The findings of the re-licensure survey, conducted 08/12/24 through 08/15/24, 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 for Home and Community Based Services Regulations.
Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with H refer to the Home and Community Based Services rules.
Abbreviations possibly used in this document:
ADL:activities of daily living
bid:twice a day
CBG:capillary blood glucose or
blood sugar
CG:caregiver
cm:centimeter
ED:Executive Director
F:Fahrenheit
HH:Home Health
LPN:Licensed Practical Nurse
MA: Medication Aide
MAR:Medication Administration
Record
MCC:Memory Care Community
mg:milligram
ml:milliliter
MT:Medication Technician
OT:Occupational Therapist
PT: Physical Therapist
PRN:as needed
qd:every day or daily
qid:four times a day
QI: quality improvement
RCC: Resident Care Coordinator
RN: Registered Nurse
TAR: Treatment Administration
Record
tid: three times a day
The findings of the first revisit to the re-licensure survey of 08/15/24, conducted 02/19/25 through 02/21/25, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.
Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with H refer to the Home and Community Based Services rules.
Abbreviations possibly used in this document:
ADL:activities of daily living
bid:twice a day
CBG:capillary blood glucose or
blood sugar
CG:caregiver
cm:centimeter
ED:Executive Director
F:Fahrenheit
HH:Home Health
LPN:Licensed Practical Nurse
MA: Medication Aide
MAR:Medication Administration
Record
MCC:Memory Care Community
mg:milligram
ml:milliliter
MT:Medication Technician
OT:Occupational Therapist
PT: Physical Therapist
PRN:as needed
qd:every day or daily
qid:four times a day
QI: quality improvement
RCC: Resident Care Coordinator
RN: Registered Nurse
TAR: Treatment Administration
Record
tid: three times a day
The findings of the second revisit to the re-licensure survey of 08/15/24, conducted 04/30/25, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.
Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with H refer to the Home and Community Based Services rules.
Abbreviations possibly used in this document:
ADL:activities of daily living
bid:twice a day
CBG:capillary blood glucose or
blood sugar
CG:caregiver
cm:centimeter
ED:Executive Director
F:Fahrenheit
HH:Home Health
LPN:Licensed Practical Nurse
MA: Medication Aide
MAR:Medication Administration
Record
MCC:Memory Care Community
mg:milligram
ml:milliliter
MT:Medication Technician
OT:Occupational Therapist
PT: Physical Therapist
PRN:as needed
qd:every day or daily
qid:four times a day
QI: quality improvement
RCC: Resident Care Coordinator
RN: Registered Nurse
TAR: Treatment Administration
Record
tid: three times a day
The findings of the third re-visit to the re-licensure survey of 08/15/24, conducted 07/30/25, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.
Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with H refer to the Home and Community Based Services rules.
Abbreviations possibly used in this document:
ADL:activities of daily living
bid:twice a day
CBG:capillary blood glucose or
blood sugar
CG:caregiver
cm:centimeter
ED:Executive Director
F:Fahrenheit
HH:Home Health
LPN:Licensed Practical Nurse
MA: Medication Aide
MAR:Medication Administration
Record
MCC:Memory Care Community
mg:milligram
ml:milliliter
MT:Medication Technician
OT:Occupational Therapist
PT: Physical Therapist
PRN:as needed
qd:every day or daily
qid:four times a day
QI: quality improvement
RCC: Resident Care Coordinator
RN: Registered Nurse
TAR: Treatment Administration
Record
tid: three times a day
The findings of the fourth re-visit to the re-licensure survey of 08/15/24, conducted 09/18/25, 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 Home and Community Based Services Regulations OARs 411 Division 004.
Based on observation, interview, and record review, it was determined the facility failed to develop and conduct ongoing quality improvement programs that evaluated services, resident outcomes, and resident satisfaction. Findings include, but are not limited to:
During the survey, conducted 08/12/24 through 08/15/24, quality improvement oversight to ensure adequate resident care, services, and satisfaction was found to be ineffective.
Refer to the deficiencies in the report.
See individual POC statements for each C-tag
Executive director will meet with applicable department managers weekly to oversee adherence to the POC for ongoing compliance.
Weekly
Executive Director
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure residents were treated with dignity and respect and received services in a manner that protected privacy and dignity for 2 of 2 unsampled residents. Findings include, but are not limited to:
On 08/13/24, from 1:00 pm to 2:10 pm, a group interview was conducted with six unsampled residents. During the group interview the following was revealed:
1. One unsampled resident recounted an incident in the dining room which took place three days prior to the group interview. Two staff members went to his/her table with a scale and requested a weight of another resident who was sitting at the table. The individual was weighed at the table with a scale brought to the dining room, and the weight was stated audibly for others to hear.
2. A second unsampled resident in attendance at the group interview, who was a two-person transfer with use of a hoyer, stated s/he had pressed his/her pendant requesting to be assisted with getting out of bed for the day. The unsampled resident stated there was a wait time of "two hours." The unsampled resident stated one staff member responded to the pendant and said, "the MT is coming" to assist with getting the resident up. The unsampled resident stated, "Eventually she did." However, while waiting for staff to return to assist, s/he had soiled the bedding. The unsampled resident indicated the bedding was changed.
Review of the pendant logs obtained by the survey team on 08/14/24 confirmed the unsampled resident had pressed his/her pendant at 11:07 am, and it was acknowledged at 11:55 am, which constituted a wait time of 48 minutes.
In an interview with Staff 1 (ED) on 08/14/24, at 11:50 am, the above findings were shared, and Staff 1 was unaware the incidents had occurred. An investigation was requested to determine whether they had occurred as stated and to report them to the local Adult Protective Services (APS) office due to failing to protect residents from humiliation or loss of dignity. Confirmation of the self-report was received which indicated they had been reported on 08/16/24 at 4:05 pm via fax to the local APS office.
The need to ensure all residents were treated with dignity and respect and received services in a manner that protected privacy and dignity was discussed with Staff 1 on 08/15/24 at 2:00 pm. She acknowledged the findings.
Self report of the incident was made on 8/16/24.
Re-education provided to CG's and MT's on confidentiality and privacy for health related monitoring.
Re-education was provided to CG/MT staff on timely response to resident call lights and how to access assistance if unable to answer timely.
Call response times will be reviewed during daily stand up to assure timely awareness and follow up to any noted issues.
Observations will be done once daily rotating meals times by ED. ALD or designee to assure health monitoring issues are not being performed in the dining room. This will be done for 30 days to assure adherence to training provided.
Daily
ED, ALD, Designee
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure resident move-in evaluations addressed all required elements for 1 of 3 sampled residents (#5) whose move-in evaluations were reviewed. Findings include, but are not limited to:
Resident 5 moved into the facility in 04/2024 with diagnoses including intracerebral hemorrhage (stroke), aphasia (language disorder), and dysphagia (swallowing disorder).
The move-in evaluation failed to address the following elements:
* Mental health issues, including: effective non-drug interventions;
* Cognition, including: memory and confusion;
* Dental status;
* Pain including: non-pharmaceutical interventions and how a person expresses pain or discomfort; and
* Indicators of nursing needs including potential for delegated nursing tasks.
The need to ensure move-in evaluations included all required elements was discussed with Staff 1 (ED) on 08/15/24 at 2:30 pm. She acknowledged the findings.
Current care plan for resident 5 was updated to include missing elements from the Pre-Move in evaluation.
An audit of all move ins since July 1st was conducted to verify completion of a pre-move in evaluation.
Re-education provided to the ALD, WD and Nurse on the proper process and form for all pre move in evals.
ALD/ED or designee will review charts of new incoming residents within 48 hrs of move in to assure completion of documented premove in evals to assure ongoing compliance.
Within 48 hours of move in
ALD/ED or designee
There are no detail notes for this visit.
Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, to include resident preferences that supported the principles of choice, to provide clear direction regarding the delivery of services including a written description of who should provide the services, and to ensure changes made to the service plan were dated and initialed for 2 of 5 sampled residents (#s 1 and 5) whose service plans were reviewed. Findings include, but are not limited to:
1. Resident 5 was admitted to the facility in 04/2024 with diagnoses including intracerebral hemorrhage (stroke) and hemiplegia (paralysis of one side of the body).
