The findings of the re-licensure survey, conducted 06/21/22 through 06/23/22, 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 Home and Community Based Services Regulations OARs 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 re-visit to the re-licensure survey of 06/23/22, conducted 04/17/23 through 04/19/23, 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 Home and Community Based Services Regulations OARs 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 06/23/22, conducted on 07/17/23 through 07/18/23, are documented in this report. It was determined the facility was in compliance with 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 provide effective administrative oversight to ensure the quality of care and services that were rendered in the facility. Findings include, but are not limited to:

During the re-licensure survey, conducted 06/21/22 through 06/23/22, administrative oversight to ensure adequate care and services rendered in the facility was found to be ineffective, based on the severity and number of citations issued.

Refer to deficiencies in report.

Refer to C152, C155, C156, C160, C240, C252, C260, C270, C280, C290, C300, C302, C303, C310, C320, C330, C340, C365, C370, C372, C374, C420, C422, C610, C613, C655.

Administrator and RCC will do onsite job specific training in another community.

Based on observation, interview and record review, it was determined the facility failed to ensure required postings were displayed, in a routinely accessible and conspicuous location accessible to residents and visitors, and available for inspection. Findings include, but are not limited to:

A tour of the facility conducted on 06/21/22 identified the following required postings were not being displayed:

* The current facility staffing plan; and

* There was no posting of the name of administrator or designee in charge.

On 06/22/22, the need to ensure all required postings were in an accessible and conspicuous location was discussed with Staff 1 (Administrator). She acknowledged the findings.

1. The staffing plan is posted. The name of the administrator or designee is posted.

2. The administrator and RCC will check daily to ensure required postings.

3. Weekly.

4. Administrator & RCC.

2. Resident 2 was admitted to the facility in 12/2022. On 06/21/22 during the acuity interview, Resident 2 was noted to have a skin condition and to smoke.

a. Staff 1 (Administrator) was unable to locate the initial evaluation for Resident 2. There was no documented evidence Resident 2 had been evaluated to smoke safely.  

b. Resident 2 was observed on 6/22/22 to have multiple scabbed and open wounds across the shoulders, upper back, lower back, and abdomen.

A review of the resident's clinical record revealed no evaluation or monitoring of the wounds or skin condition. There was no documented notation of the resident's skin issue and the most current evaluation and service plan indicated "N/A" for skin issues.

The failure to ensure complete and accurate records of the resident's status was shared with Staff 1 and Staff 3 (RN) on 6/23/22. They acknowledged the findings.

3. Resident 3 was identified as recently moving into the facility during the acuity interview on 06/21/22. Resident 3 was admitted in 03/2022.

A review of Resident 3's initial evaluation found two evaluation forms had been completed, one on 03/21/22 and one on 04/01/21. There was conflicting information in multiple areas on the evaluations.

During an interview on 06/23/22, Staff 1 explained the initial evaluation had been misplaced and Resident 3's Nurse Practitioner had completed a new evaluation. She acknowledged the resident records were not accurate.  

The need to ensure the preparation, completeness, accuracy, and preservation of resident records was discussed with Staff 1 (Administrator) and Staff 3 (RN) on 06/23/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to maintain complete and accurate records for 3 of 3 sampled residents (#s 1, 2 and 3) whose records were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in April 2022 with diagnosis including diabetes, congestive heart failure, and COPD. His/Her record was reviewed during the survey and found to be incomplete or inaccurate in the following areas:

a. On 06/21/22 during the acuity interview, Resident 1 was identified as having experienced a fall resulting in a fractured neck and arm. During an interview with Resident 1 on 06/22/22, it was reported s/he had multiple falls prior to the fall with a fractured neck and arm. There was no documented evidence the facility had evaluated the incidents of Resident 1 falling or an RN assessment for the significant change of condition.

b. On 06/21/22 during the acuity interview, Resident 1 was identified as recently admitted to hospice. During an interview with Resident 1 on 06/22/22, it was reported that hospice services were coming 1 time a week, and were going to be coming into the facility 2 times a week starting the following week. The surveyor requested a copy of resident hospice admission, notes, and recommendations for the facility. Staff 1 (Administrator) was unable to locate any hospice information for the resident.

c. On 06/21/22 a copy of Resident 1's signed physician's orders were requested. Staff 1 was unable to locate any current signed physician's orders and needed to contact Resident 1's physician to have new orders sent to the facility. On 06/22/22, survey was provided with signed physician's orders for Resident 1.

d. Staff 1 was unable to locate a side rail evaluation for Resident 1. There was no documented evidence Resident 1 had been evaluated for the use of side rails on his/her bed.

