The findings of the change of ownership survey conducted 11/14/22 through 11/17/22 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the revisit to the re-licensure survey of 11/17/22, conducted, 04/12/23 through 04/13/23 are documented in this report. The survey was conducted to determine compliance with the OAR 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OAR 411 Division 004.

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 second revisit to the re-licensure survey of 11/17/22, conducted 07/27/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

Based on observation, interview and record review, it was determined the facility failed to implement effective methods of responding to and resolving resident complaints. Findings include, but are not limited to:

During interviews with sampled and un-sampled residents on 11/14/22, 11/15/22 and 11/16/22, residents reported the following concerns had not been resolved:

* Meal service- Menus were frequently not followed, the kitchen frequently ran out of menu items and nutritionally adequate substitutes were consistently not provided;

* The facility's activity van was no longer available; and

* The facility's elevator was frequently out of order.

Observations of lunch meal services on 11/14/22 and 11/16/22, revealed the menu was not followed and nutritionally adequate substitutes were not provided.

* On 11/14/22, salad and baked squash was not served per the November menu, and no nutritionally adequate substitute was provided; and

* On 11/15/22, the lunch menu for beef enchilada casserole and Spanish rice was changed to pineapple chicken and white rice. Additionally, green salad per the menu was not served.

During an interview on 11/16/22, Staff 1 (Executive Director) and Staff 3 (Business Office Manager) stated the facility was in the processes of implementing a new resident grievance process but did not have documentation of recent grievances reported by residents.

The need to ensure the facility had an effective method of responding to and resolving resident complaints was discussed with Staff 1 and Staff 3 on 11/16/22. They acknowledged the findings.

Cedar Village/Frontier has a grievance policy that will be reviewed by ED and BOM and a new binder will be put into place to house written and typed grievances and resolutions in them.

System to prevent re-occurance, ED to follow through with each grievance and do a monthly audit as part of the QA process.

Based on observation, interview and record review, it was determined the facility failed to develop and conduct ongoing quality improvement programs that evaluated services, staff performance, resident outcomes and resident satisfaction. Findings included, but are not limited to:

During the survey, conducted 11/14/22 through 11/17/22, quality improvement oversight to ensure adequate resident care, services, satisfaction and staff performance was found to be ineffective.

Refer to the deficiencies in the report.

Cedar Village/Frontier has a QA policy that will be implemented and followed. It will be 15 minutes of compliance audits daily.

System to prevent re-occurance, ED to ensure all audits are done and returned weekly.

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

Observation of the main kitchen in the Assisted Living on 11/14/22 at 9:30 am revealed the following:

a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on or underneath the following:

* Pipes, walls, gauges, disposal, drain and flooring behind/underneath the dish machine;

* Flour, powdered sugar and cornstarch bins;

* Spice shelves;

* Juice dispenser;

* Kitchen drains;

* Electrical outlets and light switches;

* Trash cans;

* Pipes and flooring underneath the three compartment sink;

* Interior and exterior of cabinets and drawers;

* Ceiling fire sprinklers;

* Walls above/adjacent to stove/grill and steamer;

* Cabinets under the steamtable;

* Stainless steel cart with plastic drawers with utensils;

* Toaster;

* Walk-in refrigerator door and shelves:

* Freezer floor;

* Interior and exterior of microwave;

* Walls throughout kitchen area;

* Stove/grill knobs, doors, interior, exposed piping and vents;

* Wall behind hand wash sink and the sink;

* Rolling carts;

* Two radios;

* Bugs in the light fixtures;

* Open shelving throughout kitchen;

* Interior and exterior of walk-in refrigerator and freezer;

* Industrial mixer and slicer;

* The top of the dish machine; and

* Floors throughout the kitchen had black matter build-up, food debris and grease in corners, under equipment and around perimeter edges.

b. The following areas were in need of repair:

* Several cabinet doors had exposed wood corners and edges;

* The hand washing sink had black matter in the caulking; and

* Entry doors and jambs were scraped, gouged and had peeling paint.

c. Staff 7 (Cook) was asked about chemical sanitizer test strips. She was unable to locate test strips and could not explain how to use them.

d. Staff 10 (Dietary Aid) was observed cleaning off dirty dishes and touching clean dishes without washing her hands.

e. A non kitchen staff person was observed to enter the kitchen without a hair restraint and did not wash her hands. She proceed to grab a cart and exited out the side door while food was being prepared.

f. The kitchen did not have pasteurized eggs available for the residents who received soft-cooked eggs.

g. The walk-in refrigerator had a half cut tomato, onion and jello uncovered.

h. There was a dented can in the dry storage, cup in the rice bin, and a spoon in the bag of brown sugar.

i. Clean glassware were stored on towels that were visibly dirty.

