The findings of the change of ownership survey, conducted 08/05/24 through 08/07/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.
Abbreviations possibly used in this document:
ADL:activities of daily living
bid:twice a day
CBG:capillary blood glucose or
blood sugar
CG:caregiver
cm:centimeter
ED:Executive Director
F:Fahrenheit
HH:Home Health
LPN:Licensed Practical Nurse
MA: Medication Aide
MAR:Medication Administration
Record
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 change of ownership survey of 08/07/2024, conducted 12/17/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.
Abbreviations possibly used in this document:
ADL:activities of daily living
bid:twice a day
CBG:capillary blood glucose or
blood sugar
CG:caregiver
cm:centimeter
ED:Executive Director
F:Fahrenheit
HH:Home Health
LPN:Licensed Practical Nurse
MA: Medication Aide
MAR:Medication Administration
Record
MCC:Memory Care Community
mg:milligram
ml:milliliter
MT:Medication Technician
OT:Occupational Therapist
PT: Physical Therapist
PRN:as needed
qd:every day or daily
qid:four times a day
QI: quality improvement
RCC: Resident Care Coordinator
RN: Registered Nurse
TAR: Treatment Administration
Record
tid: three times a day
The findings of the second re-visit to the re-licensure survey of 08/07/24, conducted on 02/27/25, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, and OARs 411 Division 004 Home and Community Based Services Regulations.
Based on observation, interview, and record review, it was determined the facility failed to provide effective administrative oversight to ensure quality of care and services rendered in the facility. Findings include, but are not limited to:
During the re-licensure survey, conducted 08/05/24 through 08/07/24, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the scope, severity, and number of citations.
Refer to deficiencies in the report.
1. Markham House will employ a full-time, 40 hours a week, licensed RCF Administrator with experience and a successful history in leading a community-based care setting as an Executive Director.
2. The Executive Director, in addition to the business office manager, will have meetings and check-ins with the owner and provide updates in the resident care and services rendered by the facility.
3. Owner will evaluate the Executive Director's ability to provide administrative oversight during the bi-monthly check-ins with the Executive Director and the business office manager
4. The Executive Director is responsible for providing effective administrative oversight to the facility. The business office manager and the owner will be responsible for monitoring the successful administrative oversight in the facility.
There are no detail notes for this visit.
Based on observation and interview, it was determined the facility failed to ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to:
On 08/05/24 at 10:15 am, the following areas were observed in the kitchen:
* The ceiling vents and sprinklers had a layer of dust;
* The floor underneath the dishwasher had an uneven surface, cracks and water damage;
* The dishwasher digital thermometer indicated that the rinse cycle temperature reached between 150 F and 170 F, not 180 F as indicated on the dishwasher data plate.
* Two staff did not restrain their hair.
The findings were discussed with Staff 1 (Resident Care Manager) and Staff 2 (Chef) on 08/07/24. The findings were acknowledged.
1. The following actions will be taken to correct the violations:
a. The ceiling vents and sprinklers covered with dust will be cleaned by the Maintenance manager.
b. The floor underneath the dishwasher has an uneven surface, cracks and water damage. The uneven surface, cracks on flooring and water damaged will be repaired and fixed by an outside provider / maintenance manager.
c. The dishwaher digital thermometer indicated rinse cycle temprature reached between 150 F and 170 F, not 180 F as indicated on the diswasher data plate. The digital thermometer has been fixed and is consistently reaching 180 F temprature rinse cycle.
d. Two staff did not restrain their hair. Dietary staff will be provided an in-service training regarding safe food handling and infection control procedure, including wearing aprons and tying/restratining hair during kitchen service. Signs/ reminders will be placed regarding restraining/ tying their hair while in service.
2. How will the system be corrected so this violation will not happen again?
a. Chef Manager and POD will complete a visual check of the kitchen for potential needs for repair quarterly and as needed. POD will clean the clean the vents and sprinkler quarterly and as needed. Chef manager will be checking the dishwasher temprature monthly to ensure that the thermometer is acccurate.
b.Every dietary employees will continue to receive biannual trainings of safe food handling practices. For every new employee, dining staff members will receive safe food handling training as part of pre-service requirements, in addition to the bi-annual scheduled trainings.
3.The systems to ensure that food is prepared and served in accordance with the Oregon Food Sanitation Rules including cleaning, repairs, proper safe food handling practices will be evaluated by Executive Director monthly during monthly Management Meeting.
4. The Excutive Director will be responsible for overseeing that the above systems are in place and continously monitored.
Based on observation and interview, it was determined the facility failed to ensure the kitchen was maintained and food was stored in accordance with the Food Sanitation Rules OARs 333-150-0000. This is a repeat citation. Findings include, but are not limited to:
On 12/17/24, the following areas were observed in the kitchen:
* The flooring below the dish machine was damaged and pulling up.
* The hand washing sink faucet was damaged and basin was soiled and had debris.
* There were multiple undated, unlabeled, or uncovered food items in the walk in refrigerator and the deli-refrigerator.
* Butter, a potentially hazard food, was left un-refrigerated on the dining room tables.
The areas in need of repair and the food storage concerns were discussed with Staff 2 (Culinary Services Director) and Staff 18 (ED). They acknowledged the findings.
1. The following actions will be taken to correct the violations.
a. The flooring underneath the dish machine was damaged and pulling up. The flooring underneath the dish machine will be replaced/repaired by an outside contractor.
b. The handwashing sink faucet was damaged and basin was soiled and had debris. Maintenance Manager will fix the faucet, clean the sink and put a " hand washing sink" sign only.
c.There were multiple undated, unlabeled, or uncovered food items in the walk-in refrigerator & the deli-refrigerator. Chef manager will re-train all kitchen staff with safe food handling with regards to food labeling and food storage.
d. Butter, a potentially hazard food, was left un-refrigerated on the dining room tables. Chef manager has instructed kitchen staff to refrigirate the butter and serve the butter as needed/ requested by residents and not be left out in the dining room.
2. How will the system be corrected so this violation will not happen again?
a. Chef Manager and POD will complete a visual check of the kitchen for potential needs for repair quarterly and as needed.
b. Every dietary employees will continue to receive biannual trainings of safe food handling practices. For every new employee, dining staff members will receive safe food handling training as part of pre-service requirements, in addition to the bi-annual scheduled trainings.
3. How often will the area needing correction be evaluated?
The systems to ensure that food is prepared and served in accordance with the Oregon Food Sanitation Rules including cleaning, repairs, proper safe food handling practices will be evaluated by Executive
Director monthly during monthly Management Meeting.
4. Who will be responsible to see that the corrections are completed/ monitored?
The Excutive Director will be responsible for overseeing that the above systems are in place and
continously monitored.
There are no detail notes for this visit.
2. Resident 1 moved into the facility in 07/2024 with diagnoses including type II diabetes without complication.
The resident's 07/02/24 service plan was reviewed, observations were made, and interviews with caregivers were conducted during the survey.
a. The 07/02/24 service plan, which was available to staff, was not updated within 30-days of move-in to reflect changes in skin and ADLs status.
b. In addition, Resident 1's service plan was not reflective, did not provide clear direction to staff and/or was not implemented in the following areas:
* Customary routines;
* Oral health status;
* Personal hygiene status;
* Repositioning/bed mobility status;
* Use of side rails;
* Ability to use call system;
* Bowel management;
* Transfer status including using mechanical lift; and
* Pain status.