On 06/23/22, the need to ensure the facility had complete and accurate records for residents' was discussed with Staff 1. She acknowledged the findings.

1. Resident 1 records are being reviewed and RN is completing an assessment, hospice information was obtained, orders are current, and supportive device assessment will be done. Resident 2 records are being reviewed, evaluation will be updated, smoking evaluation will be completed, skin assessment completed and monitoring will continue. Resident 3 records are being reviewed and evaluation updated. New hospice binder for communication and notes.

2. A new evaluation process and schedule will be implemented. All resident records will be reviewed for order and completeness. All evaluations are being updated. A new communication system for outside providers is being implemented. A room to room audit for supportive devices will be completed and assessments done. A new wound/skin log is in place. A whiteboard has been ordered and will be created with visual reminders. All orders will be reviewed quarterly with evaluations and service plans.

3. Weekly.

4. Administrator, RCC & RN.  

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, and resident outcomes. Findings included, but are not limited to:

During the survey, conducted 06/21/22 through 06/23/22, quality improvement oversight to ensure adequate staff performance, resident care, and resident services was found to be ineffective.

Refer to the deficiencies in the report.

1. Refer to all citations.

2. Monthly quality improvement meetings will be scheduled. Consultant will provide meeting checklist.

3. Monthly.

4. Administrator.

Based on observation and interview, it was determined the facility failed to implement effective methods of infection control. Findings include, but are not limited to:

During the survey, conducted 06/21/22 through 06/23/22, Oregon Department of Human Services infection control guidelines, which were established to protect the facility staff and residents from the spread of COVID-19 and made available to all facilities, were not being followed by the facility.

Self screening stations were set up at the entrances of the facility. Staff were not monitoring visitors for symptoms upon entry.

On 06/21/22, facility staff were not wearing masks. Staff 1 (Administrator) reported she was not aware of the requirement for universal mask use in Long Term Care Communities.

From 06/21/22 through 06/23/22, numerous facility staff were observed without face masks or wearing face masks below their noses or chins on multiple occasions.

The failure to ensure facility staff consistently utilized COVID-19 protocols was discussed with Staff 1 on 06/21/22 and 06/23/22. She acknowledged the findings.

1. Staff training was provided by administrator, RCC, and consultant on PPE use. All staff are completing OCP pre-service infection control course. A sign will be placed on the door reminding visitors of the screening requirement.

2. Families and visitors will be informed of the screening requirements. A screening assignment schedule will be created.

3. Weekly.

4. Administrator & RCC.

2. Resident 4 was admitted to the facility in 04/2022 with diagnoses including chronic pain and rheumatoid arthritis.

Observations of the resident, interviews with staff, and review of the resident's 01/24/23 service plan, 01/20/23 through 04/17/23 temporary service plans, progress notes, physician communications, and incident investigations were completed.

The resident was noted to be alert and oriented and could direct his/her own care. The resident required two staff for transfers and some ADL care related to physical abilities, refusals of care, and aggression with staff. The resident spent most of his/her time in their apartment.  

Review of the resident's record showed the following:

* A progress note dated 01/23/23 indicated the resident stated s/he "continues to be abused by staff either yelling or withholding food." No additional information was noted about the allegation.

* A progress note dated 02/01/23 indicated the resident self-reported a fall with increased pain to his/her hip and hand. The resident called EMTs on his/her own and was taken to the emergency room for evaluation. The resident returned with no fractures noted. No additional information was noted about the incident.

* A progress note dated 02/08/23 indicated the resident reported the nurse went into his/her room "yelled" at the resident and told the resident to pack his/her stuff and get out. No additional information was noted about the allegation.

No investigations had been completed at the time of the incidents and no reports were made to the local SPD office.

In an interview on 04/17/23, Resident 4 indicated s/he had no concerns with his/her care at this time and s/he received the help s/he needed. The resident acknowledged s/he has experienced falls and called dispatch on his/her own. The resident offered no additional information about the incidents.

The facility was asked to report the fall with injury and the allegations of abuse and neglect to the local SPD office, and confirmation of the reports was received prior to exit.

