The findings of the Change of Ownership survey, conducted 03/04/24 through 03/07/24, 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 004 Home and Community Based Services Regulations.

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 03/07/24, conducted 11/18/24 through 11/20/24, 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 004 Home and Community Based Services Regulations.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:

Observations of the facility kitchen, food storage areas, food preparation, and food service on 03/04/24 and 03/05/24 revealed the following areas in need of cleaning or repair:

* The faucet located above the three-compartment sink in the dish area and the faucet located to the left of the stove was constantly dripping;

* The wall located to the right of the stove had exposed dry wall present, thus making it an uncleanable surface; and

* The heating unit, directly above the food on the steam table, was rusted.    

The need to ensure the kitchen was maintained in accordance with the Food Sanitation Rules was discussed with Staff 1 (ED) and Staff 6 (Director of Dining Services) on 03/05/24. They acknowledged the findings.

2 faucets were ordered 3/18/2024 and will be installed upon arrival from HD supply Installation will be completed prior to 5/6/2024

Exposed drywall was covered with FRP 3/7/2024

Heating unit deep cleaned with stainless steal cleaner no residual rust after deep clean 3/19/2024

Dietary Director will do weekly rounds to ensure kitchen is operating correctly with no maintenance issues. And input any mainteance issues into the TELS system

Dietary Director will ensure all needed repairs are done in a timely fashion. ED will monitor TELS to make sure repairs are in process and completed as well as weekly maintenance rounds in the kitchen

4. Resident 1 was admitted to the facility in 05/2021 with diagnoses including atrial fibrillation and flutter, and polyneuropathy.

Observations of the resident, interviews with staff and Resident 1, review of the resident's current service plan dated 01/16/24, and review of the progress notes dated 12/01/23 through 03/03/24, showed the service plan was not reflective and did not provide clear direction to staff in the following areas:

* Evacuation assistance;

* Recent losses;  

* Self-administering medications;

* Preference of where to receive medications;  

* Preference of where s/he eats meals;

* Which day the resident's apartment was cleaned;

* Clothing choices including giving the resident time to decide;

* Use of a four wheeled walker;

* Assistance with all transfers;

* Two caregivers for assistance;

* Ensuring the call pendent was within reach at all times;

* Assistance with a sponge bath;

* Scheduled set up assistance for grooming, hygiene, and oral care;

* Staff assistance with laundry including personal detergent used;

* Weight loss interventions; and

* Behavior interventions.

The need to ensure service plans were reflective of resident needs and included clear direction to staff was discussed with Staff 1 (ED) and Staff 2 (RN) on 03/07/24. They acknowledged the findings.

5. Resident 4 was admitted to the facility in 04/2019 with diagnoses including chronic obstructive pulmonary disease and dependence on supplemental oxygen.

Observations of the resident, interviews with staff and Resident 4, review of the resident's current service plan dated 02/14/24, and review of the progress notes dated 02/01/24 through 03/04/24, showed the service plan was not reflective and did not provide clear direction to staff in the following areas:

* Evacuation assistance;

* Preference to have apartment door propped open;

* PRN assistance to change oxygen tubing;

* Smoking;

* Behaviors and interventions; and

* Where the resident preferred to take his/her medications.

The need to ensure service plans were reflective of resident needs and included clear direction to staff was discussed with Staff 1 (ED) and Staff 2 (RN) on 03/07/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs and provided clear directions to staff regarding the delivery of services for 5 of 6 sampled residents (1, 2, 3, 4 and 5) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 12/2022 with diagnoses including chronic obstructive pulmonary disease and recurrence of major depressive disorder.

Observations of the resident, interviews with staff between 03/05/24 and 03/07/24, and review of the resident's current service plan dated 01/24/24 and progress notes dated 12/04/23 through 03/04/24 showed the service plan was not reflective and did not provide clear direction to staff in the following areas:

* Staying in bed;

* Decreased appetite;

* Care refusals and interventions;

* Number of staff needed to assist with ADL cares;

* Use of wheelchair;

* Meal assistance;

* Pain areas and non-pharmaceutical interventions;

* Instructions for use of portable oxygen concentrator; and

* Weight loss and interventions.

The need to ensure service plans were reflective of resident needs and included clear direction to staff was discussed with Staff 1 (ED) on 03/07/24. She acknowledged the findings.

2. Resident 5 was admitted to the facility in 01/2024 with diagnoses including major depressive disorder and post traumatic stress disorder.