The resident's current service plan, dated 05/26/24, was reviewed, observations were made, and interviews with the resident and caregivers were conducted between 08/12/24 and 08/15/24. Resident 5's service plan was not reflective and/or did not provide clear instruction to staff in the following areas:
* Home health services provided;
* Arm splint, including instructions for donning and doffing, when it should be worn, and risks associated with the splint;
* Positioning support for arm and back while in the wheelchair; and
* Floating heels while in bed.
The need to ensure service plans were reflective of the identified needs of the resident and provided clear direction regarding the delivery of services was discussed with Staff 1 (ED) on 08/15/24 at 2:30 pm. She acknowledged the findings.
2. Resident 1 moved into the facility in 05/2024 with diagnoses including chronic sacral decubitus (pressure wound), cirrhosis (liver damage), and chronic kidney disease stage 3.
The current service plan, dated 06/17/24, and temporary care plans were reviewed. Observations and interviews with staff and Resident 1 were completed during the survey.
a. The service plan had handwritten updates and entries that lacked initials and dates for when the changes occurred.
b. The service plan was not reflective of the resident's needs, did not include resident preferences that supported the principles of choice, did not provide clear direction regarding the delivery of services and did not include a written description of who shall provide the services in the following areas:
* Instructions for weight monitoring;
* Instructions related to the use of a pressure alternating mattress;
* Instructions including infection control practices for emptying and cleaning the urinal and ileostomy bag;
* Preference for caregiver gender;
* Preference for who would provide services related to transfers, ostomy care, and bathing (caregiver, friend, or hospice); and
* Dental status.
The need to ensure the service plan reflected the resident's needs, included resident preferences that supported the principles of choice, individuality, and independence, provided clear direction regarding the delivery of services that included a written description of who shall provide the services and changes made to the service plan were dated and initialed was discussed with Staff 1 (ED) and Staff 2 (Health and Wellness Director) on 08/14/24 at 12:28 pm. They acknowledged the findings.
Service plans for sampled residents have been updated.
An audit of remaining residents service plans will be conducted to verify accuracy.
Re-education was provided to ALD and Nurse to assure understanding of how TCP's interact with the service plan and how to properly manually update a service plan.
Routine weekly audits to include review of new orders, outside agency visits, changes of condition etc. will be conducted to assure TCP's and/or service plans are reflective of any changes.
Service plans will be updated with accurate and relevant information during the quarterly updates.
Weekly/quarterly
ALD/Nurse
There are no detail notes for this visit.
2. Resident 5 moved into the facility in 04/2024 with diagnoses including intracerebral hemorrhage (stroke), depression, and congestive heart failure.
The current service plan dated 05/26/24, temporary care plans, and progress notes dated 05/14/24 through 08/09/24 were reviewed. Observations and interviews with staff and Resident 5 were completed between 08/12/24 and 08/15/24.
The facility failed to determine action or intervention needed for the resident, communicate the action or intervention to staff on each shift, and/or document weekly progress until the condition resolved for the following conditions:
* 05/28/24 - Decrease in fluoxetine and start of sertraline (both for depression);
* 06/03/24 - Urinary tract infection;
* 06/03/24 - Antibiotic for infection;
* 06/14/24 - Seizure activity and hospital stay;
* 06/23/24 - New medications initiated;
* 06/28/24 - Hospital visit and dehydration;
* 07/10/24 - 3.5 pound weight change in 24 hours;
* 07/10/24 - Increase in potassium;
* 07/14/24 - Seizure activity; and
* 07/27/24 - Change in furosemide dosing.
The need to ensure the facility determined and documented what action or interventions were needed for changes of condition, the interventions were communicated to staff on all shifts, and were monitored at least weekly through resolution was discussed with Staff 1 (ED) on 08/15/24 at 2:30 pm. She acknowledged the findings, and no additional information was provided.
Based on observation, interview, and record review, it was determined the facility failed to determine and document what actions or interventions were needed for short-term changes of condition, to communicate resident-specific instructions and interventions to staff on each shift, and monitor the change of condition, at least weekly, until resolved for 2 of 5 sampled residents (#s 1 and 5) who experienced changes of condition. Findings include, but are not limited to:
1. Resident 1 moved into the facility in 05/2024 with diagnoses including chronic sacral decubitus (pressure wound), cirrhosis (liver damage), and chronic kidney disease stage 3.
The current service plan, dated 06/17/24, temporary care plans, progress notes, dated 05/14/24 through 08/13/24, and wound assessments were reviewed. Observations and interviews with staff and Resident 1 were completed during the survey.
The facility failed to determine action or intervention needed for the resident, communicate the action or intervention to staff on each shift, and/or document weekly progress until the condition resolved for the following conditions:
* 05/08/24 - Lump on right leg;
* 05/14/24 - Discontinue the use of the following medications: routine Tylenol, multi-vitamins, and tamsulosin;
* 05/14/24 - Decrease metoprolol and oxycodone and increase scheduled methadone;
* 05/16/24 - The resident reported tightness in both feet;
* 05/20/24 - Wound on the front right foot, little toe;
* 05/20/24 - Skin tear on the front left wrist;
* 06/03/24 - Skin tear on the back of the left elbow;
* 06/16/24 - Discontinue valacyclovir;
* 06/24/24 - Pressure wound on the front left outer knee;
* 07/10/24 - Skin tear on the front left elbow;
* 07/23/24 - Rash on back and new medication hydrocortisone;
* 07/29/24 - Abrasion on the front left outer knee; and
* 07/29/24 - Skin tear on the front left lower arm.
The need to ensure the facility determined and documented what action or interventions were needed for changes of condition, the interventions were communicated to staff on all shifts, and were monitored at least weekly through resolution was discussed with Staff 1 (ED) and Staff 2 (Health and Wellness Director) on 08/14/24 at 12:28 pm. They acknowledged the findings.
Resident # 1 & 5 were re-assessed and documentation of said assessment and plans for meeting care needs placed in resident chart notes.
A review of remaining residents with changes of condition in the last 14 days were reviewed to verify adherence to community monitoring system.
Re-Education provided to the ALD and Nurse on alert charting systems and change of condition systems to assure understanding.
ALD/Nurse will conduct routine audits of resident chart notes to assure residents are appropriately placed on alert and monitoring is provided as well as closure notes present for each series.
Weekly
ALD/Nurse
There are no detail notes for this visit.
Based on observation, interview, and record review, it was determined the facility failed to coordinate care with outside providers, and the facility failed to ensure staff were informed of new interventions and the service plan was adjusted if necessary for 1 of 3 sampled residents (#5) who received outside services. Findings include, but are not limited to:
Resident 5 moved into the facility in 04/2024 with diagnoses including intracerebral hemorrhage (stroke), hemiplegia (paralysis of one side of the body), aphasia (language disorder), and dysphagia (swallowing disorder).
During the acuity interview on 08/12/24 at 9:30 am, the resident was identified to receive home health services.
Resident 5's outside provider notes, dated 05/17/24 through 08/13/24, and progress notes, dated 05/17/24 through 08/09/24, were reviewed during the survey and revealed the following recommendations:
* 05/17/24 - "Advance diet to regular (pre-cut) ...all meals in communal dining room. General aspiration precautions";
* 05/22/24 - "[Resident 5] requires additional time to communicate ...if [s/he] gets stuck ...[clarify] the topic ...proceed with yes/no questions ...ask the question in two ways"; and
* 05/29/24 - "[Resident 5] should be in dining room for all meals. [S/he] is at higher risk for choking if eating reclined in bed, and if [s/he's] alone in [his/her] room."
There was no documented evidence caregiving staff were informed of new interventions and the service plan adjusted to ensure continuity of care.
On 08/13/24 at 9:30 am, Staff 13 (MA) brought Resident 5 his/her breakfast meal to the resident in bed and then left the room. No supervision was provided while the resident ate. In an interview on 08/14/24 at 10:41 am, Staff 12 (CG) reported she was not aware of the resident's swallowing problems.