The need to ensure all incidents were promptly investigated to rule out abuse and/or neglect and reported to the local SPD as needed was discussed with Staff 12 (Administrator), Staff 13 (RN) and Witness 1 (RN Consultant) on 04/18/23 and 04/19/23. The staff acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure injuries of unknown cause, falls, and resident allegations of abuse were promptly investigated to rule out abuse and neglect and reported to the local SPD office as required for 2 of 2 sampled residents (#s 4 and 6) whose incidents were reviewed. Findings include, but are not limited to:

1. Resident 6 was admitted to the facility in 07/2016 with diagnoses including pain and diabetes.    

Review of incident investigations and progress notes from 01/10/23 through 04/17/23 identified Resident 6 was found with a bruise to the  

right arm.

There was no documented investigation of the bruise to determine cause and to rule out abuse or neglect.

The facility was asked to report the injury of unknown cause to the local SPD office and confirmation of the report was received prior to exit.

The need to ensure resident incidents were promptly investigated to rule out abuse and neglect and reviewed by the administrator was discussed with Staff 12 (Administrator), Staff 13 (RN), and Witness 1 (RN Consultant) on 04/18/23 and 04/19/23. They acknowledged the findings.

1. Incidents identified for resident 6 and 4 were written up, investigated, and faxed to APS during survey. Copies were provided to surveyors.

2. Care staff training for identifying incidents and how to communicate incidents to nursing and administrator. RN and administrator will review incident report during clinical meetings. RN and administrator will investigate and report as appropriate to APS with consultanat assistance. Care staff training to be done at next all staff meeting. OCP/Relias Abuse and Neglect online training. RN and administrator will review incident reports daily.

3. 3-5 times a week to review incident reports. Education done by compliance date.

4. Administrator and RN.

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

On 6/21/22 at approximately 11:55 am the following was observed in the facility kitchen:

* Doors to the kitchen had chipped paint, gouges, dirt, and debris;

* A pile of soiled towels was in the corner by the entry door;

* Hand washing sink had stains and debris with damage to the bowl;

* Black matter and sticky debris on the blade and casing of the can opener;

* Floors throughout the kitchen and storage areas had thick black matter build-up and food debris in corners, under equipment, and around edges/inside of floor drains;

* Damage to cove baseboard molding in corners;

* Carts, Drawers, cupboards, inside and out, shelving, walls, refrigerator doors and handles, and ceilings throughout the kitchen, had multiple spills, smears, splatters, and debris;

* The ceiling grates had a layer of dust and dirt;

* Grease build-up and food debris was observed on stove, grill, and underneath appliances;

* Stove hood vents had a layer of grease and dust;

* Pipes behind multiple appliances had grease, dirt, and debris on them;

* Dried-on food matter and debris was on the stand mixer;

* Spills, splatters, and debris were noted on the dry storage racks and floor;

* Open food items were noted in the dry storage;

* Scoops, with the handles in the food, were noted in the bins of food;

* A large trash can with dried-on food and no lid;

* Spills, splatters and debris inside the reach in refrigerator;

* Spills, splatters and debris inside the walk in refrigerator and freezer;

* Build up of debris and brown matter on walk in refrigerator racks; and

* Walk in and reach in refrigerator had uncovered, undated, and unlabeled containers of food;

A large package of stew meat was soaking in warm water in the sink. Staff 7 (CG/Cook) reported the meat had been in the sink since she arrived at 6:00 am.

There was no documented evidence the temperatures of the refrigerators, dish machine, or food were being monitored.

In an interview with Staff 7, she indicated she was covering the position as cook and was not aware of a cleaning schedule or monitoring of temperatures of the dishmachine, foods, and refrigerators.

At 12:30 pm, the surveyor and Staff 1 (Administrator) toured the kitchen. Staff 1 acknowledged the above areas needed to be cleaned and repaired. The uncovered and undated foods in the refrigerator and the meat in the sink were thrown away.

1. The kitchen will be deep cleaned on July 21, 2022. A lid has been ordered for the trash can. Staff will be trained in how to label/date food, defrost meat, clean the kitchen, handle laundry. Scoops were removed from bins. Door will be repaired. Sink will be repaired or replaced. Baseboard will be fixed. Temperature logs will be implemented for refrigerators, freezer, dishwasher. New dish racks were ordered and received. Ceiling tiles will be replaced. Cutting board will be replaced. Racks in walk-in will be cleaned and repainted. New storage bins will be purchased. Handwash soap dispenser will be reinstalled.

2. A cleaning checklist will be developed. Staff will be trained in how to clean surfaces and appliances, and store foods. A pressure washer will be used to clean mats. Staff will be trained in how to prepare, temp, and serve foods. Recruitment and hire of a dining director.