The need to ensure service plans were reflective of the resident's needs, provided clear direction to staff and implemented was discussed with Staff 1 (Resident Care Manager) and Witness 1 (Consultant RN) on 08/06/24 and 08/07/24. The findings were acknowledged.
Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were updated at 30-days after move-in, at least quarterly, reflective of residents' needs, were readily available to staff, and provided clear direction regarding the delivery of services for 2 of 4 sampled residents (#s 1 and 3) whose service plans were reviewed. Findings include, but are not limited to:
1. Resident 3 was admitted to the facility in 11/2021 with diagnoses including cognitive impairment and dementia.
Observations of the resident, interviews with staff, and review of the resident's record, were completed during the survey.
a. The current service plan available to staff, dated 02/05/24, had not been updated quarterly, was not reflective of the resident's current care needs or did not provide clear direction to staff in the following area:
* weight change status.
b. Review of the resident's record noted a significant change of condition on 06/24/24 related to weight loss. There was no documented evidence the service plan had been reviewed and updated as needed.
The need to ensure resident service plans were updated at least quarterly, available to staff, reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (Resident Care Manager) and Staff 4 (Business Office Manager) on 08/07/24. They acknowledged the findings.
1.) The following actions will be taken to correct the violation for each resident:
a. Resident 3's service plan, dated 2/5/24 has been reviewed by the Registered Nurse and the service plan updated to reflect the weight change status. Resident 3's service plan will be updated to include clear instructions to care staff on how to assist resident with her current care needs, including any interventions with a significant change of condition like a weight change. Updates to the resident's service plan and directions for staff on how to provide and deliver services will be discussed at the upcoming All-Staff Meeting amd Health & Wellness Meeting to allow for a clear understanding of responsibilities and for questions and concerns to be discussed.
b. Resident 1's service plan dated 7/2/24 has been reviewed and updated to reflect resident's current care needs, the identified missing items, and resident preferences. Additionally, Resident 1's service plan will be updated to include clear instruction to care staff on how to assist resident with his current care needs. Updates to the resident's service plan and directions for staff on how to provide and deliver services will be discussed at the upcoming All-Staff Meeting & Health and Wellness Meeting to allow for a clear understanding of responsibilities and for questions and concerns to be discussed.
2. To prevent reoccurence, all service plans will be audited weekly by the RCC or designee to reflect the resident's current care and and provide clear direction to the staff. RCC or designee will do a weekly audit on the service plan binder to ensure the most current service plan is availabe to the staff and that stafff has read and signed the service plans that have been reviewed. A portion of all staff meeting will be set aside to discuss any concerns and questions about how to provide care services to any resident to ensure understanding of staff responsibilities.
3.The systems to ensure the thorough completion of quarterly service plans, including clear directions to staff, will be evaluated by Wellness Manager,Licensed Nurse and the Excutive Director monthly during Monthly Wellness Meetings.
4. The Executive Director and the Health and Wellness Manager will be responsible for overseeing that the above systems are in place and continously monitored.
There are no detail notes for this visit.
Based on observation, interview, and record review, it was determined the facility failed to ensure changes of condition had determined and documented resident specific actions or interventions, were communicated to staff, and/or were monitored weekly through resolution for 3 of 4 sampled residents (#s 1, 2 and 3) who experienced changes of condition. Resident 1 developed unstageable pressure sores. Findings include, but are not limited to:
Resident 1 moved into the facility in 07/2024 with diagnoses including, type II diabetes mellitus without complications, aftercare following surgical amputation and acquired absence of left foot.
a. During the acuity interview on 08/05/24, the resident was identified to have a pressure sore in the coccyx area and received hospice services.
The 07/01/24 initial evaluation indicated "no skin concerns needing treatment or monitoring."
During an interview on 08/06/24, Witness 1 (RN Consultant) reported the resident admitted with a pressure sore on the coccyx area.
The resident's current service plan, updated 07/02/24, hospice visit notes, dated 07/09/24 through 07/31/24, progress notes dated 07/03/24 through 08/04/24 and "Skin Issues (minor) LN[licensed nurse] Tracking and Weekly Progress note" were reviewed. Staff were interviewed.
Staff documented the following in the resident's progress notes:
* 07/05/24 - "Barrier cream applied to 1 cm x 2 cm redness to coccyx."; and
* 07/10/24 - " ...another bed sore starting."
The skin issues tracking and weekly progress note showed the following:
* 07/03/24 - 3 cm x 1 cm. stage II;
* 07/10/24 - hospice changed dressing; and
* 07/17/24 - dressing intact. No complaint of pain.
There was no documented evidence the facility evaluated the resident condition, document the changes and updated the service plan when the facility identified the pressure sores. Additionally, there was no documented evidence the facility monitored the pressure sores at least weekly.
Further review of the skin tracking and weekly progress notes showed the following:
* 07/24/24 - worsening wound bed. Unstageable; and
* 07/31/24 - no changes to wound bed.
Hospice visit notes showed the following:
* 07/24/24 - "Worsening coccyx wound stage I, now unstageable."
During the survey, between 08/05/24 and 08/07/24, Resident 1 was observed in bed at all times and required staff assistance with bed mobility.
There was no documented evidence the facility completed a full evaluation to determine the resident's condition, monitored the resident's change in skin condition, or re-evaluated the resident when the new pressure sore was identified. In addition, there was no documented evidence the facility developed interventions to ensure the pressure sore did not get worse.
The facility's failure to evaluate the resident's skin condition and to determine actions or interventions, document and communicate the actions or interventions with staff on all shifts, and to monitor interventions for effectiveness created a risk of harm to the resident as s/he developed unstageable pressure sores.
b. Resident 1's progress note, dated 07/03/24 through 08/04/24 and the MAR, dated 07/0124 through 08/06/24 showed the following:
* 07/03/24 - "on alert for new move in."; and
* 07/23/24 - on antibiotic for cellulitis.
There was no documented evidence the changes of condition in skin and initiation of antibiotic were monitored through resolution.
The need to ensure changes in residents' skin was evaluated, actions or interventions were determined, documented, communicated to staff on all shifts, and implemented, ensure interventions were monitored for effectiveness and the changes of condition were monitored through resolution was discussed with Staff 1 (RCM) and Staff 4 (Business Office Manager) on 08/07/24. They acknowledged the findings.
3. Resident 2 moved into the facility in 07/2024 with diagnoses including dementia and syncope.
The resident's current service plan dated 07/09/24, and progress notes dated 07/16/24 through 08/05/24 were reviewed.
The following short-term changes of condition lacked documentation of resident-specific actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts and progress noted at least weekly through resolution:
* 07/20/24: Return from the hospital due to elevated blood pressure.
