Print Inspection: ZR9C

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 03/24/2023.  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 observation, interview, and record review,  it was confirmed that the failed to exercise reasonable precautions against any condition that may threaten the health, safety, and welfare of the residents. Findings include but not limited to:

During an unannounced site visit on 3/24/2023, Compliance Specialist (CS)

observed the following rooms and bedrooms which were not clean:

Room 18 had unknown stains and trash on the floor with incontinence supplies scattered around.

Room 15 had bowel movement stains in the toilet.

Room 16 had a large ball of hair on top of the shower drain.

Room 12 had bowel movement on toilet and toilet seat and the floor was dirty and did not have hand sanitizer.

Room 11 had dirty ring in the toilet, shower and debris all over the carpet.

Room 6 had a dirty ring in the toilet and sink and debris all over carpet.

Room 2 had a pervasive odor of urine, the floor was very sticky and an unknown brown material in the sink.

During separate interview, Staff #1 - Staff #2 (S1-S2) stated:

*They don't refill hand sanitizer because they don't have any.

*They clean rooms on resident shower days.

*They do not have any housekeeping staff.

*They do not clean the toilets because they don't have toilet brushes.

A review of facility's shower/skin evaluations revealed that residents in rooms 2, 16, 19 and 10 had showers the previous day 3/23/2023.

These findings were reviewed with Staff #3 on 3/24/2022 who was in agreement.

Plan of Correction: Facility to deep clean 2-3 resident rooms per day beginning 3/25/2023. Facility to add cleaning room to ADL task list.

Based on observation, interview, and record review,  it was confirmed that the facility failed to provide household services essential for the health and comfort of the resident that are based upon the resident's needs and preferences (e.g., floor cleaning, dusting, bed making, etc.) Findings include but not limited to:

During an unannounced site visit on 3/24/2023, Compliance Specialist (CS) observed  the following rooms and bedrooms which were not clean:

Room 18 had unknown stains and trash on the floor with incontinence supplies scattered around.

Room 15 had bowel movement stains in the toilet.

Room 16 had a large ball of hair on top of the shower drain.

Room 12 had bowel movement on toilet and toilet seat and the floor was dirty and did not have hand sanitizer.

Room 11 had dirty ring in the toilet, shower and debris all over the carpet.

Room 6 had a dirty ring in the toilet and sink and debris all over carpet.

Room 2 had a pervasive odor of urine, the floor was very sticky and an unknown brown material in the sink.

During separate interview, Staff #1 - Staff #2 (S1-S2) stated:

*They don't refill hand sanitizer because they don't have any.

*They clean rooms on resident shower days.

*They do not have any housekeeping staff.

*They do not clean the toilets because they don't have toilet brushes.

A review of facility's shower/skin evaluations revealed that residents in rooms 2, 16, 19 and 10 had showers the previous day 3/23/2023.

These findings were reviewed with Staff #3 on 3/24/2022 who was in agreement.

Plan of Correction: Facility to deep clean of 2-3 resident rooms per day beginning 3/25/23. Facility to add cleaning room to ADL task list.

Based on interview and record review, it was confirmed that the facility failed to contact the emergency contact. Findings include but not limited to:

During a phone interview on 3/24/2023, Witness #1 (W1) stated that the facility called their partner, an employee of the facility to notify of Resident #2 (R2)'s passing. W1 never received a call from the facility to notify of R2's passing and stated that the partner was not to be contacted.

A review of R2's facesheet and progress notes for November 2022 revealed W1 is the Power of Attorney and there is no documentation about anyone being notified of R2's passing.

These findings were reviewed Staff #3 on 3/24/2023 who was in agreement.

Plan of Correction: Facility to in-service staff on notification and documentation practices within 24 hours.

Based on observation and interview, it was confirmed that the facility failed to establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. Findings include but not limited to:

During an unannounced site visit on 3/24/2023, Compliance Specialist (CS) observed Staff #2 and Staff #4 in the kitchen and not wearing masks. Staff #1 (S1) was wearing an ill-fitted mask that was below the nose and mouth was exposed. CS heard S1 coughing and overheard S1 tell a resident that they were starting to feel better but still had a cough. Room 12 did not have hand sanitizer.

During interview, S1 stated that they don't refill hand sanitizer because they don't have any.

These findings were reviewed with Staff #3 on 3/24/2022 who was in agreement.