The current service plan dated 01/24/24 and progress notes from 01/24/24 through 03/04/24 were reviewed. Observations and interviews with staff and Resident 5 were completed during the survey. The following was identified:

The service plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas:

* Sleeping in recliner chair;

* Mental Health;

* Left arm fracture;

* Wears a left-hand wrist brace;

* Off site PT services twice a week; and

* Recent losses.

The need to ensure service plans were reflective of resident needs and included clear direction to staff was discussed with Staff 1 (ED) on 03/07/24. She acknowledged the findings.

3. Resident 2 was admitted to the facility in 08/2022, with diagnoses including atrial fibrillation, heart disease, and depression.

Observations of the resident, interviews with staff and Resident 2, and review of the resident's current service plan, dated 01/24/24, showed the service plan was not reflective or did not provide clear direction to staff in the following areas:

* Use of side rails on bed;

* Positioning/turning in bed;

* Transfers;

* Emergency evacuation assistance;

* Use of HH Nursing services; and

* Activity interests.

On 03/07/24, the need to ensure service plans were reflective of current resident care needs and provided clear instruction to staff was discussed with Staff 1 (ED). She acknowledged the findings.

Service Plans;

1. Resident #3 was discharged from facility 3/13 no updates done to service plan

Resident #5 service plan updated to reflect sleeping in her recliner, left arm fracture, left hand brace, outside services, mental health/recent losses done 3/21/2024

Resident # 2 Service plan updated to reflect use of side rails, positioning and turning in bed, transfers, evacuation assistance, activity preferences and outside providers services done 3/21/2024

Resident #1 service plan updated to reflect change of condition including, evacuation, recent losses, medications, weight loss interventions, resident preferences with and ADL's, done 3/24/2024

Resident #4 service plan updated to reflect preferences including having his door propped open, evacuation ability re-assesed remains independent/Where he prefers to take medications re assesed and remains the same. Updated behaviors and interventions on SP 3/21/2024  

Service plans were updated to reflect missing information completed 3/27/2024

2. Implemented digital review. All service plans now need to be reviewed and signed off electronically in PCC by ED/RN/RCC/AD before they are printed and put out for floor staff, family and resident to ensure accuracy

All service plans will be evaluated quarterly and as needed with each COC by LN/RCC/ED

RN/RCC/ED will be monitoring quarterly and as needed  

3. Resident 3 was admitted to the facility in 12/2022 with diagnoses including chronic obstructive pulmonary disease,  hypertension and recurrence of major depressive disorder.

The resident's current service plan, dated 01/24/24, Interim Service Plans and progress notes dated 12/04/23 through 03/04/24, incident reports and weight records were reviewed, and staff were interviewed.

a. The following short-term changes of condition lacked documented evidence actions or interventions were determined and communicated to staff on all shifts, and the conditions were monitored at least weekly, through resolution.

* On 12/20/23, the RN documented the resident had complaints of right-side pain for three days. She noted the resident "winces in pain when attempting to move and yelling and cussing with any attempt to move." Emergency medical services were called. The resident was sent to the hospital; and

* On 01/02/24, staff documented the resident was vomiting in his/her trash can and on his/her bed.

b. Resident 3's current service plan dated 01/24/24  indicated s/he was a fall risk and listed the following fall interventions:

* Clutter free;

* Pull cord and call light within reach; and

* Encourage resident to use oxygen.

Progress notes indicated that s/he experienced falls on 02/06/24, 02/10/24, 02/12/24, 02/17/24, and 02/19/24. There was no documented evidence the facility consistently evaluated if service-planned interventions were implemented, were effective, or if new interventions were needed.

c. On 01/12/24 staff noted the resident has not been eating any of his/her meals in his/her room or in the dining room. The resident was put on alert for not eating; however, there was no documented evidence the facility determined, documented, and communicated to staff any actions or interventions.

An interview on 03/05/24, with Staff 15 (CG) confirmed the resident was not eating much. Observations made later that same day showed the resident had not eaten his/her lunch.   

Review of facility weight records showed on 01/30/24 the resident weighed 121 lbs and on 02/27/24 s/he weighed 115.7 lbs. The resident had lost 5.3 lbs in 28 days. There was no documented evidence actions or interventions were determined and communicated to staff on all shifts, and progress noted at least weekly through resolution:

The need to ensure actions or interventions for short-term changes of condition were documented and communicated to staff on each shift, fall interventions were monitored for effectiveness and the changes of condition were monitored with weekly progress noted through resolution was discussed with Staff 1 ( ED) on 03/07/24. No additional information was provided.