At 10:24 am, the surveyors and Staff 1 (Executive Director) toured the kitchen. Staff 1 acknowledged the above areas needed to be cleaned and repaired. Staff 1 further indicated she would have staff clean the kitchen right away.

A zone cleaning check list is now in place. Zones will be cleaned twice weekly. There was a kitchen staff training on 12/5/22 on test strips and how to use them along with the CBC training on kitchen readiness.

Executive Chef to oversee zone cleaning.

System to prevent re-occurance: Quarterly QA meetings to include walk-through inspection, with Executive Chef, ED and ESD monthly.  

Based on observation, interview and record review, it was determined the facility failed to ensure quarterly evaluations were reflective of the residents' current health status for 1 of 4 sampled residents (#3) whose evaluations were reviewed. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 04/2021, with diagnoses including congestive heart failure, bilateral hearing loss and kidney disease.

Observations, interviews, and review of Resident 3's clinical records dated 07/25/22 - 11/14/22, revealed the quarterly evaluation, dated 09/12/22, was not reflective of Resident 3's health status including:

* Order for the use of continuous oxygen;

* History of leg edema;

* Hearing loss and use of hearing aids; and

* Use of a motorized scooter.

During an interview on 11/14/22, Resident 3 reported s/he used supplemental oxygen, hearing aids and a motorized scooter and had a history of leg edema. During the interview an oxygen concentrator, motorized scooter and hearing aids were observed in Resident 3's apartment.

The need to ensure quarterly evaluations were reflective of residents' health status was discussed with Staff 2 (RN) and Staff 4 (RCC) on 11/15/22, and Staff 1 (Executive Director) on 11/16/22. They acknowledged the findings.

Resident #3 service plan to be updated to include comprehenisve elements listed in OAR 411-054-0034.

Ongoing auditing of initial, quarterly service plans, change of condition service plans to make sure they are comprehensive and completed timely to be done by ED, VPO and/or Regional Nurse Consultant at least quarterly.

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

1. Resident 2 was admitted to the facility in 06/2021, with diagnoses including diabetes and hypertension.

Interviews with staff and review of Resident 2's clinical records dated 07/30/22 - 11/14/22,  revealed the following:

Resident 2 returned to the facility on 11/09/22, following a hospitalization and rehabilitation stay related to hemorrhagic shock due to GI bleed, acute gastric ulcer and repeated falls.

During an interview on 11/15/22, Staff 2 (RN) stated she evaluated Resident 2 prior to his/her readmission to the facility and was aware Resident 2's transfer and mobility status had changed from independent to a one-person assist with transfers and use of a wheelchair for mobility.

An interim service plan dated 11/09/22, related to "return from rehabilitation" did not provide clear direction to staff related to Resident 2's following care needs:

* One person assist with transfers;

* Use of a wheel chair for mobility; and

* Fall risk and fall interventions.

The need to ensure the service plan provided clear direction to staff was discussed with Staff 2 (RN) and Staff 4 (RCC) on 11/15/22, and Staff 1 (Executive Director) on 11/16/22. They acknowledged the findings.

2. Resident 3 was admitted to the facility in 04/2021, with diagnoses including congestive heart failure, bilateral hearing loss and kidney disease.

Observations, interviews and review of Resident 3's clinical records revealed the resident's service plan dated 09/12/22, was not reflective of Resident 3's current status and care needs and/or did not provide clear direction to staff in the following areas:

* Assistance with dressing;

* Use of continuous oxygen;

* History leg edema;

* Hearing loss and use of hearing aids; and

* Use of a motorized scooter.

