The findings of the change of ownership survey, conducted 07/15/24 through 07/18/24, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 Home and Community Based Services Regulations.
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. Tag numbers beginning with the letter H refer to the Home and Community Based Services 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 change of ownership survey of 07/18/24, conducted 11/12/24 through 11/15/24, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.
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. Tag numbers beginning with the letter H refer to the Home and Community Based Services 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
Situations were identified where there was a failure of the facility to comply with Department's rules that represented an immediate threat to residents' health and safety and required an immediate plan of correction in the following areas:
OAR 411-054-0090 - Fire and Life Safety; and
OAR 411-054-0020 (8) - Heating and Ventilation Systems.
The facility put immediate plans of correction in place during the survey.
Based on interview and record review, it was determined the facility failed to ensure all incidents of abuse or suspected abuse were immediately reported to the local Seniors & People with Disabilities (SPD) office and were promptly investigated for 1 of 1 sampled resident (#10) whose record was reviewed. Findings include, but are not limited to:
Resident 10 was admitted to the facility in 04/2019 with diagnoses including unspecified dementia.
A review of the resident's facility record, including progress notes dated 10/13/24 through 11/13/24, and temporary service plans was completed, and staff were interviewed. The following was identified:
* On 10/28/24, Staff 30 (CG) documented the resident ". . .was found in [his/her] bed with another resident."
There was no documented evidence this incident was promptly investigated at the time it occurred to rule out abuse, nor that it was reported to the local SPD office if abuse could not be ruled out. On 11/14/24 at 1:40 pm, Staff 1 (ED) confirmed an investigation was not promptly completed. Survey requested the facility report the incident to the local SPD office.
On 11/14/24 at 2:32 pm, verification was received of reporting the incident to the local SPD office.
The need to ensure all incidents of abuse or suspected abuse were immediately reported to the local SPD office and were promptly investigated was discussed with Staff 1, Staff 2 (Nurse), Staff 6 (RCC), Staff 26 (Director of Operations), and Staff 27 (Nurse Consultant) on 11/14/24. They acknowledged the findings.
1. All community staff are required to complete mandatory education/training on reporting and investigating abuse/suspected abuse through Oregon Care Partners by December 18, 2024.
2. All new team members that are hired moving forward will complete the mandatory education/training for reporting and investigating abuse/suspected abuse through Oregon Care Partners before they are allowed to work in the community. The clinical team will audit incidents through 24 hour clinical chart review.
3. Daily
4. Executive Director/RN
Based on observation, interview, and record review, it was determined the facility failed to refer a significant change of condition to the facility nurse for 1 of 3 sampled residents (#5) who experienced severe weight loss. Findings include, but are not limited to:
Resident 5 was admitted to the facility in 09/2022 with diagnoses including Alzheimer's disease.
The resident's 07/01/24 service plan, 05/15/24 through 07/15/24 progress notes, 07/01/24 through 07/15/24 MAR, and temporary service plans were reviewed. The following was identified:
* The service plan indicated Resident 5 should be offered "finger foods and easy to chew foods." Observations during lunch on 07/16/24 and 07/17/24 revealed the resident required his/her food to be cut up.
* The MAR indicated a nutritional shake was ordered twice a day after lunch and dinner.
Resident 5's weight records from June 2024 to July 2024 were reviewed and indicated the following:
* 06/04/24 - 144.3 pounds;
* 07/04/24 - 129.6 pounds; and
* 07/11/24 - 133.8 pounds.
Between 06/2024 and 07/2024, Resident 5 had a severe weight loss of 14.7 pounds in one month, or 10.2% of his/her total body weight. This represented a significant change of condition.
During the survey the following was observed:
* On 07/16/24 Resident 5 was served pulled pork (not cut up), cut up roasted potatoes, whole pieces of steamed vegetables, salad, a roll, water, and lemonade. S/he consumed 90% of the meal.
* On 7/17/24 Resident 5 was served mashed potatoes, cut up pieces of chicken, steamed carrots and green beans, cut up pieces of salad, a roll, water, apple juice, and an orange drink. During the meal s/he attempted to grab a tablemate's personal dessert, the caregiver intervened and brought Resident 5 four small cookies. S/he ate 40% of his/her meal. Following the lunch meal, Staff 13 (MT) provided Resident 5 a nutritional shake.
A progress note, dated 07/05/24, from Staff 8 (RCC) indicated, "Faxed [outside provider] PCP (primary care physician) regarding 5% weight change. Requesting health shakes to encourage intake. Awaiting response." While a temporary service plan was implemented by Staff 8 on 07/10/24, there was no documented evidence Resident 5's significant weight loss was referred to the facility nurse.
On 7/17/24 Resident 5 was weighed and was 139 pounds.
In an interview on 07/17/24 at 1:45 pm, Staff 2 (RN) acknowledged she had not been notified Resident 5 had a significant weight loss.
The need to ensure significant changes of condition were referred to the facility nurse was discussed with Staff 1 (ED), Staff 2 (RN), Staff 6 (RCC), and Witness 1 (Consultant RN) on 07/18/24 at 1:00 pm. They acknowledged the findings.
1. Resident #5 has had a significant change in condition assessment completed by the RN.
2. Changes in resident condition will be monitored and identified through the 24 hour chart review and follow up process and through alerts in PCC. Changes in condition will also be discussed at morning stand up. Nursing staff will be in-services on assess/evaluating weight changes on a weekly basis as needed.