The need to ensure the facility coordinated care with outside service providers, the facility staff were informed of new interventions, and the service plan was adjusted if necessary was discussed with Staff 1 (ED) on 08/15/24 at 2:30 pm. She acknowledged the findings, and no additional information was provided.
Resident #5 outside provider notes were audited to ensure the most updated recommendations and coordination of care are reflected in the service plan.
In-serviced all med techs on process of outside provider notes/suggestions/changes.
ALD/Nurse will conduct routine audits of resident oustide provider notes to assure resident coordination of care and incorporation into service plan as applicable.
Weekly
ALD/Nurse
There are no detail notes for this visit.
2. Resident 5 was admitted to the facility in 04/2024 with diagnoses including intracerebral hemorrhage (stroke) and hemiplegia (paralysis of one side of the body).
Observations of the resident and interviews with staff from 08/12/24 through 08/15/24 revealed Resident 5 relied on two staff for incontinence care needs.
On 08/14/24 at 12:29 pm, Staff 12 (CG) and Staff 13 (MA) provided incontinence care for Resident 5. Staff 12 and Staff 13 donned gloves to provide incontinence care. The resident's soiled clothing and soiled brief were removed, the soiled brief was placed on the carpeted floor, perineal care was provided, and then the resident was dressed in clean clothing. Staff 12 and Staff 13 obtained a hoyer sling, and they started to reposition the resident to prepare for a hoyer transfer. Neither staff member doffed their soiled gloves or performed hand hygiene prior to dressing the resident or placing the hoyer sling. This surveyor requested the two caregivers doff their soiled gloves and perform hand hygiene prior to continuing ADL tasks.
The need to establish and maintain effective infection prevention and control protocols while performing ADL care was discussed with Staff 1 (ED) on 08/15/24 at 2:30 pm. She acknowledged the findings.
Based on observation and interview, it was determined the facility failed to establish and maintain effective infection prevention and control protocols for 2 of 2 sampled residents (#s 3 and 5) while performing ADL care. Findings include, but are not limited to:
1. Resident 3 was admitted to the facility in 12/2023 with diagnoses including short-term memory loss and a recent diagnosis of left femur fracture.
Observations of the resident and interviews with staff from 08/12/24 through 08/15/24 revealed Resident 3 relied on two staff for incontinence care needs.
On 08/13/24 at 11:58 am, Staff 8 (Activities/CG) and Staff 13 (MA) provided ADL incontinence care for Resident 3. Staff 8 and 13 donned gloves prior to providing incontinence care. Staff 13 removed the resident's soiled clothing and soiled brief, performed perineal care, and then applied barrier cream to the area without doffing soiled gloves. Staff 8 and 13 then placed clean clothes on the resident, transferred the resident from bed to wheelchair all while wearing the same gloves.
The need to establish and maintain effective infection prevention and control protocols while performing ADL care was discussed with Staff 1 (ED) on 08/15/24 at 2:00 pm. She acknowledged the findings.
Re-education provided to CG and MT staff on proper glove use, differentiating clean and dirty tasks and proper handwashing processes.
ALD will conduct routine CG ADL observations twice monthly for 45 days then resume quarterly.
Twice monthly for 45 days/then quarterly
ALD/Designee
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure a safe medication and treatment administration system. Findings include, but are not limited to:
During the re-licensure survey, conducted 08/12/24 through 08/15/24, professional oversight of the medication and treatment administration system was found to be ineffective, based on deficiencies in the following areas:
* C 302 - Tracking Controlled Substances;
* C 303 - Medication and Treatment Orders;
* C 305 - Resident Right to Refuse; and
* C 310 - Medication Administration.
The need to ensure a safe medication and treatment system was discussed with Staff 1 (ED) on 08/15/24 at 2:30 pm. She acknowledged the findings.
See individual POC statements for C302, C303, C305 & C310.
There are no detail notes for this visit.
3. Resident 5 was admitted to the facility in 04/2024 with diagnoses including intracerebral hemorrhage (stroke) and hemiplegia (paralysis of one side of the body).
Resident 5 had an order for lacosamide 100 mg, take one tab two times daily for seizures.
Resident 5's Controlled Substance Disposition Logs and MARs, reviewed from 07/01/24 through 08/11/24, revealed 81 occasions when staff signed the MAR indicating the lacosamide was given. However, the Controlled Substance Disposition Log indicated 74 times the resident received the medication. This indicated a discrepancy of seven pills.
The need to ensure the facility had a system for tracking controlled substances was discussed with Staff 1 (ED) on 08/15/24 at 2:30 pm. She acknowledged the findings.
2. Resident 3 was admitted to the facility in 12/2023 with diagnoses which included short-term memory loss and a recent diagnosis of fractured left femur.
Resident 3 had an order for oxycodone (narcotic analgesic) 5 mg, take 0.5 tab every six hours as needed for pain for up to five days.
Resident 3's Controlled Substance Disposition Logs and MARs, reviewed from 07/01/24 through 08/12/24, revealed three occasions when staff signed on the drug disposition log that the oxycodone was given. However, the MAR indicated one time the resident received the PRN medication.
Inconsistencies between the MAR and Controlled Substance Disposition logs were reviewed with Staff 10 (MA) on 08/13/24 at 3:40 pm. No additional information was provided.
The need to ensure the facility had a system for tracking controlled substances was discussed with Staff 1 (ED) on 08/15/24 at 2:00 pm. She acknowledged the findings.
Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 3 of 3 sampled residents (#s 1, 3 and 5) who were administered scheduled and as needed narcotic medications. Findings include, but are not limited to:
1. Resident 1 moved into the facility in 05/2024 with diagnoses including chronic sacral decubitus (pressure wound), cirrhosis (liver damage), and chronic kidney disease stage 3.
Review of the current written prescriber orders and MARs dated 07/01/24 through 08/01/24 were reviewed during the survey.
Resident 1 had a physician order for oxycodone 5 mg, take two tablets by mouth every four hours as needed for pain.
Resident 1's 07/01/24 through 08/12/24 MARs and Controlled Substance Disposition Logs identified the following:
Between 07/01/24 through 08/12/2024 there were 42 occasions staff signed the drug disposition log that the PRN oxycodone was removed from the drug card; however, staff failed to initial and document on the MAR that the resident received the PRN medication.
Inconsistencies between the MAR and Controlled Substance Disposition logs were reviewed with Staff 2 (Health and Wellness Director) on 08/14/24 at 12:28 pm. She acknowledged the discrepancies.
MAR sheets adjusted to reflect all doses signed out on the individual NARC log completed for sampled residents.
Audit of remaining residents who are prescribed narcotics was conducted to verify compliance.
Re-education given to MT staff on proper documentation in both narc log and MAR for narcotics.
Routine audits of sampled residents prescribed narcotics to verify accuracy between narc log and MAR sheet to maintain ongoing compliance.
Weekly
ALD/Nurse
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure physician or other legally recognized practitioner orders were carried out as prescribed for 4 of 4 sampled residents (#s 1, 2, 3 and 5) whose orders were reviewed. Findings include, but are not limited to:
1. Resident 2 was admitted in 06/2022 with diagnoses which included diabetes, congestive heart failure, and hypertension (high blood pressure).
Physician orders and MARs, reviewed from 07/01/24 through 08/13/24, revealed the following medications were not given on 07/20/24 at 5:00 pm:
* Calcium (supplement) 500 - Vit D3 one tablet;
* Cranberry EXT (supplement) one capsule;
* Advair Diskus (for difficulty breathing) 100-25 mcg one inhalation;
* Gabapentin (for pain) 300 mg one capsule;
* Memantine HCL (for memory loss) 10 mg one tablet;
* Metformin HCL (regulates blood sugar) 500 mg two tablets;
* Multivitamin (supplement) one tablet; and
* Spironolactone (for fluid reduction) 25 mg one tablet.