During an interview on 11/14/22, Resident 3 reported s/he used supplemental oxygen, hearing aids, a motorized scooter and had a history of leg edema. During the interview an oxygen concentrator, motorized scooter and hearing aids were observed in Resident 3's apartment.

The need to ensure service plans were reflective of residents' care needs and provided clear direction to staff was discussed with Staff 2 (RN) and Staff 4 (RCC) on 11/15/22, and Staff 1 (Executive Director) on 11/16/22. They acknowledged the findings.

ISP's for all changes will be implamented before a resident comes back from the hospital with information for care staff regarding transfer status, mobility status and will have fall risk interventions in place prior to readmission.

RN/RCC to oversee to completion for each resident on readmission.

Weekly high risk meeting to discuss readmissions

Based on interview and record review, it was determined the facility failed to monitor and document on the progress of short-term changes in condition at least weekly until resolved for 3 of 4 sampled residents (#s 1, 3 and 4). Findings include, but are not limited to:

1. Resident 1 was admitted in 06/2020.

Resident 1's clinical record and charting notes, reviewed from 08/15/22 through 11/14/22, revealed the following:

* On 10/05/22, Resident 1 fell and sustained a skin tear. The facility initiated short-term monitoring the same day. However, no monitoring until resolution was documented for the short-term changes in condition.

During an interview on 11/16/22, Staff 2 (RN) reviewed the resident's record and acknowledged the lack of documented resolution for the fall and skin injury.

The need to ensure the facility monitored short term changes of condition with weekly progress noted until resolution was reviewed with Staff 1 (Executive Director) and Staff 3 (Business Office Manager) on 11/16/22 at 2:30 pm. They acknowledged the findings.

2. Resident 4 was admitted in 08/2019 with diagnoses which included edema.

Resident 4's clinical record and narrative charting notes, reviewed from 07/08/22 through 11/14/22, revealed the facility initiated alert monitoring on 10/18/22 for a medication change. However, no monitoring until resolution was documented for the change in condition.

In an interview on 11/15/22 at 3:30 pm, Staff 2 (RN) stated she failed to document a resolution for the short-term change in condition.

The need to ensure the facility monitored short term changes of condition with weekly progress noted until resolution was reviewed with Staff 1 (Executive Director) and Staff 3 (Business Office Manager) on 11/16/22 at 11:15 am. They acknowledged the findings.

3. Resident 3 was admitted to the facility in 04/2021 with diagnoses including congestive heart failure, bilateral hearing loss and kidney disease.

Interviews with staff and review of Resident 3's clinical records dated 07/25/22 - 11/14/22, revealed the following:

A progress note dated 09/09/22, documented Resident 3 reported s/he thought s/he had thrush.

During an interview on 11/15/22, Staff 2 (RN) stated Resident 3 was started on antibiotics for thrush on 09/10/22 and alert charting was implemented related to starting a new medication and potential adverse reactions.

There was no documented evidence the facility monitored the thrush infection through resolution.

The need to ensure short term changes of condition were monitored through resolution was discussed with Staff 2 (RN) and Staff 4 (RCC) on 11/15/22, and Staff 1 (Executive Director) on 11/16/22. They acknowledged the findings.

RN enrolled for the role of the RN class Dec 6-8, 2022. RN to review policy about COC and when/how to do these. ED/RN to audit COC on weekly basis.

Based on interview and record review, it was determined the facility failed to ensure significant changes of condition were assessed by an RN or the assessment included documentation of findings, the resident's status and interventions made as a result of the assessment for 2 of 4 sampled residents (#s 1 and 2) reviewed for significant changes of condition. Findings include, but are not limited to:

1. Resident 1 was admitted in 06/2020 and had diagnoses which included skin breakdown.

During the entrance conference on 11/14/22, staff stated the resident had a pressure injury on his/her bottom that was being treated by home health.

Review of the resident's clinical record revealed s/he was discharged from the hospital on 10/25/22 with a pressure injury on his/her left buttock.

The wound constituted a significant change in condition for which an assessment by the facility RN was required.

There was no documented evidence the facility RN conducted an assessment.

During an interview on 11/16/22 at 10:50 am, Staff 2 (RN) reviewed the record and acknowledged she did not document an assessment of the wound.