3. Monthly audits will be completed by the Health and Wellness Director (HWD) to ensure that monitoring of any new weight changes have been assessed timely and interventions put in place and communicated to staff. Audit details to be reported at Quarterly QA meeting.
4. HWD to ensure compliance.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure an RN assessment had been completed for 1 of 3 sampled residents (# 5) who experienced a significant change of condition. Findings include, but are not limited to:
Resident 5 was admitted to the facility in 09/2022 with diagnoses including Alzheimer's disease.
The resident's 11/02/23 through 07/11/24 weight records, 05/15/24 through 07/15/24 progress notes, 07/01/24 service plan, and temporary service plans were reviewed.
On 06/04/24, Resident 5 weighed 144.3 pounds. On 07/04/24, the resident weighed 129.6 pounds, which was a 14.7 pound weight loss. This constituted a severe weight loss of 10.2 % in one month, requiring a facility RN assessment.
Although progress notes indicated Staff 8 (RCC) notified the physician on 07/05/24 "regarding 5% weight change" and requested "health shakes to encourage intake," there was no documented evidence there was an RN assessment which included findings, resident status, and interventions made as a result of the assessment. No further information was provided.
Resident 5's weight during the time of the survey was 139 pounds. No additional significant change had occurred.
The need to have an RN assessment for a significant change of condition was reviewed with Staff 1 (ED), Staff 2 (RN), Staff 6 (RCC), and Witness 1 (Consultant RN) on 07/18/24 at 1:00 pm. They acknowledged the findings.
1. Resident #5 had a significant change in status assessment completed by the RN.
2. Facility RN completed "Role of the RN in CBC setting" July 30th-August 1st. RN to audit weight reports weekly. Med-techs will be in-serviced on reporting weight loss/gain of +/- 3 pounds from previous weight to RN immediately via 24-hour report.
3. Weight audits will be conducted weekly x4 weeks then monthly. Audits will be addressed immediately and taken to the quarterly QA meeting for review.
4. RN is responsible for ensuring compliance.
There are no detail notes for this visit.
3. Resident 3 was admitted to the facility in 06/2021 with diagnoses including Alzheimer's Disease.
The current service plan, dated 03/07/24, noted the resident was dependent on staff for toileting activities, including changing incontinent products and assistance with perineal care.
During an ADL observation on 07/16/24 at 10:00 am, the following was noted:
*Staff 9 and Staff 11 (both PCAs) provided incontinence care for Resident 3;
*Staff 9 removed Resident 3's soiled incontinence product and placed it in the garbage can;
*Staff 9 applied barrier cream to the resident's perineal area and put on a new incontinence product using the same soiled gloves; and
*Staff 9 proceeded to open closet doors to retrieve clothing, assist with pants and a shirt, and brushed Resident 3's hair using the same soiled gloves.
The observation was discussed with Staff 1 (ED), Staff 6 (RCC), Witness 1 (Consultant RN), and Witness 2 (Regional Director of Operations Consultant) on 07/16/24 at 2:47 pm. No additional information was provided.
Based on observation and interview, it was determined the facility failed to establish and maintain infection prevention and control protocols to provide a safe and sanitary environment for 1 of 2 sampled residents (# 3) who received incontinence care from staff and multiple unsampled residents. Findings include, but are not limited to:
Observations were made during the survey to determine adherence to universal precautions for infection control.
1. On 07/15/24, at 12:03 pm, the surveyor observed Staff 12 (PCA (Personal Care Attendant)) providing lunch meal service to residents on the fourth floor. At 12:38 pm, Staff 12 was observed handling a partially eaten plate of food bare-handed. The thumb of his right hand was visible on the surface of the plate near the partially eaten food. Staff 12 set the plate in a dish bin located on a cart in the dining area. After setting the plate in the dish bin, Staff 12 proceeded to handle a second plate of partially eaten food with his right hand, picking up a used napkin with his left hand, placing the dish in the dish bin and the napkin in the trash can. Staff 12 proceeded to touch the back of a chair occupied by a resident with both hands without performing proper hand hygiene.
On 07/15/24 at 12:40 pm, the surveyor spoke with Staff 12 regarding the need to maintain infection prevention and control protocols to provide a safe, sanitary, and comfortable environment. He acknowledged the findings.
2. On 07/16/24 at 11:22 am, the surveyor entered the fourth floor kitchen through an unlocked door. Upon entry to the kitchen, an unsampled resident was observed to be alone in the kitchen, with one bare hand inside a plastic cereal dispenser. The resident took a handful of cereal from the dispenser and proceeded to eat the cereal.
At 11:23 am, the incident was brought to the attention of Staff 24 (PCA) who entered the kitchen and attended to the resident.
On 07/18/24, the need to ensure the facility consistently used universal precautions was discussed with Staff 1 (ED), Staff 2 (RN), Staff 6 (RCC), and Witness 1 (Consultant RN). They acknowledged the findings.
1. Scheduled an in-service for all staff regarding infection prevention and control protocols led by RN, infection preventionist with focus on universal precautions when feeding and assisting residents in the dining room.
Door to kitchenette on 4th floor to be locked by staff at all times. Maintenance to install automatic lock.
Door to kitchenette on 4th floor to be locked by staff at all times. Maintenance to install automatic lock.
2. Education/training will be provided to all nursing staff in regards to infection control and proper procedures for when to change soiled gloves during peri-care/soiled briefs during ADL care. Continued education/training on infection control procedures will be completed to staff annually and as needed.
Automatic lock to kitchenette door will prevent residents entering the kitchen unsupervised.