During an interview on 08/14/24 at 1:45 pm, the surveyor, Staff 10 (MA) and Staff 15 (Director of Health Services) checked the MARs. Staff 10 verified the above medications were not given on 07/20/24. She added that the MT working that evening was a new employee and was unable to locate the medications. Staff 15 stated that the PCP had not been notified, but "should have been." Both acknowledged that orders were not followed.
The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (ED) on 08/14/24 at 5:30 pm. She acknowledged the findings.
4. Resident 5 moved into the facility in 04/2024 with diagnoses including intracerebral hemorrhage (stroke), hemiplegia (paralysis of one side of the body), and hypertension (high blood pressure).
The resident's MAR dated 07/01/24 through 08/11/24 and current physician's orders were reviewed.
The resident had physician orders for the following medications dated 07/20/24:
* Carvedilol 25 mg - take one tablet two times daily (for hypertension);
* Debrox 6.5% - apply one drop as directed (for ear wax build-up);
* Diclofenac sodium 1% - administer four times a day to painful shoulder and knee (for pain);
* Lacosamide 100 mg - take one tablet by mouth two times daily (for seizures);
* Levetiracetam - 100 mg/mL solution - take 10 mL by mouth every 12 hours (for convulsions);
* Losartan - 100 mg tablet - take 1 tablet by mouth every morning (for hypertension);
* Miralax 17 gram - give one packet daily (for bowel care); and
* Trolamine salicylate 10% cream - apply one gram three times daily (for pain).
a. The following physician orders were not followed as written from 07/01/24 through 08/11/24:
* Debrox 6.5% was not included on Resident 5's MAR and was not administered per physician order;
* Diclofenac sodium was administered twice a day to the knee. The order indicated the cream should be administered four times a day to the knee and the shoulder;
* Losartan was administered at a dosing of 75 mg and not the 100 mg prescribed;
* Miralax once daily was not included on the MAR and was not administered as prescribed; and
* Trolamine salicylate was not measured prior to administration per physician order.
On 08/14/24 at 1:27 pm, Staff 15 (Director of Health Services) confirmed these medications were not administered as ordered.
b. The following medications were documented as not available on the following dates:
* 07/05/24 - carvedilol, diclofenac sodium, lacosamide, and trolamine salicylate;
* 07/06/24 - diclofenac sodium, lacosamide, and trolamine salicylate; and
* 07/18/24 - levetiracetam.
c. Resident 5's MAR was blank on the following occasions;
* 07/29/24 - Trolamine salicylate 10% at 2:00 pm; and
* 08/11/24 - Diclofenac sodium 1% at 8:00 am.
On 08/14/24 at 10:59 am, Staff 10 (MA) and this surveyor reviewed Resident 5's medications supply and MAR for all blanks and medications documented as unavailable. Staff 10 was unable to verify if the orders were followed as prescribed.
The need to ensure all medications were carried out as prescribed was reviewed with Staff 1 (ED) on 08/15/24 at 2:30 pm. She acknowledged the findings.
2. Resident 3 was admitted to the facility in 12/2023 with diagnoses including short-term memory loss and a recent diagnosis of left femur fracture. The resident's 07/01/24 through 08/12/24 MARs and physician's orders were reviewed and revealed the following orders were not followed as the MAR noted "Medication not arrived" for the following medications:
* Calcium carbonate antacid (supplement) on seven occasions;
* Senna Lax (medication for regulating bowel movements) on seven occasions;
* Stool softener (medication for regulating bowel movements) on seven occasions;
* Dicloflenac sodium 1% gel (medication for knee pain) on six occasions;
* Acetaminophen (a medication to treat pain) on one occasion; and
* Nystatin powder (medication for rash) on one occasion.
In an interview with Staff 10 (MA) on 08/15/24 at 10:10 am she stated the Medication Aide on duty was new and just "didn't know where to find" the medication to administer it.
The need to ensure the facility followed physician orders was discussed with Staff 1 (ED) on 08/15/24 at 2:00 pm. The findings were acknowledged.
3. Resident 1 moved into the facility in 05/2024 with diagnoses including chronic sacral decubitus (pressure wound), cirrhosis (liver damage), and chronic kidney disease stage 3.
Resident 1's clinical record including the 07/2024 MAR and current physician orders were reviewed, and the following was identified:
Resident 1 had a physician order for "metoprolol succinate 50 mg tablet. Give one tablet by mouth at 0500 for [high blood pressure]. Hold for systolic [blood pressure] less than 90."
On 07/17/24 and 07/19/24, the resident's systolic blood pressure was recorded as 78 and 87, respectively. Medication Aides initialed and documented they administered the medication on both occasions when it should have been held.
The need to ensure the facility administered medications as prescribed was discussed with Staff 2 (Health and Wellness Director) on 08/14/24 at 12:28 pm. She acknowledged the findings.
Orders and MAR sheets for August were reviewed to assure necessary corrections were made and medications were available for staff to give for sampled residents.
Audit of remaining residents current August MARs were reviewed to assure accuracy and availability of medications.
Re-education provided to the MT staff on organization of the med cart/med room to reduce "lost" meds, protocol to follow when meds not available to give and who to notify.
Medication availability will be reviewed daily by ALD/Nurse to assure timely awareness and resolution.
MAR documentation audits will be conducted weekly to assure completed.
Daily order transcription review will be conducted to assure orders have been entered in correctly.
Weekly/Daily
ALD/Nurse
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused to consent to orders for 2 of 3 sampled residents (#s 1 and 3) who had documented medication refusals. Findings include, but are not limited to:
1. Resident 3 was admitted to the facility in 12/2023 with diagnoses including short-term memory loss and a recent diagnosis of left femur fracture. The resident's 07/01/24 through 08/12/24 MARs and "Chart Notes" dated 05/14/24 through 08/06/24 were reviewed and revealed the resident refused to consent to orders for the following medications:
* Acetaminophen (a medication to treat pain) on 11 occasions;
* Atelenol (for blood pressure) on 11 occasions;
* Atoravastin calcium (medication to lower risk of heart attack or stroke) on one occasion;
* Dicloflenac sodium 1% gel (medication for knee pain) on 10 occasions;
* Nystatin 10000 unit/gm powder (medication for rash) on 10 occasions;
* Sodium chloride 1 gm tabs (supplement) on eight occasions;
* Vitamin B12 folic acid 0.4 mg tabs (medication for leg cramps) on seven occasions;
* Aspirin 81 mg tab (medication for heart health) on five occasions;
* Calcium carbonate antacid 500 mg chew (supplement) on seven occasions;
* Cholecalciferol 50 mcg capsules (supplement) on five occasions;
* Furosemide 20 mg tab (medication to reduce fluid retention) on five occasions;
* Multivitamin w/folic acid 400 mcg (supplement) on five occasions;
* Senna Lax 8.6 mg tabs (medication for regulating bowel movements) on seven occasions;
* Sertraline HCL 25 mcg tabs (medication for mood elevation) on five occasions; and
* Stool softener 250 mg tabs (medication for regulating bowel movements) on six occasions.
In an interview on 08/13/24 at 9:15 am, Staff 10 (MA) stated the facility's process was to document the refusal in the "Chart Notes" and notify the provider by fax of the refusal. Staff 10 and the surveyor reviewed the "Chart Notes" together and found there was no documented evidence of refusals being documented in the "Chart Notes," and there was no documented evidence the facility had notified the physician of the refusals. On 08/14/24 at 10:45 am Staff 10 provided a copy of the fax confirmation showing the provider had been notified via fax of the resident refusals on 08/13/24.
The need to ensure the facility notified the physician or other practitioner if the resident refused consent to an order was discussed with Staff 1 (ED) on 08/15/24 at 2:00 pm. The findings were acknowledged.
2. Resident 1 moved into the facility in 05/2024 with chronic sacral decubitus (pressure wound), cirrhosis (liver damage), and chronic kidney disease stage 3.
The resident's clinical record including charting notes dated 05/14/24 through 08/13/24 and the 07/01/24 through 08/12/24 MARs were reviewed and interviews with staff were conducted during the survey.