The need to ensure resident-specific actions or interventions for short term changes of condition were determined, documented, communicated to staff on each shift and the changes of condition were monitored, at least weekly, through resolution was discussed with Staff 1 (Resident Care Manager). She acknowledged the findings.
2. Resident 3 was admitted to the facility in 11/2021 with diagnoses which included cognitive impairment and dementia.
Observations of the resident, interviews with staff and Resident 3, and review of the resident's medical chart were conducted during the survey.
Resident 3's record revealed the following weights:
*05/10/24: 152.4 lbs.;
*06/24/24: 139.6 lbs.;
*07/05/24: 139.6 lbs.;
*08/03/24: 137.2 lbs.; and
*08/05/24: 135.2 lbs.
Between 05/10/24 and 06/24/24 Resident 3 lost 12.8 lbs or 8.4% of his/her body weight representing a significant change of condition.
An RN assessment was completed for Resident 3's weight loss on 06/24/24, however there was no documented evidence actions/interventions were developed, communicated to staff nor was the change monitored weekly through resolution.
At the time of the survey, 08/05/24 the resident weighed 135.2 lbs. On 08/05/24 at 2:45 pm, in an interview with the resident, s/he stated they ate breakfast and lunch in their room. S/he also stated the food at the facility was good. It was observed the resident had a kitchenette in unit including a refrigerator and microwave to contain and prepare snacks.
On 08/05/24 at 2:30 pm, in an interview with Staff 7 (CG/MT) and Staff 12 (CG), they stated Resident 3 was able to eat and choose meals independently.
The need to ensure the facility had a process for determining what actions or interventions were needed for a resident and providing written instructions to staff following a change of condition was reviewed with Staff 1 (Resident Care Manager) and Staff 4 (Business Office Manager) on 08/07/24. They acknowledged the findings.
1. The following actions will be taken to correct the violation for each resident:
a. Resident 1's wound has been re-assessed by a Registered Nurse and been addressed by a hospice physician. His most current wound care orders, along with additional recommendations will be added to the Treatment Administration Record on EMAR. Registered Nurse will continue to evaluate, monitor, and document on Resident 1's wound progression and effectiveness of current interventions and ordered treatments weekly until resolved or at new baseline. The Registered nurse will provide education to all care staff members on what signs and symptoms to monitor for, when to alert a licensed nurse of concerns, how to alert a licensed nurse of concerns, and when the wound needs urgent medical attention. Clear and specific directions will be provided to staff via written documentation in EMAR and in the resident's service plan. Registered Nurse will continue to monitor for any potential signs that the wound has progressed to a significant change of condition.
b. Resident 3's weights were reasseed and service plan was updated to include weekly weights, interventions such as offering snacks in between meals and offering a supplemental shake. Clear and specific directions will be provided to staff via written documentation in EMAR ans in the resident's service plan. Registered Nurse will monitor progress weekly until weight has returned to baseline or until a new baseline is determined.
c. Resident 2's service plan was re-assesed by the Registered Nurse for short-term changes due to elevated blood pressure and the findings were communicated with the resident's provider. Current orders were entered in MAR and interventions like monitoring of BP. Registered Nurse will provide training to care staff members on what signs & symptoms to monitor for and when to alert Health and Wellness Manager or Licensed Nurse. Clear and specific dierections will be provided to care staff via written documentation in EMAR and in the resident's service plan. Health and Wellness Manager will monitor weekly until resolved or unless the resident's condition changes significantly resulting in the Registered Nurse's involvement in the change of condition.
2.A visual list of residents with skin issues, wounds, falls, changes of condition, and re-admission from hospitalization will be placed on a communication board in the Health & Wellness Office, along with the most recent date of evaluation. This list of residents will be discussed during weekly clinical meetings with the rhe licensed nurse, RCC, Health & Wellness Manager , and the Executive Director. Any updates to resident-specific interventions will be communicated to care staff by providing clear instructions via the service plan. Weekly clinical meetings will include reviewing TSPs, outside provider notes, skin sheets, progress notes, and 24-hour alert logs to identify any changes of condition or wounds that have not yet been addressed by the licensed nurse.
3. The effectiveness of the visual list of residents via a communication board and the discussions of changes of conditions during weekly clinical meetings will be reviewed by the Licensed Nurse, Health & Wellness Manager and the Executive Director monthly during monthly Wellness Management meetings.
4. The Executive Director and th Health and Wellness Manager will be resposible for ensuring that the correction are completed and monitored.
There are no detail notes for this visit.
Based on observation, interview, and record review, it was determined the facility failed to ensure an RN completed an assessment that documented findings, resident status, and interventions made as a result of the assessment for 1 of 4 sampled residents (# 1), who experienced significant changes of condition in skin. Findings include, but are not limited to:
Resident 1 moved into the facility in 07/2024 with diagnoses including, type II diabetes mellitus without complications, aftercare following surgical amputation and acquired absence of left foot.
During the acuity interview on 08/05/24, the resident was identified to have a pressure sore on the coccyx area.
During the interview on 08/06/24, Witness 1 (RN Consultant) reported the resident admitted with the pressure sore on the coccyx area.
The resident's current service plan, updated 07/02/24, was reviewed. There was no specific interventions for the pressure sore provided to staff to follow.
Hospice visit notes, dated 07/09/24 through 07/31/24, progress notes dated 07/03/24 through 08/04/24 and "Skin Issues (minor) LN [Licensed Nurse] Tracking and Weekly Progress note" were reviewed. Staff were interviewed.
Staff documented the following in the resident's progress notes:
* 07/10/24 - " ...another bed sore starting."
The skin issues tracking and weekly progress note showed the following:
* 07/10/24 - hospice changed dressing;
* 07/17/24 - dressing intact. No complaint of pain;
* 07/24/24 - worsening wound bed. Unstageable; and
* 07/31/24 - no changes to wound bed.
The unstageable pressure sore represented a significant change of condition.
There was no documented evidence the facility completed assessment for the significant change of condition in skin, document the resident status, and interventions made as a result of the assessment.
On 08/07/24, Witness 1 via phone interview, reported that she was not able to answer if there was an RN assessment or not when she was aware of the unstageable pressure sore.
On 08/07/24, the need to ensure the facility RN completed an assessment for the significant change of condition was discussed with Staff 1 (Resident Care Manager) and Staff 4 (Business Office Manager). They acknowledged the findings.
1. The following actions will be taken to correct the violation for each resident:
Resident 1's service plan will be updated to include a previous significant change of condition in skin, intervention, current care needs, and resident preferences, and clear instructions to care staff and how to care for and monitor wound. Care staff will be provided education on what may constitute as a significant change of condition and when/how to alert the licensed nurse of urgent concerns during the during the upcoming All Staff Meeting and Health & Wellness Meeting.
2. A visual list of residents with skin issues, wounds, falls, changes of condition, and re-admission from hospitalization will be placed on a communication board in the Health & Wellness Office, along with the most recent date of evaluation. This list of residents will be discussed during weekly clinical meetings with the the licensed nurse, RCC, Wellness Manager , and Executive Director. Any updates to resident-specific interventions will be communicated to care staff by providing clear instructions via the service plan. Weekly clinical meetings will include reviewing TSPs, outside provider notes, skin sheets, progress notes, and 24-hour alert logs to identify any changes of condition or wounds that have not yet been addressed by the licensed nurse.