4. Resident 2 was admitted to the facility in 08/2022 with diagnoses including hypertension, atrial fibrillation, and depression.

A review of the resident's progress notes revealed an entry dated 01/29/24 stating, "Bandaid in place on [right] great toe. No blood noted."

There was no documented evidence actions or interventions had been identified nor evidence of monitroing through resolution.

On 03/07/24 the need for evaluation of short-term changes of condition, and monitoring of the conditions to resolution was discussed with Staff 1 (ED). No additional information was provided.

Based on observation, interview, and record review, it was determined the facility failed to evaluate and refer significant changes of condition to the RN, determine and document what actions or interventions were needed for a resident, and monitor and document on the progress of the condition at least weekly until resolved for 4 of 5 sampled residents (#s 1, 2, 3, and 4) who experienced changes of condition. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 05/2021 with diagnoses including atrial fibrillation and flutter, and polyneuropathy.

Observations of the resident, interviews with staff and Resident 1, and review of the resident's medical chart were conducted during the survey.   

Resident 1's record revealed the following weights:

* 10/31/23 - 130 pounds;

* 11/28/23 - 130.6 pounds;

* 12/26/23 - 131.4 pounds;

* 01/02/24 - 133.6 pounds;

* 01/09/24 - 131 pounds;

* 01/26/24 - 116 pounds; and

* 02/23/24 - 105.2 pounds.

On 03/05/24 the surveyor requested Resident 1's weight to be taken. At 1:08 pm, the resident weighed 104.8 pounds. The resident lost an additional 0.4 pounds since 02/23/24.

Resident 1 had experienced a severe weight loss of 11.71 % of his/her total body weight, or 15.4 pounds between 12/26/23 and 01/26/24. The resident experienced an additional severe weight loss of 9.31 %, or 10.8 pounds between 01/26/24 and 02/23/24.

On 01/10/24, the physician ordered 40 mgs of furosemide (for edema) to be administered every morning at 10:00 am. Progress notes, dated 01/20/24 through 01/24/24, indicated Resident 1 had not been feeling well and reported feeling dizzy and weak. On 01/24/24, the resident was sent to the emergency department relating to, "not eating, not drinking, inability to walk."

Upon returning to the facility on 01/24/24, the following Interim Service Plans (ISP) provided direction to staff:

* 01/24/24 - "Staff are to ensure [his/her] meals are within reaching distance of resident"; and

* 01/26/24 - "Lower dose of Lasix [for edema] higher dose of potassium", "Encourage meals in the dining room for better [intake] will need to be escorted down in a wheelchair", "Encourage fluid [intake], offer to bring juice or pour fresh water in [his/her] cup at each interaction".

Resident 1 was sent back and admitted to the hospital on 01/27/24. S/he returned to the facility on 02/12/24.

An ISP dated 02/12/24 directed staff to, "escort to and from meals in the dining room. [S/he] needs to be encouraged to eat maybe try sitting [him/her] with 206 in dining room."

On 03/05/24 at 11:21 am, Resident 1 was observed in his/her apartment, sitting in a recliner with a banana and a Styrofoam cup of cranberry juice to the left of him/her. The resident's ankles and feet were observed to be swollen.

During the interview with the resident, s/he confirmed that prior to him/her feeling so weak, the resident would sleep late each morning and fix him/herself a "bowl of raisin bran with either a cut up banana or berries" and would make themselves a "cup of coffee." The resident went on to report that s/he had asked staff for raisin bran and a banana each morning, but that s/he only received a banana. The resident stated not wanting that day's lunch of "black bean and corn salad." When asked if the resident was hungry, s/he confirmed s/he was and went on to say that before the weakness, s/he would get something out of the refrigerator to eat instead of eating the meal the facility provided. Resident 1 confirmed the weight loss and commented on how loose his/her clothing was.

On 03/05/24 at 1:56 pm, Staff 2 (RN) confirmed that there was an evaluation completed. The evaluation was not signed or dated.

There was no documented evidence the facility monitored the weight loss interventions for effectiveness.

The need to ensure residents were monitored with weekly progress noted until the condition resolves, which included evaluating if the weight loss actions or interventions were effective, was discussed with Staff 1 (ED) and Staff 2 on 03/05/24. They acknowledged the findings.

2. Resident 4 was admitted to the facility in 04/2019 with diagnoses including chronic obstructive pulmonary disease.

Observations of the resident, interviews with staff and Resident 4, and review of the resident's medical chart were conducted during the survey.

A progress note dated 02/09/24 stated, "Hospitalized for eye surgery."