3. Weekly.

4. Administrator.  

Based on observation and interview, it was determined the facility failed to ensure the kitchen was kept clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to:

On 04/17/23 at 11:56 am, the facility's kitchen was observed to need cleaning and/or repair in the following areas:

* Shelving throughout the kitchen and dry storage had food spills, white/gray accumulation, dust, and/or debris;

* Shelves in the walk-in refrigerator and freezer had spills, white/brown accumulation, and debris. Food, dirt, and packaging debris was noted under shelves in the dry storage, walk in refrigerator and freezer;

* Debris was noted on storage shelves which held clean dishes, pots, and pans;

* An empty cookie sheet was on the floor under the shelving in the walk-in refrigerator;

* Multiple boxes of food were on the floor in the walk-in freezer and a sealed bag of waffles was on the floor partially under a shelf;

* A pan with a large piece of packaged meat was on a pan on the floor, partially underneath a shelf in the walk in refrigerator;

* Debris was noted in the interior of the ovens;

* The small refrigerator in the back of the kitchen had spills or debris on shelves, the door, and inside drawers;

* The microwave had spills and splatters on the door and inside surfaces; and

* Numerous areas of the curved floor molding were cracked and separating at wall corners and edges throughout the kitchen.

The need to ensure the kitchen was kept clean and in good repair was shown to and discussed with Staff 12 (Administrator) on 04/18/23. She acknowledged the findings.

1. Shelves throughout kitchen will be replaced and or cleaned. All packaging/food removed from floor and thrown out or put away as appropriate. No food or cookie sheet to be placed on the floor in refrigerator, freezer, or dry storage. Thawing meat in refridgerator will be placed on a cookie sheet on the bottom shelf. All oven interior surfaces cleaned. Small refrigerator and microwave cleaned inside and out. Wall corners and curved floor molding repaired throughout the kitchen.

2. Checklist will be given to kitchen staff to complete.

3. Walk through of kitchen 3 times a week for two weeks then weekly.

4. Administrator and kitchen lead/director.

Based on interview and record review, it was determined the facility failed to ensure initial evaluations were competed and included all required elements for 3 of 3 sampled residents (#s 1, 2 and 3) whose move-in evaluations were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 12/2021.

There was no documented evidence an initial evaluation had been completed for Resident 2. There was no documented evidence of a review of Resident 2's care needs in 30 days.

Resident 2 was identified to smoke and noted to be found smoking in his/her apartment. There was no evaluation of Resident 2's ability to smoke safely.

Staff 1 (Administrator) explained the initial evaluation could not be located. The initial evaluation was recreated and a smoking evaluation was completed on 06/22/22.

The following required elements were not included on the evaluation form:

*Personality, including how the person copes with change or challenging situations; and

*Environmental factors that impact the resident's behavior including, but not limited to, noise, lighting, and room temperature.

On 06/22/22, the need to ensure the initial move-in evaluation was completed by facility staff, retained in the resident record, reviewed within 30 days, and contained all required elements was discussed with Staff 1. She acknowledged the findings.

2. Resident 3 was admitted to the facility in 03/2022.

Two initial evaluation forms were completed for Resident 1, dated 03/21/22 and 04/01/22. There was no indication of who had completed the evaluation. There was conflicting information related to:

* Sleeping pattern;

* Dietary needs;

* Diagnoses of thought disorder and treatment; and

* ADL assistance needs.

The following required elements were not included on the evaluation form:

*Personality, including how the person copes with change or challenging situations; and

*Environmental factors that impact the resident's behavior including, but not limited to, noise, lighting and room temperature.

There was no documented evidence Resident 3's evaluation was reviewed in 30 days.

On 06/22/22, the need to ensure the initial move-in evaluation was completed by facility staff, retained in the resident record, reviewed within 30 days, and contained all required elements was discussed with Staff 1 (Administrator). She acknowledged the findings.

3. Resident 1 was admitted to the facility in 04/2022. The following required elements were not included on the resident move-in evaluation:

*Personality, including how the person copes with change or challenging situations; and

*Environmental factors that impact the resident's behavior including, but not limited to, noise, lighting, and room temperature.

Additionally, there was no indication of who had completed the evaluation and during an interview with Staff 1 (Administrator) on 06/22/22, it was reported an outside provider had completed Resident 1's new move-in evaluation.

There was no documented evidence of a review of Resident 1's care needs within 30 days.

On 06/23/22, the need to ensure the initial move-in evaluation was completed by facility staff, reviewed within 30 days, and contained all required elements was discussed with Staff 1, Staff 2 (RCC/MA) and Staff 3 (RN). They acknowledged the findings.