Plan of Correction: Facility to in-service staff on infection control policies and masking beginning 3/24/2023. Mask usage audit to begin immediately. LPN will discuss further with Administrator.

Based on observation, interview, and record review,  it was confirmed that the facility failed to have sufficient staff to meet the scheduled and unscheduled needs of the residents. Findings include but not limited to:

During an unannounced site visit on 3/24/2023, Compliance Specialist (CS) observed the following rooms which were not clean:

Room 18 had unknown stains and trash on the floor with incontinence supplies scattered around.

Room 15 had bowel movement stains in the toilet.

Room 16 had a large ball of hair on top of the shower drain.

Room 12 had bowel movement on toilet and toilet seat and the floor was dirty and did not have hand sanitizer.

Room 11 had dirty ring in the toilet, shower and debris all over the carpet.

Room 6 had a dirty ring in the toilet and sink and debris all over carpet.

Room 2 had a pervasive odor of urine, the floor was very sticky and an unknown brown material in the sink.

During separate interview, Staff #1 - Staff #2 (S1-S2) stated:

*They don't refill hand sanitizer because they don't have any.

*They clean rooms on resident shower days.

*They do not have any housekeeping staff.

*They do not clean the toilets because they don't have toilet brushes.

*They do not have enough staff to keep up with housekeeping.

*Room 2 has to be mopped three times a day because the resident urinates everywhere.

A review of facility's shower/skin evaluations revealed that residents in rooms 2, 16, 19 and 10 had showers the previous day 3/23/2023. The facility's posted staffing plan indicated that Medication Technicians and caregivers are universal workers.

These findings were reviewed with Staff #3 on 3/24/2022 who was in agreement.

Plan of Correction:  Deep clean of 2-3 resident rooms per day beginning 3/25/23. Facility to add cleaning room to ADL task list. Facility to have all resident data entered into Acuity-Based Staffing Tool (ABST) by end of day 3/27/2023 and will use data to generate a staffing plan.

Based on interview and record review, it was confirmed that the facility failed to fully implement an Acuity-Based Staffing Tool (ABST). Findings include but not limited to:

During an unannounced site visit on 3/24/2023, Staff #3 (S3) stated that they did not know how the staffing plan was determined and were not aware of the facility using an ABST. S3 stated the facility census was 12 residents. Compliance Specialist (CS) interviewed Staff #5 (S5) by phone on 3/27/2023 who stated that the facility was not using an ABST but is entering the required data immediately into the Oregon Department of Human Services (ODHS) tool and will have all information entered by the end of day on 3/27/2023.

A review of the ODHS ABST tool on 3/20/2023 revealed that the facility had 14 resident names in the system. Only four residents had any data entered, and only three of those were complete. 10 of 14 had not been edited since their creation on 8/11/2022.

These findings were reviewed with S5 by phone on 3/27/2023.

Plan of Correction: Facility to enter data by end of day 3/27/2023.

Based on observation, interview, and record review, it was confirmed that the facility failed to keep all interior materials and surfaces clean. Findings include but not limited to:

During an unannounced site visit on 3/24/2023, Compliance Specialist (CS) observed  the following rooms and bedrooms which were not clean:

Room 18 had unknown stains and trash on the floor with incontinence supplies scattered around.

Room 15 had bowel movement stains in the toilet.

Room 16 had a large ball of hair on top of the shower drain.

Room 12 had bowel movement on toilet and toilet seat and the floor was dirty and did not have hand sanitizer.

Room 11 had dirty ring in the toilet, shower and debris all over the carpet.

Room 6 had a dirty ring in the toilet and sink and debris all over carpet.

Room 2 had a pervasive odor of urine, the floor was very sticky and an unknown brown material in the sink.

During separate interview, Staff #1 - Staff #2 (S1-S2) stated:

*They don't refill hand sanitizer because they don't have any.

*They clean rooms on resident shower days.

*They do not have any housekeeping staff.

*They do not clean the toilets because they don't have toilet brushes.

A review of facility's shower/skin evaluations revealed that residents in rooms 2, 16, 19 and 10 had showers the previous day 3/23/2023.

These findings were reviewed with Staff #3 on 3/24/2022 who was in agreement.

Plan of Correction: Deep clean of 2-3 resident rooms per day beginning 3/25/23. Facility to add cleaning room to ADL task list.