On 03/06/24 at 11:47 am, Resident 4 confirmed s/he had cataract surgery.

There was no documented evidence the resident had been monitored through resolution for the change of condition.

The need to monitor residents changes of condition was discussed with Staff 1 (ED) and Staff 2 (RN) on 03/07/24. They acknowledged the findings.

Change of Condition;

Resident #1 Nursing assesment and nutritional assesement completed 3/5/2024, given to surveyor 3/6/2024, weekly charting intiated and continues

Resident # 4 Past the necessary observation period need for short term coc documentation ended prior to end of survey

Resident #3 Transfer status re-evaluated and remains a 1 person transfer. Discharged from facility 3/13/204

Resident #2 LN skin assesement done 3/14/2024 no further issues on Toe and no charting necessary.  

1.Complete audit done of potential change of conditions and added to COC log and RN assesement initiated.

2.Implementation of Alert Charting and Audit Tool log to assist Staff in communication to nursing for possible coc, assists in keeping track of documentation needed and time frames they need to be completed in. This will be brought to daily stand up for review by clinical team

3.Initated Change of condition Audit tool/form that RN/RCC/ED will meet weekly on Thursdays to review

4. ED/RN

Based on interview and record review, it was determined the facility failed to ensure the RN performed a timely assessment, developed interventions based on the condition of the resident, or updated the service plan for 1 of 1 sampled resident (# 1) who experienced significant changes of condition. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 05/2021 with diagnoses including atrial fibrillation.  

a. The resident's record was reviewed during survey and indicated the resident had experienced a severe weight loss of 11.71 % of his/her total body weight, or 15.4 pounds between 12/26/23 and 01/26/24. Resident 1 experienced an additional severe weight loss of 9.31 %, or 10.8 pounds between 01/26/24 and 02/23/24. These weight losses constituted significant changes of condition.

On 01/10/24, the physician ordered 40 mgs of furosemide (for edema) to be administered every morning at 10:00 am.

Resident 1 was sent to the Emergency Department on 01/24/24 and returned to the facility with a 20 mg decrease in furosemide.

On 01/27/24, the resident was sent back and admitted to the hospital. Resident 1 returned to the facility on 02/12/24.

During an interview on 03/05/24 at 1:56 pm, Staff 2 (RN) reported the weight loss was due to the furosemide.

There was no documented evidence the RN had assessed the resident's weight loss.

b. Progress notes, dated 12/01/23 through 03/03/24, the resident's service plan, dated 01/16/24, and Interim Service Plans (ISPs), dated 01/24/24 through 02/12/24, were reviewed. The following was identified:

Resident 1's service plan reflected independence with ADLs and using a four wheeled walker for mobility.

A progress note dated 01/20/24 identified Resident 1 sleeping later than 10:00 am and complaints of "feeling dizzy". By 01/24/24, staff document the resident was not "feeling well" and "has no energy". Later that day, the facility sent Resident 1 to the Emergency Department for "not eating, not drinking, inability to walk."

On 01/24/24, Resident 1 returned to the facility. The facility put the following ISP in place, directing staff to:

* 01/24/24 - Assist resident to get up and dressed each morning, get ready for bed each evening, and ensure his/her meals are within reach; and

* 01/26/24 - Encourage meals in the dining room for better intake, escort to the dining room in a wheelchair, assist with toileting, dressing, and grooming as needed, encourage fluid intake.

Progress notes dated 01/24/24 through 01/27/24 noted the resident was still not feeling well. Resident 1 was sent back and admitted to the hospital on 01/27/24. The resident returned to the facility on 02/12/24.

An ISP dated 02/12/24, instructed staff to escort Resident 1 to and from meals in the dining room, assistance with dressing, transfers, toileting, "etc.", and check on "routinely each shift."

Resident 1 experienced a significant change of condition related to requiring more assistance with ADLs.

There was no documented evidence the RN had assessed the resident's change in ADL assistance.   

The lack of an RN assessment regarding Resident 1's significant changes of condition was reviewed with Staff 1 (ED) and Staff 2 on 03/05/24. They acknowledged the findings.

Resident Health Services;RN assesment

Nursing assesment and nutirtion assesment completed 3/5/24 and given to surveyor 3/6/24

1. Nursing assesments completed on all COC identified 3/8/2024

2. Initated COC log to prompt/assist RN to complete assessments timely.

3. Log will be reviewed in clinical stand up daily by RCC/ED and Weekly COC meetings on Thursday with clinical team.

4. ED/RN

2. Resident 1 was admitted to the facility in 05/2021 with diagnoses including atrial fibrillation and flutter, and polyneuropathy.