2. Resident 2 was admitted to the facility in 06/2021 with diagnoses including diabetes and hypertension.

Interviews with staff and review of Resident 2's clinical records revealed the following:

Resident 2 returned to the facility on 11/09/22, following a hospitalization and rehab stay related to hemorrhagic shock due to GI bleed, acute gastric ulcer and repeated falls.

A change of condition evaluation completed by the facility RN on 11/11/22 lacked information related to the following significant changes in the resident status and/or care needs:

History of recent falls, fall risk and interventions; and

Numerous medication/treatment order changes upon readmission.

The need to ensure the RN's assessment for significant changes in condition included the residents' current status and interventions made as a result of the assessment was discussed with Staff 2 (RN) and Staff 4 (RCC) on 11/15/22, and Staff 1 (Executive Director) on 11/16/22. They acknowledged the findings.

See C270

Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules, for 1 of 1 sampled resident (#4) who received insulin injections by unlicensed facility staff. Findings include, but are not limited to:

According to OSBN Division 47 Administrative Rules, delegation means an RN authorizes an unlicensed person to perform tasks of nursing care and indicates the authorization in writing. The delegation process includes nursing assessment of the client in a specific situation, evaluation of the ability of the unlicensed persons, teaching the task and observing the staff demonstrate the task.

During the acuity interview on 11/14/22, Resident 4 was identified to be administered insulin injections by non-licensed staff.

Resident 4's MARs, reviewed from 08/01/22 - 11/14/22, revealed insulin had been given by Staff 12, 14 and 16 (MTs) on several occasions.

Review of delegation documentation on 11/15/22 revealed the following:

a. The initial delegation for Staff 12 dated 09/06/22, and re-delegation dated 11/05/22, revealed no RN assessment of the condition of the resident had been completed when the initial and re-delegation occurred.

b. The initial delegation for Staff 14, completed on 08/27/22, lacked documentation in the following areas:

* Nursing assessment of the client;  

* How frequently the resident should be reassessed by the RN, including rationale for the frequency based on the client's needs;

* Frequency and rationale for how often the unlicensed person(s) should be supervised and reevaluated based on the competency of the caregiver; and

* Re-delegation completed within 60 days of the initial delegation.

c. The initial delegation for Staff 16, completed on 08/05/22, lacked documentation in the following areas:

* Nursing assessment of the client;  

* How frequently the resident should be reassessed by the RN, including rationale for the frequency based on the client's needs;

* Frequency and rationale for how often the unlicensed person(s) should be supervised and reevaluated based on the competency of the caregiver;

* Re-delegation completed within 60 days of the initial delegation; and

* None of the delegation documentation had been signed by Staff 16.

The need to ensure staff who administered insulin injections were delegated in accordance with OSBN Division 47 Rules was discussed with Staff 2 (RN) on 11/15/22 at 1:30 pm. She acknowledged the findings.

Delegation documentation was reviewed with Staff 1 (Executive Director) on 11/16/22 at 11:15 am. She acknowledged the findings.

On 12-2-22 RN reviewed Oregon Division 047 - Community Based RN Delegation Process. RN took the self evaluation at the end of reviewing Oregon Division 047 - Community Based RN Delegation Process and scored 100%

RN also enrolled in the Roles of the RN class for December 6-8, 2022

RN to audit delegations quarterly

Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care were completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules, for 1 of 1 sampled resident (# 5) who received insulin injections by unlicensed facility staff. This is a repeat citation. Findings include, but are not limited to:

According to OSBN Division 47 Administrative Rules, delegation means an RN authorizes an unlicensed person to perform tasks of nursing care and indicates the authorization in writing. The delegation process includes nursing assessment of the client in a specific situation, evaluation of the ability of the unlicensed persons, teaching the task and observing the staff demonstrate the task.

During the acuity interview on 04/12/23, Resident 5 was identified to be administered insulin injections by non-licensed staff.