3. The effectiveness of the visual list of residents via a communication board and the discussions of changes of conditions during weekly clinical meetings will be reviewed by the Licensed Nurse, Wellness Manager and the Executive Director monthly during monthly Wellness Management meetings.
4. The Executive Director and the Health & Wellness Manager will be resposible for ensuring that the correction are completed and monitored.
There are no detail notes for this visit.
2. Resident 1 moved into the facility in 07/2024 with diagnoses including type II diabetes without complication, aftercare following surgical amputation and acquired absence of left foot.
During the acuity interview on 08/05/24, the resident was identified to receive outside hospice services.
The resident's current service plan, updated 07/02/24, hospice visit notes, dated 07/09/24 through 07/31/24 and progress notes dated 07/03/24 through 08/04/24 were reviewed.
Hospice visits showed the following:
* 07/24/24 - Do not use plastic or vinyl sheets; and
* 07/31/24 - Reposition the resident every two hours while awake and every four hours at night.
In the review of the resident's clinical record, there was no documented evidence staff were informed of the new instructions and the service plan was updated for the recommendation.
The need to ensure staff were informed of new instructions and the service plan was updated as necessary after on-site health services were provided was discussed on 08/07/24 with Staff 1 (Resident Care Manager) and Witness 1 (RN Consultant) on 08/06/24 and Staff 1 and Staff 4 (Business Office Manager) on 08/07/24. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to coordinate care with outside providers in order to ensure the continuity of care, the facility failed to ensure staff were informed of new interventions, and the service plan was adjusted if necessary for 2 of 2 sampled residents (#s 1 and 2) who received outside services. Findings include, but are not limited to:
1. Resident 2 moved into the facility in 07/2024 with diagnoses including dementia and syncope.
Progress notes, outside provider notes dated 07/31/24, and the service plan dated 07/09/24 were reviewed.
There was no documented evidence staff were informed of the new instructions and the service plan was updated for the following recommendation:
* 07/31/24-HH OT noted: The resident needs positional changes every 1-2 hours with brief checked for moisture as s/he is at a higher risk for pressure injury due to immobility. Please check brief every 1-2 hours.
The need to ensure staff were informed of new instructions and the service plan was updated as necessary after on-site health services were provided was discussed on 08/07/24 with Staff 1 (Resident Care Manager). She acknowledged the findings.
1. The following actions will be taken to correct the violation for each resident:
a. Resident 2's Home Health Occupational Therapy notes will be requested for all previous visits ocucured including potential orders for and instructions for repositioning and frequent brief/ toileting assists to prevent pressure sores. The licensed nurse will review all notes, orders, and instructions. The Heaslth & Wellness Manager or designee will document outside provider service care coordination note via a progress note on EMAR. The licensed nurse will input treatment instructions on EMAR and the resident's service plan for clear instructions for care staff. New information from Home Health notes for Resident 1 will be discussed during end of shift change report, the weekly clinical meeting and at the next monthly Health & Wellness Meeting.
b. Resident 1's Hospice notes will be requested for all visits with Resident 1 for wound care, including any orders for wound care and recommendations. The licensed nurse will review all notes, orders, and instructions. The Health & Wellness or designee will document outside provider service care coordination note via a progress note on EMAR. The licensed nurse will input treatment instructions on EMAR and the resident's service plan for wound care. New information from Hospice notes for Resident 1 will be discussed during end of shift change report, at the weekly clinical meeting and at the next monthly Health & Wellness Meeting.
2 A visual list of residents receiving services from Home Health/ Hospice providers will be placed on a communication board in the Health & Wellness Office, along with the reason for visits, date of latest visit and potential date of discharge, as appropriate. Outside provider notes will be documented on as a progress note in EMAR by the medtech. The Resident Care Coordinator, or Wellness Director, will request outside provider care plans and progress notes biweekly. The licensed nurse will review the obtained outside provider care plans and progress notes, in addition to documenting findings as a progress note on EMAR and adding treatment orders on EMAR as needed. The licensed nurse will update the resident's service plan and will provide education and clear instructions to care staff on what services the resident needs, how to assist with such services, how to and when to monitor for adverse side effects, and how to and when to alert a licensed nurse of concerns. This list of residents receiving Hospice/ Home Health Services/ Outside Providers will be discussed during weekly clinical meetings with the licensed nurse, RCC, Wellness Manager and Executive Director. Weekly clinical meetings will include reviewing TSPs, outside provider notes, skin sheets, progress notes, and 24-hour alert logs to identify any needs for Hospice /Home Health Service or any current Hospice/Home Health Services that have not yet been addressed by the licensed nurse.
3. The effectiveness of the visual list of residents receiving Home Health/ Hospice Services via a communication board and the discussions held during weekly clinical meetings will be reviewed by the Health & Wellness Manager and the Executive Director monthly during monthly Wellness Management meetings.
4. The Health & Wellness Manager and the Executive Director will be responsible for ensuring that the corrections are completed and monitored.
Based on interview and record review, it was determined the facility failed to coordinate care with outside providers in order to ensure the continuity of care, the facility failed to ensure staff were informed of new interventions, and the service plan was adjusted if necessary for 1 of 1 sampled resident (# 6) who received outside services. This is a repeat citation. Findings include, but are not limited to:
Resident 6 moved into the facility in 08/2024 with diagnoses including aftercare following joint replacement surgery.
Progress notes from 10/02/24 through 12/11/24 and the 11/28/24 service plan were reviewed.
There was no documented evidence staff were informed of the new instructions and the service plan was updated for the following recommendation:
* 11/04/24: New instructions from HHPT to change the resident's shirt while seated at the edge of the bed;
* 11/06/24: Continue encouraging the resident to sit at the edge of the bed; and
* 11/19/24: New instructions from HHPT to encourage the resident sitting at the edge of the bed.
The need to ensure staff were informed of new instructions and the service plan was updated as necessary after on-site health services were provided was discussed on 12/17/24 with Staff 18 (ED) and Staff 19 (RN). They acknowledged the findings.
1. The following actions will be taken to correct the violation for Resident:
Resident 6's Home Health Physical Therapy notes will be requested for all previous visits occurred including all potential orders for instructions for encouraging resident to sit on the edge of the bed. The Registered Nurse will review all notes, orders and instructions. The RCC or Designee will document outside provider service care coordination note via a progress notes on EMAR. The RN will input treatment instruction on EMAR, Temporary Service Plan and the resident service plan for clear instructions for the care staff. New information from Home Health notes for Resident 6 will be discussed during end of shift report, the weekly clinical meeting and the next montly Health and Wellness Meeting.
2.How is the system be corrected so the violation will not happen again?