3. Maintenance to assess lock functionality quarterly. Infection control training for staff upon hire and annually. Infection preventionist or designee will audit infection control practices during dining services and ADL care monthly.
4. Executive Director.
There are no detail notes for this visit.
Based on observation, interview, and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 2 of 4 sampled residents (#s 4 and 5) whose orders were reviewed. Findings include, but are not limited to:
1. Resident 4 was admitted to the facility in 06/2024 with diagnoses including psychotic disturbance, mood disturbance, and anxiety.
Physician's orders dated 06/24/24, the 07/01/24 through 07/15/24 MAR, 06/27/24 through 07/15/24 progress notes, and an After Visit Summary electronically signed by a physician revealed the following:
* Resident 4 had a physician orders for quetiapine (for mood disturbance) 25 mg 1 tablet daily at bedtime.
* The resident was hospitalized 07/09/24 through 07/11/24. On 07/12/24, a progress note indicated, "Reviewed discharge medication list ... Changed quetiapine admin time from PM to AM."
The signed physician orders listed on the After Visit Summary, dated 07/11/24, included orders to continue quetiapine 25 mg 1 tablet at bedtime. Additionally, Resident 5 was to take quetiapine 25 mg 0.5 tablets once daily in the morning.
The MAR revealed Resident 4 stopped receiving the bedtime dose of quetiapine effective 7/11/24 and on 7/12/24 began receiving the morning dose of quetiapine 25 mg 0.5 tablet daily.
In an interview on 07/17/24 at 3:40 pm, Staff 8 (RCC) acknowledged the new orders were interpreted incorrectly and the bedtime dose of quetiapine should not have been discontinued. No further documentation was provided. She confirmed that Resident 4 would be receiving the bedtime dose until the physician provided further orders.
The need to ensure the facility administered all medications per physician orders was discussed with Staff 1 (ED), Staff 2 (RN), Staff 8 (RCC), and Witness 1 (Consultant RN) on 07/18/24 at 1:00 pm. They acknowledged the findings. The surveyor confirmed with Staff 1 that Resident 4 received the bedtime dose of quetiapine on 07/17/24.
2. Resident 5 was admitted to the facility in 09/2022 with diagnoses including Alzheimer's disease.
Resident 5's 07/01/24 through 07/15/24 MAR and physician orders were reviewed and revealed the following:
a. Resident 5 had a physician order dated 06/19/24 for Calcitonin (osteoporosis) nasal spray, "1 spray by nasal route daily."
The MAR revealed instructions to the staff were to "instill 1 spray in each nostril every day" and additional instructions "alternate nostrils daily." On 7/08/24 and 7/15/24 the MAR indicated staff administered to both the left and right nostril.
On 07/17/24 at 1:45 pm, during an interview with Staff 2 (RN), she indicated Resident 5 should not be receiving the medication in both nostrils daily, and the MTs should be alternating the spray into the left and right nostril daily. She acknowledged the conflicting instructions on the MAR and stated she would update them.
b. Resident 5 had a physician order for a multivitamin (supplement) daily. On both 07/08/24 and 07/15/24 the medication was recorded as unavailable. Between those same dates the medication was documented as administered on six occasions.
During an interview on 07/17/24 with Staff 13 (MT), she confirmed the medication was available during those dates in a bottle located in the third drawer of the medication cart, separate from the medication in bubble packs. She revealed that sometimes the MT's would report a medication as not available when not found among the bubble packs, despite the medication being in another drawer. Staff 13 showed this surveyor the medication bottle, which was marked as opened on 05/28/24.
The need to ensure the facility administered all medications per physician orders was discussed with Staff 1 (ED), Staff 2 (RN), Staff 8 (RCC), and Witness 1 (Consultant RN) on 07/18/24 at 1:00 pm. They acknowledged the findings.
1. Resident 4 - Quetiapine order was clarified and corrected in the MAR.
Resident 5 - RN spoke with pharmacy and nose spray instructions updated in the MAR.
Multivitamin located in med cart.
2. RCC, ED, and RN to ensure all orders are accurate with clear instructions for med techs via clinical chart review daily.
Med techs to be in-serviced on proper storage of medications, where backups are stored, and re-ordering medications timely, as well as reporting to supervisor if any medications cannot be located so management can properly follow up and investigate.
3. Daily via clinical chart review.
4. RN, RCC, ED.
There are no detail notes for this visit.
Based on observation, interview, and record review, it was determined the facility failed to have a sufficient number of caregiving staff to meet the 24-hour scheduled and unscheduled needs of residents. Findings include, but are not limited to:
At the time of the survey, the MCC had 31 residents. The facility was a four-story building, with residents occupying the first and fourth floors. Each floor was a separate, secured unit.
Multiple interviews with staff conducted on 11/12/24 revealed the following:
* Staff identified five residents on the first floor who required two-person assistance for transfers and/or ADL care, including the use of a mechanical lift; and
* Staff identified eight residents who required 1:1 feeding assistance.
The facility's posted staffing plan designated one CG on the first and fourth floors and one MT between the first and fourth floors for the NOC shift. Considering resident acuity, facility structural design, and the number of residents requiring two-person transfers, as listed above, this was not an adequate number of floor staff in case of an actual emergency evacuation. In addition, the NOC shift failed to have a minimum of two direct care staff scheduled and available at all times whenever a resident required the assistance of two direct care staff for scheduled and unscheduled needs.