1. New evaluation form will be implemented with all required elements (consultant provided). Resident 2 evaluation will be updated and smoking evaluation completed. Resident 3 evaluation will be updated. New smoking evaluation form will be used and all residents who smoke will be evaluated for safety.

2. An evaluation process and schedule will be implemented. Consultant will provide training on how to complete evaluations.

3. Weekly then monthly.

4. Administrator & RCC.  

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and provided clear direction to staff for 3 of 3 sampled residents (#s 1, 2 and 3). Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 12/2022.

Observations of the resident, interviews with staff from 06/21/22 to 06/23/22, review of the evaluation/service plan, dated 06/06/22, Tenant Service Notes from 03/08/22 to 05/22/22, showed the service plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas:

* Amputation of left arm;

* Hearing loss and assistive device;

* Refusal of care;

* Chronic skin issues; and

* Smoking.

The need to ensure residents' service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (Administrator) on 06/22/22 and 06/23/22. She acknowledged the findings.

2. Resident 3 was admitted to the facility in 03/2022 and was receiving Hospice services for end of life care.

Observations of Resident 3, interviews with Resident 3 and staff from 06/21/22 to 06/23/22, review of the service plan, dated 06/20/22, Tenant Service Notes from 04/02/22 to 05/07/22 showed the service plan was not reflective of the resident's ADL care needs and hospice services being provided.

The need to ensure residents' service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (Administrator) on 06/22/22 and 06/23/22. She acknowledged the findings.

3. Resident 1 was admitted to the facility in April 2022.

Observations of the resident, interviews with staff and Resident 1 from 06/21/22 through 06/23/22, review of the resident evaluation/service plan, dated 06/20/22, tenant service notes from 04/30/22 to 06/14/22, showed the service plan was not reflective of Resident 1's current care needs and failed to provide clear direction to staff in the following areas:

* Fall history and interventions;

* Use of an oxygen concentrator;

* Hospice services provided; and

* Use of side rails.

On 06/23/22, the need to ensure residents' service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (Administrator), Staff 2 (RCC/MA), and Staff 3 (RN). They acknowledged the findings.

1. Resident 1, 2, and 3 service plans will be updated. The service plan template will be revised to include all required elements.

2. The service plan template will include all required elements. A service plan schedule will be developed. Consultant will provide training on service planning.

3. Weekly and monthly.

4. Administrator & RCC.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and provided clear direction to staff regarding care and services for 2 of 4 sampled residents (#s 4 and 5). This is a repeat citation. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 04/2022 with diagnoses including chronic pain and rheumatoid arthritis.

Observations of the resident, interviews with staff, and review of the service plan, dated 01/24/23, showed the service plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas:

* Non-drug interventions for chronic pain;

* Aggression, yelling, swearing, and throwing items at staff;

* Falls;

* Smoking in apartment and illegal drug use;

* Transfer assistance;

* Weight loss, intake issues, refusal of meals and ADL care; and

* Departing the facility for extended periods without informing staff.

The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 12 (Administrator), Staff 13 (RN) and Witness 1 (RN Consultant) on 04/18/23 and 04/19/23. The staff acknowledged the findings.

2. Resident 5 was admitted to the facility in 04/2022 with diagnoses including dementia.

Observations of the resident, interviews with staff, and review of the service plan, dated 02/03/23, showed the service plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas:

* Walker use;

* Hygiene assistance including oral care and shaving;

* Behaviors including aggression towards staff, refusals to return indoors, and threats towards others;

* Smoking abilities and supervision needs;

* Illegal drug use in facility;

* Hallucinations; and

* Continence/incontinence, brief changing, and toileting needs.

The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 12 (Administrator), Staff 13 (RN) and Witness 1 (RN Consultant) on 04/18/23 and 04/19/23. The staff acknowledged the findings.

1. Resident 4 & 5 service plans reviewed and updated.

2. Service plan reviews and updates scheduled for all residents on a quarterly bases or if there is a significant change of condition. Each week RN and administrator to check calendar for service plans needing updating for the week/month.

3. Weekly

4. Administrator and RN

2. Resident 2 was admitted to the facility in 12/2022 with diagnoses including edema and neuropathy.

Staff 2 (RCC/MA) reported Resident 2 moved in with multiple open sores on his/her back.

Observation of Resident 2 revealed multiple open and scabbed wounds across the shoulders, upper back, lower back, and abdomen. Resident 2 stated "...they have just always been there."

Staff 2 said monitoring of the skin condition would be documented in the Tenant Service Notes.

There was no documented evidence the chronic skin condition had been evaluated and monitored.