Resident 5's insulin administration record and MARs, reviewed from 03/01/23 through 04/12/23, revealed insulin had been administered by Staff 12 (MT), Staff 18 (MT) and Staff 20 (MT) on multiple occasions.

a. The most recent periodic inspection, supervision and re-evaluation of the delegation for Staff 12, completed 02/15/23, lacked documentation in the following areas:

* Nursing assessment and condition of the resident, to include determination that the resident's condition remained stable and predictable; and

* The initial re-evaluation was not completed within 60 days of the initial delegation.

b.  Staff 18 was delegated to administer insulin to Resident 5 until she took a leave of absence from 12/02/21 until 03/25/23. There was no documented evidence that Staff 18 was delegated to administer insulin to the resident after her return to work on 03/25/23.

c.  Staff 20's initial delegation to administer insulin to Resident 5 was completed on 02/10/23 and lacked documentation in the following area:

* Nursing assessment and condition of the resident, to include determination that the resident's condition remained stable and predictable.

d. The most recent periodic inspection, supervision and re-evaluation of the delegation for Staff 20, completed on 03/06/23, lacked documentation in the following area:

* Nursing assessment and condition of the resident, to include determination that the resident's condition remained stable and predictable.

The need to ensure staff who administered insulin injections were delegated in accordance with OSBN Division 47 Rules was discussed with Staff 1 (Executive Director), Staff 2 (RN) and Staff 17 (Regional RN) on 04/13/23. They acknowledged the findings. Staff  2 completed the delegation process for Resident 5 with Staff 18 on 04/13/23.

RN completed Roles of the RN class December 8, 2022.

RN will do her diabetic assessment on residents monthly.

Form for Justification for Delegation edited to add information missing to meet regulations.

Justification for Delegation to be done quarterly or PRN by RN

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 1 of 1 sampled resident (#2) whose MARs and Controlled Substance Drug Disposition logs were reviewed for accuracy. Findings include, but are not limited to:

Resident 2 was admitted in 06/2021 and had diagnoses which included pain.

On 11/09/22, Resident 2 returned to the facility following a hospitalization and rehabilitation stay and was readmitted to the facility with an order for hydrocodone-acetaminophen (narcotic analgesic) 5-325 mg, one tablet every six hours PRN for pain.

Resident 2's Controlled Substance Disposition Logs and MARs, dated 11/09/22 - 11/14/22, revealed two occasions when staff signed on the drug disposition log that the hydrocodone was given. However, the MAR lacked documentation that the resident received the medication.

Inconsistencies between the MARs and Controlled Substance Disposition logs were reviewed with Staff 1 (Executive Director) and Staff 2 (RN) on 11/16/22. Staff 2 reviewed the documentation and acknowledged the discrepancies.

A narcotic audit will be done weekly by RN. We will be going over our Narc policy and retraining staff at the med tech meeting on 12/9/22.

Based on observation, interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed, and written, signed physician or other legally recognized practitioner orders were documented in the residents' facility records for all medications and treatments that the facility is responsible to administer for 3 of 4 sampled residents (#s 2, 3 and 4) whose orders were reviewed. Findings include, but are not limited to:

1. Resident 4 was admitted in 08/2019 with diagnoses which included insulin dependent diabetes.

S/he had orders for Humulin 70 units of insulin to be given before breakfast. Additionally, staff were to administer an additional 2 units if the CBG (blood sugar) was between 300 and 600.

Resident 4's TARs, reviewed from 10/01/22 - 11/15/22, revealed five occasions when the resident should have received the additional 2 units of Humulin insulin based on CBG results, but none had been documented as given.

Staff 4 (RCC) and Staff 12 (MT) were interviewed on 11/15/22. They reviewed the TARs and confirmed staff had not documented if the resident received the insulin as ordered.

The need to ensure orders were followed was discussed with Staff 1 (Executive Director) on 11/16/22. She acknowledged the findings.

2. Resident 2 was admitted to the facility in 06/21, with diagnoses including diabetes and hypertension.

Interviews with staff and review of Resident 2's clinical records revealed the following:

Resident 2 returned to the facility on 11/09/22, following a hospitalization and rehabilitation stay related to hemorrhagic shock due to GI bleed, acute gastric ulcer and repeated falls.