On 11/12/24 at 3:14 pm, the above findings were discussed with Staff 1 (Executive Director) and Staff 6 (Residential Care Coordinator). The survey team requested the facility schedule an additional direct care staff for NOC shift to ensure the facility meets the evacuation level and the minimum of two direct care staff scheduled and available for residents requiring the assistance of two caregivers.
On 11/13/24, the facility provided the survey team with a schedule dated 11/13/24 through 11/30/24 that showed two CGs were scheduled on first floor and one CG on the fourth floor and one MT between the floors for NOC shift.
On 11/15/24, the need to ensure the facility provided a sufficient number of direct care staff to meet the 24-hour scheduled and unscheduled needs of residents was discussed with Staff 1, Staff 2 (Nurse), Staff 6, and Staff 27 (Nurse Consultant).
1. An additional caregiver has been added on the schedule for NOC shift indefinitely.
2. ED, RN, RCC, will audit ABST and adjust staffing accordingly always ensuring that NOC shift has the additional person necessary to assist with any fire/life safety emergencies/evacuations.
3. Monthly and PRN with significant changes, new admissions, etc.
4. Executive Direcctor, RN, Resident Care Coordinator.
Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted according to the Oregon Fire Code (OFC) and failed to provide fire and life safety instruction to staff on alternate months. Findings include, but are not limited to:
On 07/18/24, fire and life safety records dated between 01/2024 and 07/2024, were reviewed. Fire drill records lacked documentation of the following required elements:
* Problems encountered, comments relating to residents who resisted or failed to participate in the drills;
* Evacuation time-period needed; and
* The number of occupants evacuated.
The facility provided no documented evidence staff were given fire and life safety training on alternate months.
On 07/18/24 at 12:00 pm, the need to ensure fire drills were conducted according to the OFC and to provide fire and life safety instruction to staff on alternating months was discussed with Staff 1 (ED) and Staff 4 (Maintenance Director). They acknowledged the findings.
1. Fire drills and staff trainings have been set on an alternating schedule each month for the remainder of the year. Fire drill documentation form has been updated to include all required elements.
2. ED to audit documentation monthly and correct as needed.
3. Monthly
4. ED, Maintenance Director
Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted in accordance with the Oregon Fire Code, fire and life safety instruction was provided to staff on alternate months, and that resident evacuation needs were met. The fourth floor had multiple residents who required assistive devices and assistance of staff for mobility, and no plan was in place on how to assist the residents in the event of a fire. This placed the residents at risk and constituted an immediate threat to the residents' health and safety. This is a repeat citation. Findings include, but are not limited to:
a. Fire and life safety records dated 09/2024 through 10/2024 were reviewed. The documentation showed no drills were conducted which simulated fires on the fourth floor, and the escape route was not identified.
During an interview on 11/13/24 at 9:35 am, Staff 4 (Maintenance Director), confirmed there was not a plan in place to assist the residents on the fourth floor. He stated he had a phone call with the Fire Authority on how to best assist residents who were the least mobile, and the plan was to move them "as far away from the fire behind a fire door and wait on the fire department for rescue." However, there was no documented evidence of approval for this plan by the Fire Marshal. Staff 4 also confirmed he was unaware of any equipment such as transfers blankets in the facility which would assist staff in evacuating residents from the fourth floor if they were unable to ambulate down the stairs. Staff 4 further confirmed he was not sure when the last full evacuation the facility had been completed.
Service plans for Resident 7 and Resident 8, who lived on the fourth floor, were reviewed for assistance level needed to evacuate the facility.
Resident 7 moved into the facility in 07/2024 and required use of a walker for ambulation. The resident's service plan, dated, 10/12/24, stated Resident 7 was "unable to exit building without total assistance" and "mobile with a walker/cane" in the mobility section. The emergency evacuation ability stated, "provide cues and direction for [Resident 8] during an emergency evacuation."
Resident 8 moved into the facility in 05/2020 and required use of walker for ambulation and was on continuous oxygen. The resident's service plan, dated 10/11/24, stated Resident 8 was "unable to exit building without total assistance" and "unable to use stairs without assistance" in the mobility section. The emergency evacuation ability stated Resident 8 "requires assistance with evacuation, she will use her 2WW [two wheeled walker] but needs cueing and direction from staff."
Multiple staff were interviewed on day and swing shifts. All staff indicated they did not know how they would get residents who could not ambulate independently down the stairs from the fourth floor to the main level. Staff identified ten residents who lived on the fourth floor that would not be able to ambulate down the stairs independently in case of a fire and who relied on a walker as an assistive device.
During interviews on 11/13/24 at 10:40 am, Staff 1 (ED), Staff 2 (Nurse), Staff 6 (RCC), and Staff 27 (Nurse Consultant) stated they were unaware of a current plan for evacuating residents who were unable to ambulate independently from the fourth floor. In the event of a fire, they had instructed staff to evacuate the most mobile residents first, and any residents who could not be evacuated should be moved behind a fire door until the fire department arrived. On 11/13/24, the survey team reviewed with Staff 1, Staff 2, Staff 6, and Staff 27 that staff must provide fire evacuation assistance to residents from the building to a designated point of safety.
When asked how many staff were available on each shift to help evacuate residents, Staff 1 and Staff 5 stated they tried to staff a total of three care staff (one MT and two personal care attendants) on night shift. During the acuity interview on 11/12/24 at 9:45 am, Staff 2 had confirmed there were up to five residents who required a mechanical lift or two staff members to assist them for transfers on the first floor.
