The findings of the re-licensure survey conducted 11/15/21 through 11/17/21 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

MCCMemory 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 re-licensure survey of 11/17/21, conducted 02/22/22 through 02/24/22, 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 second re-visit to the re-licensure survey of 11/17/21, conducted 07/13/22 through 07/15/22, 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.

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 third revisit to the re-licensure survey of 11/17/21 conducted 08/31/22 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.

Based on interview and record review, it was determined the facility failed to document evidence of an immediate investigation which reasonably concluded resident incidents were not the result of abuse or neglect for 1 of 2 sampled residents (# 4) relating to medications. Findings include, but are not limited to:

Resident 4 was admitted in 08/2021 with diagnoses including diabetes and hypertension.

A review of Resident 4's incident reports and progress notes dated 08/17/21 through 11/15/21 were reviewed.

Staff documented in a progress note dated 11/02/21 that Resident 4 was administered an extra dose of Isosorbide Dinitrate (for heart heath) and stated the resident was concerned s/he was "over dosed."

There was no documented evidence the facility completed an investigation to rule out abuse or neglect.

The need to ensure investigations contained the required documentation was discussed with Staff 1 (Administrator) and Staff 3 (RN) on 11/17/21. They acknowledged the findings.

Abuse Reporting and Investigation

1. Staff are to immediately take action to protect residents from abuse, and call 911 if the resident is in imminent danger.  Staff are required to immediatley report to their onsite supervisor all suspected abuse or abuse or injury of unknown cause by filling out an incident report. The onsite supervisor (Administrator, Nurse, Med-Tech) present will be responsible to call SPD or local AAA on the day of the incident.

Initial investigation will be done by the Administrator or Nurse on the day of the incident, or until 5p of next business day. The Administrator or Nurse will have five (5) business days to complete the investigation.  

2. If staff is the suspected abuser, staff member will be suspended until the result of the abuse investigation is received. Staff will be terminated immediately if abuse is substanciated.

If another resident is the suspected abusers, staff is to call the licensing agency. Staff are to ensure residents safety, 1:1 care or increase safety checks if needed.

All suspected abuse or abuse of injury of unknown cause must be immediately reported to the local SPD or local AAA- abuse including but not limited to rape, murder, assault, burglary, kidnapping, or theft of controlled substances.

3. Once the Administrator recieves an Incident report, the investigation will begin immediate. Evaluation will take place on weekly basis to ensure resident safety.

4. The Administrator and the Facility RN will be responsible to see that the investigation is complete and proper documentation has been completed.

Based on interview and record review, it was determined the facility failed to ensure falls and injuries of unknown cause were thoroughly investigated to rule out abuse and reported to the local SPD as suspected abuse for 1 of 1 sampled resident (#5) whose incidents were reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 5 was admitted to the facility in 03/2020 with diagnoses including Parkinson's Disease and cognitive impairment.

The resident's service plan, dated 01/07/22, and interviews with care staff between 02/22/22 and 02/24/22 indicated the resident required assistance for most ADL care and mobility.

Review of incident investigations and progress notes from 01/16/22 through 02/25/22 showed the following:

* A progress note and incident report dated 01/24/22 indicated the resident was found on the floor with skin tears on both knees. The incident report indicated Resident 5 was "not interviewable: Dementia, Parkinson's";

* A progress note and incident report dated 02/06/22 indicated the resident was found on the floor with a skin tear to the knee. The incident report indicated Resident 5 was "not interviewable: Dementia, Parkinson's".

The 01/24/22 and 02/06/22 incidents were unwitnessed, and the resident was evaluated as not interviewable.

The incident investigations did not clearly document how potential abuse and neglect were ruled out for the injuries of unknown origin, and the incidents were not reported to the local SPD office.

The need to ensure resident incidents were promptly investigated to rule out abuse and neglect was discussed with Staff 1 (Administrator) and Staff 3 (RN) on 02/24/22. The staff acknowledged the findings.

The facility was asked to report both injuries of unknown cause to the local SPD office. Confirmation of the reports was provided prior to survey exit.

Abuse Reporting and Investigation

1. Staff are to immediately take action to protect residents from abuse, and call 911 if the resident is in imminent danger.  Staff are required to immediatley report to their onsite supervisor all suspected abuse or abuse of injury of unknown cause by filling out an incident report. The onsite supervisor (Administrator, Nurse, Med-Tech) present will be responsible to call SPD or local AAA on the day of the incident.

Initial investigation will be done by the Administrator or Nurse on the day of the incident, or until 5p of next business day. The Administrator or Nurse will have five (5) business days to complete the investigation.  

2. If staff is the suspected abuser, staff member will be suspended until the result of the abuse investigation is received. Staff will be terminated immediately if abuse is substanciated. If another resident is the suspected abusers, staff is to call the licensing agency. Staff are to ensure residents safety, 1:1 care or increase safety checks if needed.

All suspected abuse or abuse of injury of unknown cause must be immediately reported to the local SPD or local AAA- abuse including but not limited to rape, murder, assault, burglary, kidnapping, or theft of controlled substances. Once the investigation is complete, the Administrator and/or RN must clearly document the findings of their investigation. Documentation must state how potential abuse and neglect were ruled out for injuries of unknown origin.

3. Once the Administrator recieves an Incident report, the investigation will begin immediate. Evaluation will take place on a weekly basis to ensure residents safety.

4. The Administrator and the Facility RN will be responsible to see that the investigation is complete and proper documentation has been completed.js     

Based on interview and record review, it was determined the facility failed to report injuries of unknown cause to the local SPD office as suspected abuse unless an immediate facility investigation reasonably ruled out abuse for 1 of 1 sampled resident (#8) with a reportable incident. This is a repeat citation. Findings include, but are not limited to:

During the acuity interview on 07/13/22, Resident 8 was identified with an injury of unknown cause.

The resident's facility record, including progress notes from 04/16/22 through 07/08/22, incident reports, investigations, and interviews with staff, identified the following:

* An incident report and investigation dated 07/01/22 indicated the resident had a bruise on his/her left thigh, and staff documented s/he did not know the cause of the bruise. In its documented investigation, the facility did not rule out abuse.

In an interview on 07/13/22, Staff 3 (RN) stated the injury of unknown cause was not reported to the local SPD office. The facility was asked to report the injury of unknown cause to the local SPD office, and confirmation was provided on 07/13/22.

The need to either reasonably rule out abuse/neglect for injuries of unknown cause or report the injuries to the local SPD office was discussed with Staff 3 and Staff 19 (Administrator) on 07/14/22. They acknowledged the findings.

Reporting & Investigating Abuse-Other Action

1. Once staff complete an incident report for all suspected abuse or injury of unknown cause, the Administrator and/or facility RN will be responsible to call or fax SPD on the day of the reported incident; unless able to resonably rule out abuse/neglect for injuries of unknow cause. An initial investigation will be done by the Administrator or the Nurse immediately.  All communication with SPD will be documented and kept in the pink 'APS Reporting and Investigation' binder, located in the office.

2. Once the investigation is complete, the Administrator and/or RN must clearly document the findings of their investigation. Administrator or RN to either contact SPD to report abuse/neglect or to document on the incident report how potential abuse and neglect were ruled out for injuries of unknown origin. If abuse is found unsubstantial, the facility RN must state in complete detail why abuse/neglect was ruled out.

3. Once the facility RN recieves an Incident report, the investigation will begin immediate. Evaluation will take place on a weekly basis to ensure residents safety.

4. The Administrator and the Facility RN will be responsible to see that the investigation is complete and proper, in detail, documentation has been completed.   

2. Resident 4 was admitted to the facility in 08/2021 with diagnoses including Type 2 diabetes.

During an interview with the resident on 11/15/21 at 1:45 pm, s/he stated there were "too many carbs" offered on the menu. When asked if there was alternative food choices offered, Resident 4 stated there was but, "they're not always available." An example the resident provided was "the other night" s/he asked for the baked chicken and was told by staff there wasn't any.  

Resident 4's 08/17/21 through 11/15/21 MARs and physician orders were reviewed. The resident's Insulin Glargine (for diabetes) injection was ordered for eight units, each evening at 7:30 pm. The insulin was increased from eight to ten units a day on 11/10/21. Resident 4 stated during the interview, s/he felt the increase in insulin was due to not being able to limit his/her carbohydrate intake related to the availability of food choices.

The need to provide modified, special diets that were appropriate to the residents' needs and choices was discussed with Staff 1 (Administrator) and Staff 3 (RN). They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to provide modified special diets that were appropriate to residents' needs and choices for 2 of 2 sampled residents (#s 1 and 4) who required diabetic diets. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 07/2019 with diagnoses including Type 2 diabetes mellitus and a physician's order for "no added sugar, diabetic diet."

During an interview on 11/16/21, Resident 1 stated s/he was concerned "there are too many carbs" when asked how s/he liked the food. Resident 1 stated s/he had talked to staff about it "sometimes, but it hasn't changed." Resident 1 was aware of the alternative menu provided by the facility and stated "many of those are carbs too, not enough protein."

Observations of the lunch meal on 11/15/21 revealed the resident received an open-faced turkey sandwich which included a slice of white bread, turkey meat and brown gravy. The lunch meal observed on 11/16/21 revealed the resident received pork chow mein which consisted of pork, green beans and white rice. The facility provided a snack cart twice daily for residents to select a snack. The snack cart on 11/15/21 and 11/16/21 included small bags of potato chips, granola bars, flavored yogurt, cookies, muffins and string cheese.

During an interview on 11/16/21, Staff 2 (Assistant Manager) stated the menu was created by Staff 2 and Staff 18 (Facility Chef). When asked, Staff 2 stated the menu was not reviewed by a dietician. Staff 2 stated that an alternative menu was available with items to meet diabetic needs and preferences however this menu was "subject to availability" therefore, not all of the items listed may be available at all times.