Observations of the resident, interviews with staff and Resident 1, and review of the resident's medical record revealed the following:

Resident 1 was receiving HHRN services for wound care. An Outside Health Care Services Communication Form dated 02/23/24 recommended staff to "Maintain thick layer of barrier cream and re-apply after pericare. No need to clean down to bare skin. May use sacral dressing to add off loading. Aggressive off-loading, encourage patient to shift weight frequently. Frequent checks by staff to ensure brief is dry. Monitor for yeast symptoms."

On 03/07/24 at 9:52 am, Staff 15 (CG) confirmed it was the standard practice of care in the facility to apply barrier cream after pericare. She also confirmed the standard practice of care to do frequent checks and encourage repositioning. Staff 15 stated she was unaware of the other recommendations.

The need to ensure staff are informed of new interventions recommended by outside service providers, and the service plan was adjusted if necessary, was discussed with Staff 1 (ED) and Staff 2 (RN) on 03/07/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to coordinate care with outside service providers to ensure staff were informed of new interventions, and that the service plan was adjusted if necessary, for 2 of 2 sampled residents (#s 1 and 2) who received outside services. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 08/2022, with diagnoses including atrial fibrillation, kidney disease, and depression.

Review of the resident's progress notes, dated 12/03/23 through 03/04/24, and HH visit notes indicated Resident 2 had received HH Nursing care. There was no documented evidence the HH Nursing recommendations were communicated to staff, or the service plan was adjusted for the following:

* Keep buttocks clean and dry;

* Encourage patient to shift weight/change position frequently;

* Assist to relieve weight by turning to side, adjusting bed position several times daily; and

* Resident needs cues to participate in bed mobility. Bend [his/her] knees, and have [him/her] pull rails to roll.

In an interview on 03/06/24, Staff 18 (CG) stated "We just do the best we can to change [his/her] position frequently." Staff 18 stated "No, I wasn't aware of that", when asked if he/she was aware of the recommendations from the outside provider.

On 03/07/24, the need to ensure staff were informed of new interventions made by outside providers, and the service plan was adjusted if necessary, was reviewed with Staff 1 (ED). She acknowledge the findings.

Outside provider coordination;

Resident #2 outside provider added to service plan updated TSP with outside provider recommendations included done 3/12/2024

Resident #  1 Home Health nursing recommendations added to TSP 3/7/2024  

1. All residents with outside providers will be audited and brought into compliance with TSP/Service planning and updated notes by 3/29/2024.

2.RCC/LN/ED have initiated an outside provider tracking log which prompts TSP/ISP, f/up and charting. Also educating all outside providers to fill out visit slips when in house with any new recommendations.

3.This log will be reivewed in daily clinical rounds to ensure the RCC/LN/ED are aware and correct documentation is in place

4.Monthly spot audits by ED/LN to ensure compliance

Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed for 2 of 6 sampled residents (#s 2 and 3) whose orders were reviewed. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 12/2022 with diagnoses including chronic obstructive pulmonary disease, hypertension and recurrence of major depressive disorder.

Review of Resident 3's current physician orders, dated 12/21/23 and 01/18/24 and MARs from 12/01/24 through 03/04/24 identified the following:

Resident 3 had physician orders to receive the following medications:

* Ipratropium nasal spray (for runny nose) three times daily.

There was no documented evidence the medication was administered three times daily between 12/01/23 and 12/25/23, and between 02/01/24 and 02/09/24 as prescribed.

* Fluoxetine 20 mg (antidepressant) to be given daily.

There was no documented evidence the medication was administered once daily between 12/27/23 and 01/08/24 as prescribed.

* Vitamin B-12 500 mg (supplement) to be given daily.

There was no documented evidence the medication was administered once daily between 01/22/24 and 03/04/24 as prescribed.

In a 03/07/24 interview with Staff 2 (RN), confirmed the above medications were not administered as prescribed due to having issues with the pharmacy.  

The need to ensure physician or other legally recognized practitioner orders were carried out as prescribed was reviewed with Staff 1 (ED) on 03/07/24. She acknowledged the findings.

2. Resident 2 was admitted to the facility in 08/2022 with diagnoses including hypertension, kidney disease, and depression.

Review of Resident 2's MARs, dated 02/01/24 through 03/04/24, and physician orders, dated 02/01/24, revealed the following:  

The MAR included the routine medication carvedilol 6.25 mg (for hypertension), with instructions to "Take 1 tablet by mouth 2 times daily. Hold for [systolic blood pressure] below 100 and/or [heart rate] below 60".