This constituted a significant risk to resident health and safety and required an immediate plan of correction to ensure residents on the fourth floor could be safely and effectively evacuated to the designated point of safety in case of a fire.
The facility submitted a plan of correction to the survey team which included:
* Evaluating residents for their ability to evacuate and thereby identifying residents who would require assistance;
* Updated the residents' service plans to include the ability, time, and level of assistance required from staff to evacuate;
* Immediately obtaining a mechanical stair climber and a fire safety blanket/transfer sling which could be used to evacuate non-ambulatory residents down the stairs and educating staff on all shifts on correct usage; and
* Ensuring no less than four staff were available on all shifts, including the night shift.
An immediate plan of correction was requested on 11/13/24 at 11:20 am. The facility provided a plan of correction on 11/13/24 at 1:01 pm, prior to survey exit. The immediate risk was addressed, however the facility will need to evaluate the overall system failures associated with the licensing violation.
Refer to C 360.
b. Fire and life safety records, dated 09/2024 through 10/2024, showed fire drill documentation was lacking in the following areas:
* Escape route used;
* Problems encountered;
* Evidence of alternate routes used;
* Evacuation time-period needed;
* Staff members on duty and participating; and
* The number of occupants evacuated.
Additionally, the records reviewed did not show fire and life safety training was provided to staff on alternating months from the fire drills.
The need to ensure all required components were addressed and documented for each fire drill and that drills were conducted on alternating months from fire and life safety training was discussed with Staff 1, Staff 2, Staff 6, Staff 26 (Director of Operations), and Staff 27 on 11/13/24 at 1:10 pm. They acknowledged the findings.
1. Fire drills will be conducted every other month with evacuations of all occupied floors and documentation including * Escape route used; * Problems encountered; * Evidence of alternate routes used; * Evacuation time-period needed; * Staff members on duty and participating; and * The number of occupants evacuated.
Staff training on fire and life safety will be held on alternating months. All staff including Maintenance Director will be trained on fire procedures and escape routes used. Resident 7 & 8 evacuated via the stairs with assistance from staff in mock evacuation, as well as all other residents willing to participte. Time and level of assistance needed to evacuate has been documented. Facility has fire chair and sling.
2. Maintenance Director has been given a fire and life safety schedule of fire drills and training dates.
3. Monthly
4. Executive Director/Maintenance Director.
Based on observation, interview, and record review, it was determined the facility failed to ensure their change of ownership survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:
Refer to C 420, C 510, C 513, and H 1518.
1. A new POC has been written and to be implemented and followed.
2. POC will be addressed in a timely manner.
3. Daily.
4. Executive Director
Based on observation and interview, it was determined the facility failed to ensure all poisons, chemicals, and other toxic materials were secured in locked storage, and failed to ensure facility grounds were free of litter and refuse and garbage was stored in covered refuse containers. Findings include, but are not limited to:
The facility was toured on 07/16/24 at 9:30 am and the following was observed:
a. First floor:
* Disinfectant cleaner, personal care products, boxes of lancets (containing a blade/needle to puncture skin), and a specimen cup with dark-colored contents located in an unlocked storage room;
* Peroxide Multi Surface Cleaner and Disinfectant stored in an unlocked cabinet under the sink in the resident dining room; and
* Personal care products stored in an unlocked cabinet above the microwave in the resident dining room.
b. Fourth floor kitchenette:
* Cleaning chemicals stored in an unlocked cabinet under the sink.
On 07/16/24 at 11:50 am, the facility was directed to ensure the identified unsecured toxic materials were stored in a secured location.
On 7/17/24 at 8:15 am, the first-floor storage room was again observed to be unlocked with the items listed above unsecured.
c. Building Exterior:
* Two dumpsters containing large garbage bags were observed to be uncovered; and
* Litter and refuse was on the ground near the dumpsters.
The need to ensure all poisons, chemicals, and other toxic materials were stored in locked storage, and to ensure the grounds were free of litter and refuse and refuse containers were covered, was discussed with Staff 1 (ED) and Staff 4 (Maintenance Director) on 07/17/24. They acknowledged the findings.
1. First floor - all cleaners/chemicals, personal care items removed from dining room and locked in secure location. Install automatic lock for storage room on first floor.
Fourth floor kitchenette - Automatic lock to be installed on kitchenette door. All cleaning chemicals relocated to linen closet on fourth floor with automatic lock is already installed.
Litter and refuse to be cleared from outdoor dumpster area. Dumpters to be covered at all times when not in use to promote proper pest control.
2. Maintenance Director to audit lock function quarterly. Staff to be in-serviced on the need to ensure all poisons, chemicals, and other toxic materials are locked and stored in appropriate locations and out of reach from residents. Maintenance Director to walk the exterior building daily.
3. Quarterly and as needed.
4. ED, Maintenance Director
Based on observation and interview, it was determined the facility failed to ensure all poisons, chemicals, and other toxic materials were secured in locked storage, and failed to ensure facility grounds were free of litter and refuse and garbage was stored in covered refuse containers. This is a repeat citation. Findings include, but are not limited to:
The facility was toured on 11/12/24 at 11:10 am and the following was observed:
* Personal care products that contained potentially toxic material stored out on shelves and countertops were not in locked cabinets in resident bathrooms on the first and fourth floors.
The need to ensure all poisons, chemicals, and other toxic materials were stored in locked storage, and to ensure all exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways were made of hard, smooth material, were accessible, and maintained in good repair, was discussed with Staff 1 (ED), Staff 4 (Maintenance Director), and Staff 26 (Director of Operations) on 11/14/24. They acknowledged the findings.