The need to provide modified, special diets that were appropriate to residents' needs and choices was reviewed with Staff 1 (Administrator) on 11/17/21. No new information was provided.

Resident Service Meals and Food Sanitation Rules

1. The residents will be given three daily nutritious meals with snacks, 7 days per week, that corresponds with recommendations from our Facility Dietician.

The Facility Dietician will review and or/make changes to the weekly menus that coincide with modified special diets that's appropriate to residents' needs and choices. A resident food council meeting will be conducted monthly to ensure residents involvement in developing the menus.

2. The Facility Dietician will review the menus on a monthly basis, and make changes as needed to accommediate residents' diets.

3. The evaluation will be done on a monthly basis and upon residents' diet changes.

4. The Administrator and Dietician will be responsible to monitoring residents' diets and menus.

2. Resident 3 was admitted to the facility in 03/2021 with diagnoses including quadriplegia and suprapubic catheter. The resident's record was reviewed and multiple staff were interviewed regarding the resident's current level of functioning and care needs.

Resident 3's current service plan, dated 11/11/21, was not reflective or lacked adequate instruction for staff in the following areas:

* Assist with oral care prior to bed;

* The term "arm brace" was unclear in the service plan;

* Instructions for proper use of leg straps and seatbelt for safety when in power wheelchair;

* Instructions for proper catheter bag placement when in bed and proper placement and use of privacy pouch for catheter bag when using power wheelchair;

* Specific instructions for placement of phone holder on power wheelchair;

* Safety instructions for the use of side rails in bed; and

* Bedtime assistance/routine regarding use of wedge for phone charger and proper application and use of leg boots/braces.

The need to ensure resident service plans were reflective of the resident's current care needs and provided adequate instruction for staff as to how to provide care was reviewed with Staff 1 (Administrator), Staff 3 (RN) and Staff 5 (Human Resources Director) on 11/17/21. They acknowledged the information lacking from Resident 3's service plan.

3. Resident 4 was admitted to the facility 08/2021 with diagnosis including a right below knee amputation. The 08/17/21 service plan and subsequent Temporary Service Plans (TSP) were reviewed. The service plan was not reflective of the resident's current needs or did not provide clear caregiving instructions in the following areas:

* Behaviors;

* Skin checks;

* Safety devices with potential restraining qualities;

* Diet texture following a dental procedure; and

* Emergency evacuation.

The need to ensure service plans were reflective of the resident's current needs and provide clear caregiving instructions was discussed with Staff 1 (Administrator) and Staff 3 (RN) on 11/17/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current needs, provided clear instruction to staff and were readily available to staff for 3 of 4 sampled residents (#s 1, 3 and 4) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 07/2019 and sustained a left lower extremity fracture.

Progress notes dated 08/18/21 through 11/15/21, service plans dated 10/12/21 and 11/03/21, and temporary service plans were reviewed and identified the following:

The service plan, dated 11/03/21, was not available for staff to review. The service plan available to staff, located in the "current service plan" binder contained the service plan dated 10/12/21 and was not reflective of the resident's needs in the following areas:

* Recent ankle fracture and cast care;

* Pain monitoring;

* Use of hoyer lift and 2-persons for transfers;

* Non-weight bearing status;

* Instructions for toileting and bathing related to cast care; and

* Change in weight and instructions for weight monitoring.

The need to ensure service plans were reflective of residents' current needs and were readily available to staff were reviewed with Staff 1 (Administrator) and Staff 3 (RN) on 11/17/21. They acknowledged the findings.

Service Plan

1. The facility will ensure the timely and accurate completion of the service plan, and to provide for appropriate care according to resident needs and desires.

The facility will reconstruct each service plan to incorporate all elements identified in person-centered care and individualize each service plan so it is geared directly for that resident. Service plans will be completed before resident move-in with updates and changes within the first 30-days. Quarterly evaluations will be completed. Once a service plan is completed (initial/quarterly/TSP), staff will be notifed of changes and will be required to sign once information is reviewed.

2. All resident's service plans will be updated. Once updated and reviewed by Administrator and Facility RN, staff will be alerted of changes and required to review and sign.  

3. Quality improvement program has been implemented and will be conducted on a monthly basis to ensure timely completion of service plans.

4. The Administrator and RN will be responsible for completing service plans in a timely manner.   

2. Resident 5 was admitted to the facility in March 2020 with diagnoses including Parkinson's Disease and cognitive impairment.

Progress notes dated 01/25/22 through 02/22/22, the service plan dated 01/07/22,  and temporary service plans were reviewed and identified the following:

The service plan, dated 01/07/22, was not reflective of the resident's status and didn't provide clear instructions for staff in the following areas:

* Risks, precautions, and instructions for the use of bilateral side rails;

* Fall risk interventions and fall history; and

* Blood thinner use and precautions.

The need to ensure service plans were reflective of residents' current needs was reviewed with Staff 1 (Administrator), Staff 2 (Assistant Manager), Staff 3 (RN) on 02/24/22. 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 needs, provided clear instruction to staff and were followed for 2 of 2 sampled residents (#s 5 and 6) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 6 was admitted to the facility in 04/2019 with diagnosis including Type 2 diabetes and diastolic congestive heart failure.

Observations, interviews with care staff and the resident, review of the service plan dated 01/05/22 and temporary service plans were conducted during the survey.

The service plan, dated 01/05/22, was not reflective of the resident's status, lacked clear instructions for staff and was not followed in the following areas:

* Risks and precautions for the use of bilateral side rails;

* Two person incontinent care completed in bed;

* Skin issues including chronic diabetic ulcers on the left heel and Achilles tendon;

* Instructions to float heels and avoid placing pillow under the Achilles tendon;

* Instructions for aspiration precautions; and

* Diet orders to include nectar thick liquids.

Observations made from 02/22/22 through 02/23/22 showed direct care staff were not providing aspiration precautions when the resident was given a cookie to eat while laying down in bed, nectar thick liquids were not being provided and the resident's heels were not floated.

The need to ensure service plans were reflective of residents' current needs, provided clear instructions for staff, and staff followed the care plans was reviewed with Staff 1 (Administrator), Staff 2 (Assistant Manager), Staff 3 (RN) and Staff 5 (Human Resource Director) on 02/24/22. They acknowledged the findings.

Service Plan

1. The facility will ensure the timely and accurate completion of the service plan, and to provide for appropriate care according to resident needs and desires. The facility will reconstruct each service plan to incorporate all elements identified in person-centered care and individualize each service plan so it is geared directly for that resident. The service plan will reflect the residents status and provide clear instructions to staff for each task listed. Service plans will be completed before resident move-in with updates and changes within the first 30-days. Quarterly evaluations will be completed. Once a service plan is completed (initial/quarterly/TSP), staff will be notifed of changes and will be required to sign once information is reviewed.

2. All resident's service plans will be updated. Once updated and reviewed by Administrator and Facility RN, staff will be alerted of changes and required to review and sign.  

3. Quality improvement program has been implemented and will be conducted on a monthly basis to ensure timely completion of service plans.

4. The Administrator and RN will be responsible for completing service plans in a timely manner.

2. Resident 8 was admitted to the facility in 05/2018 with diagnoses including dementia, diabetes, and depression.

A review of the resident's progress notes dated 04/16/22 through 07/08/22, the service plan dated 06/15/22, temporary service plans, observations, and interviews conducted between 07/13/22 and 07/15/22, identified that the service plan was not reflective of the resident's status and did not provide clear instruction to staff in the following areas:

* Recent falls and fall risk interventions;

* Preferred language in Spanish; and

* Increased confusion, sleepiness, and resistance to care.

The need to ensure that service plans were reflective of the resident's status and provided clear direction to staff was discussed with Staff 3 (RN) and Staff 19 (Administrator) on 07/14/22. 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 needs and provided clear instruction to staff regarding delivery of services for 2 of 3 sampled residents (#s 8 and 9) whose service plans were reviewed.  This is a repeat citation. Findings include, but are not limited to:

1. Resident 9 was admitted to the facility in 10/2021 with diagnosis including dementia and chronic obstructive pulmonary disease.

Observations, interviews with care staff and the resident, and review of the service plan dated 07/12/2022 were conducted during the survey.

The service plan was not reflective of the resident's status, and lacked clear instructions for staff in the following areas:

* Dentures;

* Dressing;  

* Transfers;

* Toileting;

* Safety devices including instructions for staff on the use of and precautions related to siderails; and

* Eyeglasses.

The need to ensure service plans were reflective of residents' current needs and provided clear instructions to staff was reviewed with Staff 3 (RN), Staff 5 (Program and Human Resources Director) and Staff 19 (Administrator) on 07/15/22.  They acknowledged the findings.

Service Plan

1. All Residents service plans have been updated.

2. The facility will ensure the timely and accurate completion of the service plan, and to provide for appropriate care according to resident needs and desires. The facility will reconstruct each service plan to incorporate all elements identified in person-centered care and individualize each service plan so it is geared directly for that resident. The service plan will reflect the residents status and provide clear instructions to staff for each task listed. Service plans will be completed before resident move-in with updates and changes within the first 30-days. Quarterly evaluations will be completed. Once a service plan is completed (initial/quarterly/TSP), staff will be notifed of changes and will be required to sign once information is reviewed.

3. Quality improvement program has been implemented and will be conducted on a monthly basis to ensure timely completion of service plans.

4. The Administrator and RN will be responsible for completing service plans in a timely manner     

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that included the resident, the resident's legal representative if applicable, any person of the resident's choice, the Administrator or designee, and at least one other staff person who was familiar with or who was going to provide services to the resident for 3 of 3 sampled residents (#s 1, 2 and 3) whose service plans were reviewed. Findings include, but are not limited to:

Service plans for 3 of 3 sampled residents reviewed lacked documented evidence that a Service Planning Team reviewed and participated in the development of the service plans.