Resident 1 had refused consent to the following written prescriber orders:
* 05/17/24 - A chart note indicated the "Resident refused [his/her] 5:00 am meds..."; and
* 07/24/24 - The July 2024 MAR indicated the resident refused the 5:00 am dose of metoprolol succinate (for high blood pressure).
During an interview with Staff 19 (Regional RN) on 08/13/24 at 4:30 pm, verification of reporting Resident 1's refusal to consent to the above written orders was requested. No further information was received.
The need to ensure the facility notified the physician or other practitioner if the resident refused consent to an order was discussed with Staff 2 (Health and Wellness Director) on 08/14/24 at 12:28 pm. She acknowledged the findings.
MD notification send for refusals noted for sampled residents.
Audit of remaining residents for refusals in August to verify MD notification occurred.
Re-education provided to MT staff on required notification of refusals to residents MD.
Routine weekly audits will take place to assure MD notification for any/all refusals of meds/treatments has been completed.
Weekly
ALD/Nurse
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was maintained for all facility administered medications for 3 of 4 sampled residents (#s 1, 2 and 5) whose MARs were reviewed. Findings include, but are not limited to:
1. Resident 2 was admitted in 06/2022 with diagnoses which included diabetes, congestive heart failure, and hypertension (high blood pressure).
Physician orders and MARs, reviewed from 07/01/24 through 08/13/24, were reviewed during the survey. The following were identified:
Resident 2 had an order for Advair Diskus 250-50 (for respiratory complications) one inhalation twice daily.
According to the MAR, staff documented on multiple occasions between 07/01/24 and 07/11/24, that the inhaler was not available. However, there were also multiple occasions that staff initialed that the inhaler was administered during the same time frame.
The discrepancies on the MAR were reviewed with Staff 10 (MA) and Staff 15 (Director of Health Services) on 08/14/24 at 1:45 pm. Staff 10 confirmed that staff initialed that the inhaler had been administered when it was documented as unavailable. Both acknowledged the MAR was inaccurate.
The need to ensure MARs were accurate was discussed Staff 1 (ED) on 08/14/24 at 5:30 pm. She acknowledged the findings.
3. Resident 5 was admitted to the facility in 04/2024 with diagnoses including hypertension (high blood pressure).
Resident 5's MAR, dated 07/01/24 through 08/11/24, and corresponding physician orders were reviewed and revealed the following:
* Resident 5 had a physician order dated 07/20/24 to receive one 20 mg tablet of furosemide every morning for fluid retention. The resident's MAR indicated the resident was to receive 40 mg daily. On 08/14/24 at 1:27 pm, Staff 10 (MA), Staff 15 (Director of Health Services), and this surveyor reviewed the resident's medication supply and MAR. It was determined the resident received the correct dose of furosemide, but the MAR was inaccurate.
* The resident had an order to receive carvedilol 25 mg two times daily for hypertension. The resident's MAR was blank for this medication on 08/11/24 at 8:00 am. On 08/14/24 at 11:07 am, Staff 10 and this surveyor reviewed the resident's medication supply and MAR.
It was determined the resident did receive the medication as ordered, and the MAR was not initialed.
* Miconazole powder PRN (for fungal rash) was documented on the resident's MAR; however, the resident did not have an active order.
* There was no documented reason for use listed for nitrofurantoin (antibiotic).
The need to ensure MARs were accurate was discussed with Staff 1 (ED) on 08/15/24 at 2:30 pm. She acknowledged the findings.
2. Resident 1 moved into the facility in 05/2024 with diagnoses including chronic sacral decubitus (pressure wound), cirrhosis (liver damage), and chronic kidney disease stage 3.
Resident 1's 07/01/24 through 08/12/24 MARs were reviewed and identified the following as needed medications lacked resident specific parameters and clear instructions for unlicensed staff.
* Lidocaine 4% cream apply to the affected area once daily for pain;
* Morphine sulfate every hour as needed for pain; and
* Oxycodone 5 mg tablet every four hours as needed for pain.
Review of the 07/01/24 through 08/12/24 MAR identified staff only administered the oxycodone, and there was not clear instructions for the sequence of use or instructions for where to apply the PRN lidocaine cream.
The need to ensure medications had resident-specific parameters for PRN medications and clear instructions to staff was reviewed with Staff 2 (Health and Wellness Director) on 08/14/24 at 12:28 pm. She acknowledged the findings.
Medications are available for all sampled residents. MARs reviewed and corrections made to findings noted in the survey document.
Audit of remaining residents MAR sheets conducted to verify adequate information and availability of meds verified.
Re-education given to MT staff on proper and consistent MAR documentation, protocol to follow when meds are not available.
Re-education provided to ALD/Nurse of requirements of appropriate parameters and directions on the MAR for MTs to reference.
ALD/Nurse will conduct daily audits for any meds not available, daily review of order transcription and weekly MAR audits to assure ongoing compliance.
Daily/Weekly
ALD/Nurse
There are no detail notes for this visit.
Based on observation, interview, and record review, it was determined the facility failed to ensure a thorough RN, PT, or OT assessment was completed prior to the use of a supportive device with restraining qualities, failed to document other less restrictive alternatives were evaluated prior to the use of the device, failed to instruct caregivers on the correct use and precautions related to the use of the device and included in the service plan for 1 of 1 sampled resident (# 1) who used a supportive device with restraining qualities. Findings include, but are not limited to:
Resident 1 moved into the facility in 05/2024 with diagnoses including chronic sacral decubitus (pressure wound), cirrhosis (liver damage), and chronic kidney disease stage 3.
The current service plan dated 06/17/24 and temporary care plans were reviewed. Observations of the resident and interviews with staff identified the resident had bilateral half-length side rails on his/her bed.
During observations and interviews with Resident 1 on 08/13/24 at 10:30 am, the resident's bed was located in the middle of the bedroom, the siderails were in good repair, and they were flush with the mattress. The resident reported s/he was unable to lower and raise the bed rails without staff assistance.
The resident's current service plan failed to document other less restrictive alternatives were evaluated prior to the use of the device and to instruct caregivers on the correct use and precautions related to the use of the side rails. Staff reported the resident was primarily bedbound, was a two-person hoyer transfer and received the hospital bed with side rails from the hospice provider.
On 08/12/24 at 1:27 pm, Staff 20 (Regional RN) confirmed an assessment of the side rails was not previously completed. Staff 5 stated "it's now completed" and provided a copy of a "Supportive Devices with Restraining Qualities Evaluation" completed by the facility RN, dated 08/12/24.
The need to ensure supportive devices with restraining qualities were assessed by an RN, PT, or OT and were included in the resident's service plan was discussed with Staff 2 (Health and Wellness Director) on 08/14/24 at 12:28 pm. She acknowledged the findings.
Restraint evaluation completed for sampled resident prior to the conclusion of the survey visit.
A review of remaining residents using supportive devices was conducted to verify completion of the necessary evaluations.
-ALD and RN will review weekly for any new devices and monthly to assure evaluations are current.
Weekly/monthly
ALD/RN
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to have direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident, and adequate direct care staff to meet the fire safety evacuation standards as required by the fire authority or the Department. Findings include, but are not limited to:
The facility was licensed as an Assisted Living Facility (ALF) with a capacity of 72 beds. A Memory Care Facility (separate licensure) resided on the same campus and was attached to the ALF.
During the entrance conference on 08/12/24 at 9:30 am, the following was identified:
* The assisted living was home to 57 residents who resided on three floors;
* Five residents required a mechanical lift using two staff for transfers. Two of the residents who required a mechanical lift resided on the second and third floors of the facility;
* Two residents required two-person assist for transfers; and
* Several residents required high levels of caregiving assistance due to hospice, cognitive decline, and/or due to fall risk.
a. Interviews with sampled and unsampled residents, and facility staff between 08/12/24 and 08/14/24 revealed the following:
* One unsampled resident reported s/he was told multiple times by staff that s/he would need to wait for care, including two-person transfer. When s/he was told to wait, often it was in excessive of one hour and today s/he waited two hours and missed breakfast with his/her peers;
* "Some people [staff] don't respond at all [to the call light]. Depends on who is on shift, it will sit there [pointing to a urinal] for three or four hours after I ring the bell.";
* "Some caregivers don't call in and they don't show up.";
* "They're short staffed.";
* "Being short staffed is definitely a problem here.";
* "I [CG on day shift] work alone a lot of the time.";
* "I think they are short staffed.";
* Residents reported concerns on multiple occasions that the facility didn't have enough staff and concerns that several residents had "too high of care needs for the number of staff on shift.";
* The MCC staff come over and assist with the two person transfers when needed;
* "Usually when we have full staff we get [Resident 5] up for breakfast. When we are short staffed we don't always have time to get [him/her] up for breakfast.";
* "If we don't have three [caregivers], it's crazy because of all the two person transfers."; and
* "The plan is to have three caregivers and one med tech."