A visual list of residents receiving services from Home Health/ Hospice providers will be placed on a communication board in the Health & Wellness Office, along with the reason for visits, date of latest visit and potential date of discharge, as appropriate. Outside
provider notes will be documented on as a progress note in EMAR by the medtech. The Resident Care
Coordinator, or Wellness Director, will request outside provider care
plans and progress notes biweekly. The licensed nurse will review the obtained outside provider care plans and progress notes, in addition to documenting findings as a progress note on EMAR and adding treatment
orders on EMAR as needed. The licensed nurse will update the resident's service plan and will provide education and clear instructions to care staff on what
services the resident needs, howto assist with such services, how to and when to monitor for adverse side effects, and how to and when to alert a licensed nurse of concerns. This list of residents receiving Hospice/ Home Health Services/ Outside Providers will be
discussed during weekly clinical meetings with the licensed nurse, RCC, Wellness Manager and
Executive Director. Weekly clinical meetings will include reviewing TSPs, outside provider notes, skin
sheets, progress notes, and 24-hour alert logs to identify any needs for Hospice /Home Health Service or any current Hospice/Home Health Services that have not yet been addressed by the licensed nurse.
3. How often will the area needing correction be evaluated?
The effectiveness of the visual list of residents receiving Home Health/ Hospice Services via a
communication board and the discussions held during weekly clinical meetings will be reviewed by the Health & Wellness Managerand the Executive Director monthly during monthly Wellness Management meetings.
4. Who will be responsible to see that the corrections are completed/monitored?
The Health & Wellness Manager and the Executive
Director will be responsible for ensuring that the corrections are completed and monitored.
There are no detail notes for this visit.
2. Resident 1 moved into the facility in 07/2024 with diagnoses including type II diabetes without complication, aftercare following surgical amputation and acquired absence of left foot.
Review of Resident 1's current physician orders and MARs from 07/01/24 through 08/06/24 identified the following:
* The resident was prescribed Keflex 250 mg [antibiotic] three times a day for 5 days for suspected cellulitis, however, the MAR indicated the resident received four extra doses of the antibiotic.
* The resident was prescribed wound care orders to coccyx and Polyethylene powder once a day for constipation; however, the wound care and the Polyethylene powder orders were not transcribed on the MAR for staff to follow.
The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (Resident Care Manager) and Staff 4 (Business Office Manager) on 08/07/24. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 2 of 4 sampled residents (#s 1 and 2) whose orders were reviewed. Findings include, but are not limited to:
1. Resident 2 was admitted to the facility in 07/2024 with diagnoses including dementia and syncope.
Resident 2's current physician orders and MAR, dated 07/01/24 through 07/31/24, were reviewed and revealed the following:
The resident had physician orders dated 07/26/24 for the following:
* Monitor blood pressure in the morning before giving meds; if systolic blood pressure is less than 100, let home health know.
On 08/06/24 at 9:50 am, the surveyor and Staff 6 (MT) reviewed the electronic MAR and physician orders. Staff 6 confirmed the order to monitor blood pressure in the morning before giving meds; if systolic blood pressure is less than 100, let home health know, was not transcribed on the MAR for staff to follow.
The need to ensure all physician orders were carried out as prescribed was discussed with Staff 1 (Resident Care Manager) on 08/07/24. She acknowledged the findings.
1.) The following actions will be taken to correct the violation for each resident:
a. Resident 2's current medication list will be reviewed by the licensed nurse to ensure that all medications and treatments being administered has a signed physician's order and that all orders are accurately reflected on EMAR, including parameters. Once the medication list has been reviewed, a most recent up-to-date signed physician's order will be requested from the provider.
b. Resident 1's current orders for medicaiton and Hospice orders for wound care will be reviewed by the licensed nurse to ensure that all medications and treatments being administered has a signed physician's order and that all orders are accurately reflected on EMAR. Once the medication list has been reviewed, a most recent up-to-date signed physician's order will be requested from the provider.
2. All med-techs for the community will receive a re-training conducted by Registered Nurse regarding policies and procedures, including requirement for signed physician's orders with all administered medications/treatments and importance of accurate medication administration as prescribed. The RCC, or Health & Wellness Manager, will review and audit the "three check system" in the medroom and make changes as needed to continue to make sure that all orders have been processed appropriately. The RCC, or Health & Wellness Director, will immediately alert the licensed nurse of any discrepancies.
3.) The audit and review of physician orders will be reviewed by the Wellness Manager and the Executive Director monthly during monthly Wellness Management meetings.
4.) The Wellness Manager and the Executive Director will be responsible for ensuring that the corrections are completed and monitored.
There are no detail notes for this visit.
2. Resident 1 was admitted to the facility in 2018 with diagnoses including diabetes, aftercare following surgical amputation and acquired absence of left foot.
a. Resident 1 had a physician order to administer Senna Plus one tablet once a day as needed and Bisacodyl 10 mg suppository once a day as needed for constipation.
Resident 1's 07/01/24 through 08/06/24 MAR showed there were no resident-specific parameters including when to administer the PRN medication.
b. Resident 1 had a physician order to administer Ativan 0.5 mg every four hours as needed for agitation/anxiety.
Resident 1's 07/01/24 through 08/06/24 MAR showed there were no resident-specific instructions on how the resident expressed agitation and anxiety to determine when staff were to administer the PRN medication. The medication was administered three occasions (07/05/24, 07/10/24 and 07/13/24) during the review period.
The need to ensure medications had resident-specific parameters for PRN medications and clear instructions for unlicensed staff was reviewed with Staff 1 (Resident Care Manager) and Staff 4 (Business Office Manager) on 08/07/24. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure MARs had resident-specific parameters for PRN medications and clear instructions to staff for 2 of 4 sampled residents (#s 1 and 3) whose MARs were reviewed. Findings include, but are not limited to:
1. Resident 3's 07/01/24 through 07/13/24 MAR was reviewed and revealed the following:
Resident 3's MAR revealed multiple PRN medications that lacked resident-specific parameters and clear instructions to staff.
* Acetaminophen 325 Mg Tabs (for fever, pain or headache) 1 - 2 tabs as PRN; and
* Acetaminophen 500 Mg Caplet (for pain or fever) every eight hours PRN.
In an interview with Staff 1 (Resident Care Manager) at 11:00 am on 08/07/24, she acknowledged the lack of parameters and instruction for Resident 3's use of PRN Acetaminophen.
The need to ensure PRN medications had resident-specific parameters and clear instructions to staff was reviewed with Staff 1 and Staff 4 (Business Office Manager) on 08/07/24. Staff acknowledged the finding.
1.) The following actions will be taken to correct the violation for each resident:
a. Resident 3's current PRN orders for pain will be reviewed by the Registerd Nurse (RN). The RN will add clear parameters to provide clear and direct instructions for unlicesned staff as to when to, in what order, and what symptoms to administer each medication for pain as needed.
b.1 Resident 1's current PRN orders for bowel care will be reviewed by the Registered Nurse. The RN will add clear parameters to provide instructions to unlicensed staff when to administer each medicaiton for bowel care, in addition to how long to wait in between doses and when a dose is considered to be ineffective requiring another dose or a different bowel care PRN medication.
b.2 Resident 1's current PRN orders for Ativan for agitation/anxiety will be reviewed by the Registed nurse. The RN will provide clear & specific instructions on how resident expresses agitation and axiety and when it is appropriate to offer PRN medications for these symptoms.