The need to ensure service plans were developed by a service planning team was discussed with Staff 1 (Administrator) and Staff 2 (Assistant Manager) 11/17/21. They acknowledged the findings.

Service Planning Team

1. The residents' service plan form has been revised to now show attending participant signatures as well as documentation on full communication on who was unable to attend. (Resident, family member/POA, case manager, RN, Administrator).

2. All residents' service plans will be updated and reviewed and signed by all attending participants.

3. This area will be evaluated upon move-in, quarterly and any significant change of condition.

4. The Administrator and RN will be responsible for conducting all service plan team meetings.  

2. Resident 3 was admitted to the facility in 03/2021 with diagnoses including quadriplegia and suprapubic catheter. The resident's record was reviewed including progress notes, service plans, evaluations, Temporary Service Plans (TSPs) and the MAR. The following deficiencies were identified:

a. Staff documented in progress notes on 10/11/21 that Resident 3's catheter was leaking, and two attempts to flush the catheter were ineffective and the catheter was clogged. Written delegation instructions directed staff to call the RN if there was leaking around the catheter site or no urine was draining into the collection bag.

There was no documented evidence the issue with the catheter was referred to the facility RN for evaluation. The facility failed to determine and document what action or intervention was needed for the resident, communicate the action/intervention to staff and monitor the resident's condition and document progress at least weekly until resolved. Staff documented the catheter continued to leak and was not flushed until the resident went to a urology appointment on 10/21/21 where the catheter was replaced.

b. Staff documented in a progress note on 11/03/21 that Resident 3 had a "sore" and a closed blister on one of his/her heels. Physician orders instructed the facility to complete a "skin report" (a form that was routed to an RN for review) for any new skin breakdown or blisters.

There was no documented evidence the heel issues were referred to the facility RN for evaluation. The facility failed to determine and document what action or intervention was needed for the resident, communicate the action/intervention to staff and monitor the resident's condition and document progress at least weekly until resolved.

c. On 11/03/21, 11/04/21 and 11/05/21 staff documented on the MAR that the resident had a blister on the inside right upper thigh. Physician orders instructed the facility to complete a "skin report" for any new skin breakdown or blisters.

There was no documented evidence the skin issue on the thigh was referred to the facility RN for evaluation. The facility failed to determine and document what action or intervention was needed for the resident, communicate the action/intervention to staff and monitor the resident's condition and document progress at least weekly until resolved.

In an interview on 11/16/21, Staff 3 (RN) acknowledged she was not made aware of the issues with the catheter, heel wounds or blister on the thigh. She acknowledged the facility did not determine and document what interventions were needed for each of the changes of condition and did not monitor and document on the progress of the conditions at least weekly until resolved.

The need to ensure the facility had a system for identifying and communicating changes of condition to the facility RN as needed, and that interventions were determined and documented, communicated to staff and the condition monitored until resolution was reviewed with Staff 1 (Administrator), Staff 3 and Staff 5 (Human Resources Director) on 11/17/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure residents who had short term changes of condition were evaluated, resident-specific instructions or interventions were developed, the condition was monitored weekly until resolved, and residents were monitored per their evaluated needs for 3 of 4 sampled residents (#s 2, 3 and 4) who experienced changes of condition. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 08/2021 with diagnoses including a right below knee amputation, diabetes and hypertension.

a. Staff documented in a progress note dated 09/19/21, "Resident has been crying and has expressed that [s/he] is suicidal."

During an interview on 11/15/21 at 1:45 pm, Resident 4 confirmed s/he was feeling depressed that day and stated the plan was to jump out of his/her second story unit window. When asked if s/he was still feeling "depressed," the resident confirmed s/he was not.

Documentation of monitoring the incident was requested on 11/16/21. Staff 1 (Administrator) confirmed on the same day at 11:34 am staff were not aware of the incident and there was no documented evidence Resident 4 was monitored or that interventions were implemented.

b. Staff documented in a progress note dated 11/02/21 Resident 4 was administered an extra dose of Isosorbide Dinitrate (for heart health) and was upset because s/he "was over dosed."

Documentation of monitoring the incident was requested on 11/16/21. Staff 1 confirmed on the same day at 11:34 am there was no documented evidence the resident was monitored through resolution.

c. Weight records, dated 08/20/21 and 11/10/21 indicated the resident experienced a 24 pound weight gain. This constituted a 10.57% severe weight gain over three months.

In an interview with Staff 3 (RN) on 11/16/21 at approximately 1:45 pm, she reported the staff were supposed to notify her for any weight fluctuations with the residents and confirmed she was not notified of Resident 4's weight gain.

The facility failed to ensure the RN was notified of the resident's severe weight gain.  

The need to ensure appropriate staff were alerted to changes of conditions and residents were monitored per their evaluated needs was discussed with Staff 1 and Staff 3 on 11/17/21. They acknowledged the findings.

3. Resident 2 was admitted to facility 04/2018.

On 10/19/21, record review showed care staff documented "redness on left thigh toward hip. Appears to be scratches." There was no additional documentation to indicate staff had monitored the skin issue to resolution. Staff did not notify the RN.

In an interview on 11/16/21, Staff 3 (RN) stated she was unaware of the injury.

There was no additional documentation of follow-up treatment instructions to staff or monitoring until resolution.

The need for staff to notify RN of findings, ensure all changes of conditions were reviewed,  resident specific actions and interventions were developed and communicated to staff, and conditions were monitored until resolution was discussed with Staff 1 (Administrator) and Staff 3 on 11/16/21. They acknowledged the findings.

Change of Condition and Monitoring

1. Caregivers will inform in change of condition by listing out any issues that arise and informing their findings to the Med Tech on duty. Med Tech will be responsible for creating a Temporary Service Plan (TSP) immediately and informing RN. RN is to assess and investigate to rule out abuse. If the change of condition is indefinite, then a Change of Condition (COC) form will be filled out with clear instructions by the RN, monitored on a weekly basis.and reported to the resident physcian. Resident service plan will then be updated.

2. Caregivers and Med Tech's will be re-trained on the facilities change of condition policy and procedure. All TSP's will be followed up the nurse in a timely manner and all resident service agreements will be updated.

3. The facility RN will be responsible for monitoring TSP's and OCO on weekly basis.  

4. The Administrator and the RN will be responsible for assessing all TSP's and OCO within 24 hours.  

Based on observation, interview and record review, it was determined the facility failed to ensure interventions were determined, documented and communicated to staff, the determined actions were resident-specific and the resident was monitored consistent with his/her evaluated needs, for 1 of 1 sampled resident (#5) who had changes of condition or required monitoring. This is a repeat citation. Findings include, but are not limited to:

Resident 5 was admitted to the facility in 03/2020 with diagnoses including Parkinson's Disease and cognitive impairment. The 01/07/22 service plan did not indicate Resident 5 was a fall risk.

Review of progress notes and incident reports revealed Resident 5 fell on 01/24/22. The incident report identified "Are care plan adjustments needed:  No", and recommended "proper body alignment in recliner chair". There was no documented evidence the determined intervention was added to the service plan and communicated to staff on all shifts.

Resident 5 experienced additional falls on 01/26/22, 01/28/22, 02/02/22. Each investigation noted, "Are care plan adjustments needed?: No"  After each fall, a temporary service plan (TSP) was created which noted the fall and placed the resident on alert charting, however, the service plan was not updated with interventions to prevent additional falls.

Resident 5 experienced another fall on 02/06/22, the incident investigation recommended the interventions of safety checks, hip protectors, and referral to PT/OT. There was no documented evidence the determined interventions were added to the service plan and communicated to staff on all shifts.

Observations and interviews with care staff revealed that safety checks and repositioning were being done by staff, however, the service plan wasn't updated with the new interventions. There was no documented monitoring of whether other previous fall interventions were being done across all shifts, if they were effective, or whether new interventions needed to be developed.

The facility's failure to ensure interventions were developed, added to the resident's service plan, communicated to staff, and that previous interventions were monitored for effectiveness was reviewed with Staff 1 (Administrator), Staff 2 (Assistant Manager) and Staff 3 (RN) on 02/24/22. They acknowledged the findings.

Change of Condition and Monitoring

1. Caregivers will inform in change of condition by listing out any issues that arise and informing their findings to the Med Tech on duty. Med Tech will be responsible for creating a Temporary Service Plan (TSP) immediately and informing RN. RN is to assess and investigate to rule out abuse. If the change of condition is indefinite, then a Change of Condition (COC) form will be filled out with clear instructions by the RN, monitored on a weekly basis and reported to the resident physcian. Resident service plan will then be updated with clear documentation that ensure interventions were determined and monitored in accordance to resident needs. Updated service plans will be printed and communicated to staff of any changes.

2. Caregivers and Med Tech's will be re-trained on the facilities change of condition policy and procedure. All TSP's will be followed up the nurse in a timely manner and all resident service agreements will be updated.

3. The facility RN will be responsible for monitoring TSP's and COC on weekly basis.  

4. The Administrator and the RN will be responsible for assessing all TSP's and COC within 24 hours.

Based on interview and record review, it was determined the facility failed to determine, document and communicate to staff what actions or interventions were needed for a resident and document on the status of the condition at least weekly until resolved, failed to monitor the resident consistent with his/her evaluated needs and service plan following changes of condition, and failed to identify and document significant changes of condition, evaluate the resident and refer the change to the facility nurse, for 1 of 3 sampled residents (#9) with falls, injuries and a significant weight change. This is a repeat citation. Findings include, but are not limited to:

Resident 9 was admitted to the facility in 10/2021 with diagnoses including dementia, atrial fibrillation, and chronic obstructive pulmonary disease.