1. All chemicals or other toxic materials secured in locked storage rooms on first and fourth floor. Facility will plan to purchase shower caddys for each resident's personal items such as shampoo to be stored in activities office outside of the resident unit.
2. Prevenative maintenance schedule.
3. Daily with environmental walk throughs.
4. Executive Director/Maintenance Director.
Based on observation and interview, it was determined the facility failed to keep all interior materials and surfaces clean and in good repair. Findings include, but are not limited to:
The facility's interior was toured on 07/16/24 at 9:35 am and the following was observed to need cleaning and/or repair:
a. First-floor interior:
* Walls had gouges and exposed drywall/missing paint;
* Ceiling vents had a build-up of dust;
* Light fixtures had light bulbs out;
* Ceiling light covers were missing in the storage room;
* Furniture chair legs in the corridor outside the dining room were gouged and had exposed wood;
* Ceiling tiles in the storage room, dining room, and near the exit had staining; and
* Exit door had damage to the door and door frame.
b. Fourth-floor interior:
* Walls had gouges and exposed drywall/missing paint;
* Ceiling vents had a build-up of dust;
* Light fixtures had light bulbs out;
* Flooring in the resident corridor had peeling/missing pieces;
* Room number outside of room 409 was missing;
* Table in the resident corridor had a worn finish/exposed wood; and
* Baseboard at the end of the corridor was pulled away from the wall.
The facility was toured with Staff 1 (Executive Director) and Staff 4 (Maintenance Director) on 07/17/24 at 10:05 am. They acknowledged the areas needing cleaning and/or repair.
1. First floor - Maintenance Director will repair/address/clean wall gouges, exposed paint/drywall, ceiling vents, light fixtures, ceiling tiles, damaged doors, and remove damaged furniture.
Fourth floor - Maitenance Director will repair corridor, baseboards, replace tables with exposed wood, and refer to #1.
2. Create a preventative maintenance schedule.
3. Daily environmental walk throughs.
4. Maintenance Director, ED.
Based on observations and interviews, it was determined the facility failed to keep all interior materials and surfaces and equipment clean and in good repair, including all equipment related to heating elements necessary for the health, safety, and comfort of the resident. This is a repeat citation. Findings include, but are not limited to:
The facility's interior was toured on 11/12/24 at 11:10 am and the following was observed to need cleaning and/or repair:
a. First-floor interior:
* Walls had gouges and exposed drywall/missing paint;
* Ceiling vents had a build-up of dust;
* Light fixtures had light bulbs out;
* Furniture chair legs in the corridor outside the dining room were gouged and had exposed wood;
* Ceiling tiles in the storage room, dining room, and near the exit had staining;
* Exit door had damage to the door and door frame;
* Room 102 had multiple cracks in the ceiling; and
* Room 109 was missing flooring near the wardrobe.
b. Fourth-floor interior:
* Walls had gouges and exposed drywall/missing paint;
* Ceiling vents had a build-up of dust;
* Light fixtures had light bulbs out;
* Flooring in the resident corridor had peeling/missing pieces;
* Room number outside of room 409 was missing;
* Table in the resident corridor had a worn finish/exposed wood;
* Baseboard at the end of the corridor was pulled away from the wall;
* Room 413 had a hole in the bathroom ceiling; and
* Room 416 had pieces of flooring missing.
c. Several baseboard heaters in resident rooms were damaged, separating from the wall, and exposed inner wires and/or pipes on both floors.
On 11/15/24 between 9:52 am and 10:17 am, the baseboard heaters in rooms 105 and 409 were observed to be in disrepair with exposed pipes and/or wires.
Observations identified base board heaters in multiple resident units were damaged. The heaters were located where residents could come into incidental contact, and combustible materials were placed against the heating elements that posed a risk to the residents.
The facility was toured with Staff 1 (Executive Director), Staff 4 (Maintenance Director), and Staff 26 (Director of Operations) on 11/14/24 at 12:10 pm. They acknowledged the areas needing cleaning and/or repair.
Refer to C 540.
1. Maintenance Director will be given a list of building interior areas to be address/cleaned/repaired with timeline of completion such as wall gouges and esposed dry wall on first floor, replacing light bulbs, repairing ceiling in room 102 that has cracks and flooring in room 109 Fourth floor light fixtures will be replaced with working bulbs, repair bathroom ceiling in room 413, and the flooring in room 416. We have contacted several outside providers to obtain quotes to work on the boiler and temperature regulation. Staff have been temping baseboard heaters every hour and adjusting accordingly. Baseboard heaters in room 105 and 409 repaired.
2. Will identify areas needing attention through interior environmental walk throughs as well as initiated work order requests from community team members.
3. Daily.
4. Executive Director/Maintenance Director.
Based on observation and interview, it was determined the facility failed to ensure washing machines had a minimum rinse temperature of 140 degrees Fahrenheit or a chemical disinfectant was used when washing soiled linens and soiled clothing. Findings include, but are not limited to:
The facility laundry room was observed on 07/16/24. Two commercial washing machines in the laundry room had no indicator of the water temperature. The laundry detergent observed next to the washing machines did not contain a chemical disinfectant.
In an interview on 07/17/24 at 8:45 am, Staff 23 (Housekeeper) confirmed the washing machines and laundry detergent were used to wash resident linens and clothing soiled with urine.
In an interview on 07/17/24 at 9:00 am, Staff 4 (Maintenance Director) stated the water temperatures of the washing machines were measured at 110 degrees F. Staff 4 acknowledged the water rinse temperature should be at a minimum of 140 degrees F.
