Print Inspection: 61ZJ

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 11/29/2022.  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 confirmed that the facility failed to post the current staffing plan. Findings include but not limited to:

During an unannouced site visit on 11/29/2022, Compliance Specialist toured facility and was unable to locate the posted staffing plan.

During interview Staff #1 (S1) stated that they had a past Activities Director that must have taken it down.

Plan of Correction: S1 to post staffing plan by end of day 11/30/2022.

Based on observation, interview and record review it was confirmed that the facility failed to provide three daily palatable meals. Findings include but not limited to:

During an announced site visit on 11/29/2022, Compliance Specialist observed Staff #9 (S9) pass boxed lunches to all rooms on the first floor of the facility. Beverages were offered to each resident. This process began at 1140 and ended at 1219. The temperature of the taco in remaining lunch box was 87 degrees Fahrenheit.

During lunch service a resident yelled at S9 to not take their breakfast. Resident stated they were at an appointment and their breakfast tray was removed before they could eat it.

During separate interviews, Staff #8 (S8), Staff #9 (S9), Resident #4 (R4), Resident #2 (R2) and Resident #8 (R8) stated:

*Sometimes it takes an hour to pass boxed lunches.

*The best we can do is try to serve lunches quickly.

*There are no alternates offered at this time, because of COVID, unless there

is a medical reason.

*The food is always cold.

*I make my own food because the food here is too salty and cold.

A review of the facility's resident meal roster for 11/28/2022 revealed several resident meals had not been documented as received or refused.

These findings were reviewed with and acknowledged by Staff #1 on 11/29/2022.

Plan of Correction: Facility has requested heated carts from owner to use while dining room is closed. Dietary staff to use resident roster to sign off when meals have been passed to each resident.

Based on observation, interview and record review it was confirmed that the facility failed to provide assistance with bathing and washing hair. Findings include but not limited to:

During an unannounced site visit on 11/29/2022, Compliance Specialist (CS) observed Staff #6 (S6) sitting at the caregiver station and using their personal laptop for several hours of the day shift.

During interview, S6 and Staff #7 (S7) stated they had asked the four residents on the shower schedules if they wanted a shower and all four had refused.

During interview, two of the four residents stated they had not been offered a shower that day. Resident #7 (R7) stated they are frequently denied showers when they are needed and that they don't know when there scheduled showers are because they change so often.

A review of Resident #7's (R7) progress notes for October 2022 revealed an instance on 10/06/2022 when resident was upset about not receiving a shower.

These finding were reviewed with and acknowledged by Staff #1 on 11/29/2022.

Plan of Correction: Create task sheet and implement by end of December 2022. PCC implementation in January 2023.

Based on observation, interview and record review, it was confirmed that the facility failed to update service plans quarterly. Findings include but not limited to:

During an unannounced site visit on 11/29/2022, Compliance Specialist (CS) observed Service Plans binders that included at least four service plans that were over 90 days from their last reviewed dates.

A review of service plans provided by Staff #1 revealed:

*Resident #8 (R8)'s service plan was dated 07/07/2022.

*Resident #4 (R4)'s service plan was dated 07/07/2022.

*Resident #2 (R2)'s service plan was dated 04/21/2022.

During interview, Staff #1 stated that the facility had a plan of correction for this from a previous site visit and is working to update service plans.

Plan of Correction: 5-10 care conferences are scheduled per week in December.

Based on observation,  interview and record review it was confirmed that the facility failed to comply with masking requirements. Findings include but not limited to:

During an unannounced site visit on 11/29/2022 Compliance Specialist (CS) observed signage on entry doors indicating the facility had active COVID cases in the community. CS observed only one staff member wearing an ill-fitted N95 that was falling below their nose. All other staff members only had surgical masks upon entrance. CS observed isolation rooms with no PPE bins and several bins were empty, or without an element of PPE. CS observed Staff #10 (S10) enter an isolation room without a faceshield.

During separate interviews, Staff #1, Staff #3-Staff #7 stated:

*I didn't know we needed an N95.

*We didn't have N95s until today.

*We were told surgical masks were ok.

*I went in a COVID+ resident room without an N95 yesterday.

* A resident had to be sent to the hospital yesterday with COVID.

A review of the facility's Coronavirus Precautions policy states that "Staff entering a suspected infected resident apartment should wear a N95 repirator..."

These findings were reviewed with Staff #1 on 11/29/2022 who stated that an RN consultant had completed an in-service with all staff about infection control. CS requested the documentation of this in-service but S1 said they didn't know where it was.

Based on observation, record review and interview it was confirmed that the facility failed to ensure adequate professional oversight of the medication and treatment administration system by the administrator. Findings include but not limited to:

During an unannounced site visit on 11/29/2022, Compliance Specialist observed Staff #4 (S4) pass medications to Resident #1 (R1). R1's medications were due at 0800 and it was 0910 when they received their medications. S4 then returned to the med room and documented that meds were given.

A review of R1's MAR for November 2022 did not include information about R1's medications being given late on 11/29/2022. A review of the administration history for a specific medication did indicate that this med was "LATE: Done late. Medications given" on 11/29/2022.

During interview, S4 stated that they have a one-hour window to administer medications and acknowledged that R1's meds were given outside of that window.

A review of Resident #8 (R8)'s MAR for October-November 2022 revealed instances where a medication was "signed out late" or unavailable."

During interview R8 stated their evening medications are often one to two hours late.