Progress notes from 04/15/22 to 07/13/22, Incident Reports, the resident's current (07/12/22) and previous service plans, temporary service plans, and Alert Charting log were reviewed during the survey.

a. The service plan indicated the resident could transfer independently using a four-wheeled walker, could verbalize the need to go to the bathroom and could toilet him/herself. The service plan also instructed staff to check on the resident every two hours for safety, and to assist with toileting as needed.

In an interview on 07/14/22, Staff 20 (CG) reported the resident could no longer transfer without staff assistance, and required full staff assistance with toileting.

Review of the record indicated Resident 9 had the following falls:

* 04/28/22: Found on the floor, no injuries noted;

* 05/31/22: Found on the floor, no injuries noted;

* 06/02/22: Found on the floor, no injuries noted;

* 06/18/22: Found on the floor, bruising to the forehead/eye area; and

* 07/03/22: Found on the floor, no injuries noted.

Resident 9 had five falls between 04/28/22 and 07/03/22 for which the facility failed to monitor whether interventions in the service plan were being followed and were effective. New interventions that were identified were not added to the resident's service plan, communicated to staff and monitored to ensure they were implemented and effective. The facility failed to consistently monitor the resident following the falls for changes in mobility, pain or injuries.

b. The resident was being weighed daily. From 06/01/22 to 07/01/22, the resident gained 14 pounds or 8.8% body weight in one month. This represented a significant change of condition. There was no documented evidence the facility evaluated and documented the significant weight gain and referred it to the facility nurse. In an interview on 07/14/22, Staff 3 (RN) acknowledged she was not aware of Resident 9's weight gain.

Refer to C 280.

The need to ensure the facility had a process for monitoring whether service-planned interventions were being followed and updating the resident's service plan as needed, monitoring the resident following changes of condition, and evaluating, documenting and referring significant changes of condition to the facility nurse, was discussed with Staff 3, Staff 5 (Program and Human Resources Director) and Staff 19 (Administrator) on 07/15/22. They acknowledged the findings.

Change of Condition

1. Resident service plans have been updated and a productive TSP and weight change policy has been implemented and corrected.

2. Once a change of condition is reported to the Med Tech on duty, the Med Tech will be responsible for creating a Temporary Service Plan (TSP) immediately and informing RN by placing all TSP's into the RN inbox.The RN will be responsible for determining proper interventions and documenting all new interventions on the TSP. The facility Administrator is responsible for checking all resident weights on a daily basis. Any significant weight change of three or more pounds will be printed out and reported to the RN. The RN will complete a weight change assessment with full explanation on how and why the weight change occurred. The RN will then notify the residents doctor and facility dietician to determine a plan. The resident will be placed on alert and monitored per doctors request. All residents with a TSP will be placed on alert and monitored on a daily basis until resolved. If a Change of Condition is indefinite, then a Change of condition form will be filled out with clear instructions by the RN, and the resident serivce plan will then be updated with clear documentation that ensure interventions were determined and monitored in accordance to resident needs. Updated service plans will be printed and communicated to staff of any changes.  

3. The RN will be responsible for monitoring all TSP's, resident weights and COC on a weekly basis.

4. The Administrator and the RN will be responsible for assessing all TSP's, weights and COC within 24 hours.  

Based on observation, interview and record review, it was determined the facility failed to ensure a complete RN assessment was documented for 2 of 2 sampled residents (#s 1 and 4) who experienced significant changes of condition related to weight gain and a fracture. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 08/2021 with diagnoses including diabetes and hypertension.  

Weight records, dated 08/20/21 and 11/10/21 indicated the resident experienced a 24 pound weight gain. This constituted a 10.57% severe weight gain in three months. The facility failed to ensure an RN assessment was completed for the weight gain which documented findings, resident status, and interventions made as a result of the assessment.

The need to ensure an RN conducted an assessment of all residents with significant changes of condition was discussed with Staff 1 (Administrator) and Staff 3 (RN) on 11/16/21 and 11/17/21. They acknowledged the findings.

2. Resident 1 returned to the facility on 11/03/21 following treatment for a diagnosis of left lower extremity fracture.

A review of the clinical record showed the following:

a. Staff 2 (RN) documented an assessment of Resident 1 on 10/26/21, prior to his/her return to the facility. The assessment lacked some of the required elements including findings, resident status, and interventions made as a result of the assessment.

b. Staff 2 completed an assessment on 11/11/21 (eight days after Resident 1 returned to the facility). The assessment was not completed timely and there was no documented evidence the service plan was updated as a result of the assessment.

The need to ensure the RN conducts a timely and complete assessment of all residents with significant changes of condition was discussed with Staff 1 (Administrator) and Staff 2 on 11/17/21. They acknowledged the findings.

Resident Health Services

1. RN assessments will be completed with review of clinicals, significant change of condition and prior to re-admission. Resident service plans will be updated once the resident returns to facility along with a TSP for monitoring.

2. Face to face nursing assessment will be required prior to re-admission.

3. RN will be responsible for following up with doctors/nurses when a resident gets sent out.

4. The Administrator and RN will be responsible in conducting a full-assessment prior to re-admission.  

Based on observation, interview and record review, it was determined the facility failed to ensure the RN performed an assessment, developed interventions based on the condition of the resident, and updated the service plan for 1 of 1 sampled resident (#5 ) who experienced a significant change of condition. This is a repeat citation. Findings include, but are not limited to:

Resident 5 was admitted to the facility in March 2020 with diagnoses including Parkinson's Disease and cognitive impairment.

The service plan dated 01/07/22 listed assistance for mobility and use of a walker, however, Resident 5 was not identified as a fall risk.

Progress notes and physician communications dated 01/17/22 through 02/22/22 and interviews with care staff on 02/22/22 and 02/23/22 indicated the resident had an ongoing decline. Resident 5 experienced a cluster of six falls in four weeks. On 01/21/22 Resident 5 was diagnosed with Covid-19, and then on 01/31/22 was diagnosed with a urinary tract infection. Care staff interviews indicated the resident was frequently falling and spent increased time asleep.

An RN progress note dated 02/14/22 documented "resident had become unresponsive, language unintelligible"... and "Advised to just send out 911 due to change in mental status" and "Follow up due to frequent falls, decreased appetite and decreased strength with ADL function."

The cluster of falls and overall decline, Covid-19 diagnosis, UTI diagnosis, ER visits, decreased appetite and decreased strength constituted a significant change of condition.

The facility failed to ensure an RN assessment was completed for the change of condition which documented findings, resident status and interventions made as a result of the assessment.

The need to ensure an RN assessment was completed related to significant changes in condition which documented findings, resident status and interventions made as a result of the assessment was discussed with Staff 1 (Administrator) and Staff 3 (RN) on 02/24/22. The staff acknowledged the findings.

Resident Health Services

1. RN assessments will be completed with review of clinicals, significant change of condition and prior to re-admission. Resident service plans will be updated once the resident returns to facility along with a TSP for monitoring. Once the RN has performed an assessment, clear instructions on interventions based on the condition of the resident will be documented in the updated service plan.

2. Face to face nursing assessment will be required prior to re-admission.

3. RN will be responsible for following up with doctors/nurses when a resident gets sent out.

4. The Administrator and RN will be responsible in conducting a full-assessment prior to re-admission.

Based on observation, interview and record review, it was determined the facility failed to ensure the facility RN completed an assessment of a resident's significant change of condition, for 1 of 2 sampled residents (#9) who had significant weight gain. This is a repeat citation. Findings include, but are not limited to:

Resident 9 was admitted to the facility in 10/2021 with diagnoses including dementia, atrial fibrillation, and chronic obstructive pulmonary disease.

The resident was being weighed daily. Review of the weight record from 06/01/22 through 07/12/22 indicated the following weights:

06/01/22: 159 pounds; and

07/01/22: 173 pounds.

Between 06/01/22 and 07/01/22, Resident 9 gained 14 pounds or 8.8% body weight in one month. This constituted a severe weight gain and represented a significant change of condition for which a facility RN assessment was required.

There was no documented evidence the facility RN conducted an assessment of the weight gain which documented findings, resident status and interventions made as a result of the assessment.

On 07/14/22, staff reported Resident 9 ate his/her entire breakfast. During lunch on 07/14/22, the resident was observed to not eat any of the meal, even though caregivers repeatedly offered verbal encouragement and asked if s/he wanted something different to eat. On 07/15/22, the resident was observed to eat approximately 75% of the breakfast and lunch meals, though it took him/her over an hour to finish. The resident had been receiving nutritional shakes twice daily since admission; staff reported the resident enjoyed the shakes and consumed them fully. Between 07/01/22 and 07/12/22, Resident 9's weight remained steady at between 171 and 173 pounds.

The resident's weight gain was discussed with Staff 3 (RN) on 07/14/22. Staff 3 acknowledged she had not been made aware of the weight gain and had not conducted an assessment. She stated she believed the resident's weight gain was due to the resident being less active recently and no longer ambulating as much as s/he had done in the past.

The need to ensure the facility RN completed an assessment of residents' significant changes of condition was discussed with Staff 3, Staff 5 (Program and Human Resources Director) and Staff 19 (Administrator) on 07/15/22. They acknowledged the findings. No additional information was provided.

Resident Health Services

1. An assessment for each resident with a significant change of condition of weight gain has been completed.

2.  Weights will be monitored by the Administrator on a daily basis and reported to the RN. The facility RN will be responsible for completing an assessment of a residents significant weight change of three or more pounds, unless doctors orders state otherwise. Detailed documentation of the findings, resident status and interventions will be placed on the weight change assessment form. The resident physician will be notified and the resident will be placed on alert following doctors recommendation. A TSP will be created stating proper interventions and resident status. If a severe weight gain occurs within a month, a Change of condition form will be completed and the resident service plan will be updated accordingly.