2.All med-techs for the community will receive a re-training conducted by Registered Nurse regarding policies and procedures, including importance of parameters and clear instructions on how to administer PRN medications and treatments that are ordered for the same diagnosis. The Registered nurse will review and audit the MAR/TAR and add clear parameters to multiple PRN orders for the same diagnosis. The registered nurse will add clear parameters to all PRN medications and treatments as prescribed if needed. The registered nurse will review all PRN orders and include parameters, if needed, prior to sending out the 90 day physician orders every quarter.
3.) The audit and review of PRN orders to include clear parameters to unlicensed staff will be reviewed by the Health & Wellness Manager and the Executive Director monthly during monthly Wellness Management meetings.
4.) The Health & Wellness Manager and the Executive Director will be responsible for ensuring that the corrections are completed and monitored.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure all pre-service orientation topics for 4 of 4 newly-hired staff (#s 6, 12, 15 and 17) and pre-service dementia training for 4 of 4 newly-hired staff (#s 6, 7, 10 and 12) had been completed prior to staff beginning their job duties and HCBS training for 1 of 4 long-term staff (# 9) had been completed. Findings include, but are not limited to:
The facility's training records were reviewed on 08/06/24 and the following was identified:
a. There was no documented evidence Staff 6 (MT), Staff 12 (CG), Staff 15 (Cook), and Staff 17 (Dietary Server), hired 05/14/24, 06/03/24, 06/19/24, and 07/08/24, respectively, completed the following pre-service orientation topics prior to beginning their job duties:
* Resident rights and the values of community-based care;
* Fire safety and emergency procedures;
* Infectious disease prevention training;
* Fire safety and emergency procedures; and
* Approved HCBS course.
b. There was no documented evidence Staff 6, 7, 10, and 12 completed the following pre-service dementia training courses prior to providing care to residents:
* Dementia disease process including progression, memory loss, psychiatric and behavioral symptoms;
* Techniques for understanding, communicating and responding to behaviors, including, but not limited to, reducing use of antipsychotic medications;
* Strategies for addressing social needs & engaging persons with dementia in meaningful activities; and
* Specific aspects of dementia including pain, providing food/fluids, preventing wandering, and the use of a person-centered approach.
c. There was no documented evidence Staff 9 (CG), hired 11/01/22, completed HCBS training by 03/31/24.
The requirements for pre-service orientation and training for all employees was reviewed with Staff 1 (Resident Care Manager) and Staff 4 (Business Office Manager) on 08/07/24. They acknowledged the findings.
1.) The following actions will be taken to correct the violation:
a. Staff #6, Staff #12, Staff #15 and #17 will have all required pre-service trainings completed before working with residents and continuing their job duties
b. Staff #6, staff #7, staff #10 and Staff #12 will have required pre-dementia training completed before working with residents and continuing their job duties.
c.Staff #9 will have required HCBS training completed before working with residents and continuing their job duties.
2.) Pre-service training for all current employees will be completed prior to beginning their job duties. For the newly-hired employees,all pre-service trainings including pre-service dementia (6hr training), pre-service infection disease (2hr), resident rights and values of CBC, abuse reporting requirements, HCBS training, Fire & Safety emergency procedure, and food handler's certification, will be required prior to being placed on the schedule and working with residents. The appropriate department head will be responsible for reviewing completed training certifications for newly-hired employees in their department prior to adding them to the schedule to provide direct care to residents.
3.) The system to ensure that all employees have completed all required pre-service trainings prior to working with residents will be evaluated monthly during the monthly Management Meetings. The Executive Director and BOM director will do a monthly audit of the pre-service training requirements to ensure compliance.
4.) The Executive Director will be responsible for ensuring that the above corrections are completed and monitored.
Based on interview and record review, it was determined the facility failed to ensure all pre-service orientation topics for 4 of 4 newly-hired staff (#s 20, 21, 22 and 23) and pre-service dementia training for 2 of 4 newly-hired staff (#s 20 and 21) had been completed prior to staff beginning their job duties. This is a repeat citation. Findings include, but are not limited to:
The facility's training records were reviewed on 12/17/24 and the following was identified:
1. There was no documented evidence Staff 20 (MT), hired 10/8/24, and Staff 21 (MT), hired 10/18/24 completed the following pre-service orientation topics prior to beginning their job duties:
* Infectious disease prevention training; and
* Pre-service dementia training.
2. There was no documented evidence Staff 22 (MT), hired 10/2/24, and Staff 23 (CG), hired 11/5/24, completed the following pre-service orientation topics prior to beginning their job duties:
* Resident Rights and values of CBC care;
* Abuse Reporting; and
* Fire Safety and emergency procedures.
The requirements for pre-service orientation and training for all employees was reviewed with Staff 18 (ED), Staff 4 (Business Office Manager), and Staff 8 (RCC) on 10/17/24. They acknowledged the findings.
1. The follwing actions will be taken to correct the violation:
a. Staff #20 & staff 21 will have all required pre-service infectious disease prevention and pre-service training will be completed before working with residents and continuing their job duties.
b. Staff 22 & staff 23 will have required pre-service orientation Resident Rights & Values of CBC Care, Abuse Reporting and Fire Safety & Emergency Procedure will be completed before working with residents and continuing their job duties.
2.Pre-service training for all current employees will be
completed prior to beginning their job duties. For the newly-hired employees,all pre-service trainings
including pre-service dementia (6hr training), pre-service infection disease (2hr), resident rights and
values of CBC, abuse reporting requirements, HCBS training, Fire & Safety emergency procedure, Providing Inclusive Care: Training for Oregon Long-Term Care Facility Staff and food handler's certification, will be required prior to beginning their job duties.
3. The system to ensure all employees have completed all required pre-service trainings prior to working with residents will be evaluated monthly during the monthly management meetings. The Executive Director and BOM Director will do a montly audit of pre-service training requirements to ensure compliance.
4.The Executive Director will be the responsible for ensuring the above corrections are completed and monitored.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure and document that direct care staff demonstrated knowledge and performance in all required areas within 30 days of hire for 4 of 4 newly-hired staff (#s 6, 7, 10 and 12). Findings include, but are not limited to:
The facility's training records were reviewed on 08/06/24 and the following was identified:
There was no documented evidence Staff 6 (MT), Staff 7 (CG), Staff 10 (CG) and Staff 12 (CG), hired 05/14/24, 05/10/24, 02/15/24, and 06/03/24, respectively, demonstrated knowledge and satisfactory performance in the following topics:
* Role of service plans in providing individualized care;
* Providing assistance with ADLs;
* Changes associated with normal aging;
* Identification, documentation and reporting of changes of condition;
* Conditions that require assessment, treatment, observation and reporting;
* General food safety, serving and sanitation; and
* Fire aid/abdominal thrust.
The need to ensure the facility documented direct care staff demonstrated knowledge and performance in all required areas within 30 days of hire was discussed with Staff 1 (Resident Care Manager) and Staff 2 (Business Office Manager) on 08/06/24 and 08/07/24. They acknowledged the findings.