In an interview with Staff 3 (RN) on 06/22/22, she indicated she had not monitored Resident 2's wounds and reported the resident's Nurse Practitioner was treating the condition.

The need to ensure residents were monitored per there evaluated needs was reviewed with Staff 1 (Administrator) on 06/23/22. She acknowledged there was no documented evidence Resident 2's wounds were being monitored.

Based on observation, interview and record review, it was determined the facility failed to monitor resident conditions consistent with evaluated needs and service plan, determine and document what actions or interventions were needed for changes of condition,  including resident specific instructions communicated to staff on each shift and weekly monitoring until the condition resolved, for 2 of 2 sampled residents (#s 1 and 2) reviewed with changes of condition.  The facility failed to refer significant changes of condition to the facility RN for 1 of 2 sampled residents (#s 1) who experienced a significant change of condition. Resident 1 experienced multiple injury and non-injury falls. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in April 2022, with diagnoses including diabetes and congestive heart failure.

a. During an interview on 06/21/22, Staff 1 (Administrator) and Staff 2 (RCC/MA) reported Resident 1 had recently had multiple falls, one of which resulted in a fractured neck and arm.

In an interview on 06/22/22, Resident 1 reported s/he had multiple falls prior to the fall resulting in a fractured neck and arm. Resident 1 was observed during the interview with multiple scabs and wounds on his/her knees and legs, and bruising throughout his/her arms, legs, and abdomen.

Record review indicated that Resident 1 experienced multiple injury and non-injury falls as follows:

*On 05/05/22, the resident was found lying on the floor with no visible injury. Resident 1 was helped up and asked to use his/her call light when transferring or needing anything when feeling weak.

*On 05/14/22, the resident fell in his/her room while being served lunch. Resident 1 obtained a skin tear on his/her left shin and was assisted back to bed. Documentation noted the staff treated the resident's wounds and assisted the resident with putting on non-skid socks.

*On 05/22/22, the resident slipped and fell out of his/her bed. Emergency Medical Services (EMS) was called and assisted the resident back to bed. There was no documented incident report, investigation, or interventions found in the resident record.

*On 05/28/22, the resident had a fall and was assisted back to bed using a hoyer lift. There was no documented incident report, investigation, or interventions found in the resident record.

*On 06/10/22, the resident slid off his/her wheelchair. Resident 1 couldn't reach his/her call light and scooted to the restroom. Resident 1 reopened scabs on his/her knees. Resident 1 was assisted back to his/her wheelchair and his/her wounds were treated. No interventions were noted to minimize the resident's risk of falling.

*On 06/11/22, the resident had a fall in the restroom and obtained bruises on his/her right shoulder and forearm. EMS was called to help the resident up and the resident was reminded to pull their call light when needing to use the restroom.

There was no documentation to show ongoing evaluation of existing fall interventions, determination and implementation of any new interventions and monitoring of those interventions for effectiveness after each of the resident's falls. The facility's investigations of the falls indicated the service plan was not updated. There was no documentation of the resident fall where s/he obtained the fractured neck and arm, if interventions were in place and effective in preventing further falls, if the resident was being monitored weekly, and if the change of condition was resolved.

Resident 1 had repeated falls without determining what actions or interventions were needed following each fall.  There was no documented evidence the service planned interventions were monitored for effectiveness. Resident 1 experienced fractures to the neck and arm, constituting a significant change in condition. There was no evidence the change had been referred to the facility RN.

b. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness, and lacked resident-specific directions to staff in the following areas:

* Scrapes, scratches, and skin tears to the resident's shin's and knees;

* Bruises throughout the resident's body; and

* New medications and medication changes.

On 06/23/22, the need to monitor residents per their evaluated needs, refer significant changes of condition to the facility RN, and to ensure short-term changes of condition had documentation to reflect monitoring to resolution at least weekly and provided clear, resident-specific directions to staff was discussed with Staff 1 (Administrator), Staff 2 (RCC/MA), and Staff 3 (RN). They acknowledged the findings.

1. Significant change of condition assessments have been completed by RN for Resident 1 and 2. New shift report binders are in place for communication of change of condition. Consultant provided examples of short term and significant change of condition. New RN form for change of condition. New whiteboard for change of condition. Temporary service plans will be used to communicate change of condition.

2. Consultant will provide training on change of condition, documentation, and monitoring. New QuickMAR system for documentation will be implemented. New skin/wound log and process. New whiteboard system. Consultant will provide training on fall interventions and documentation. A clinical meeting will be scheduled at least 3 times per week - consultant will train and provide meeting checklist. The administrator and RCC will receive additional training at another community. The RN will attend the role of the nurse in community based care training in August 2022 through Leading Age.