3. RN and Administrator will be responsbily for monitoring resident weights and creating a COC in a timely manner.  

4. The Administrator and RN will be responsible in conducting a full-assessment on all significant change of conditions.  

Based on interview and record review, it was determined the facility failed to ensure the delegation and supervision of special tasks of nursing care were completed in accordance with the Oregon State Board of Nursing (OSBN) Administrative Rules, for 2 of 2 sampled residents (#s 3 and 4) who had catheter care and insulin injections provided by unlicensed staff. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 03/2021 with diagnoses including quadriplegia and suprapubic catheter. The facility had signed physician orders to irrigate/flush the resident's catheter each evening. Records indicated non-licensed caregivers were delegated to provide this nursing task.

Delegation records for Resident 3, reviewed on 11/17/21, indicated Staff 3 (RN) failed to document all required components of delegation in accordance with the OSBN Administrative Rules, including:

* The stability of the resident's condition based on a nursing assessment;

* The rationale that the task can be safely delegated to an unlicensed caregiver;

* The rationale for how frequently the resident should be reassessed;

* Skill and ability of the caregiver;

* The rationale for how frequently the caregiver should be supervised and re-evaluated based on the competency of the caregiver; and

* That the RN takes responsibility for delegating the task and ensures supervision will occur for as long as the RN is supervising performance.

The process for completing and documenting the delegation process was reviewed with Staff 1 (Administrator), Staff 3 (RN) and Staff 5 (Human Resources Director) on 11/17/21. Staff 3 acknowledged the lacking documentation.

2. Resident 4 was admitted to the facility in 08/2021 with diagnoses including diabetes. The facility had a physician order to inject ten units of semglee insulin (for diabetes) every evening at 7:30 pm. Records indicated non-licensed caregivers were delegated to provide this nursing task.

Delegation records for Resident 4, reviewed on 11/16/21, indicated Staff 3 (RN) failed to document all required components of delegation in accordance with the OSBN Administrative Rules, including:

* The stability of the resident's condition based on a nursing assessment prior to delegating the task;

* The rationale that the task can be safely delegated to an unlicensed caregiver;

* The rationale for how frequently the resident should be reassessed;

* Skill and ability of the caregiver;

* The rationale for how frequently the caregiver should be supervised and re-evaluated based on the competency of the caregiver; and

* That the RN takes responsibility for delegating the task and ensures supervision will occur for as long as the RN is supervising performance.

The process for completing and documenting the delegation process was reviewed with Staff 1 (Administrator) and Staff 3 on 11/17/21. They acknowledged the findings.

Delegation and Teaching

1. The RN will re-delegate and re-teach all Med-Techs. Documentation will be individualized for each med tech, and delegations will be re-evaluated depending on the specific nursing task and the Med-techs competency level.

2. Retraining and re-delagation to be conducted. RN to follow up with Med-Tech and re-delegate as needed.

3. Evaluation will be conducted upon completion of med-training and competency level for a particular nursing task.

4. The Administrator and RN will be responsible for maintaining delegations.   

Based on interview and record review, it was determined the facility failed to ensure the delegation and supervision of special tasks of nursing care were completed in accordance with the Oregon State Board of Nursing (OSBN) Administrative Rules, for 1 of 1 sampled resident (# 6) who had insulin injections provided by unlicensed staff. This is a repeat citation. Findings include, but are not limited to:

Resident 6 was admitted to the facility in 04/2019 with diagnoses including Type 2 diabetes. The facility had signed physician orders to administer four units of Lantus, daily. Records indicated non-licensed caregivers were delegated to provide this nursing task.

Delegation records for Resident 6, reviewed on 02/24/22, indicated Staff 3 (RN) failed to document all required components of delegation in accordance with the OSBN Administrative Rules, including:

* The stability of the resident's condition based on a nursing assessment;

* The rationale for how frequently the resident should be reassessed;

* The rationale that the task can be safely delegated to an unlicensed caregiver; and

* The rationale for how frequently the caregiver should be supervised and re-evaluated based on the competency of the caregiver.

The process for documenting the delegation process was reviewed with Staff 1 (Administrator), Staff 2 (Assistant Manager), Staff 3 (RN) and Staff 5 (Human Resources Director) on 02/24/22. They acknowledged the findings.

Delegation and Teaching

1. The RN will re-delegate and re-teach all Med-Techs. Documentation will be individualized for each med tech, and delegations will be re-evaluated depending on the specific nursing task and the Med-techs competency level. The delegation form will be revised to include how frequent the resident should be assessed and how frequent the Med-Techs should be supervised and re-evaluated based on the Med-Techs competency level for a particular nursing task.

2. Retraining and re-delagation to be conducted. RN to follow up with Med-Tech and re-delegate as needed.

3. Evaluation will be conducted upon completion of med-training and competency level for a particular nursing task.

4. The Administrator and RN will be responsible for maintaining delegations.

Based on interview and record review, it was determined the facility failed to ensure a safe medication system and failed to ensure adequate professional oversight for 1 of 1 sampled resident (#7). Findings include, but are not limited to:

During the acuity interview on 07/13/22, staff reported Resident 7 required assistance with medication administration and was prescribed insulin based on the resident's CBG's prior to administration (sliding scale).

A review of Resident 7's 06/01/22 through 07/13/22 MAR's identified the MAR's lacked documented evidence for the dosage of sliding scale insulin that had been administered. This represented an unsafe medication system.

In an interview on 07/14/22, Staff 3 (RN), Staff 5(Program and Human Resource Director) and Staff 19 (Administrator) were unaware of the issue and had not previously identified the lack of documentation.

The need to ensure adequate professional oversight of the medication system was discussed with Staff 3, Staff 5 and Staff 19 on 07/14/22. They acknowledged the findings.

Refer to C 303, example 1

Systems: Medications and Treatments

1. All medication orders have been reviewed and re-inputted in the system with parameters. The system will prompt Med Techs to document the exact dosage given, following the parameters.

2. The administrator will be responsible for ensuring adequate professional oversight of the medication and treatment administration system. Once the facility inputs new doctors orders into the system, the Administor and/or facility RN will be responsible for reviewing and approving new orders. RN will ensure that all parameters are documented correctly in the system and med tech will be responsible for inputting exact dosage of sliding scale insulin.

3. Medication oversight to be checked on a daily basis by Administrator and RN and when new medication orders are inputted into the system.

4. Administrator and RN will be responsible for reviewing all medications and treatment orders and ensuring it is inputted correctly into the system.  

2. Resident 3 was admitted to the facility in 03/2021 with diagnoses including quadriplegia. Physician orders, the MAR and progress notes were reviewed. The following deficiencies were identified:

a. The facility had signed physician orders to obtain Resident 3's weight on the 1st of each month. Review of the MAR from 08/2021 through 11/14/21 indicated the facility failed to obtain the resident's weight on the 1st of each month as ordered, often documenting the resident was "out of facility."

b. The facility had signed physician orders to perform daily skin checks in the morning and before bed. Instructions directed staff to complete a "skin report" (a form that was routed to an RN for review) for any new skin breakdown or blisters.

Staff documented in a progress note on 11/03/21 that Resident 3 had a "sore" and a closed blister on one of his/her heels. On 11/03/21, 11/04/21 and 11/05/21 staff documented on the MAR that the resident had a blister on the inside right upper thigh.

There was no documented evidence the facility completed a skin report as ordered. In an interview on 11/16/21, Staff 3 (RN) reported she had not been made aware of the skin issues on Resident 3's heel and thigh.

The need to ensure orders were carried out as prescribed was discussed with Staff 1 (Administrator), Staff 3 and Staff 5 (Human Resources Director) on 11/17/21. They acknowledged the findings.

3. Resident 4 was admitted in 08/2021 with diagnoses including diabetes and hypertension. August 17, 2021 through November 15, 2021 MARs and physician orders dated 08/12/21, 09/27/21, 10/17/21 and 11/10/21 were reviewed.

a. Physician orders directed staff to administer 5 mg of Glipizide (for diabetes) three times a day. The MARs reflected Resident 4 was administered Glipizide twice a day from 08/18/21 through 10/18/21.

b. The resident had an order for amlodipine besylate (for blood pressure) with parameters to hold the medication for a systolic blood pressure lower than 100. On 11/9/21, staff documented a systolic blood pressure of 92. Documentation showed the medication was administered when parameters indicated it should have been held.

The need to ensure physician orders were carried out as prescribed was discussed with Staff 1 (Administrator) and Staff 3 (RN) on 11/17/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed, for 3 of 4 sampled residents (#s 1, 3 and 4) whose orders were reviewed. Findings include, but are not limited to:

1. Resident 1 moved into the facility in 07/2019 with diagnoses including congestive heart failure and edema.

Physician orders and MARs for Resident 1, reviewed from 11/01/21 - 11/15/21, revealed the following orders were not followed:

* Acetaminophen 1000 mg TID (for pain) was not administered as ordered from 11/01/21 - 11/16/21;

* Potassium CL ER 10 MEQ (for edema) was not administered as ordered. The facility was administering 20 MEQ; and

* Torsemide 20 mg (for edema) was not administered as ordered. The facility was administering 30 mg.

The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (Administrator) and Staff 3 (RN) on 11/17/21. They acknowledged the findings. Staff 3 provided a copy of orders, signed by the physician on 11/16/21, to clarify current orders.

Treatment Orders

1. Once Doctors orders are received, RN must review orders and approve in MAR. RN must review orders to the exact dose and wording prior to approval. Med Techs are required to follow the MAR and order medication specifically to doctors orders.

