Print Inspection: YZCY

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 01/05/2023.  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 interview and record review it was confirmed the facility failed to implement and compete service plans before a resident moves in or quarterly evaluations. Findings include:

During separate interviews on 01/05/2023, Staff #1-3 (S1, S2, and S3) stated that the facility is behind on service plans and admits there are a handful out of date. S2 stated that they have been working on updating them and made that their priority.

A review of the facility ' s service plan binder indicates at least 8 service plans to be out of date. The dates the service plans should have been completed are 12/6/2022, 12/21/2022, 12/12/2022, 10/19/2022, 1/2/2023, 10/2/2022, and 2 are new residents that did not receive updated service plans after they moved in 30 days later.

On 01/05/2023, these findings were reviewed and acknowledged by S1.

Plan of Correction: S2 had made updating service plans their priority. S2 has been and continues to update service plans to make them all in compliance with resident ' s current needs.

Based on interview, observation, and record review it was confirmed the facility failed to establish, maintain, and comply with infection prevention and control protocols. Findings include:

During an interview on 01/05/2023, Staff #1 (S1) stated that this is the resident ' s home, and we suggest guests wear masks but do not require them too. S1 also stated observing guests enter the facility without a mask on and that S1 did not ask them to wear a mask while in the facility.

During an unannounced site visit on 01/05/2023, Compliance Specialist (CS) observed no required signs posted for infection control or mask requirements on the entrance or throughout the building.

A review of the Oregon Health Care Association covid updated guidelines for facility ' s dated 11/23/2022 states that masks requirements remain. Consistent masking by health care providers in health care settings, as well as masking by visitors. Also stating, Visitors: No screening requirements for visitors entering facility, but facility should provide guidance (e.g., posted signs at entrances, reception area and/or visitor sign-in area). Infection prevention, such as providing instructional signage in the facility on hand hygiene, use of a mask, or other applicable facility practices). Visitors who do not adhere to the core principles of infection prevention may be asked to leave.

On 01/05/2023, these findings were reviewed with S1.

Plan of Correction: Starting on 01/05/2023. S1 will be finding the proper sign posting for the entrance of the facility and will remind visitors to put masks on when entering the facility.

Based on interview and record review it was confirmed that the facility failed to document that they have observed and evaluated the individual's ability to perform safe medication and treatment administration unsupervised. Findings include:

During an onsite interview on 01/05/2023, Staff #1 (S1) stated that they were administering insulin and other medications in October and November 2022. S1 stated that they were administering insulin before their delegation from the Registered Nurse.

A review of S1 Initial staff skills assessment for RN delegation dated 11/11/2022 and the complaint dated 11/3/2022 shows that S1 was administering insulin before the delegation was provided. S1 did not provide other training or delegations for medication administration. The delegation for insulin is not for specific residents but a general one for the building.

On 01/05/2023, these findings were reviewed and acknowledged by S1.

Plan of Correction: S1 is no longer working as a med tech. There is now a delegation for S1 to administer insulin.