Print Inspection: CSYJ

The findings of the on-site investigation, conducted 08/30/23 through 08/31/23 are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

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, interview and record review during an onsite visit 08/30/23 through 08/31/23, it was confirmed the facility failed to implement policies and procedures to assure the prevention and appropriate response to any incident for 2 of 2 sampled residents (#s 1 and 2). Findings include, but are not limited to:

1. On 08/30/23 at approximately 4:30 pm, a resident to resident physical altercation was observed between two unsampled residents. There were no staff present immediately on the floor to intervene. A staff member separated the residents after two minutes.

On 08/31/23 Staff 13 (Administrator) stated there was no documentation of the above incident, no investigation had been initiated and she was unaware it occurred.  The Compliance Specialist notified Staff 13 on 08/31/23 that an investigation needed to be completed and the incident reported to APS. The CS reported the event to APS.

2. During interview on 08/30/23, Staff 6 (Care Partner) and Staff 7 (Care Partner) stated another Care Partner had been rough with a resident, gave the resident a cold bed bath, and scrubbed the resident's genitalia, arms and mouth rough during the bed bath. Staff 6 and 7 stated they reported the event to the facility's staffing director the previous week and reported it to Staff 2 (Executive Director) and Staff 8 (Consultant) on 08/30/23.

On 08/31/23, Staff 13 (Administrator) stated there was no evidence that an investigation had been initiated on this concern or that it was reported to APS.

3. A review of progress notes for Resident 1 and Resident 2 dated 07/01/23 through 08/31/23 revealed the following:

* 07/07/23 Care staff reported to LPN that Resident 1 has been having sexual behaviors towards other males on the unit including touching, massaging and kissing.

*07/09/23 Resident 1 found in Resident 2's room helping him lay down in bed;

*07/12/23 Resident 2 found in Resident 1's room with pants off;

*07/12/23 Resident 1 was seen touching and rubbing Resident 2's shoulders

*07/13/23 Resident 1 was seen walking with Resident 2 and followed another resident into his/her room;

*07/18/23 Resident 1 was inviting other residents into his room, holding hands and rubbing their backs;

*07/20/23 Resident 1 was seen trying to lure resident 2 into his room and rubbing shoulders;

*07/21/23 Resident 1 was seen rubbing Resident 2's back and neck;

*07/23/23 Resident 1 was found naked in Resident 2's room;

*07/24/23 Resident 1 was seen exhibiting sexual/touchy behavior towards an unsampled resident;

*07/25/23 Resident 1 was seen touching an unsampled resident and holding Resident 2's hand;

*07/26/23 Resident 1 was seen rubbing an unsampled resident's head, neck and back;

*07/28/23 Resident 1 was seen touching an unsampled resident's back and neck;

*07/28/23 Resident 1 found in Resident 2's room. Resident stated he was "helping him get cleaned up";

*08/01/23 Resident was seen guiding Resident 2 back to Resident 1's room;

*08/05/23 Resident 1 found kissing Resident 2;

*08/09/23 Resident 1 found grabbing Resident 2's hand and attempting to get Resident 2 to walk down the hall;

*08/11/23 Resident 1 found holding hands with an unsampled resident. The unsampled resident became agitated and attempted to grab at Resident 1. Resident 1 then attempted to strike unsampled resident; and

*08/14/23 Resident 1 was moved into a different part of the community.

There was no evidence the facility initiated any investigations into the above events or initiated any interventions to prevent those incidences. Progress notes repeatedly indicated residents were redirected and monitored.

Resident 2's current service plan noted s/he has a "significant history of mental/emotional trauma which can present itself as paranoia, fear of sexual harm or sexual inappropriateness of others."

During an interview on 08/30/23, Staff 3 (Care Partner/MT) stated if Resident 1 was sexually aggressive with another resident, they would separate them, help them get dressed if needed. S/he further stated they didn't know what to do to prevent the behaviors, just to monitor and redirect.

The findings were reviewed with and acknowledged by Staff 13 on 08/31/23.

The facility failed to investigate Resident 1's sexual behaviors towards other residents, place interventions for staff to follow and to protect other residents from sexual abuse.  

Verbal plan of correction: Administrator to be present on shift to shift meetings and ask probing questions regarding residents behaviors. Administrator will review charting every day and follow up with staff members daily, ask and verify what staff did in response to incidents, and confirm interventions are in place. Compliant Specialist provided Oregon Department of Human Services Abuse Investigation and Reporting Guide to the Administrator.

Based on interview and record review, conducted during an onsite visit on 08/30/23 through 08/31/23, the facility failed to develop a service plan that is reflective of the resident's needs for 1 of 1 sampled residents (# 1). Findings include, but are not limited to:

1. A review of progress notes for Resident 1, dated 07/01/23 through 08/31/23 revealed the following:

* 07/07/23 Care staff reported to LPN that Resident 1 has been having sexual behaviors towards other males on the unit including touching, massaging and kissing.