2. RN and Administrator will review the MAR for all residents and compare to doctors orders. Changes will be made to match all orders.

3. RN and Administrator will need to evaluate for every new doctors order.

4. The Administrator, RN and Med Techs will be responsible for maintaining accurate MAR orders.  

Based on observation, interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed, for 1 of 2 sampled residents (# 6) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 6 moved into the facility in 04/2019 with diagnoses including Type 2 diabetes and diastolic congestive heart failure (CHF). Resident 6 was dependant on staff for all transfers and repositioning while in bed.

Physician orders dated 02/17/22 and 02/01/22 through 02/22/22 MAR was reviewed and identified the following orders were not administered as prescribed:

* Daily weights related to CHF, notify RN with significant weight change of 3 lbs or more within one day;

* Fax daily weights and blood pressure (BP) to NWRC (clinic) every 2 weeks;

* Aspiration precautions to include: sit upright to 90 degrees for all oral intake, small bites and sips, eat and drink slowly, swallow completely and alternate small bites and small sips;

* Nectar thick liquids; and

* Float heels and avoid placing pillow under the left Achilles tendon.

The MAR indicated Resident 6 had a 3 pound weight gain from 02/04/22- 02/05/22.

Interview with Staff 8 (Nursing Aide), 02/22/22, confirmed there was no documentation that the RN was notified of the three pound weight change from 02/04/22-02/05/22 and no documentation that the clinic was notified of daily weights or BP every two weeks.

Observations of Resident 6 completed 02/22/22 through 02/23/22 showed the following:

* During both days, thin liquids were served during breakfast and lunch meals;

* During both days, Resident 6 was served cookies while laying down in bed and the staff member didn't follow the aspiration protocols to sit him/her upright 90 degrees; and

* During both days, the resident's heels were not floated.

On 2/23/22 at 11:20 am, surveyor requested Staff 3 (RN) observe Resident 6's heels for potential skin breakdown and aspiration protocols that were not being followed. Resident 6's left side of heel had a reddened area, however was not warm to the touch and the skin was intact. Staff 3 indicated s/he would provide clear aspiration protocols for staff to follow and would ensure the resident's heels were floated, while in bed.

The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (Administrator), Staff 2 (Assistant Manager), Staff 3 and Staff 5 (Human Resources Director) on 02/24/22. They acknowledged the findings.

Treatment Orders

1. Once Doctors orders are received, RN must review orders and approve in MAR. RN must review orders to the exact dose and wording prior to approval. Med Techs are required to follow the MAR and order medication specifically to doctors orders. Daily weights and blood pressures will be faxed to the clinic requested per order and placed in the "weights and blood pressure binder" for documentation. Aspiration precautions will be posted in residents rooms per order and updated in the service plan to reflect, in detail,  resident needs and staff instructions.

2. RN and Administrator will review the MAR for all residents and compare to doctors orders. Changes will be made to match all orders.

3. RN and Administrator will need to evaluate for every new doctors order.

4. The Administrator, RN and Med Techs will be responsible for maintaining accurate MAR orders.  

2. Resident 9 was admitted to the facility in 10/2021 with diagnoses including dementia, atrial fibrillation, and chronic obstructive pulmonary disease.

The resident had signed physician orders for the facility to obtain daily weights, and instructions on the MAR directed the facility to notify the the resident's health care provider for a weight increase of 3 pounds in one day or 5 pounds in one week.

Review of the resident's MAR from 06/01/22 through 07/13/22 indicated the resident's weight increased from 161 pounds on 06/15/22 to 164.5 pounds on 06/16/22 - an increase of 3.5 pounds in one day.

There was no documented evidence the facility notified the provider as ordered.

The need to ensure physician orders are carried out as prescribed was reviewed with Staff 1 (Lead MT) on 07/14/22, and with Staff 3 (RN), Staff 5 (Program and Human Resources Director) and Staff 19 (Administrator) on 07/15/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed, for 2 of 3 sampled residents (#s 7 and 9) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 7 moved into the facility in 01/2020 with diagnoses including Type 2 diabetes.

Physician orders dated 12/10/21, pharmacy review dated 03/29/22, subsequent insulin orders dated 05/28/22 and 06/01/22 through 07/13/22 MAR's were reviewed during the survey and identified the following:

* Resident 7 was prescribed Lispro 100 insulin per sliding scale where the dosage was based on the resident's CBG obtained just prior to administration. The sliding scale directed the insulin to be held for a CBG less than 150. There was no documentation the medication was held as ordered for 33 occasions where the resident's CBGs were less than 150; and

* The facility was not documenting the number of sliding scale insulin units administered; therefore, there was no documented evidence the facility had administered the correct insulin dosage.

During an observation and interview on 07/14/22 at 1:17 pm, Staff 10(MT), showed the surveyor the resident's electronic MAR. Staff 10 explained the MAR failed to automatically prompt MT's to enter the reason for holding the insulin which would then reflect on the MAR as if the insulin had been administered. Staff 10 further reported "sometimes when we are working too quickly, some MT's will forget to manually enter an exception note which would then indicate the medication was in fact held."

During an interview with Staff 3 (RN), Staff 5 (Program and Human Resources Director) and Staff 19 (Administrator) on 07/14/22, it was reported that they were unaware of both issues on the MAR and immediately began problem solving the issue.

A review of Resident 7's quarterly diabetic assessment and CBG record between 06/01/22 through 07/13/22 indicated the resident's CBG's stayed within normal range, which indicated no apparent negative impact on the resident.

The need to ensure physician orders were carried out as prescribed was reviewed with Staff 3 (RN), Staff 5 (Program and Human Resources Director) and Staff 19 (Administrator) on 07/14/22. They acknowledged the findings.

Systems: Treatment Orders

1. Parameters have been added for all insulin orders. A prompt is now showing requiring all med techs to input the insulin units that were given or "Held" if the insulin was not given. The system requires all Med techs to complete each prompt prior to completing the task. All Med Techs have been retrained on how to properly follow doctors orders on the MAR.

2. Med Techs are required to follow specific doctors orders on the MAR. On all sliding scale insulin orders, parameters will be noted in the description of the MAR and Med Techs will be responsible for documenting the number of sliding scale insulin units that was administrated. If the doctors order states to hold insulin if CBG is less than a specific number, the med techs are required to document that the insulin was held.

3. RN and Administrator will review the MAR on a weekly basis to ensure that all meds techs are documenting the insulin units given, correctly.

4. The Administrator, RN and Med Techs will be responsible for maintaining accurate MAR orders and training Med Techs on all new orders.   

3. Resident 3 was admitted to the facility in 03/2021 with diagnoses including quadriplegia and suprapubic catheter. The record indicated Resident 3 experienced chronic, intermittent body pain for which s/he was prescribed PRN hydrocodone 5mg/acetaminophen 325 mg (a narcotic pain medication).

Review of Resident 3's MAR and the Narcotic Disposition Log from 11/01/21 through 11/14/21 indicated multiple instances where the MAR and the disposition log did not match. It appeared medication technicians sometimes failed to document on the MAR when the PRN medication had been packed and given to the resident to self-administer when s/he was out of the facility for the day.

The need to ensure the facility maintained an accurate MAR was reviewed with Staff 1 (Administrator), Staff 3 (RN) and Staff 5 (Human Resources Director) on 11/17/21. They acknowledged the findings.

4. Resident 4 was admitted to the facility with diagnosis including diabetes. The August 2021 MAR and 08/12/21 physician's orders were reviewed.

The physician order directed staff to inject ten units of semglee (for diabetes) at 8:00 pm. There were blanks on the MAR on 08/18/21 and 08/19/21. There was no documented evidence if the resident received the medication.

The need to ensure resident MARs were accurate was discussed with Staff 1 (Administrator) and Staff 3 (RN). They acknowledged the findings.  

2. Resident 1 was admitted to the facility in 07/2019 and had diagnoses including a recent ankle fracture. The resident's current physician's orders and 11/01/21 through 11/16/21 MARs were reviewed and revealed the following medication orders had not been transcribed to the current MAR:

* Bisacodyl suppository (for bowel care);

* Diclofenac gel (for pain);

* Lidocaine patch (for pain);

* Miconazole powder (for rash);

* Miralax powder (for bowel care); and

* Oxycodone (for pain).

The need to ensure resident MARs were accurate was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 11/17/21. They acknowledged the findings. Staff 2 provided a copy of orders, signed by the physician on 11/16/21, to clarify current orders.

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

1. Resident 2's 10/01/21 through 10/31/21 MAR was reviewed.

Resident 2's MAR revealed multiple blanks for monitoring the resident's discomfort and monitoring a lesion on his/her middle finger.

In an interview with Staff 1 (Administrator) at 1:50 pm on 11/15/21, she acknowledged the blanks on the MAR.

The need to ensure an accurate Medication Administration Record (MAR) must be kept of all medications, including date and time given, was reviewed with Staff 1 (Administrator) and Staff 2 (Assistant Manager) on 11/17/21. They acknowledged the MARs were not accurate.

Medication Administration

1. All Med-Techs to be retrained to ensure that all medications on the MAR are checked off as they are given. RN to ensure that correct doctors orders are inputted into the MAR.

2. RN and Administrator to review the MAR for all residents to make sure they coincide with the most recent doctors order.

3. RN and Administrator will need to evaluate for every new doctors order.

4. The Administrator, RN and Med-Techs will be responsible for making sure the MAR follows the most recent doctors order.  