1.) The following actions will be taken to correct the violation:
a. Staff #9, #7, #10, #12 will have all required 30-day trainings completed and have demonstrated satisfactory performance in their required job duties.
2.) All current employees will be required to complete all the 30-day training requirements immediately. For newly-hired employees, all 30-day training requirements will be completed prior to their 30th day of hire. The Business Office Manager (BOM) and the RCC will be monitoring the 30-day training checklist for each employee. Those who have been unable to complete the 30-day training checklist prior to their 30th day of hire will be taken off the schedule until all required trainings have been completed.
3.) The system to ensure that all employees have completed all required trainings prior to their 30th day of hire will be evaluated monthly during the monthly Management Meetings. The Executive Director and BOM director will do a monthly audit of the pre-service training requirements to ensure timely compliance.
4.) The Executive Director will be responsible for ensuring that the above corrections are completed and monitored.
Based on interview and record review, it was determined the facility failed to ensure and document that direct care staff demonstrated knowledge and performance in all required areas within 30 days of hire for 4 of 4 newly-hired staff (#s 20, 21, 22 and 23). This is a repeat citation. Findings include, but are not limited to:
The facility's training records were reviewed on 12/17/24 and the following was identified:
There was no documented evidence Staff 20 (MT), hired 10/8/24, Staff 21 (MT), hired 10/8/24, Staff 22 (MT), hired 10/2/24, and Staff 23 (CG), hired 11/5/24, demonstrated knowledge and satisfactory performance in the following topics:
* Role of service plans in providing individualized care;
* Providing assistance with ADLs;
* Changes associated with normal aging;
* Identification, documentation and reporting of changes of condition;
* Conditions that require assessment, treatment, observation and reporting;
* General food safety, serving and sanitation; and
* Fire aid/abdominal thrust.
Staff 20 (MT), Staff 21 (MT), and Staff 22 (MT), lacked evidence of demonstrating competence in medication pass. The need to ensure the staff had documented evidence of demonstrating competence in passing medications before working as a medication aide and passing medications was discussed with Staff 18 (ED) and Staff 8 (RCC). Staff 18 (ED) and Staff 8 (RCC) agreed the staff would not pass medications until they had demonstrated competence.
The need to ensure the facility documented direct care staff demonstrated knowledge and performance in all required areas within 30 days of hire was discussed with Staff 18, Staff 4 (Business Office Manager), and Staff 8 on 12/17/24. They acknowledged the findings.
1. The follwing actions will be taken to correct the violation:
a. Staff #20, 21, 22 and 23 will have all the required 30 day trainings completed and have demonstrated statisfactory performance in their required job duties.
b. Staff 20 (MT), Staff 21 (MT), Staff 22 (MT) will have all required medication pass training and have a evidence of demonstration on medication competency pass reviewed and signed by Health and Services Director (RN).
2. All current employees will be required to complete all the 30-day training requirements immediately.
For newly-hired employees, all 30-day training requirements will be completed prior to their 30th
day of hire. All Medication Aide will have required medication pass training and demonstrated mediction competecy pass signed off by the HSD/Nurse.
The Business Office Manager (BOM) and the RCC will be monitoring the ,medication pass competency for medicatiion aides and 30-day training checklist for each employee. Those who have been unable to complete the 30-day training checklist prior to their 30th day of hire will be taken off the schedule until all required trainings have been completed.
3.The system to ensure that all employees have completed all required trainings prior to their 30th day of hire will be evaluated monthly during the monthly
Management Meetings. The Executive Director and BOM director will do a monthly audit of the pre-service training requirements to ensure timely compliance.
4.) The Executive Director will be responsible for ensuring that the above corrections are completed
and monitored.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to have documented evidence that 12 hours of annual in-service training, including six hours related to the care of the dementia resident, was completed for 2 of 4 long-term staff (#s 8 and 9) and completed infectious disease training for 2 of 2 non-direct long-term staff (#s 14 and 16) whose training records were reviewed. Findings include, but are not limited to:
Facility staff training records were reviewed on 08/06/24 and revealed the following:
a. Training records for Staff 8 (MT/CG), hired 12/14/21 and Staff 9 (CG), hired 11/01/22, did not have documented evidence of required annual in-service training, including six hours relating to the care of residents with dementia.
b. Training records for Staff 14 (Cook), hired 12/06/03 and Staff 16 (Dietary Server), re-hired 07/2023, did not have documented evidence of annual required infectious disease training.
The need to ensure staff completed the required annual in-service training, based on anniversary dates of hire and infectious disease training was discussed with Staff 1 (Resident Care Manager) and Staff 4 (Business Office Manager) on 08/07/24. They acknowledged the findings.
1.) The following actions will be taken to correct the violation:
a. Staff #8 and #9 will have all required annual in-service trainings, including 6 hours of dementia-related training, completed per the agreed upon schedule and deadline with each staff member.
b.Staff #14 and #16 will have all required annual infectious desease training, completed per the agreed upon schedule and deadline with each staff member.
2.) All current employees will be required to immediately complete all 12 hours of annual in-service training requirements, including 6 hours of dementia-related training. For newly hired employees, monthly in-services through Relias and through scheduled in-person trainings will be tracked and monitored by the BOM and the RCC monthly. The BOM/RCC, or designee, will review certificates of trainings once a month and will provide assistance through a plan of action for those employees who have not yet fulfilled the monthly training requirement.
3.) The system to ensure that all employees have completed all 12 hours of annual in-service trainings will be evaluated monthly by the BOM and the Executive Director during the monthly Management Meetings.
4.) The Executive Director will be responsible for ensuring that the above corrections are completed and monitored.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to provide documentation that fire drills were being conducted every other month, all required components of fire drills were documented, and fire and life safety instruction was provided on alternate months to staff. Findings include, but are not limited to:
1. Review of fire drill records on 08/05/24, dated 07/02/24, showed the facility failed to document the following required components:
* Escape routes used;
* Problems encountered, comments relating to residents who resisted or failed to participate in the drills;
* Evacuation time-period needed; and
* Number of occupants evacuated.
2. The facility failed to provide documented evidence that fire and life safety instruction was being provided to staff on alternating months from fire drills.
On 08/06/24, the need to ensure all required components of fire drills were documented, fire and life safety instruction was provided on alternate months to staff was discussed with Staff 3 (Maintenance Director). He acknowledged the findings.
1.) The following actions will be taken to correct the violation:
a. The fire drill record form will be updated to include all required elements including escape route, problems encountered, comments, related to residents who are resisted or failed to participate in the drills; staff members on duty & participating, evidence of alternate routes used during the fire drill and number of occupants evacuated.
b. Staff will be provided with fire and life safety instructions by September 2024. Documentation of these instructions and each staff will be kept in the Fire and Life Safety binder.
2.) Fire drills will include the practice of relocating identified residents to safe points/horizontal exits. Fire drills will be documented on the updated Fire and Life Safety form that will include all required elements. The Maintenance Manager, or designee, will be responsible for properly completing and documenting fire drills as required every other month. Additionally, a schedule has been developed by the Maintenance Manager to provide instructions and documentation of fire and life safety trainings, including emergency disaster preparedness, earthquakes, flooding, active shooter, ice storms, and electric outages, provided for all staff on alternate months from fire drills.
