Print Inspection: X008

The findings of the Health and Safety Monitoring survey, conducted 8/24/21, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, and OARs 411 Division 57 for Memory Care Communities.

Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first re-visit to the Health and Safety Monitoring survey of 8/24/21, conducted on 11/5/21, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 57 for Memory Care Communities.

Based on observations and interviews, 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 implement recommendations placed residents at risk for exposure to the COVID-19 virus.  Findings include, but are not limited to:

On 8/24/21, 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:

a. The facility had not established adequate storage and disinfection practices for eye protection.

b. Staff were disinfecting high touch areas twice a shift, but not documenting it. Facility was not utilizing a cleaning checklist or log to ensure disinfection was completed. Staff were unaware of contact time for disinfectants used.

c. The staff break room lacked instruction and supplies for staff to manage PPE, instruction to social distance, and cleaning/disinfection of area after use, including shared items and table. Two loose face masks were observed on a table.

d. Staff were performing self-screening, including temperature checks and symptom screening.

e. Facility had not been consistently performing and documenting staff competency audits for performance/adherence to infection control practices and proper PPE use.

f. The following was observed in the east laundry room:

*No clear separation or sign noting clean and dirty areas;

*Loose dirty laundry was observed on the floor. Additionally, incontinent and soiled laundry was stacked in the hopper basin, on tables, in square cube shelving, and in laundry baskets. Soiled laundry had overflowed from the baskets and tables onto the floor;

*The handwashing sink was full of miscellaneous items which included boxes of gloves, fabric incontinence pads, blankets, and a food tray, rendering the sink unusable for hand hygiene;

*Trash and debris were observed on the floor in both the clean and dirty sides;

*The hopper was in the clean side of the laundry room. There was no barrier between the hopper and clean laundry area to prevent cross contamination. In addition, clean clothing was stored near the hopper; and

*The laundry room had a strong urine odor.  

The following was observed in the west laundry room:

*No clear separation or sign noting clean and dirty areas;

*Loose incontinent and soiled laundry was stacked on tables, in square cube shelving, and in laundry baskets. Laundry had overflown from hampers/baskets onto the floor;

*Clean fabric incontinence pads were observed on the floor; and

*Miscellaneous broken items were stored in the room.

The need to implement effective infection control practices was reviewed with Staff 1 (Administrator) on 8/24/21. She acknowledged the need for increased oversight of infection control practices in the building.

A. Storage and disinfection area was put into the foyer.   Staff are to clean eye protection before storing in the plastic bin when leaving work.  A disinfection area was also placed in Staff break room.   Each space has a table with disinfectant, gloves, hand sanitizer, and tissue or paper towel to place eye protection on when cleaning.  This will be monitored weekly for 1 month then monthly for 3 months, and then quarterly, by RCC and/or Admin.   

B.Cleaning checklist/log has been started for Staff to sign daily of cleaning duties preformed.  Noc shift is to clean Fabrics with Lysol disinfectant daily.  All bottles of disinfectant have contact time on them.  This will be monitored weekly for 1 month then monthly for 3 months, and then quarterly, by RCC and/or Admin.   

C.Staff break room has instructions posted and supplies for eye protection that is 6 feet from eating table.  Sign for 3 persons only in breakroom at a time is posted on door.   Staff room was also de cluttered and signs posted for keeping areas clear of clutter.  This will be checked daily by RCC and/or Admin.     

D.Staff are to screen each other in.   Making sure no symptoms are seen.   Rapid test available if Staff are showing signs of COVID-19.  Team Lead will monitor daily.   RCC and/or Admin will monitor weekly for 1 month, then monthly for 3 months, then quarterly.  

E.Staff are preforming competency audits for performance/adherence to infection control practice, proper PPE donning and doffing, and hand washing.   This will be done by RCC/Admin weekly for 1 month, monthly for 3 months and then quarterly.  

F.Clean and Dirty areas are posted in Laundry rooms.   Both East and West laundry rooms were deep cleaned and cleared of clutter.  All Residents now have a laundry basket in their rooms with plastic liners in them.   Staff are taking everything out of Residents rooms in a plastic bag.   Laundry will be washed twice weekly and/or as needed.    Hopper area on clean side will have a plastic barrier built around it so not to contaminate clean area.  A 3-drawer container will hold eye protection, gloves, wipes, and disinfecting wipes as needed under sink next to hopper.  We have water resistant washable suits to be worn when using hopper to prevent contamination onto clothes.   They will be located next to hopper.   All soiled linens will be in plastic bags.  This will be monitored weekly for 1 month then monthly for 3 months, and then quarterly, by RCC and/or Admin.   Results of audits will be shared with the quarterly QAPI meeting to identify any opportunities for further education/training.  

Based on interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to C 160.

See C 160.