On 02/09/24, the resident's pulse was documented as 58, prior to the 8:00 am administration of carvedilol, but the medication was still given.

On 03/07/24, the need to ensure all physician orders were followed as prescribed was discussed with Staff 1 (ED) and Staff 2 (RN). They acknowledged the findings.

Resident #3 Discharged from facility 3/13/2024

Resident #2 PCP notified that medication had been given outside of the parameters

Medication orders;

1. MAR/TAR reviewed/audited and corrected, physicians notified and pharmacy contacted for issues identified during survey process. Education provided to all Med Aids regarding provider orders.

2. Daily review of dashboard in PCC to identify MAR discrepencies and RCC to verify notification of PCP and LN.

3. Weekly MAR to CART audits, Weekly missed med reports to be ran and audited by LN/RCC

2. Resident 1 was admitted to the facility in 05/2021 with diagnoses including atrial fibrillation and flutter.

The resident's 01/01/24 through 03/04/24 MARs, physician's orders, and progress notes were reviewed.

On Resident 1's 01/01/24 through 01/31/24 MAR, there were duplicate orders for a cyanocobalamin (for vitamin B deficiency) injection every two weeks. Additionally, there were initials indicating that an unlicensed staff member administered the injection on 01/10/24.

On 03/07/24, Staff 2 (RN) confirmed she had administered the 01/10/24 injection as no staff were delegated to do so. Staff 2 also confirmed she forgot to log in to the computer, thus showing the unlicensed staff member's initials rather than hers.

Resident 1 had an order for doxycycline (for skin infection), 100 mgs by mouth, twice daily with probiotic for 14 days. On 01/10/24, there were three entries signed by staff. The first entry was confirming the resident received the medication at 10:00 am, the second entry also confirmed Resident 1 received the medication at 9:00 pm. There was an additional entry for 9:00 pm, stating the medication was not available for administration. Also, there was no documented evidence of a probiotic on the resident's 01/2024 MAR.

The need to ensure residents' MARs were accurate was discussed with Staff 1 (ED) and Staff 2 (RN) on 03/07/24. They acknowledged the findings.

3. Resident 4 was admitted to the facility in 04/2019 with diagnoses including chronic obstructive pulmonary disease (COPD) and dependence on supplemental oxygen.

The resident's 02/01/24 through 03/04/24 MARs and physician's orders were reviewed.

Resident 4 was identified as self-administering the following medications:

* Scheduled Spiriva (for COPD);

* Scheduled Symbicort (for COPD);

* PRN acetaminophen (for pain);

* PRN ibuprofen (for pain);

* PRN albuteral nebulizer (for shortness of breath); and

* PRN ventolin (for COPD).

Although the MAR was clear on which scheduled medications the resident self-administered, it was not clear relating to which PRN medications the resident was self-administering.

Resident 4 had a physician's order for staff to ensure s/he was wearing his/her oxygen at three liters per minute, three times a day. There was a blank on 03/01/24 for the "Night" entry.

On 03/06/24 at 11:47 am, the resident confirmed s/he always wore his/her oxygen.

The need to ensure residents' MARs were accurate was discussed with Staff 1 (ED) and Staff 2 (RN) on 03/07/24. They acknowledged the findings.   

Based on interview and record review, it was determined the facility failed to ensure residents' MARs were accurate, and provided resident specific parameters and instructions for PRN medications for 3 of 6 sampled residents (#s 1, 2, and 4) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 08/2022 with diagnoses including heart failure, cerebral infarction, and atrial fibrillation.

The resident's MARs, dated 02/01/24 through 03/04/24, were reviewed.  

The following PRN bowel medications, to treat constipation, lacked resident-specific parameters and instructions:

* Lactulose 10 gm/15 mL;

* Senna 8.6 mg; and

* Senna/docusate 8.6-50 mg.

There were no instructions for the sequential order of administration for these PRN medications.

On 03/07/24, the need to ensure an accurate MAR was kept of all medications ordered by a legally recognized prescriber and administered by the facility was discussed with Staff 1 (ED). She acknowledged the findings.