3.) The system to provide proper documentation of all required elements during a fire drill and proper documentation of safety instructions provided to staff on alternate months from the fire drill will be reviewed once a month during the monthly Management Meetings.
4.) The Executive Director will be responsible in ensuring that the above corrections are completed and monitored.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure each resident was instructed within 24 hours of admission and re-instructed, at least annually, 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. Findings include, but are not limited to:
In an interview on 08/06/24 at 9:00 am with Staff 3 (Maintenance Director), he 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.
Resident fire life safety training records were reviewed on 08/07/24 at 11:00 am with Staff 1 (Resident Care Manager). Staff 1 stated going forward she would be completing fire life safety instruction with residents within 24 hours of admission.
The requirements for fire life safety instruction for residents were reviewed with Staff 1 and Staff 4 (Business Office Manager) on 08/07/24. They acknowledged the findings.
1.) The following actions will be taken to correct the violation:
a. All current residents will receive training on the facility's Fire and Life Safety Policies in September 2024 during the Town Hall Meeting and individually io in small groups for those who are not in attendance.
2.) All newly admitted residents will receive training on the facility's Fire and Life Safety Policies within 24 hours of admission - this task will be added on the new resident checklist for the RCC, or Wellness Director, to complete during the admission process. The Maintenance Manager, or designee, will complete the annual training for fire and life safety procedures with all residents once a year - presently scheduled on January 31st through the TELS system. Residents who are unable to attend the annual training will be provided the information for fire and life safety procedures one-on-one. The Maintenance Manager will keep a record of annual tranings provided for each resident and when they were completed in the Fire and Life Safety Binder.
3.) The system to complete annual tranings and provide proper documentation of fire and life safety policies and procedures to all residents within 24 hours of admission and annually will be reviewed once a month during the monthly Management Meetings.
4.) The Executive Director will be responsible in ensuring that the above corrections are completed and monitored.
There are no detail notes for this visit.
Based on observation, interview, and record review, it was determined the facility failed to ensure their change of ownership survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:
Refer to C240, C290, C370 and C372.
Please refer to C240, C290, C370, and C372 response.
There are no detail notes for this visit.
Based on observation and interview, it was determined the facility failed to maintain all exterior pathways in good repair, and to ensure all facility grounds were kept orderly and free of refuse. Findings include, but are not limited to:
The exterior of the building was toured on 08/05/24. The following issues were noted:
* Multiple sections of the concrete path that encircled the building had drop-offs from the surface of the path to the planting bed of greater than two inches. This represented a fall risk for residents; and
* An area observed on the rear grounds which included a mixture of old medical equipment, furniture, and building materials. This area was not kept orderly and presented a potential safety hazard for residents.
On 08/06/24 at 9:00 am the need to ensure all exterior areas were maintained in good repair was discussed with Staff 1 (Resident Care Manager) and Staff 3 (Maintenance Director). They acknowledged the findings.
1.) The following actions will be taken to correct the violation:
a. Concrete path around the building that has drop-offs from the surface of the path to the planting bed of greater than 2 inches will be filled with barkdust or pebbles.
b. The rear grounds which included a mixture of old medical equipment, furniture and building materials were disposed. This area will be kept orderly to prevent any potential safety hazard for residents.
2. Maintenance Manager will do a weekly walkthough outside the community to identify potential safety hazard or fall risks - such as rear grounds or drops offs from the conrete path. Identified risks will be communicated to the Executive Director immediately and addressed and corrected in an an urgent matter. Executive Director and Maintenance Manager will complete a walk-through inspection of the community once a month to ensure that the building is kept clean and organized.
3.The system to keep the outside area will be evaluated once a month during the monthly management meeting.
4. The Executive Director is responsible for ensuring that the above corrections are completed and monitored.
There are no detail notes for this visit.
Based on observation and interview, it was determined the facility failed to maintain all interior surfaces in good repair. Findings include, but are not limited to:
The interior of the building was toured on 08/05/24. The following areas needed repair:
* The carpet transition next to the front to the first floor wing was frayed and tearing;
* The carpet throughout the first and second floors had spots and stains, particularly in the first floor activity room, and outside rooms 213, 216 and 223; and
* The settee on the second floor (across from room 202) had a stain on it.
On 08/06/23 at 9:00 am, the areas in need of repair were reviewed with Staff 3 (Maintenance Director). He acknowledged the findings.
1.) The following actions will be taken to correct the violation:
a. The carpet transition next to the front of 1st floor was frayed and tearing will repaired or replaced by the Manintenance Manager or a third=party provider.
b. The carpeting throught the first floor activity room and throughout the second floor, outside rooms 213,216, abd 233 will be professionally shampooed and cleaned to remove dark spots or stains.
c. The settee on the 2nd floor across room 202 that had stain on it will be cleaned or replaced.
2.The Maintenance Manager will schedule carpet shampooing and cleaning of all hallway and activity area through TELS system. The Manaintenace Manager will be responsible for having identified carpets needing to be shampooed and cleaned as before dark spots or stains set in. Quarterly upholstery cleaning for all community benches and chairs will be scheduled through the TELS system for the Maintenance and Housekeeping department to complete as scheduled and as needed.
3.) Maintenance Manager will complete a weekly walk-through inside the community to identify potential needs to clean and repair areas. Executive Director and Maintenance Manger will complete a walk-through inspection of the community once a month to ensure that the building is kept clean and good repair.
The system to keep the building in clean and good repair will be evaluated once a month during the monthly Management Meetings.
4.) The Executive Director is responsible for ensuring that the above corrections are completed and monitored.
There are no detail notes for this visit.
Based on observation and interview, it was determined the facility failed to ensure operable windows were designed to prevent accidental falls when sill heights were lower than 36 inches and above the first floor. Findings include, but are not limited to:
The facility was toured on 08/05/24. Resident unit windows on the second floor opened vertically, and windowsills were lower than 36 inches. The windows lacked a system which limited how much the window could be opened to prevent accidental falls.
The lack of a mechanism to prevent accidental falls was discussed with Staff 3 (Maintenance Director) on 08/06/24 at 9:00 am. He acknowledged the findings.
1.) The following actions will be taken to correct the violation:
The windows on the second floor lacked a system on how much a window could be opened to prevent accidental falls. Maintenance manager will install a locking device to all windows on the second floor to prevent accidental falls.
2. The mainatenace manager will schedule a walkthrough quarterly through TELS to all apartments to check the window locks if it still in place. All staff will be instructed on how to identify potential safety hazards,who, when, and how to report potential safety concerns during the monthly All Staff Meeting. Maintenance Manager to immediately make a plan to investigate and address if appropiate all identified safety concerns.
3. The system to keep the resident safe will be evaluated oncee a month during the monthly Management meeting.
4.) The Executive Director is responsible for ensuring that the above corrections are completed and monitored.
There are no detail notes for this visit.