These findings were reviewed with and acknowledged by Staff #1 (S1) who stated they needed to review the current EMAR system.

Plan of Correction: Facility switching to use of PCC for clinical documentation in January 2023. Admin to review current EMAR system which does not seem to be tracking late meds at this time.

Based on observation, record review and interview it was confirmed that the facility failed to carry out medications and treatments as prescribed. Findings include but not limited to:

During an unannounced site visit on 11/29/2022, Compliance Specialist observed Staff #4 (S4) pass medications to Resident #1 (R1). R1's medications were due at 0800 and it was 0910 when they received their medications. S4 then returned to the med room and documented that meds were given.

A review of R1's MAR for November 2022 did not include information about R1's medications being given late on 11/29/2022. A review of the administration history for a specific medication did indicate that this med was "LATE: Done late. Medications given" on 11/29/2022.

During interview, S4 stated that they have a one-hour window to administer medications and acknowledged that R1's meds were given outside of that window.

A review of Resident #8 (R8)'s MAR for October-November 2022 revealed instances where a medication was "signed out late" or unavailable."

During interview R8 stated their evening medications are often one to two hours late.

These findings were reviewed with and acknowledged by Staff #1 on 11/29/2022.

Plan of Correction: Facility switching to use of PCC for clinical documentation in January 2023. Admin to review current EMAR system which does not seem to be tracking late meds at this time.

Based on observation, record review and interview it was confirmed that the facility failed to keep an accurate Medication Administration Report (MAR). Findings include but not limited to:

During an unannounced site visit on 11/29/2022, Compliance Specialist observed Staff #4 (S4) pass medications to Resident #1 (R1). R1's medications were due at 0800 and it was 0910 when they received their medications. S4 then returned to the med room and documented that meds were given.

A review of R1's MAR for November 2022 did not include information about R1's medications being given late on 11/29/2022. A review of the administration history for a specific medication did indicate that this med was "LATE: Done late. Medications given" on 11/29/2022.

During interview, S4 stated that they have a one-hour window to administer medications and acknowledged that R1's meds were given outside of that window.

A review of Resident #8 (R8)'s MAR for October-November 2022 revealed instances where a medication was "signed out late" or unavailable."

During interview R8 stated their evening medications are often one to two hours late.

These findings were reviewed with and acknowledged by Staff #1 (S1) who stated they needed to review the current EMAR system.

Plan of Correction: Facility switching to use of PCC for clinical documentation in January 2023. Admin to review current EMAR system which does not seem to be tracking late meds at this time.

Based on interview and record review it was confirmed that the facility failed to prevent the entry of rodents. Findings include but not limited to:

During an unannounced site visit on 11/29/2022, Compliance Specialist interviewed Staff #2 who indicated that the facility had a mouse outbreak around July after having a new batch of bark brought in for landscaping.

A review of PurCor Pest Solutions invoiced dated 8/15/2022, 9/1/2022, 9/14/2022, 9/22/2022, 10/7/2022 and 11/11/2022 confirmed interior rodent activity in apartments 211, 106, 103 and 105.

These findings were reviewed with Staff #1 on 11/29/2022.

Plan of Correction: Continue to work with Pest Control service to eradicate.

Based on observation and interview it was confirmed that the facility failed to keep in good repair all equipment necessary for the health, safety, and comfort of the resident. Findings include but not limited to:

During an unannounced site visit on 11/29/2022 Compliance Specialist measured the temperature of Resident #5's bathroom sink and shower water at 1000. CS allowed water to run in the sink for three minutes and maximum temperature reached was 81 degrees. The shower reached 100 degrees. and when the toilet was flushed, temperature increased to 107 degrees.

During interview, Staff #2 (S2) stated that they had received complaints about R5s water temperature but there is no way to stop these fluctuations in a 53 year old building. S2 stated that water temperatures should be between 120 and 130 degrees.

In the afternoon, S2 asked to show CS 201's water temp. S2 turned on the entrance sink and the sink came apart at this time. After re-assembling the sink, turning on the bathroom sink and allowing water to run for several minutes, the temperature reached 114 degrees.

A review of facility's Water temp logs for September and October revealed 7 instances where water temperatures were outside the 110-120 degree range.

These findings were reviewed with and acknowledged by Staff #1 on 11/29/2022.

Plan of Correction: Admin to discuss solution with maintenance director and adjust water heater.

Based on observation and interview it was confirmed that the facility failed to maintain hot water temperature within a range of 110-120 degrees. Findings include but not limited to:

During an unannounced site visit on 11/29/2022 Compliance Specialist measured the temperature of Resident #5's bathroom sink and shower water at 1000. CS allowed water to run in the sink for three minutes and maximum temperature reached was 81 degrees. The shower reached 100 degrees. and when the toilet was flushed, temperature increased to 107 degrees.

During interview, Staff #2 (S2) stated that they had received complaints about R5s water temperature but there is no way to stop these fluctuations in a 53 yearold building. S2 stated that water temperatures should be between 120 and 130 degrees.

In the afternoon, S2 asked to show CS 201's water temp. S2 turned on the entrance sink and the sink came apart at this time. After re-assembling the sink, turning on the bathroom sink and allowing water to run for several minutes, the temperature reached 114 degrees.

A review of facility's Water temp logs for September and October revealed 7 instances where water temperatures were outside the 110-120 degree range.

These findings were reviewed with and acknowledged by Staff #1 on 11/29/2022.

Plan of Correction: Admin to discuss solution with maintenance director and adjust water heater.