The current posted staffing plan was as follows:
* Day shift: 2 CGs and 1 MA;
* Swing shift: 2 CGs and 1 MA; and
* Noc shift: 1 CG and 1 MA.
During the survey, the facility staffing policy or a tool to determine number of caregiving staff needed to provide scheduled and unscheduled residents' care needs was requested by survey. Staff 1 (ED) stated the facility used the service plan points generated to determine staffing levels. The facility acuity-based staffing tool (ABST) was reviewed during the survey.
The facility ABST for multiple sampled residents had not been reviewed or updated as required and/or was not reflective of current needs. Therefore, the tool could not be used to determine an appropriate staffing plan.
b. Interviews during the survey with multiple residents who were alert and oriented, reported the facility did not schedule adequate numbers of staff which resulted in staff not responding to call lights in a timely manner. On 08/14/24, call light logs from 08/01/24 through 08/14/24 were reviewed. The call logs showed call light response times in excess of 15 minutes occurred more than 150 times with some call response times exceeding one hour.
On 08/14/24 at 2:30 pm, Staff 3 (Assisted Living Director) and Staff 14 (MA) stated the facility's expectation for answering call lights was between three to five minutes.
c. Review of MARs for sampled residents revealed several occasions when medications and/or treatments were "documented late" because of "insufficient staffing in caregiving department."
d. During an interview on 08/12/24 at 12:00 pm, Staff 1 and Staff 6 (Maintenance Director) reported the facility was not relocating residents during fire drills. During the interview, Staff 1 and Staff 6 were unable to explain how the facility would be able to safely evacuate multiple residents requiring two-person transfers who resided on the second and third floors if they were not relocating residents during fire drills. Documentation was requested for an alternate written fire safety plan to shelter/dwell in place from the Department or local fire jurisdiction but no additional information was provided.
e. During an interview with Staff 1 on 08/15/24 at 11:50 am, she said she would use the MCC staff to help evacuate in the ALF if needed.
The facility lacked a sufficient number of staff to meet the scheduled and unscheduled needs of residents, and fire evacuation standards of the multiple residents who required the assist of two care staff for transfers, had high levels of care needs, and resided on three distinct floors.
The need to ensure the facility had direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident, including fire safety evacuation needs and extended call light times was discussed with Staff 1 on 08/15/24 at 2:30 pm. She acknowledged the findings.
Refer to C 361.
Job fair completed with 1 successful hire
-ALD and ED will review staffing and scheduling needs daily during daily stand up meeting.
ALD will re-evaluate resident needs and accuracy of ABST tool for correlating staffing needs weekly with the ED.
ALD and ED will assure monthly staffing schedules are archived for future reference.
Daily/weekly/monthly
ED/ALD
Based on interview and record review, it was determined the facility failed to have sufficient staff to meet the scheduled and unscheduled needs of the residents per the facility's ABST and adequate direct care staff to meet the fire safety evacuation standards as required by the Department. This is a repeat citation. Findings include, but are not limited to:
The facility was licensed as an Assisted Living Facility (ALF) with a capacity of 72 residents. A Memory Care Facility (separate licensure) resided on the same campus and was attached to the ALF.
a. On 02/19/25 at 10:45 am, during the entrance conference the following was identified:
* The current census was 60 residents;
* The assisted living was home to residents who resided on three floors;
* Three residents required a mechanical lift using two staff for transfers and resided on the second and third floors;
* Several residents required staff assistance to get to a location; and
* Multiple residents required two staff for transfers.
b. A review of the facility's posted staffing plan, schedule from 02/10/25 through 02/16/25, and current ABST indicated the following:
* Day Shift: 6:00 am - 2:00 pm - One Med-aide and three Caregivers;
* Swing Shift: 2:00 pm - 10:00 pm - One Med-aide and three Caregivers;
* Overnight Shift: 10:00 pm - 6:00 am - One Med-aide and One Caregiver; and
* Five of seven days reviewed were not staffed to the posted staffing plan.
c. Review of fire drill records dated 10/23/24 indicated a resident who lived on the second floor required three people and the use of stair chair for evacuation. During the revisit survey on 02/19/25, the resident was still living in a unit on the second floor.
The staffing plan for overnight shift showed two care staff scheduled, which indicted this would not be sufficient staff to meet this resident's unscheduled needs.
d. During an interview with Staff 12 (CG) and Staff 22 (MA) on 02/21/25 at 9:50 am, it was reported there was one resident on the third floor that would take three to four staff to evacuate using the stair chair (fire evacuation equipment) and three more residents that would require minimum two care staff simultaneously using the stair chair to evacuate the resident. Additionally, the care staff reported eight residents lived on the second floor and required a minimum of two care staff and the stair chair to evacuate the residents, which would leave the remaining residents unattended during a potential evacuation.
e. Review of Resident 6's ABST identified the facility failed to accurately update Resident 6's ABST and ensure scheduled care time and care elements had sufficient time to complete the care elements, including care time for multiple two-person care needs.
The facility failed to have sufficient staff to meet the scheduled and unscheduled needs of the residents per the facility's ABST and adequate direct care staff to meet the fire safety evacuation standards as required by the Department.
The need to ensure the facility was staffing sufficient staff per the ABST to meet the scheduled and unscheduled needs of the residents was discussed with Staff 1 (ED), Staff 2 (Health and Wellness Director), Staff 23 (Chief Operations Officer), Staff 24 (Regional Operations Director), and Staff 25 (Memory Care Director) on 02/20/25 at 3:40 pm. They acknowledged the findings.
Refer to C 362.
1. We will re-evaluate the evacuation need status for resident 6 and all residents to ensure adequate staffing for evacuation needs. There is an agreed upon plan that resident noted as needing 3 people for use of the stair chair during evacuation will be reolcated to the 1st floor as soon as a room becomes available. We expect this to happen in the next 30 days.
2.We will re-evaluate the resident transfer needs for all 2 person transfers and update service plans and the ABST tool accordingly. We will re-train and re-educated staff on all resident evacuation needs and use of the stair chair as well as alternate methods of evacuation.
3. We will continue to evaluate evacuation needs upon move in, during fire drills, service plan updates, and with any change of condition.
4. Assisted Living Director with oversight from Health & Wellness Director and Executive Director.
Based on interview and record review, it was determined the facility failed to have sufficient staff to meet the scheduled and unscheduled needs of the residents per the facility's ABST and adequate direct care staff to meet the fire safety evacuation standards as required by the Department. This is a repeat citation. Findings include, but are not limited to:
The facility was licensed as an Assisted Living Facility (ALF) with a capacity of 72 residents. A Memory Care Facility (separate licensure) resided on the same campus and was attached to the ALF.
a. On 04/30/25 at 9:15 am, during the entrance conference the following was identified:
* The current census was 59 residents;
* The assisted living was home to residents who resided on three floors;
* Four residents required a mechanical lift using two staff for transfers and resided on the second and third floors;
* Several residents required staff assistance to get to a location; and
* Multiple residents required two staff for transfers.
b. A review of the facility's posted staffing plan, schedule from 04/20/25 through 04/27/25, and current ABST indicated the following:
* Day Shift: 6:00 am - 2:00 pm - One Med-aide and three Caregivers;
* Swing Shift: 2:00 pm - 10:00 pm - One Med-aide and three Caregivers; and
* Overnight Shift: 10:00 pm - 6:00 am - One Med-aide and one Caregiver.
c. Review of fire drill records dated 04/03/25 indicated four residents who lived on the second floor and one resident who lived on the third floor required two people and the use of a stair chair for evacuation. Additionally, there was one resident who resided on the first floor who also required two person assist for evacuation. During the 04/03/25 fire drill, four of the residents requiring two person transfer and a stair chair for evacuation were not in the building or refused to participate.