Based on interview and record review, it was determined the facility failed to ensure residents' MARs included medication specific instructions and had parameters for multiple PRN medications prescribed for the condition for 1 of 2 sampled residents (# 6) whose MARs were reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 6's 02/01/22 through 02/22/22 MAR reviewed identified the following inaccuracies:

* Vitamin C tablet notes to give 1-2 tablets daily, lacked instructions indicating when unlicensed staff should administer the second tablet;

* LMX cream prescribed for pain lacked instructions regarding the location of the pain; and

* PRN Gvoke Hypopen and PRN glutose gel prescribed for hypoglycemia lacked parameters regarding the sequence of administration.

The need to ensure the MAR had medication specific instructions and parameters for multiple PRN medications prescribed to treat the same condition was reviewed with Staff 1 (Administrator), Staff 2 (Assistant Manager), Staff 3 (RN) and Staff 5 (Human Resource Director) on 02/24/22. They acknowledged the findings.

Medication Administration

1. All Med-Techs to be retrained to ensure that all medications on the MAR are checked off as they are given. RN to ensure that correct doctors orders are inputted into the MAR. Residents MAR will include specific medication instructions and parameters for PRN medications prescribed for the condition.

2. RN and Administrator to review the MAR for all residents to make sure they coincide with the most recent doctors order and updated doctors orders with specifications will be requested if needed.

3. RN and Administrator will need to evaluate for every new doctors order.

4. The Administrator, RN and Med-Techs will be responsible for making sure the MAR follows the most recent doctors order.

Based on observation, interview and record review, it was determined the facility failed to ensure documentation of the use of supportive devices with restraining qualities was included in the resident's service plan and evaluated on a quarterly basis, for 1 of 2 sampled residents (#3) with devices with restraining qualities. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 03/2021 with diagnoses including quadriplegia. During a tour of the resident's room on 11/15/21, bilateral half-length side rails were observed on Resident 3's hospital bed. The side rails were in the up position and fastened securely to the bed.

In an interview on 11/16/21, Staff 14 (CG) acknowledged the use of the side rails and explained they were used to position personal items such as the call light and the resident's cell phone charger within easy reach for the resident. Staff 14 also reported the resident used a seat belt for safety and security when in his/her power wheelchair. Staff 14 stated she did not think the resident could remove the seatbelt independently.

Resident 3's record included documentation by the facility RN of the use of the side rails and the seatbelt. The initial documentation was dated 03/19/21; only the side rails had been re-evaluated (dated 05/26/21). The use of the side rails was documented in the resident's current service plan; the use of the seat belt was not included in the service plan.

The need to ensure all devices with restraining qualities were evaluated quarterly and their use documented in the resident's service plan was reviewed with Staff 1 (Administrator), Staff 3 (RN) and Staff 5 (Human Resources Director) on 11/17/21. They acknowledged the devices had not been evaluated quarterly and the seatbelt was not documented in the service plan.

Restraints and Supportive Devices

1. All restraints and supportive devices will be evaluated quarterly and documented in the service plan with specifics for each resident.

2. All restraints and supportive devices will be re-evaluated for each resident and service plans will reflect the re-evaluations per resident.

3. Evaluation will be conducted upon move-in and quarterly or with doctors orders on new equipment.

4. The Administrator and RN will be responsible for conducting the evaluations.

2. Resident 6 was admitted to the facility in March 2020 with diagnoses including Parkinson's Disease and cognitive impairment.

Observations on 02/22/22 showed two side rails attached to the bed and in the upright position while Resident 5 was seated in a reclining chair. The rails appeared firmly attached to the bed, and did not show a gap between the bed and the mattress.

In an interview on 2/23/22, Staff 9 (CG) stated she had not received training on how to the side rails were used.

The most recent service plan, dated 1/7/22 referenced the side rails, however it lacked:

* Instructions for when and how the side rails were to be used;

* Clear documentation of the use, risk and precautions related to the device; and

* The evaluation was not updated quarterly, with the most recent review completed on 10/13/21.

An interview on 02/23/22, Staff 2 (Assistant Manager), reported s/he did safety checks on all the devices quarterly, to ensure they were working properly, however s/he doesn't complete an evaluation for the appropriate use of the device or the residents' ability to continue using the device.

The need to ensure all devices with restraining qualities were evaluated quarterly and the use of the device was documented in the resident's service plan was reviewed with Staff 1 (Administrator), Staff 2, Staff 3 (RN) on 02/24/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure documentation of the use of supportive devices with restraining qualities was included in the resident's service plan and evaluated on a quarterly basis, for 2 of 2 sampled residents (#s 5 and 6). This is a repeat citation.  Findings include, but are not limited to:

1. Resident 6 was admitted to the facility in 04/2019 with diagnoses including myocardial infarction, diastolic congestive heart failure, chronic respiratory failure and Type 2 diabetes.

On 02/22/22 the door to Resident 6's apartment was open while the resident was asleep from 12:50 pm- 3:30 pm. Bilateral half-length side rails were observed on the hospital bed and the side rails were in the up position. The hospital bed was positioned approximately three feet from the ground and in the middle of the room.

During an interview on 02/23/22, Resident 6 reported s/he was unable to raise or lower the side rails, was unable to use the side rails to reposition in the bed, and unable to use the side rails during ADL care. S/he stated this was due to lack of strength in the upper body and arms. S/he reported the bed rails were always up and were used to prevent falling from bed.

The most recent half-length bilateral side rail evaluation was completed on 04/07/20. The evaluation noted the following:

* Bed rails were not usually in use and found in the down position, bed placement at the lowest position;

* Risks were avoided by lowering the bed, proper mattress and monitoring gaps between mattress and side rails;

* A signature page indicating "safety check" was completed on 01/27/22;

* There were no instructions for caregivers on the correct use and the risk and precautions related to the use of the device;

* Clear documentation of the use, risk and precautions related to the device were not added to the current service plan; and

* The evaluation was not updated quarterly.

An interview on 02/23/22, Staff 2 (Assistant Manager), reported s/he did safety checks on all the devices quarterly, to ensure they were working properly, however s/he doesn't complete an evaluation for the appropriate use of the device or the residents' ability to continue using the device.

The need to ensure all devices with restraining qualities were evaluated quarterly and the use of the device was documented in the resident's service plan was reviewed with Staff 1 (Administrator), Staff 2, Staff 3 (RN) and Staff 5 (Human Resources Director) on 02/24/22. They acknowledged the findings.

Restraints and Supportive Devices

1. All restraints and supportive devices will be evaluated quarterly and documented in the service plan with specifics for each resident. The documentations will include restraining qualities with specific instructions for the care staff on the correct use and the risks and precautions related to the device.

2. All restraints and supportive devices will be re-evaluated for each resident and service plans will reflect the re-evaluations per resident.

3. Evaluation will be conducted upon move-in and quarterly or with doctors orders on new equipment.

4. The Administrator and RN will be responsible for conducting the evaluations.

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 newly hired staff (#s 7 and 15) had completed First Aid certification and been trained in abdominal thrust within 30 days of hire. Findings include, but are not limited to:

The facility's training records were reviewed on 11/16/21 and the following was identified:

Staff 7 (MT) hired 08/23/21 and Staff 15 (CG) hired 08/31/21, lacked documented evidence of First Aid and abdominal thrust training.

The need to ensure First Aid and abdominal thrust was completed within 30-days of hire was discussed with Staff 1 (Administrator) and Staff 5 (Human Resources Director) on 11/16/21 and 11/17/21. They acknowledged the findings.

Training within 30-days: Direct Care Staff

1. First Aid/CPR instructor is scheduled to come out to the facility on 12/16 and 12/17 to certify direct care staff in First aid/cpr and abdominal thrust. Once certification is completed, documentation will be recorded and place into the employee folders.

2. First Aid/CPR and Adominal Thrust training will be held for direct care staff or within 30 days for new hires.

3. Human Resource Director will review all training certificates during the Quality Improvement meetings on a monthly basis.

4. Human Resourse Director will be responsible for scheduling First aid/cpr classes when needed.

Based on interview and record review, it was determined the facility failed to ensure all required elements were documented for fire drills in accordance with Oregon Fire Code (OFC) and fire and life safety instruction was provided on alternate months. Findings include, but are not limited to:

Review of fire drill and fire and life safety records from June 2021 through October 2021 identified the following:

* The facility failed to provide fire and life safety instruction to staff on alternate months: and

* Problems encountered, comments relating to residents who resisted or failed to participate in the drill were not documented.  

The need to ensure the facility documented all required elements for fire drills was reviewed with Staff 1 (Administrator), Staff 2 (Assistant Manager) and Staff 5 (Human Resources Director). They acknowledged the findings.

Fire and Life Safety: Drills and Instructions

1. Fire and Life Safety training with residents and staff will be conducted on alternate months effective immediately.  On 11/2021- Lockdown/Active Shooter in Healthcare Training was completed. Any consistent refusal from residents will be documented in the resident service plans.

2. Training will continue every other month.

3. Every other month, assistant manager will determine a specific training for fire and life safety.

4. The Administrator and the assistant manager will be responsible for conducting the training with the staff.

Based on interview and record review, it was determined the facility failed to instruct new residents on fire and life safety within 24 hours of admission and provide Fire and Life Safety instruction to residents annually. Findings include, but are not limited to:

Fire drill records, from 06/2021 through 10/2021, were reviewed on 11/16/21 with Staff 2 (Assistant Manager).  

* There was no documented evidence new residents were instructed on fire and life safety within 24 hours of admission; and

* Staff 2 stated the facility was not providing or documenting annual instruction for residents in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire.

The requirements for Fire and Life Safety instruction for residents were reviewed with Staff 1 (Administrator), Staff 2 and Staff 5 (Human Resources Director) on 11/16/21. They acknowledged the findings.

Fire and Life Safety: General

1. Instruct new residents on fire and life safety within 24 hours of admission. The facility move-in package includes Procedure for Emergency Evacuation & Fire Safety. Follow up training with residents will be conducted annually. Fire and safety will be documented in resident service plan.  

