work late, or leave the floor that they are scheduled to work on leaving the floor unattended or understaffed and no one comes into support. In an interview with Staff #3 (S3) it was stated that the facility was short staffed this evening.

During an unannounced site visit on 04/20/2023 Compliance Specialist (CS) reviewed the facility posted staffing plan which was as follows:

Day shift - 6 caregivers; 2 medication technicians

Evening shift - 6 caregivers; 2 medication technicians

Night shift - 4 Caregivers; 1 medication technician

CS reviewed posted staff schedule for April 2023 which revealed 38 of the 90 scheduled shifts did not meet the posted staffing plan. CS reviewed the Daily Assignment sheets for 04/19-04/26/2023 which revealed staff are to take staggered lunches and that on the date of the site visit one staff member had called off for swing shift.

CS observed two med techs, and three staff identified as caregivers, two of which were on their breaks, upon entering the facility. CS encountered two other staff members working one was identified as the RCC and the other was the facility administrator.

Based on interview and record review it was confirmed that the facility has not fully implemented and updated an Acuity-Based Staffing Tool (ABST). Findings include the following:

During an unannounced site visit on 04/20/2023 Staff #1 (S1) provided Compliance Specialist (CS) with a document titled Care Levels and stated that this was their ABST. Document did not address all of the required ABST elements for each resident, nor did it provide an explanation of how the facility determines their staffing plan.

CS asked S1 how they get their staffing plan and S1 stated that they use the staffing plan that the State has required them to use.

In an interview with Staff #2 (S2) during an unannounced site visit on 04/25/2023 it was stated that they were unsure of what ABST the facility used, but they would do further research and would email what they could find.

CS reviewed the ABST that S2 provided via email on 04/26/2023. Last edit date was 12/06/2022, 51 residents were entered into the tool, the current resident census is 46. Newly admitted residents and residents that have experienced a change of condition or an updated service plan were not reflected in the provided ABST.

Based on interview and record review it was confirmed that the facility failed to train direct care staff within the first 30 days. Findings include the following:

During an unannounced site visit on 04/25/2023 in an interview with Staff #2 (S2) it was stated that the facility had a staff member that was hired to train new staff and after approximately a week they quit and disposed of the training documents that they had, but they are working on getting all training documents for staff.

Compliance Specialist (CS) reviewed training documents for Staff #5 - #11 (S5 - S11) which revealed one of seven staff members did not have any training documents. Training documents for S9 appear to have the training dates whited out and are illegible and four of the remaining five staff members training documents were completed more than 30 days after staffs hire date.

Based on interview and record review it was confirmed that the facility failed to have a pre-service orientation and training program for all direct care staff. Findings include the following:

During an unannounced site visit on 04/25/2023 in an interview with Staff #2 (S2) it was stated that the facility had a staff member that was hired to train new staff and after approximately a week they quit and disposed of the training documents that they had, but they are working on getting all training documents for staff.

Compliance Specialist (CS) reviewed training documents for Staff #5 - #11 (S5 - S11) which revealed four of seven staff members had incomplete pre-service training and/or orientation records.

Based on interview and record review it was confirmed that the facility failed to ensure that they have documented that they have observed and evaluated the individual staff members ability to perform safe medication and treatment administration unsupervised. Findings include the following:

During an unannounced site visit on 04/25/2023 in an interview with Staff #2 (S2) it was stated that the facility had a staff member that was hired to train new staff and after approximately a week they quit and disposed of the training documents that they had, but they are working on getting all training documents for staff.

Compliance Specialist (CS) reviewed training documents for Staff #5 - #11 (S5 - S11) three of which staff members were listed as med techs on the Employee Roster. One of three staff members did not have any demonstrated competencies for passing medications. CS also reviewed Medication Administration Records (MARs) for Resident #1 - #3 and Resident #5 (R1 - R3 & R5) for January 2023 to current and discovered two staff members signing off on medication passes that were not listed as med techs on the Employee Roster. CS reviewed both staff members training records which revealed one of those staff members does not have demonstrated competencies for passing medications.

Based on interview and observation it was confirmed that the facility failed to ensure a copy of the most current inspection report and any conditions placed upon the license is posted with the facility ' s license in public view near the main entrance to the facility. Findings include the following:

During unannounced site visits on 04/20/2023 and 04/25/2023 Compliance Specialist (CS) did not observe a copy of the facility ' s condition posted anywhere in the front entrance.

In an interview with the facility policy analyst, it was stated that the facility does have a restriction of admissions condition that should be posted. In an interview with Staff #2 (S2) it was stated that they were unaware of the facility condition but would look in to locating it to get it posted.

Based on interview, observation, and record review it was confirmed that the facility failed to keep all interior and exterior materials and surfaces clean and in good repair. Findings include the following:

According to Witness #4 (W4) it was stated that resident rooms are not being cleaned either daily or even weekly, toilets and handrails are dirty with brown matter.

During an unannounced site visit on 04/25/2023 Compliance Specialist (CS) observed a dark brown substance in the shared restroom for Resident #1 (R1), substance was around the toilet, on the floor and around the doorframe near the restroom light switch. CS also observed a yellowish substance that appeared to run down the wall from approximately waist height and collected and dried at the baseboards in Resident #6 (R6) ' s restroom, the floor was sticky with a strong urine odor while the restroom fan was running.

A review of the facility housekeeping schedule revealed that on Tuesdays all floors should have been cleaned as well as a deep clean of the fourth floor. A review of service plans for R1 and R6 revealed staff are to ensure R1 ' s shower and bathroom are clean and dry and R6 ' s states that care staff are to go into room daily on day and swing shift to clean along with housekeeping deep cleans once per week.

See findings in C-tags C0360, C0365, C0370 and C0372

Based on interview and observation it was confirmed that the facility failed to have a secured outdoor recreation area with outdoor furniture sufficient in weight, stability, design, and maintained to prevent resident injury or aid in elopement. Findings include the following:

During unannounced site visits on 04/20/2023 and 04/25/2023 Compliance Specialist (CS) observed an unlocked gate, on 04/25/2023 there was a bungee cord holding the gate closed. The gate led to an area that contained the facility ' s dumpsters as well as what appeared to be heating and cooling systems. Within this unsecured area there was a door that was held closed with a screw through the door latch. CS was able to lift screw up and push the door open to gain access to the street. CS also observed on 04/25/2023 a lightweight lawn chair in outdoor recreation area.

In an interview with Staff #2 (S2) they identified the lawn chair and stated that they would remove it. S2 also acknowledged photographs of the unsecured doors in the recreation area and stated that they would make sure they got the doors/gate secured as soon as possible.