The need to ensure washing machines had a minimum rinse temperature of 140 degrees or a chemical disinfectant was used when washing soiled linens and soiled clothing was discussed with Staff 4 and Staff 1 (ED) on 07/17/24 and 07/18/24. They acknowledged the findings.
1. Chemical disinfectant purchased for washers that do not reach a minimum temperature of 140 degrees when washing soiled linens.
2. Housekeeping/Laundry staff in-serviced on the requirements and proper use of the chemical disinfectant. Maintenance Director to order chemical disinfectant as needed and ensure supply is always on hand.
3. Quartly.
4. Maintenance Director.
There are no detail notes for this visit.
Based on observations and interviews, it was determined the facility failed to keep all equipment in good repair, and associated heating elements did not exceed 120 degrees Fahrenheit when installed in locations subject to incidental contact by residents or with combustible material. The facility was using baseboard heaters in resident rooms. Several baseboard heaters were in disrepair and exceeded 120 degrees F, which constituted an immediate threat to residents' health and safety. Findings include, but are not limited to:
During an interview with Staff 4 (Maintenance Director) on 11/15/24 at 9:45 am, Staff 4 reported that to keep the temperature in the building between 67-71 degrees F, the boiler pipes had to be heated between 165-200 degrees F.
On 11/15/24 between 9:52 am and 10:17 am, the baseboard heaters in rooms 105 and 409 were observed to be in disrepair with exposed pipes and/or wires. Temperatures measured with the surveyor's digital thermometer showed that both baseboard heaters exceeded 120 degrees F.
At 1:19 pm, resident room baseboard heaters were measured with Staff 4 (Maintenance Director) using the facility's infrared thermometer.
Baseboard heaters in the following resident rooms: 102 B, 103, 111, 123, and 413 exceeded 120 degrees F.
Baseboard heaters in the following resident rooms: 402 A/B, 410, 411, 412, 414 and 415 failed to maintain 110 degrees F.
Observations identified base board heaters in resident units were damaged. The heaters were located where residents could come into incidental contact, and combustible materials were placed against the heating elements that posed a risk to the residents.
An immediate plan of correction was requested on 11/15/24 at 11:48 am. The facility provided a plan of correction on 11/15/24 at 3:47 pm, prior to survey exit. The immediate risk was addressed, however the facility will need to evaluate the overall system(s) failure(s) associated with the licensing violation.
On 11/15/24, the findings were reviewed with Staff 1, Staff 2 (Nurse), Staff 6 (Resident Care Coordinator), and Staff 27 (Nurse Consultant). They acknowledged the findings.
1. Will consult with heating specialist to aquire quotes for repairs to boiler/heaters and reccommendations on heat regulation.
2. Repairs will be made to existing system.
3. Monthly temperature audits to be done following repair to ensure working order.
4. Executive Director/Maintenance Director.
Based on observation and interview, it was determined the facility failed to ensure privacy and dignity related to information being accessible in common areas of the facility. Findings include, but are not limited to:
During the survey on 07/15/24 and 07/16/24, resident service plans were observed in a binder on a table in the dining room accessible to anyone in the area on the first and fourth floors. In addition, resident meal percentage intake was being documented on a white board in the first floor dining room for public viewing. The accessibility to service plans and meal intake jeopardized residents' rights to privacy and dignity.
The observation was reviewed with Staff 1 (ED), Staff 6 (RCC) , Witness 1 (Consultant RN), and Witness 2 (Regional Director of Operations, Consultant) on 07/16/24 at 2:47 pm. No additional information was provided.
1. Service plan binders were removed from common areas. Fourth floor service plans to be kept in a cabinet in the kitchenette, which will be installed with auto-locking door. Facility will purchase locking file cabinet with key access for service plans on the first floor. Meal monitoring white boards have been removed from both floors.
2. Staff will be in-serviced on the importance of residents' rights to privacy and dignity, as well as instructed on where service plans are located. Facility will create a tool for caregivers to track residents' intake, to be given to the med techs for documentation after each shift. This will be kept in a binder in the same location as the service plans on both floors.
3.Quarterly
4. RCC.
There are no detail notes for this visit.
Based on observation, interview, and record review, it was determined the facility failed to provide each individual privacy in his or her own unit for 3 of 3 sampled residents (#s 1, 3, and 5). Findings include, but are not limited to:
During the survey on 07/15/24 and 07/16/24, Residents 1, 3, and 5 were observed in their units with doors open, creating a lack of privacy.
Interviews with care staff indicated the residents' doors were left open to conduct frequent safety checks.
Review of Residents 1, 3, and 5's service plans did not indicate the residents' preference for their doors to be left open.
Resident unit doors being open all the time jeopardized residents' rights to privacy and dignity.
The observation was reviewed with Staff 1 (ED), Staff 2 (RN), Staff 6 (RCC) , Witness 1 (Consultant RN), and Witness 2 (Regional Director of Operations, Consultant) on 07/18/24. No additional information was provided.
1. Resident #1, #3, #5 were interviewed regarding their preference of keeping apartment door open/closed. RCC or designee to follow up with all other residents regarding preferences regarding their doors being open/closed.
2. Information gathered from #1 will be indicated in each individual resident's service plan for staff to review and implement based on preferences.
3. Quaterly service plan reviews.
4. RCC.
There are no detail notes for this visit.