MAR accuracy;

Resident #1 MAR corrected to reflect RN as administering  re evaluated "duplicate" order and found there is no duplicate that one order is for the med and one is for route(supplies to give it ie; needle syringe)

Resident #2 Updated MAR/Orders/SP to reflect ability to self direct use of PRN medications

1. Parameters provided to all Medications that were not self directed. If self directed use it was added to the Service plan and MAR

2. All new orders to be reviewed within 72 hours by LN for parameters and if appropriate fax pcp for parameters.

3. MAR to CART will be done weekly to identify and audit any issues.

ED/RCC/LN and Pharmacist review quarterly

Based on observation, interview, and record review, it was determined the facility failed to update an acuity-based staffing tool (ABST) no less than quarterly for 1 of 1 sampled resident (# 3) and 15 unsampled residents and failed to have an accurate number of minutes for 2 of 2 sampled residents (#s 1 and 4) for residents whose ABST was reviewed. Findings include, but are not limited to:

1. Review of the facility's ABST, revealed not all residents had been reviewed or updated quarterly. Resident 3's acuity had not been reviewed since 02/2023. Fifteen unsampled residents lacked evidence of their acuity being reviewed or updated quarterly.

2. Resident 1 and 4's medical record was reviewed and revealed an inaccurate number of minutes assigned relating to their ABST.

a. Observations and interviews of Resident 1 and staff revealed the resident needing assistance with ADLs and two caregivers were needed during each interaction.  

Although the resident's ABST was updated in some areas on 02/13/24, the following areas were not reflective of Resident 1's current ADL assistance:

* Time spent supervising, cueing, or supporting while eating when the resident chose to eat in his/her apartment;

* Bowel and bladder management;

* Dressing and undressing;

* Grooming; and

* Requiring the assistance of two caregivers.   

b. Both Resident 4 and staff were interviewed. The following areas were not reflective of the resident's current ADL assistance:

* Responding to call lights;

* Ensuring non-drug interventions for behaviors; and

* Time spent supervising, cueing, or supporting while eating.

The need to ensure the ABST was updated and the number of minutes were accurate for the staffing plan to meet the 24 hour scheduled and unscheduled needs of residents was discussed with Staff 1 (ED) and Staff 2 (RN) on 03/07/24. They acknowledged the findings.

ABST;

Resident #3 ABST discharged 3/13/2024

Resident #1 ABST updated 2/13/2024 surveyor wanted ABST updated to reflect time spent cueing supervising or support while eating our facility does not provide this service as spelled out in our UDA. ABST updated to reflect toileting 3/5/2024

Resident #4  ABST updated to reflect call light use and behavior interventions

1. All ABST tools for survey sample residents updated by  3/7/2024

2. RCC to update ABST with each new TSP if applicable real time vs quarterly.  

3. LN to update ABST with each COC nursing assesment that is completed this task has been added to the COC log implemented

4. ED/RCC to double check ABST weekly during coc meeting Thursdays.

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff (#s 18, 19, 20 and 22) completed all required pre-service infectious disease prevention training prior to beginning their job responsibilities. Findings include, but are not limited to:

Training records were reviewed on 03/06/24.

Staff 18, 19, 20 and 22 (CGs), hired on 01/09/24, 01/09/24, 01/17/24, and 02/02/24 respectively, lacked documented evidence of completing all required pre-service infectious disease prevention training in the following areas:

* Hand hygiene.

* Disinfecting high-touch surfaces and equipment; and

* Handling, storing, processing and transporting linens to prevent the spread of infection.

The need to ensure documented evidence newly hired staff completed all required pre-service infectious disease prevention training prior to beginning their job responsibilities was discussed with Staff 1 (ED) on 03/07/24.

Staff training;infection control

1. Additional Infection control classes were immediately assigned in Relias to meet the current OAR

2. These will now be assigned automatically annually

3. Relias audits are done monthly to ensure Staff are completing them ontime as required by the state

4. ED and BOM will be doing monthly audits.

Based on interview and record review, it was determined the facility failed to document all required elements for fire drills in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to:

On 03/05/24 and 03/06/24, fire and life safety records, dated 08/2023 through 02/2024, were reviewed. The fire drill records lacked the following components:

* Escape route used;

* Problems encountered, comments relating to residents who resisted or failed to participate in the drills;

* Evacuation time-period needed;

* All staff members on duty and participating; and

* Number of occupants evacuated.

Due to the escape route not being documented, there was no evidence alternative routes were used during fire drills.

Additionally, any problems encountered with residents being resistive to participate in drill was not documented, thus the facility was unable to determine if the evacuation standard had been met.

The need to ensure fire drills included documentation of all required components was discussed with Staff 1 (ED) on 03/06/24. She acknowledged the findings.

