Print Inspection: QP7X

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 11/01/2022.  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 exercise reasonable precautions against any condition that may threaten the health, safety or welfare of residents. Findings include but no limited to:

During an unannounced site visit on 11/01/2022, Compliance Specialist (CS) observed the strong, pervasive smell of cigarette in one hall of the facility.

During interview, Staff #1 and Staff #7 reported there is a resident who smokes both marijuana and cigarettes in his room.

These findings were reviewed with Staff #1-Staff #5 on 11/01/2022 who were in agreement.

Plan of Correction: Facility has issued a 30 day move out notice to this resident who continually refuses to follow non-smoking rules.

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

During an unannounced site visit on 11/01/2022, Compliance Specialist (CS) observed signage indicating this facility had an active COVID 19 outbreak. Upon entrance, CS observed staff members wearing surgical masks, not wearing N95s, wearing masks layered with a surgical mask flush to skin and an N95 over the surgical mask and one employee in facility not wearing any mask.

During interview, Staff #1 explained that facility has a COVID + staff member living in an ALF apartment and 5 COVID+ residents in their memory care.

Later in the afternoon, Staff #4 (S4) was still only wearing a surgical mask. During interview S4 did not answer CS questions about why they had not yet changed into an N95 instead they shrugged their shoulders and then put on an N95.

These findings were reviewed with and acknowledged by Staff #1-Staff #5 on 11/01/2022.

Plan of correction: In-service to be conducted on 11/2/2022-11/3/2022 on masking and PPE requirements.

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."

A review of Resident #2's (R2) MAR for September 2022 revealed three occasions when a medication administration did not occur due to a medication not being available in-house. A review of Resident #3 (R3)'s MAR for October 2022 revealed one instance when a medication was not given due to not being available.

During an interview conducted 10/31/2022 Witness #3 (W3) stated that this facility's medication practices are unsafe and disorganized.

During interviews R2 and Witnesses #1- #2 stated that sometimes the resident gets the wrong medications or medications are very late.

These findings were reviewed with and acknowledged by Staff #1-Staff #5 on 11/01/2022.

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 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."

A review of Resident #2's (R2) MAR for September 2022 revealed three occasions when a medication administration did not occur due to a medication not being available in-house. A review of Resident #3 (R3)'s MAR for October 2022 revealed one instance when a medication was not given due to not being available.

During an interview conducted 10/31/2022 Witness #3 (W3) stated that this facility's medication practices are unsafe and disorganized.

During interviews R2 and Witnesses #1- #2 stated that sometimes the resident gets the wrong medications or medications are very late.

These findings were reviewed with and acknowledged by Staff #1-Staff #5 on 11/01/2022.

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 failed to have enough staff to meet the scheduled and unscheduled needs of the residents.

During an unannounced site visit on 11/01/2022, Compliance Specialist (CS) observed one caregiver and one med tech working on swing shift. The facility's posted staffing plan indicated the need for two caregivers and one med tech on swing shift. CS did not observe any residents serving other residents meals.

A review of the facility's ABST revealed a need for 19.42 hours of care for that shift.

During separate interviews, Staff #10 (S10), Resident #2 (R2), Resident #6 and Witness #1-Witness #2 stated:

*Two caregivers are needed on swing shift.

*There were supposed to be two caregivers, but someone quit.

*Sometimes it takes a long time for someone to answer the call lights.

These findings were reviewed with and acknowledged by Staff #1-Staff #5 on 11/01/2022.

Plan of Correction: Follow guidelines outlined in condition.

Based on record review and interview it was confirmed that the facility failed to have a training program that includes methods to determine the competency of direct care staff. Findings include but not limited to:

During an unannounced site visit on 11/01/2022 Compliance Specialist requested all training documents for two medication technicians. A review of requested documents revealed that one of them, Staff #7 (S7) had not completed a training competencies checklist and was administering medications to residents.

During interview Staff #1 and Staff #5 stated they were unable to locate competency checklist for S7 and could not verify that competencies were demonstrated.

These findings were reviewed with and acknowledged by Staff #1-Staff #5 on 11/01/2022.

Plan of Correction: Facility to request that staff member with no verifiable competency training to have competencies verified with RN consultant beginning 11/02/2022.

Based on observation and interview it was confirmed that the facility failed keep the interior of the facility free from unpleasant odors. Findings include but no limited to:

During an unannounced site visit on 11/01/2022, Compliance Specialist (CS) observed the strong, pervasive smell of cigarette in one hall of the facility.

During interview, Staff #1 and Staff #7 reported there is a resident who smokes both marijuana and cigarettes in his room.

These findings were reviewed with Staff #1-Staff #5 on 11/01/2022 who were in agreement.

Plan of Correction: Facility has issued a 30 day move out notice to this resident who continually refuses to follow non-smoking rules.