*07/09/23 Resident 1 found in Resident 2's room helping him lay down in bed;

*07/12/23 Resident 2 found in Resident 1's room with pants off;

*07/12/23 Resident 1 was seen touching and rubbing Resident 2's shoulders

*07/13/23 Resident 1 was seen walking with Resident 2 and followed another resident into his/her room;

*07/18/23 Resident 1 was inviting other residents into his room, holding hands and rubbing their backs;

*07/20/23 Resident 1 was seen trying to lure resident 2 into his room and rubbing shoulders;

*07/21/23 Resident 1 was seen rubbing Resident 2's back and neck;

*07/23/23 Resident 1 was found naked in Resident 2's room;

*07/24/23 Resident 1 was seen exhibiting sexual/touchy behavior towards an unsampled resident;

*07/25/23 Resident 1 was seen touching an unsampled resident and holding Resident 2's hand;

*07/26/23 Resident 1 was seen rubbing an unsampled resident's head, neck and back;

*07/28/23 Resident 1 was seen touching an unsampled resident's back and neck;

*07/28/23 Resident 1 found in Resident 2's room. Resident stated he was "helping him get cleaned up";

*08/01/23 Resident was seen guiding Resident 2 back to Resident 1's room;

*08/05/23 Resident 1 found kissing Resident 2;

*08/09/23 Resident 1 found grabbing Resident 2's hand and attempting to get Resident 2 to walk down the hall;

*08/11/23 Resident 1 found holding hands with an unsampled resident. The unsampled resident became agitated and attempted to grab at Resident 1. Resident 1 then attempted to strike unsampled resident; and

*08/14/23 Resident 1 was moved into a different part of the community.

A review of Resident 1's current service plan did not indicate the resident had sexual behaviors nor did it include any behavior interventions.

During an interview on 08/31/23 Staff 13 (Administrator) stated they had a service planning meeting for Resident 1 on 08/28/23 and would be updating his/her service plan by the end of the day.

The findings were reviewed and acknowledged by Staff 13 on 08/31/23.

The facility failed to develop a service plan that revealed the resident had behaviors and develop interventions for staff to implement.  

Verbal plan of Correction: The facility had scheduled every required care conference for the next two weeks. The new Resident Care Coordinator would be starting on 09/05/23. Resident 1's service plan to be updated on 08/31/23.

Based on interview and record review, conducted during a site visit on 08/30/23 through 08/31/23, it was confirmed the facility failed to carry out medication orders as prescribed for 1 of 1 sampled residents (# 3). Findings include, but are not limited to:

A review of Resident 3's signed physician orders, dated 06/15/23 revealed the resident received Rivoraxaban (blood thinning medication) 20 mg oral tablet take 20 mg once daily with dinner.

A review of Resident 3's 06/01/23 though 07/31/23 MAR and progress notes revealed this medication was not given until 07/05/23.

During an interview 08/30/23, Staff 2 stated the Rivoraxaban had been added incorrectly into the MAR when Resident 3 was admitted and was not visible to the MTs to administer the medication.

The findings were reviewed with and acknowledged by Staff 13 (Administrator) on 08/31/23.

The facility failed to carry out medication orders as prescribed.

Verbal Plan of correction: Pharmacy integration between Consensus and Point Click Care happened in July 2023. MTs receive orders,scan to Consonus and then facility should triple check by RCC and then LPN or RN. Staff 13 will reach out to Integrated Staffing agency on 08/31/23 for nursing needs until a new nurse is onboarded to verify if there are medication errors.

Based on observation, interview and record review, conducted during a site visit from 08/30/23 through 08/31/23, it was confirmed the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident for 2 of 3 sampled residents (#s 1 and 2). Findings include, but are not limited to:

The facility's posted staffing plan indicated the facility needed 2 MTs' and 5 Care Partners during day shift.

During the site visit, 2 MTs' and 4 Care partners were observed working on day shift on 08/30/23 and 08/31/23.

1. A review of Resident 1's service plan revealed the resident required assistance with dressing. Bathing instructions were not included on the service plan.

On 08/30/23 and 08/31/23, Resident 1 was observed wearing the same clothes and had not been changed.

During an interview, Witness 1 ( Family Member) stated Resident 1 required assistance for showering, but s/he does not believe the resident received showers and there was often fecal matter in his/her underwear.

2. A review of Resident 2's service plan revealed s/he required one to one assistance with meals and oral care assistance every morning.

During an observation on 08/31/23, Resident 2 did not receive any assistance with the morning meal.