3. Daily, weekly, monthly.

4. Administrator, RN & RCC.

3. Resident 4 was admitted to the facility in 04/2022 with diagnoses including chronic pain and rheumatoid arthritis.

Observations of the resident, interviews with staff and Resident 4, review of the resident's 01/24/23 service plan, 01/20/23 through 04/17/23 Charting Notes, incident investigations, and physician communications were completed.

.

The resident experienced multiple short-term changes without documented progress noted until resolved and/or lacked resident-specific directions to staff in the following areas:

* Falls, chest pain and ER visits;

* Behaviors including aggression towards staff, refusals of care and throwing items;

* Skin tear and skin injury:

* Chronic hip pain;

* Hand swelling, pain, splint use and foot pain and swelling;

* Illegal drug use;

* An unplanned and undocumented six-day absence from the facility;

* Infusions and medication changes; and

* Accusations of abuse and neglect.

The need to ensure short-term changes of condition had documentation of weekly progress until resolution and resident-specific directions to staff was discussed with Staff 12 (Administrator), Staff 13 (RN), and Witness 1 (RN Consultant) on 04/18/23 and 04/19/23. The staff acknowledged the findings.

4. Resident 5 was admitted to the facility in 04/2022 with diagnoses including edema.

Observations of the resident, interviews with staff, review of the resident's 02/03/23 service plan, 01/21/23 through 04/17/23 progress notes, incident investigations, and physician communications were completed.

The resident experienced multiple short-term changes without documented progress noted until resolved and/or lacked resident-specific directions to staff in the following areas:

* Medication changes;

* Hallucinations and threatening entities not present;

* Aggression towards staff, neighbors, and other residents;

* Leaving facility property during very early/very late hours and refusing to return;

* Staying outside for several hours during the day and night, refusing to return indoors, and damaging property; and

* Smoking in room and illegal drug use.

The need to ensure short-term changes of condition had documentation of weekly progress until resolution and resident-specific directions to staff was discussed with Staff 12 (Administrator), Staff 13 (RN), and Witness 1 (RN Consultant) on 04/18/23 and 04/19/23. The staff acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents who had short term changes of condition were evaluated, resident-specific instructions or interventions were developed, and the condition was monitored at least weekly until resolved for 4 of 4 sampled residents (#s 4, 5, 6 and 7) who experienced changes of condition. This is a repeat citation. Findings include, but are not limited to:

1. Resident 6 was admitted to the facility in 07/2016 with diagnoses including diabetes.

The resident's 01/17/23 service plan, 01/18/23 through 04/17/23 Charting Notes, and interim service plans were reviewed. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, in the following areas:

* Rash; and

* Bruising.

The need to ensure short-term changes of condition had documentation to reflect monitoring to resolution at least weekly and provided clear, resident-specific directions to staff was discussed with Staff 12 (Administrator), Staff 13 (RN), and Witness 1 (RN Consultant) on 04/18/23 and 04/19/23. They acknowledged the findings.

2. Resident 7 was admitted to the facility in 08/2014 with diagnoses including Parkinson's.

The resident's 04/06/23 service plan, 01/31/23 through 04/17/23 Charting Notes, and interim service plans were reviewed.

The resident noted to have vomited on his/her rug on 03/26/23.

There was no documented monitoring at least weekly until resolution of the change in condition.

The need to ensure short-term changes of condition had documentation to reflect monitoring to resolution at least weekly and provided clear, resident-specific directions to staff was discussed with Staff 12 (Administrator), Staff 13 (RN), and Witness 1 (RN Consultant) on 04/18/23 and 04/19/23. They acknowledged the findings.

1. 24-hour book contains the alert log and temporary service plans to be implemented by care staff and/or nursing. Temporary service plans will be used to communicate change of condition. All 4 resident service plans reviewed and updated and any changes communicated using temporary service planning.

2. At next all staff meeting education for staff on short-term change of condition and how to communicate to nursing. Education will also include all forms reviewed and how to document in EMR. Whiteboard to be updated during clinical meetings, a minimum of 3 times a week. Skin log will also be used to track monitoring.

3. 3 times a week clinical meetings, weekly skin assessments/whiteboard update

4. Administrator, RN

Based on observation, interview and record review, it was determined the facility failed to ensure an RN assessment was completed for 1 of 1 sampled resident (#1) who experienced a significant change of condition related to falls with injury. Findings include, but are not limited to:

Resident 1 admitted to the facility in April 2022.