Based on observation and interview, it was determined the facility failed to ensure the individual and only appropriate staff had a key to access the unit for multiple unsampled residents who resided on the fourth floor. Findings include, but are not limited to:
During an interview on 07/17/24 at 12:15 pm with Staff 15 Personal Care Attendant (PCA), she indicated there were a small number of residents who had keys to their rooms but she believed the keys could be used on any of the resident unit doors.
An observation on 07/17/24 at 2:15 PM revealed the key to Resident 4's unit could unlock the door to an unoccupied unit on the fourth floor, where Resident 4 resided.
In an 07/18/24 interview at 10:21 am, Staff 21 (PCA) indicated at least one resident had a master key that could be used on any of the resident unit doors.
The need to ensure the individual and only appropriate staff had a key to access their unit was discussed with Staff 1 (ED), Staff 6 (RCC), and Witness 2 (Regional Director of Operations Consultant) on 07/18/24. No additional information was provided.
1. All of the locks to the units to be replaced with the individual and only appropriate staff having a key to access the unit.
2. Refer to #1.
3. Quarterly and upon new admissions.
4. Executive Director, Maintenance Director.
Based on observation, record review, and interview, it was determined the facility failed to ensure residents who lived in the facility were provided a key to their units. This is a repeat citation. Findings include, but are not limited to:
Review of records for Residents 6, 7, and 8 revealed no documented evidence the residents had been provided keys to their rooms or had been evaluated for the ability to manage keys to their rooms.
During the survey on 11/12/24 through 11/15/24, observations and interviews with residents and staff confirmed residents did not have keys to their units.
The need to ensure all residents were provided keys to their units was discussed with Staff 1 (Executive Director) on 11/15/24. She acknowledged the findings.
1. It will be documented that every resident was offered a key to their apartment. If they decline, the POA/guardian will be offered a key. If POA/guardian declines, individual keys will be hung in resident's apartment.
2. Assessments have been updated to include this information in service plans and upon new admissions.
3. Quarterly through service plan reviews and/or as needed.
4. Executive Director/Resident Care Coordinator.
Based on observation, 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 C420, C510, C513, and C530.
1. Refer to C420, C510, C513, and C530.
2. Audit plan of correction for above tags to ensure tasks are followed through/corrected.
3. Weekly.
4. Executive Director.
Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:
Refer to C 231, C 360, C 420, C 510, C 513, and C 540.
See POC for C231, C360, C420, C510, C513 & C540.
Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff (#s 16, 17, 18, and 19) completed the required dementia training and demonstrated competencies in all required areas within 30 days of hire. Findings include but are not limited to:
Training records were reviewed with Staff 3 (Business Office Manager) on 07/17/24.
a. There was no documented evidence Staff 16 Personal Care Attendant (PCA), hired 02/26/24, Staff 17 (MT), hired 03/18/24, Staff 18 (PCA), hired 04/02/24, and Staff 19 (PCA), hired 06/13/24, completed the required additional dementia care pre-service training topics, including:
* Environmental factors that are important to a resident's well-being (e.g. staff interactions, lighting, room temperature, noise, etc.);
* Family support and the role the family may have in the care of the resident;
* How to recognize behaviors that indicate a change in the resident's condition and report behaviors that require on-going assessment;
* How to provide personal care to a resident with dementia, including an orientation to the resident's service plan; and
* Use of supportive devices with restraining qualities in memory care communities.
b. There was no documented evidence Staff 16 and Staff 17 demonstrated competency in their job duties within 30 days of hire in the following areas:
* Role of service plans in providing individualized care;
* Providing assistance with ADLs;
* Changes associated with normal aging;
* Identification, documentation and reporting of changes of condition;
* Conditions that require assessment, treatment, observation and reporting; and
* General food safety, serving and sanitation.
c. There was no documented evidence Staff 17 (MT) demonstrated competency in their job duties of medication pass and treatments. On 07/17/24 survey requested medication and treatment administration demonstration for Staff 17 be completed prior to survey exit. On 07/17/24 at 2:10 pm, Staff 17 verified he demonstrated competency with medication pass and treatments within 30 days of his hire date and prior to administering medication and treatments.
d. There was no documented evidence Staff 18 demonstrated competency in their job duties within 30 days of hire in the following areas:
* Role of service plans in providing individualized care; and
* General food safety, serving and sanitation.
e. There was no documented evidence Staff 19 demonstrated competency in their job duties within 30 days of hire in the following areas:
* Providing assistance with ADLs;
* Changes associated with normal aging;
* Identification, documentation and reporting of changes of condition; and
* Conditions that require assessment, treatment, observation and reporting.
The need to ensure newly hired staff completed the required pre-service dementia care training and demonstrated competency in all required areas within 30 days of hire was discussed with Staff 1 (Executive Director) and Staff 3 (Business Office Manager) on 07/18/24. They acknowledged the findings.
1. Staff 16, 17, 18, and 19 to complete the required additional dementia care pre-service training topics as well as demonstrated competency.
2. Ensure all newly hired staff complete the required pre-service dementia care training and demonstrated compentency in all required areas within 30 days of hire. Created a training checklist of required trainings to be used as a tracking tool.
3. Quarterly employee file audits and upon all newly hired employees.
4. Business Office Manager and ED.
There are no detail notes for this visit.
Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:
Refer to C270, C280, C295, and C303.
1. Refer to C270, C280, C295, and C303.
2. Audit plan of correction for above tags to ensure tasks are followed through/corrected.
3. Weekly.
4. Executive Director.
There are no detail notes for this visit.