The staffing plan for overnight shift showed two care staff scheduled, which indicted this would not be sufficient staff to meet this resident's unscheduled needs.
d. During an interview with Staff 26 (MT) and Staff 27 (CG) on 04/30/25 at 11:50 am, it was reported there was one resident on the third floor that would take two staff to evacuate using the stair chair (fire evacuation equipment), four more residents on the second floor that would require a minimum of two care staff with the stair chair to evacuate the residents, and one resident on the first floor who required a two person assist, which would leave the remaining residents unattended during a potential evacuation.
The facility failed to have sufficient staff to meet the scheduled and unscheduled needs of the residents per the facility's ABST and adequate direct care staff to meet the fire safety evacuation standards as required by the Department.
The need to ensure the facility was staffing sufficient staff per the ABST to meet the scheduled and unscheduled needs of the residents was discussed with Staff 2 (Health and Wellness Director) on 04/30/25 at 1:00 pm. She acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure sufficient staff to meet the scheduled and unscheduled needs of the residents per the facility's Acuity-Based Staffing Tool (ABST) and staffing plan, and adequate direct care staff to meet the fire safety evacuation standards as required by the Department. This is a repeat citation. Findings include, but are not limited to:
The facility was licensed as an Assisted Living Facility (ALF) with a capacity of 72 residents. A Memory Care Facility (separate licensure) resided on the same campus and was attached to the ALF.
a. During the entrance conference on 07/30/25 at 9:15 am, the following was identified:
* The current census was 58 residents;
* The assisted living was home to residents who resided on three floors; and
* Four residents required a mechanical lift using two staff for transfers and resided on the first and second floors.
b. The current staffing plan, provided to the surveyor during the third re-visit, indicated the following information:
* Day shift (6:00 am - 2:00 pm): Four CGs and one MT;
* Swing shift (2:00 pm - 10:00 pm): Four CGs and one MTs; and
* NOC shift (10:00 pm - 6:00 am): Two CGs and one MT.
The schedule, reviewed from 07/23/25 to 07/29/25, revealed that for nine of 21 shifts, or 42%, the facility did not have the required number of direct care staff per the staffing plan.
c. The facility's current ABST revealed the facility failed to ensure the ABST was completed, updated, or reviewed before a resident moved in and no less than quarterly, and to use the results of the ABST to develop, update, and ensure the facility's staffing plan met the appropriate staffing levels to address activities of daily living and other tasks related to care and fire safety evacuation standards.
The need to ensure the facility was staffing per their staffing plan and updated the ABST per regulation, to ensure the facility's staffing plan met the appropriate staffing levels to address activities of daily living and other tasks related to care and fire safety evacuation standards, was discussed with Staff 28 (Executive Director) and Staff 29 (Health and Wellness Director) on 07/30/25. They acknowledged the findings.
Refer to C363.
We will staff according to the ABST tool to ensure appropriate staffing levels. In doing so, we will account for the fire safety evacuation standards as well as the scheduled and unscheduled needs of the residents.
The posted schedule will consistently match the staffing plan that is determined by the ABST. The approriate staffing levels will be maintained every day to meet the needs of the residents and ensure their safety during emergency evacuations.
We will continue to evaluate evacuation and general needs upon move in, during fire drills, service plan updates, and with any change of condition. The ABST tool will be updated routinely with any changes to resident needs in order to reflect the correct staffing requirements.
Assisted Living Director with oversight from Health & Wellness Director and Executive Director.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure the Acuity-Based Staffing Tool (ABST) was updated before a resident moved into the facility and no less than quarterly, and to address the amount of staff time needed to provide care for 4 of 5 sampled residents (#s 1, 2, 3, and 5) and multiple unsampled residents to determine appropriate staffing levels for the facility, and to meet the 24-hour scheduled and unscheduled needs of residents. Findings include, but are not limited to:
During the acuity interview on 08/12/24, 12 residents were identified as requiring two-person care, two-person transfers with mechanical lift, had falls with injuries, and/or were on hospice.
The facility's ABST was reviewed with Staff 1 (ED) on 08/15/24 at 10:09 am. The following was identified:
* Seven current residents had not been entered into the facility's ABST;
* Nine residents were entered into the ABST but were not current residents according to the resident roster provided upon survey's entrance;
* Resident 2's ABST was last reviewed on 11/21/23; therefore, it was not updated quarterly;
* Resident 1, 3, and 4's ABST evaluation was last documented as reviewed on 05/07/24; therefore, it was not updated quarterly.
* The ABST evaluations for Residents 1, 2, 3, and 5 were not reflective of the residents' care needs and did not include the accurate amount of staff time required to provide care for the residents.
During an interview with Staff 1 on 08/15/24 at 10:09, she acknowledged the facility's ABST did not have all of the current residents entered, and she confirmed several of the residents documented in the facility's ABST were no longer in the building. Additionally, she stated the tool had not been updated consistently since 04/2024.
The need to ensure the facility's ABST was updated prior to resident move-in and at least quarterly, addressed the amount of time needed to provide resident care, ensured all residents were entered into the ABST in order to determine appropriate staffing levels for the facility, and to meet the 24-hour scheduled and unscheduled needs of the residents was discussed with Staff 1 on 08/15/24 at 2:30 pm. She acknowledged the findings.
ABST tool is now currently reflecting all residents and their individual care needs.
ALD has received additional training on updating and maintaining the ABST tool to assure understanding.
ALD will provide weekly oversight of the ABST tool to assure new move ins/changes of condition/move outs are reflected timely on the ABST tool
Weekly
ALD.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to complete an acuity-based staffing tool (ABST) that accurately captured care time and care elements that staff were providing to each resident as outlined in each individual service plan for 1 of 1 sampled resident (#6) and failed to develop an accurate staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. Findings include, but are not limited to:
Resident 6 moved into the assisted living community in 10/2024 with diagnoses including bilateral osteoarthritis of the knees and right hand, diverticulosis of the large intestine and exhibited memory impairments. During the acuity interview on 02/19/25 staff reported the resident used a manual wheelchair and was a two-person hoyer lift transfer.
Review of Resident 6's ABST, updated on 11/11/24, indicated the resident's evaluated care needs required 10.95 direct care hours per week, however, the ABST inaccurately captured care time and care elements in the following areas:
* Two person transfer with a hoyer lift;
* Bowel and bladder management including two-person incontinence care completed while the resident was in bed;
* Two person assistance for dressing and undressing; and
* Housekeeping related to daily trash removal and soiled laundry.
On 02/20/25 at 3:20 pm, Staff 22 (Regional RN) began updating the resident's ABST to include the above findings. Once updated the ABST hours increased from 10.95 direct care hours per week to 46.38 direct care hours per week.
Resident 6's ABST was not accurate per evaluated care time therefore, the tool did not accurately determine the correct amount of staff time required to provide care to the residents and could not meet the scheduled and unscheduled needs of the residents.
The need to ensure the facility's ABST accurately captured care time and care elements that staff were providing to each resident and was used to develop an accurate staffing plan to meet the 24-hour scheduled and unscheduled needs of the residents was discussed with Staff 1 (ED), Staff 2 (Health and Wellness Director), and Staff 22 on 02/20/25 at 3:20 pm. They acknowledged the findings
1. ABST tool was updated immediately to accurately reflect the time needed for unscheduled and scheduled needs of resident 6. As of March 12th, staffing had been adjusted and is accurately reflecting hours as reflected in the ABST tool.
2. We will review remaining residents to ensure the ABST tool is accurate and that staffing is aligned. ABST tool updates from any significant COC and/or with quarterly service plan updates.
