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 01/20/2022.  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 observation and interview, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents. Failure to follow infection control guidelines to prevent the spread of COVID-19 put residents at serious risk.

During the onsite visit on 01/20/2022, multiple 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. Deficiencies that were identified included, but were not limited to:

Compliance Specialist (CS) was not screened in at any time during onsite visit. Witness #1 (Infection Control Specialist) was also not observed to be screened prior to or at any time during their time in the facility.  

Multiple staff members (Staff #1-4 [S1-4]) were observed not wearing eye protection.

Staff were observed not hand washing or using alcohol-based hand sanitizer before or after assisting covid positive residents.  

There was no disinfection station or face shields outside of the COVID positive Resident Rooms.

CS observed S1 and S4 doff gowns and gloves after leaving a covid positive residents' apartment and dispose of them down the hallway into a common area trash can with no lid. The trash can was overflowing with used Personal Protective Equipment (PPE).  

During separate interview with Staff #1-4 (S1-4), the CS was given different answers when asked questions regarding PPE, screening, and sanitation and disinfectant usage/practices.  

The above findings were discussed with Staff #1, who agreed with the immediate jeopardy situation, which was identified, and corporate leadership was notified by SOQ CBC Policy Analyst.

Based on interview, observation and record review it was confirmed the facility failed to ensure there were enough staff to meet the scheduled and unscheduled needs of residents.  Findings include, but not limited to:

During onsite visit on 01/20/2022, the Memory Care Unit had 42 high acuity residents requiring care. Compliance Specialist (CS) observed the following areas:

*Residents soiled clothing piled up in laundry room.

*Resident #1 soiled him/herself after lunch, related to no staff available to provide toileting assistance; and

*Only 1 MT and 1 CG arrived for the swing shift. Posted staffing plan indicates facility should have 3 CGs and 1 MT on for swing shift.

CS asked Staff #1 (S1-med tech) about the residents '  acuity and there was no documentation that contained information regarding the resident ' s individual care needs.  

During separate interviews with Staff #1-4 (S1-S4) the following was stated:

*We do not have an acuity tool;

*Not all Service Plans are accurate or up to date;  

*We are very short staffed. We only have 3 CGs who are not out sick. Our Executive Director, RCC and LPN have been covering night shift;

*We can ' t complete residents showers or laundry sometimes. The laundry room is a mess and full of clean and dirty laundry;

*We don ' t use agency staff and I don ' t know why;  

*Swing shift should have 3 CGs and 1 MT and most of the time it is only staffed with 1 MT and 1 CG, like today; and

The facility was unable to tell the CS how they get their staffing based on resident acuity.   

The above findings were discussed with Staff #1, who agreed with the immediate jeopardy situation which was identified, and corporate leadership was notified by SOQ CBC Policy Analyst.