2. Assistant manager will review the fire and safety plan with each resident in direct them to point of safety.

3. Fire and safety training will be done with staff and residents on alternating months. 1:1 training with individual residents will be conducted annually. Documentation in the service plan will be revised at move-in, quarterly and as needed.

4. The Administrator and the Assistant Manager are responsible for proper training with residents and documentation.  

Based on interview and record review, it was determined the facility failed to provide Fire and Life Safety instruction to residents. This is a repeat citation. Findings include, but are not limited to:

Fire drill records were reviewed on 02/22/22 with Staff 2 (Assistant Manager).  

Staff 2 reported the facility had updated the fire drill form, however the facility had not re-instructed residents on fire and life safety training topics.

The requirement to provide residents with training in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire; and to keep a written record of fire safety training, including content of the training sessions and the residents that were in attendance was discussed with Staff 1 (Administrator), Staff 2, Staff 3 (RN) and Staff 5 (Human Resources Director) on 02/24/22. They acknowledged the findings.

Fire and Life Safety: General

1. The Fire and Life Safety instructions have been provided to the residents with specifics on general safety procedures, evacuation methods, responsibilities during fire drills and designated meeting place outside the facility. A written record will be kept and recorded by the Building Manager. Kellyville will continue to instruct new residents on fire and life safety within 24 hours of admission. The facility move-in package includes Procedure for Emergency Evacuation & Fire Safety. Follow up training with residents will be conducted annually. Fire and safety will be documented in resident service plan.  

2. Assistant manager will review the fire and safety plan with each resident in direct them to point of safety.

3. Fire and safety training will be done with staff and residents on alternating months. 1:1 training with individual residents will be conducted annually. Documentation in the service plan will be revised at move-in, quarterly and as needed.

4. The Administrator and the Assistant Manager are responsible for proper training with residents and documentation.

Based on interview and record review, it was determined the facility failed to ensure their relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:

Refer to C231, C260, C270, C280, C282, C303, C310, C340, C422 and C513.

Inspections and Investigation: Insp Interval

1. The facility will ensure that the plan of correction is implemented and followed by all staff.

2-4. Refer to C231, C260, C270, C280, C282, C303, C310, C340, C422 and C513.  

Based on observation, interview and record review, it was determined the facility failed to ensure its survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:

Refer to C 231, C 260, C 270, C 280 and C 303.

Inspections and Investigations: Insp Interval

1. The facility will ensure that the plan of correction is implemented and followed by all staff.

2-4. Refer to C231, C260, C270, C280, C300, C303, and C455.  

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

The exterior patio and walkways of the building were toured on 11/15/21 at 11:15 am. There were multiple sections of the sidewalk with drop-offs of up to one and one-half inches measured from the concrete surface to the planting beds. These drop-offs represented tripping/fall risks for residents.

The drop-offs were reviewed with Staff 1 (Administrator) and Staff 2 (Assistant Manager) on 11/16/21. They acknowledged the drop-offs.

General Building: Exterior

1. The facility maintence will fill the planting beds with bark dust to level with the concrete surface. This will elimate tripping or fall risks.

2. Planting beds will be leveled out.

3. Maintenance will evaluated and refilled as needed.

4. The Administrator and facility maintenance will be responsible for ensuring our planting beds are level with the concrete surface.  

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

The interior of the facility was toured on 11/15/21 at 10:20 am. The following deficiencies were identified:

* The doors and/or door frames of resident rooms 104, 106, 112, 117, 202 and 215 were scraped, scuffed or gouged;

* The doors and/or door frames of the small shower room on "Purple Hall" and the laundry room on "Pink Hall" were scraped, scuffed or gouged;

* The fan switch in the shower room on "Blue Hall" was damaged;

* Wooden handrails across from rooms 104 - 108, on the second floor next to the Salon and across from room 218 were gouged or damaged leaving a surface that was rough to the touch; and

* The bases of the columns in the first floor main hallway were scraped and gouged.

The areas needing repair were reviewed with Staff 1 (Administrator) and Staff 2 (Assistant Manager) on 11/16/21. They acknowledged the items needing cleaning or repair.

Doors, Walls, Elevators, Odors

1. The Facility Maintenance will conduct a walk through of the facility and patch and repaint all doors, door frames and bases. The fan switch in the shower room in the blue hall will be replaced, and all wooden hand rails throughtout the facility will be sanded and repainted.

2. Facility Maintenance will conduct a walk through of the facility and fix/repair anything damaged, scraped or scuffed.

3. Facility maintenance will conduct a walk through on a weekly basis to ensure that no other damages have been made.

4. The Administrator and the facility maintenance will be responsible for maintaining the appearance of the facility.  

Based on observation and interview, it was determined the facility failed to keep all interior materials and surfaces in good repair. This is a repeat citation. Findings include, but are not limited to:

The interior of the facility was toured on 02/23/22 at 10:20 am with Staff 2 (Assistant Manager). The following deficiencies were identified:

* The doors and/or door frames of resident rooms 103, 104, 106, 107, 109, 112, 117, 202, 210, and 215 were scraped, scuffed or gouged;

* Door frames and doors to the shower room and laundry room on the blue, pink, and purple halls were damaged;

* Wall base in the dining room near the kitchen entrance was gouged and damaged, and

* The bases of the columns in the first floor main hallway were scraped and gouged.

The areas needing repair were reviewed with Staff 1 (Administrator) and Staff 2 (Assistant Manager) on 02/23/22. They acknowledged the items needing repair.

Doors, Walls, Elevators, Odors

1. The Facility Maintenance will conduct a walk through of the facility to ensure all interior materials and surfaces are in good condition.

2. Facility Maintenance will conduct a walk through of the facility and fix/repair anything damaged, scraped or scuffed.

3. Facility maintenance will conduct a walk through on a weekly basis to ensure that no other damages have been made.

4. The Administrator and the facility maintenance will be responsible for maintaining the appearance of the facility.

Based on observation and interview, it was determined the facility failed to ensure operable resident windows above the second floor with sill heights lower than 36 inches were designed to prevent accidental falls. Findings include, but are not limited to:

The interior of the facility was toured on 11/15/21 at 10:20 am. During the tour, an unsampled resident's room on the second floor was observed with the window open approximately 30 inches wide. Upon inspection, the window was found to lack any means of limiting how wide the window could be opened to prevent accidental falls. The height of the window sill was 25 inches above the floor. Another second-floor unsampled resident's window was inspected and was also found to lack any means of limiting how wide the window could be opened. Window sills on the second floor were all 25 inches above the floor.

The need to ensure second floor resident windows were designed to prevent accidental falls was reviewed with Staff 1 (Administrator) and Staff 2 (Assistant Manager) on 11/16/21. They acknowledged there were no limiting devices on the windows.

Resident Units

1. All the windows in every bedroom on the second floor will have a limiting device installed at the top of each window to prevent accidental falls.

2. Limiting devices have been ordered and will be installed in all upstairs bedrooms.

3. Facility maintenance to inspect limiting devices on a weekly basis to ensure the safety of each resident.

4. The Administrator and the facility maintenance will be responsible for ensuring the limiting device's are installed and secure.

Based on observation and interview, it was determined the facility failed to maintain hot water temperatures in residents' units within a range of 110 - 120 degrees Fahrenheit (F). Findings include, but are not limited to:

The interior of the facility was toured on 11/15/21 at 10:20 am. The hot water temperature taken in the common shower room on "Red Hall" with the surveyor's digital thermometer at 10:35 am was 140 degrees F. The hot water temperature taken in the common shower room on "Blue Hall" with the surveyor's digital thermometer at 10:47 am was 132.8 degrees F.

The surveyor informed Staff 1 (Administrator) and Staff 2 (Assistant Manager) of the excessive water temperatures on 11/15/21 at 11:15 am. Staff 2 stated she was aware the water temperatures exceeded 120 degrees F but said residents complained when she decreased the temperatures. The surveyor informed her the water temperatures could not exceed 120 degrees F.

The hot water temperatures in the two shower rooms were re-tested on 11/16/21 at 10:50 am and found to still be in excess of 120 degrees F. Staff 1 and 2 were notified of the temperatures. Staff 2 stated she would immediately decrease the water temperatures.

Plumbing Systems

1. The water temperatures in all shower rooms will be reset between 110-120 degrees F.

2. Facility maintenance will recheck and adjust, if needed, all shower rooms water temperatures.

3. The Facility maintenance will check the water temperature throughout the facility on a monthly basis.

4. The Administrator and the facility maintenance are responsible for maintaining the water temperature within a range of 110-120 degrees F.  

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

The interior of the facility was toured on 11/15/21 at 10:20 am. There were four exit doors on the first floor through which residents could exit the building: the front door, the patio door in the dining room and an exit door at the end of each of two hallways. When the surveyor exited through these doors, no audible alert was heard.

In an interview on 11/15/21 at 3:00 pm, Staff 1 (Administrator) confirmed there was no system that alerted staff when a resident exited any of the doors except video cameras. However, the video camera monitors were in Staff 1's office and were not monitored consistently or after Staff 1 left for the day. Staff 1 acknowledged the facility needed to install a system that alerted staff when a resident exited the building any time of the day or night.

Call Sys, Exit, Dr Alarm, Phones, TV or Cable

1. Exit door alarms to be installed on all doors to alert staff when/if a resident exits the facility.

2. Doors alarms have been purchased and will be installed at each exit door.

3. Maintenance will be responsible for checking each door on a daily basis to ensure staff are notifed when residents exit.

4. The Administrator and facility maintenance will be responsible for installing and ensuring the alarm works properly on a daily basis.