Review of Resident 2's rehabilitation discharge orders dated 11/07/22 and MAR dated 11/09/22 - 11/14/22, revealed the facility failed to implement new medication and treatment orders upon the resident's re-admission to the facility. The new orders were not updated on the MAR and the facility continued to administer the resident's previous medications/treatments.

a. The following medication/treatments were continued on the MAR but were not included on the re-admission orders and were administered to the resident without current signed physician orders:

* Diclofenac sodium 75 mg tab BID, for pain;

* Doxepin 25 mg, take two capsules nightly, for major depressive disorder;

* Gabapentin 300 mg, 2 capsules daily, for nerve pain;

* Hydrochlorothiazide 25 mg daily, for blood pressure;

* Melatonin 10 mg at bedtime, for insomnia;

* Metoprolol 100 mg, take 1.5 tablet daily, for high blood pressure;

* Jublia 10% solution daily, for pain;

* Lidocaine 5% ointment, TID, for pain;

* Trulicity 4.5 mg injection weekly, for diabetes; and

* Capsaicin cream, apply to legs BID, for pain.

b. The following medication/treatment orders were not added to the MAR and there was no documented evidence the medications/treatments had been administered as prescribed:

* Pantoprazole 40 mg daily, for GERD (gastroesophageal reflux disease).

* Monitor for increased BP (blood pressure) every shift. "Special instructions:     Hydrochlorothiazide dc'd [discontinued] due to low potassium."

The need to ensure the facility had signed physician orders for all medications administered by the facility and orders were carried out as prescribed was discussed with Staff 2 (RN) and Staff 4 (RCC) on 11/15/22 and Staff 1 (Executive Director) on 11/16/22. They acknowledged the findings.

3. Resident 3 was admitted to the facility in 04/2021 with diagnoses including congestive heart failure, bilateral hearing loss and kidney disease.

Observations, interview, and review of Resident 3's clinical records revealed the following:

Resident 3's service plan dated 09/12/22, stated the resident had a diagnosis of dementia and the facility was responsible for administering the resident's medications.

a. On 10/24/22, Resident 3 was ordered Midodrine 5 mg three times daily, for blood pressure. The orders included parameters for the medication to be held if the resident's SBP (systolic blood pressure) was greater than 140/90.

Review of Resident 3's MARs dated 10/01/22 - 11/13/22, revealed the medication was not held when the resident's SBP pressure was documented as greater than 140/90 on six occasions from 10/24/22 through 11/13/22.

b. On 08/16/22, Resident 3 was ordered continuous oxygen at 1 LPM (liter per minute), increase to 2 LPM with sleep, related to congestive heart failure.

The order was not included on the October or November 2022 MAR.

During an interview on 11/14/22,  Resident 3 was observed without oxygen in use and stated s/he only needed to use the oxygen every now and then.

During an interview on 11/16/22, Staff 15 (MT) stated the resident managed his/her oxygen and it seemed as though the resident didn't need it as much lately.

The need to ensure physician orders were carried out as prescribed was discussed with Staff 2 (RN) and Staff 4 (RCC) on 11/15/22, and Staff 1 (Executive Director) on 11/16/22. They acknowledged the findings.

We will be holding a med tech meeting 12/9/22 on following orders and reviewing MAR closely for details/changes and parameters.

ED/RCC/RN will hold trainings monthly at med tech meetings

2. Resident 7 was admitted to the facility in 04/2023 with diagnoses including atrial fibrillation and COPD.

Resident 7's MAR, dated 04/04/23 through 04/12/23, and prescriber orders were reviewed and revealed the following:

* The resident had an order for Lidocaine Patch 4%, apply two patches to skin daily. The MAR was blank on eight occasions between 04/04 and 04/12/23.

On 04/13/23, the lack of documentation on the MAR was discussed with Staff 15 (MT) who stated when the resident was admitted on 04/04/23 the patches they received were 5% not 4% as ordered. They didn't have an order for 5%, so no patches were used between 04/04 and 04/12/23.

The need to ensure physician's orders were carried out as prescribed was discussed with Staff 1 (Executive Director) and Staff 17 (Regional RN) on 04/13/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed for 2 of 4 sampled residents (#s 5 and 7) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 5 was admitted to the facility in 10/2021 with diagnoses including hypertension, polymyalgia rheumatic and diabetes. Facility staff administered insulin to the resident multiple times daily.