During an interview after the breakfast meal, Staff 14 (caregiver) stated s/he did not provide oral care to Resident 2 or any other residents in the morning because s/he did not have time.

3. During an interview on 08/30/23, Staff 4 (housekeeper) was observed working on the floor and providing care to residents. Staff 4 stated s/he was pulled to the floor for the day because of a Care Partner not showing up that day. Staff 4 stated s/he did not provide any showers that day because she didn't know there were any to complete. A review of the shower schedule revealed that two unsampled residents were to receive showers on day shift.

4. During the site visit on 08/31/23, a physical altercation was observed between two unsampled residents, and no staff were visible on the floor to intervene, but were able to separate the residents after two minutes.

The findings were reviewed with  Staff 13 (Administrator) on 08/31/23.

The facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident.

Verbal plan of correction: Staff 2 (Administrator) contacted Integrated Staffing for staffing needs on 08/30/23. Staff 13 followed up at 9 am on 08/31/23 with Integrated Staffing for additional staffing needs. The facility administration continued efforts to hire staff. The facility administration will conduct audits of all current staff, while agency staff would fills in holes prior to the on-boarding of new staff to ensure proper training.

Based on observation, interview and record review,  conducted during a site visit on 08/30/23 through 08/31/23, it was confirmed the facility failed to fully implement an Acuity-Based Staffing Tool for 4 of 4 sampled residents (#s 1, 2, 3 and 5). Findings include, but not limited to:

A review of the facility's ABST on 08/30/23 indicated the need for the following staff:

Day: 46.1 hours(6.14 staff);

Swing: 36.07 hours (4.80 staff); and

Noc: 9.3 hours (1.24 staff)

The facility's posted staffing plan indicted the facility needed 2 MTs' and 5 Care Partners during day shift.

During the site visit, 2 MTs' and 4 Care Partners were observed working on day shift on 08/30/23 and 08/31/23.

The facility was not staffed to the level required by their ABST.

Observations, interviews with staff, and review of the resident's records noted ABST entries were not reflective of the resident's current care needs in the following areas:

Resident 1:

Dressing;

Cueing and redirecting due to cognitive impairment;

Time spent monitoring behavioral conditions;

Behavior interventions and re-direction; and

Bathing.

Resident 2:

Dressing;

Nail care/brushing hair;

Bowel and bladder management;

Escorting to/from meals; and

Meals.

Resident 3:

toileting;

dressing;

oral care; and

transfers.

Resident 5's ABST profile was incomplete.

The findings were reviewed with and acknowledged by Staff 13 (Administrator) on 08/31/23.

The facility failed to fully implement and update an ABST.

Based on observation, interview and record review, conducted during a site visit from 08/30/23 to 08/31/23, it was confirmed the facility failed to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned for 4 of 4  sampled staff members (#s 4, 6, 9 and 10). Findings include, but are not limited to:

A review of staff training records for Staff 4 (Housekeeper), Staff 6 (Care Partner), Staff 9 (MT) and Staff 10 (MT) revealed:

*There were no training records for Staff 4 and Staff 6;

*Staff 9 had completed eight pre-service training provided by Oregon Care Partners; and

*Staff 10 completed two Relias trainings on 10/26/22 called "Welcome to Relias" and "Welcome to Relias: The Game Elements Tour".

There were no additional training records available for those four staff members including any demonstrated competencies.

Staff 4, Staff 6, Staff 9 and Staff 10 were observed working on the floor with residents independently on 08/30/23.

During an interview on 08/30/23, Staff 4 stated s/he wasn't sure what his/her title was, but thinks s/he is a care partner, but it was not official yet. S/he further stated s/he was helping on the floor with cares today because a care partner called-out, but s/he normally works as a housekeeper.

During an interview with Staff 1 (RN Consultant), Staff 2 (Executive Director) and Staff 8 (Consultant) stated the former RCC was responsible for verifying and tracking staff competencies but s/he quit.

During an interview with Staff 6 on 08/30/23, s/he stated s/he was asked to work as a MT on swing shift on 08/30/23 but had never been trained to do this and was nervous. S/he further stated that Staff 8 had told him/her they would get a "crash course" on medications and then could pass medications that night.

Staff 6 was observed with keys to the med cart and completed a narcotic count to start the shift. Compliance Specialist intervened for resident safety and asked Staff 2 and Staff 8 to remove Staff 6 from the medication cart, due to not having any training.

The findings were reviewed with Staff 13 (Administrator) on 08/31/23.

It was confirmed the facility failed to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned.

Verbal plan of correction: Facility to audit all staff training documents including relias, CPR, food handlers and competencies checklist. Facility will have all staff training documented and up to date within 30 days and will implement a policy and procedure for new hires to complete required trainings prior to starting on the floor. That will be the job on the new RCC who will start 09/05/23.