Fire Drills;

1. A new Fire Drill record/form implemented that has all necessary informaiton on it to meet OAR

2.Meeting with Fire Marshall 3/21/2024 to establish evacuation routes using the new fire drill form.

3/4. Evaulation will be monthly after each fire drill is conducted to ensure complaince by Maint. Director and ED who will sign off on the new fire drill form

Based on observation and interview, it was determined the facility failed to ensure all exterior pathways in the ALF's common-use areas were maintained in good repair. Findings include, but are not limited to:

The exterior grounds were toured on 03/04/24. There were drop-offs of two inches or greater, from the paved walkway surface to adjacent dirt or grass surfaces, in several areas around the building's perimeter. These drop-offs created potential tripping or fall hazards for residents.

On 03/04/24 at approximately 1:15 pm, the surveyor accompanied Staff 1 (ED) and Staff 9 (Maintenance Assistant) on a tour of the facility grounds, showing them the drop-offs. They acknowledged the findings.

Landscaper is working on repair, fill and build up of areas identified during survey.

Grass will be brought up to level of concrete in two areas identified and more soil brought in to bring level up to the correct hight in third area identified.

Landscaper was educated on what to look for and Maintenance will include this in their weekly walk throughs

Maint Diretor and ED to monitor

Based on observation and interview, it was determined the facility failed to maintain all interior surfaces in good repair. Findings include, but are not limited to:

The interior of the building was toured on 03/07/24. The following areas needed repair:

* Wood doors on second and third floor balconies were warped and damaged;

* Handrails were worn through finish, showing bare wood on top surface in several areas throughout the building;

* Concrete was observed to be cracked and damaged on first floor outdoor landing;

* Back door of ALF (leading to MCC) was damaged, and chipped paint was observed;

* Second floor common-use restroom had plaster damage above sink, and the wall above the interior door had an open hole from a missing vent;

* Lever door handle was missing on third floor balcony;

* Chip-board ceiling panels damaged, warped, or missing in second floor laundry room; and

* Elevator showed paint chip on door frame, and damage to back wall paneling.

On 03/07/24, the areas in need of repair were reviewed with Staff 1 (ED) and Staff 9 (Maintenance Assistant). They acknowledged the findings.

Hand rails, exterior doors, concrete,2nd floor bathroom, elevator walls, ceiling panels, door handles

1. Door handle on third floor installed 3/11/2024.

Ceiling tiles ordered and replaced as needed will be complete facility wide 5/6/2024.

Exterior doors will be patched and painted completed 5/6/2024

Handrails will be sanded and re-stained/re-sealed completed by 5/6/2024

Elevator panels will be repaired by 5/6/2024

Concrete will be re-sealed and repaired by 5/6/2024

Bathroom on 2nd floor repairs completed 3/15/2024

Based on observation and interview, it was determined the facility failed to ensure soiled clothing and linens were laundered in a machine with a minimum rinse temperature of 140 degrees Fahrenheit or with a chemical disinfectant. Findings include, but are not limited to:

During observation of the facility on 03/07/24, the resident laundry rooms had washing machines in which staff laundered all resident soiled linens and clothing. The washing machines had automatic laundry detergent dispensers. The laundry detergent used lacked a chemical disinfectant.

In an interview on 03/07/24, Staff 18 (CG) stated the floor staff washed laundry for all residents who requested laundry services, and confirmed the same laundry detergent was used.

On 03/07/24, the facility's failure to properly launder soiled resident linens and clothing was reviewed with Staff 1 (ED). She acknowledged the findings

Laundry Sanitizer

Ordered and installed by Auto Chlor 3/8/2024

On Contract with Auto Chlor to refill and maintain monthly

Housekeeping supervisor to double check monthly when Auto chlor here that the right product is delievered.  

Based on observation and interview, it was determined the facility failed to provide an exit door alarm or other acceptable system to alert staff when residents exited the ALF. Findings include, but are not limited to:

The facility was toured on 03/04/24. The building was comprised of three floors, including a main front entrance, a rear entrance, several doors on first floor which led to outdoor common areas, and two additional balcony doors on each of the second and third floors. There were no exit door alarms, or other acceptable system, to alert staff when a resident exited the building.

On 03/07/24, the need to have a system which alerted staff when residents exited the building was discussed with Staff 1 (ED) and Staff 9 (Maintenance Assistant). They acknowledged the findings.

Door Alarms;

Door Alarms installed 3/11/2024 and intergrated with JNL call system to alert staff via pager system

Weekly audits of the system initated in TELS

Maint. Dept to do monthly audits and report any issues to ED