Review of Resident 5's current physician orders and MARs/TARs from 03/01/23-04/13/23 revealed the following:

* Humalog 100 U/ml insulin sliding scale for diabetes was ordered for administration with each meal based on Resident 5's blood glucose level. There was no documented evidence the correct dose of insulin was administered on six occasions;

* Blood sugar checks (CBG's) were ordered before every meal and at bedtime (for diabetes). The physician was to be notified of any CBG below 70 or above 350. There was no documented evidence the facility notified the physician of blood sugars above 350 on five occasions; and

* Potassium Chloride ER 10mEq was ordered to be administered one dose on 03/07/23. There was no documented evidence the medication was administered.

The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (MCC Director/Business Office Manager), and Staff 17 (Regional RN) on 04/13/23 at 12:20 pm. They acknowledged the findings. No further information was provided.

QMAR changes were made to include yes or no answers/notifications to RN and PCP on med pass.

Med Tech trainings will now be held twice a month instead of monthly by the RN to continue med administration training and follow through.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate for 1 of 4 sampled residents (#4). Findings include, but are not limited to:

Resident 4 was admitted in 08/2019 with diagnoses which included diabetes, edema and a skin rash.

Residents 4's MARs were reviewed from 10/01/22 through 11/14/22 and the following was noted:

* Reasons for use was not indicated for all medications;

* Lack of resident-specific instructions for daily weights; and

* S/he had an order for Nystatin powder (antifungal) twice daily. According to the MARs, MTs were initialing that they administered the powder. However, in an interview on 11/15/22 at 10:35 am, Staff 12 (MT) reviewed the MAR and stated the resident applied the Nystatin, not the MTs.

On 11/16/22 at 11:15 am, the need for the facility to ensure MARs were accurate was discussed with Staff 1 (Executive Director). She reviewed the MARs and acknowledged the findings.

Weekly audit for discrepancies in parameters. Will go through MAR and make sure daily weights, blood pressure, CBG and further have directions on what to do with the information gathered. Ex: Notify RN, Fax PCP weekly, etc.

RN/ED will audit weekly

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly-hired staff (#s 6, 12 and 14) completed all required pre-service orientation training prior to beginning their job responsibilities, and 2 of 2 long-term staff (#s 7 and 8) completed approved infectious disease prevention training prior to 07/01/22. Findings include, but are not limited to:

Staff training records were reviewed on 11/16/22. The following deficiencies were identified:

a. There was no documented evidence Staff 6 (Dietary Aide), Staff 12 (MT), or Staff 14 (MT), hired 07/21/22, 07/22/22, and 07/15/22, respectively, completed approved infectious disease prevention training prior to beginning their job responsibilities.

b. There was no documented evidence Staff 7 (Cook), hired 09/08/20, and Staff 8 (Cook), hired 01/01/19, had completed approved infectious disease prevention training prior to 07/01/22 as required.

The need to ensure newly hired staff completed all required pre-service orientation training prior to beginning their job responsibilities and all long-term staff completed approved infectious disease prevention training in a timely manner was discussed with Staff 1 (Executive Director) and Staff 3 (RCC) on 11/16/22. They acknowledged the findings.

Proper Infectious Disease modules were added to relias and will be automatically added to all trainings for new hires. Preservice oientation will be complete prior to working the floor.

Business Office Manager to oversee all trainings for new hires and veteran staff.

BOM to audit trainings monthly

Based on interview and record review, it was determined the facility failed to provide fire and life safety instruction to staff on alternating months from fire drills and include all required components on fire drill records. Findings include, but are not limited to:

Fire and Life Safety records for the previous six months were reviewed on 11/016/22.

Review of the documentation provided identified the following:

a. There was no documented evidence fire and life safety instruction was provided to staff on alternate months from fire drills; and

b. Fire drill records did not contain the following required elements:

* Number of residents evacuated; and

* Problems encountered and comments relating to residents who resisted or failed to participate in the drills.