3. We will continue to update the ABST tool prior to new move ins, at quarterly service plan updates, in conjuction with change of condition, and weekly check ins with caregiver.
4. Assisted Living Director with oversight from Health & Wellness Director and Executive Director.
Based on interview and record review, it was determined the facility failed to ensure the Acuity-Based Staffing Tool (ABST) was updated before each resident moved in and at least quarterly, to determine appropriate staffing levels to address activities of daily living and other tasks related to care, for 4 of 4 sampled residents (#s 13, 14, 15, and 16). Findings include, but are not limited to:
Review of the facility's ABST entries, staff schedule, calculated staffing hours, posted staffing plan, and interviews with staff were completed during the third re-visit and showed the following:
a. Resident 13 moved into the facility on 06/17/25. During interviews on 07/30/25 with Staff 28 (Executive Director), Staff 29 (Health and Wellness Director), Staff 30 (MT), and Staff 31 (CG) on 07/30/25, they stated Resident 13 was a two-person transfer and a Hoyer lift was used. Review of the facility ABST tool on 07/30/25 revealed the resident had not been entered into the system.
b. Resident 14 moved into the facility on 06/16/25. During interviews on 07/30/25 with Staff 28 (Executive Director), Staff 29 (Health and Wellness Director), Staff 30 (MT), and Staff 31 (CG) on 07/30/25, they stated Resident 14 was a one- to two-person transfer. Review of the facility ABST tool on 07/30/25 revealed the resident had not been entered into the system.
c. Resident 15 moved into the facility on 02/09/24. As of the third re-visit survey on 07/30/25, the resident required two staff for transfers and used a Hoyer lift. Review of the ABST tool revealed the last review and update occurred on 10/03/24.
d. Resident 16 moved into the facility on 02/11/23. As of the third re-visit survey on 07/30/25, the resident required two staff for transfers and used a Hoyer lift. Review of the ABST tool revealed the last review and update occurred on 08/12/23.
On 07/30/25, Staff 29 acknowledged the facility's ABST did not have all the current residents entered and/or reviewed and updated quarterly, and therefore, the tool did not accurately determine the correct amount of staff time required to provide care to the residents.
The need to ensure the ABST was completed, updated, or reviewed for each resident before a resident moved in and no less than quarterly, and to use the results of the ABST to develop, update, and ensure the facility's staffing plan met the appropriate staffing levels to address activities of daily living and other tasks related to care, was reviewed with Staff 28 (Executive Director) on 07/30/25. She acknowledged the findings.
An audit of the ABST tool will occurr to ensure that all resident needs are accurately reflected. The ABST will be updated if inaccuracies are noted.
The ABST will be updated routinely (at least quarterly) with any changes to resident needs in order to reflect the correct staffing requirements. The ABST will also be updated before a resident moves in and in the event that a resident passes away
We will continue to evaluate evacuation and general needs upon move in, during fire drills, service plan updates, and with any change of condition. The ABST tool will be updated routinely with any changes to resident needs in order to reflect the correct staffing requirements.
Assisted Living Director with oversight from Health & Wellness Director and Executive Director.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure 3 of 4 newly-hired staff (#s 13, 16 and 17) completed all required pre-service orientation training, and 2 of 3 long-term staff (#s 4 and 18) completed required HCBS (Home and Community-Based Services) training. Findings include, but are not limited to:
Staff training records were reviewed on 08/13/24 at 1:00 pm and 08/14/24 at 3:00 pm with Staff 2 (Health and Wellness Director), and the following was identified:
a. There was no documented evidence Staff 13 (MA), Staff 16 (Housekeeper) or Staff 17 (CG), hired 05/01/24, 06/25/24 and 06/05/24, respectively, had completed one or more of the following required pre-service orientation topics prior to beginning their job responsibilities:
* Infectious disease prevention training; and
* Home and Community-Based Services training.
b. There was no documented evidence Staff 4 (Office Manager) hired 10/01/20, and Staff 18 (Cook) hired 04/28/22, completed HCBS training by 03/31/24.
The requirements for pre-service orientation and training for all employees were reviewed with Staff 1 (ED) on 08/14/24 at 5:20 pm. She acknowledged the findings.
Missing training has been completed for sampled staff.
Audit of remaining staff completed to verify compliance.
ALD/Executive Director will complete audits of all new employee training files upon completion of the orientation process and at least twice monthly thereafter to maintain ongoing compliance.
Twice monthly
ED/ALD
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure 3 of 4 long-term direct care staff (#s 12, 21 and 23) completed 12 hours of annual in-service training, including at least six hours of dementia care based on their anniversary date of hire, and failed to ensure 2 of 2 long-term non-direct care staff (#s 4 and 18) completed infectious disease training. Findings include, but are not limited to:
Staff training records were reviewed on 08/13/24 at 1:00 pm and 08/14/24 at 3:00 pm with Staff 2 (Health and Wellness Director), and the following was identified:
a. There was no documented evidence Staff 12 (CG), Staff 21 (CG), and Staff 23 (CG), hired 10/13/16, 05/30/22, and 04/09/18, respectively, completed at least 12 hours of training based on their anniversary date of hire related to the provision of care in CBC, including a minimum of six hours of training on dementia care topics.
b. There was no documented evidence Staff 4 (Office Manager) hired 10/13/20, and Staff 18 (Cook) hired 04/28/22, completed annual training on infectious disease outbreak and control.
The need to ensure and document that long-term direct care staff completed the required number of hours of annual in-service training and that long-term non-care staff completed annual infectious disease training was discussed with Staff 1 (ED) on 08/14/24 at 5:20 pm. She acknowledged the findings.
Missing annual training has been completed for sampled staff.
Audit of remaining staff completed to verify compliance.
ALD/Executive Director will complete audits of all new and veteran employee training files at least twice monthly to maintain ongoing compliance.
Twice monthly
ED/ALD
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to conduct fire drills in accordance with the Oregon Fire Code (OFC) and have a written fire drill record that documented all required components of a fire drill. Findings include, but are not limited to:
Fire and life safety records dated 02/27/24 through 07/29/24 were reviewed with Staff 6 (Maintenance Director) on 08/12/24 at 11:04 am.
During an interview on 08/12/24 at 12:27 pm, Staff 1 (ED) and Staff 6 reported the facility was not relocating residents during fire drills. During the interview Staff 1 and Staff 6 were unable to explain how the facility would be able to safely meet the evacuation standard and evacuate multiple residents requiring two-person transfers who resided on the second and third floors if they were not relocating residents during fire drills. An alternate written fire safety plan to shelter/dwell in place that was approved by the local fire jurisdiction and submitted to the Department was requested. No additional information was provided.
The written fire drill records failed to document the following required components:
* Problems encountered and comments relating to residents who resisted or failed to participate in the drills;
* Evacuation time period needed; and
* The number of occupants that were evacuated.
The need to ensure fire drill records documented all required components of a fire drill as required by the OFC and the facility was relocating resident's to a designated point of safety unless a written alternate plan to dwell in place was approved by the local fire jurisdiction was discussed with Staff 1 and Staff 6 on 08/12/24 at 12:27 pm. They acknowledged the findings.
ED and designated management staff have reviewed fire drill rules/community policy to assure understanding
Fire drill calendar created for the balance of 2024.
Re-education conducted with CG/MT staff on needed resident active participation or decline during fire drills.
ED and MD will review fire drill schedule and completed documentation monthly to oversee ongoing compliance.
ED/Maintenance Director
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:
Refer to C 360.
See POC statement for C362
Based on interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include, but are not limited to:
Refer to C 360.
Based on interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include, but are not limited to:
Refer to C360.
See POC statement for C360 and C363
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure residents' rights of privacy and dignity. Findings include, but are not limited to:
Refer to C 200.
See POC statement for C200
There are no detail notes for this visit.
Based on observation, interview, and record review, it was determined the facility failed to ensure individuals had the right to freedom from restraints. Findings include, but are not limited to the following:
Refer to C 340.
See POC statement for C340.
There are no detail notes for this visit.