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Rampant safety violations at Portland nursing home where at least 14 residents may be dead from COVID-19

DHS officials saw numerous safety violations, including but not limited to staff not washing their hands and being limited to using one mask per shift.

PORTLAND, Ore. — The Oregon Department of Human Services filed a scathing review of the conditions at a Southeast Portland nursing home where at least nine residents, and possibly more than 14, have died from COVID-19 during the pandemic.

State officials say there have been 50 confirmed cases of COVID-19 at Healthcare at Foster Creek, located at 6003 SE 136th Avenue. As of Tuesday, nine residents had died from complications related to COVID-19, according to data from the Oregon Health Authority. On Wednesday, the home reported to the Oregon Department of Human Services that at least 14 resident deaths could be attributed to the coronavirus.

DHS, as part of a multi-agency state team, visited the nursing home from April 10-12. During those visits, DHS officials saw numerous safety violations, including but not limited to staff not washing their hands, staff being limited to using one mask per shift, staff not being screened before entering the facility, no overnight housekeeping, and care plans not being updated for at least two residents who had tested positive for the coronavirus.

Staff at the home told DHS officials they received no training regarding COVID-19 infection and preventing the spread of the virus.

“DHS finds that the residents of the facility are at risk of immediate jeopardy. That is because the facility’s failure to comply with DHS’ rules has caused or is likely to cause serious injury, serious harm, serious impairment, or death to a resident or residents,” officials concluded.

Click here to read the full list of violations

Based on what officials saw and learned during the visits, DHS determined Healthcare at Foster Creek violated the following rules:

Comprehensive assessment and care plan

  • Failing to assess respiratory changes.
  • Failing to update COVID-19 diagnosis.
  • Failing to update resident care plans.

Staffing of nursing services

  • Failing to provide sufficient staff to prevent staff from going between units in order to prevent the spread of COVID-19.

Notification of condition changes

  • Failing to notify residents’ physician(s) of change in condition that warranted medical or nursing intervention.

Problem resolution and preventative care

  • Failing to prevent the spread of COVID-19.

Infection control and universal precautions

  • Failing to appropriately use personal protective equipment to prevent the spread of COVID-19.

As a result of the violations, DHS put in place new conditions for the nursing home’s continued operation during the pandemic. Those conditions include further safety restrictions, such as not allowing any residents to be admitted or re-admitted to the facility, eliminating communal dining and group activities and relocating residents to private rooms if possible. Staff must also be trained immediately on COVID-19 infection control policing.

DHS also took the following steps on Thursday.

  • Securing a management consultant to oversee infection control improvements and assist with operations at the facility.
  • Dedicating two DHS registered nurse surveyors to monitor the facility on site and work with the consultant, facility management and staff to ensure residents’ needs are met.
  • Requiring the submission of daily staffing reports from the home.

The new conditions placed on Healthcare at Foster Creek will only be lifted when the Oregon Health Authority or Centers for Disease Control and Prevention report there are no suspected or confirmed COVID-19 cases.

“With this additional oversight, the state can better work with facility management to take additional measures to slow the spread of COVID-19 infections. We share a deep concern for the residents and staff impacted by the virus,” said Mike McCormick, interim director of the DHS Office of Aging and People with Disabilities, which licenses long-term care facilities.

There are currently 24 long-term care facilities in Oregon reporting confirmed COVID-19 cases involving staff or residents. More than 50 other facilities are awaiting results for tests pending from staff or residents.

The Oregon Health Authority reports there have been 1,736 coronavirus cases in Oregon, including 64 people who have died.

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