The requirements regarding fire and life safety instruction for staff and fire drill record components were reviewed with Staff 1 (Executive Director), Staff 3 (RCC), and Staff 11 (Environmental Services Director) on 11/16/22. They acknowledged the findings.

Fire/Life Safety training will be held on alternating months at all staff meetings.

Fire drills form will include # of residents who participated, # of residents who resisted to participate and why they chose not to participate.

ESD/ED to hold trainings

Based on interview and record review, it was determined the facility failed to include all required components on fire drill records. This is a repeat citation. Findings include, but are not limited to:

On 04/12/23, fire drill and fire and life safety training records since 01/30/23 were requested.

Review of the documentation provided identified that fire drill records did not contain the following required elements:

* Number of residents evacuated; and

* Problems encountered and comments relating to residents who resisted or failed to participate in the drills.

The requirements regarding fire drill documentation were reviewed with Staff 1 (Executive Director) on 04/012/23. She acknowledged the findings.

Fire Drill logs have been updated to include sections to contain the number of residents evacuated, problems encountered and comments relating to residents who resisted or failed to participate in the drills.

ESD to conduct fire drills every other month.

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

Refer to C282, C303 and C420.

See C282, C303 and C420.

Based on observation and interview, it was determined the facility failed to maintain all exterior pathways smooth and in good repair, and ensure the grounds were kept free of litter and refuse. Findings include, but are not limited to:

The exterior of the building was toured on 11/15/22. The following deficiencies were identified:

a. On the pathway between the dining room and parking lot a section of sidewalk was raised, creating an uneven surface approximately 1" deep across the length of the pathway; and

b. Three mini-refrigerators were against the back of the building. On top of the refrigerators were towels and empty potting containers.

The findings were reviewed with Staff 1 (Executive Director) and Staff 11 (Environmental Services Director) on 11/17/22. They acknowledged the findings.

Sidewalk repair completed on November 23, 2022

Mini fridges removed on 11/22/22.

ESD and ED to conduct walk throughs weekly of building inside and out.

2. Room 204 was observed on 11/14/22 and the following was revealed:

* Brown matter was observed on the bathroom floor in front of the toilet;

* The bathroom door frame was scraped and gouged in several areas;

* The bathroom wall had an approximate 2 x 6 inch scrape near the entrance;

* Carpet throughout the apartment had several stained areas; and

* The kitchen area had loose vinyl flooring, baseboard coming apart from the wall, gouged wall corners and baseboard, and broken or missing cupboard handles.

The surveyor and Staff 1 (Executive Director) toured the apartment on 11/16/22 at 11:15 am. She acknowledged the findings.

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

1. The interior of the facility was toured on 11/15/22. The following areas needed cleaning or repair:

* Stains on carpet throughout common areas of the facility;

* Gouges and chunks of missing plaster on pillar edges throughout the facility;

* Rust-covered drain in drinking fountain on 2nd floor; and

* Chipped and bubbling shelf liner, along with brown debris build-up, in beverage bar drawers.

The building was toured and areas needing cleaning or repair were discussed with Staff 1 (Executive Director) and Staff 11 (Environmental Services Director) on 11/17/22. They acknowledged the areas needing cleaning and repair.

ED scheduled carpet cleaning for Dec 13, 2022 and January 10. 2023.

We will remove drinking fountain upstairs due to poor repair.

ESD to order clear plaster corner covers for pillars.

Room 204, complete renovation started 12/5/22.

ESD and ED to walk through building monthly

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 11/15/22. 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 1 (Executive Director) and Staff 11 (Environmental Services Director) on 11/16/22. They acknowledged the findings.

ESD will order window locks and install on all second story windows to lock at a certain point to prevent accidental falls.

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

The facility laundry process was observed on 11/15/22. The washing machines had general temperature settings but no device to determine the water temperature. Soiled linens were washed with laundry detergent, which was identified as lacking a chemical disinfectant.

The facility's failure to properly launder soiled resident linens and clothing was reviewed with Staff 1 (Executive Director) and Staff 11 (Environmental Services Director) on 11/16/22. They acknowledged the findings.

ESD will order a chemical disinfectent to be added to wash/rinse cycles to ensure proper sanitization of soiled linens.

ESD to order disinfecting chemicals monthly