An acuity interview indicated Resident 1 sustained a fall which resulted in a fractured neck and arm.

In an interview, on 06/22/22, Resident 1 reported s/he had experienced multiple falls at the facility and sustained a fractured neck and arm from one of the falls. Resident 1 reported that his/her care needs had increased since the injuries due to his/her range of motion had decreased, and certain movements were now more painful.

There was no documented evidence an RN assessment had been completed related to the resident's significant change of condition resulting from the fractured neck and arm.

On 06/23/22, the need to document an RN assessment for significant changes of condition were discussed with Staff 1 (Administrator), Staff 2 (RCC/MA) and Staff 3 (RN).  They acknowledged the findings.  

1. The RN completed a significant change of condition assessment for Resident 1. Consultant provided training on significant change of condition assessments. New shift report binder.

2. Staff will be trained on change of condition, monitoring, and documentation. A new electronic documentation system will be implemented (QuickMAR). The RN will attend the role of the nurse in the community based care training in August 2022.

3. Daily, weekly, monthly.

4. RN, RCC & Administrator.

Based on observation, interview, and record review, it was determined the facility failed to ensure an RN assessment was completed timely and documented findings, resident status, and interventions made as a result of the assessment for 1 of 1 sampled residents (#4) who experienced significant changes of condition. This is a repeat citation. Findings include, but are not limited to:

Resident 4 was admitted to the facility in 04/2022 with diagnoses including chronic pain and rheumatoid arthritis.  

Weight records, dated 02/09/23 through 03/13/23 and progress notes, dated 01/20/23 through 04/17/23, indicated the resident experienced a 14 pound weight loss between 02/09/23 and 03/13/23, which constituted a 12.65% severe loss in a month.

A weight of 101.8 was obtained on 04/17/23, at the request of the surveyor.  This represented a 2.4 pound increase since March 2023, which was not significant for the resident.

Charting Notes, temporary service plans, and physician communications dated 01/20/23 through 04/17/23, indicated the resident could be independent with meals. The resident at times requested to be fed his/her meal, told staff s/he was unable to feed him/herself and recently began refusing meals. The resident would refuse requested items when staff offered alternates or the resident specifically asked for certain foods. The resident required staff assistance for transfers and assistance for ADLs which varied related to his/her pain and behaviors. The resident was alert and oriented and could direct his/her own care.

Multiple observations of the resident between 04/17/23 and 04/19/23 showed the resident had all meals in his/her apartment. The resident was observed to eat between 25% and 50% of the observed dinner meal, without staff assistance. The resident both refused and accepted additional meal options during the three days of survey. The resident kept his/her door closed and became impatient with repeated interruptions.  

In an interview on 04/17/23, Resident 4 indicated s/he had no concerns with his/her care at this time and that s/he received the help s/he needed. The resident indicated s/he received plenty to eat and drink but sometimes s/he did not have a good appetite. The resident stated the staff helped him/her as much as s/he would allow and alternate food items could be requested.

In an interview on 04/17/23, Staff 13 (RN) indicated she was new to the facility at the time the resident experienced the weight loss and could not offer any additional information. Staff 13 stated she was currently working on a significant change of condition around the residents increased ADL needs and skin issues. Staff 13 explained the resident frequently refused to participate in any of his/her ADLs despite having the ability and staff offered the resident a variety of options for meals but Resident 4 would frequently refuse them.

The facility failed to ensure an RN assessment was completed for the weight loss from February 2023 to March 2023 which documented findings, resident status, and interventions made as a result of the assessment.

The need to ensure an RN assessment was completed for a significant change of condition, which documented findings, resident status, and interventions made was discussed with Staff 12 (Administrator), Staff 13 (RN) and Witness 1 (RN Consultant) on 04/17/23, 04/18/23 and 04/19/23. The staff acknowledged the findings.  

1. The RN completed a significant change of condition for resident 4. Weight monitoring and tracking being done weekly/monthly and reviewed by RN.

2. Next staff meeting will include training on change of condition, monitoring and documentation. Change of condition monitoring and domentation reviewed during clinical meetings.

3. 3 times weekly with clinical meeting.

4. Administrator and RN

Based on observation, interview and record review, it was determined the facility failed to coordinate care with outside service providers in order to ensure the continuity of care, for 1 of 2 sampled residents (#1) who received outside services. Findings include, but are not limited to:

During the survey, Resident 1's records were reviewed and staff were interviewed about his/her care needs.

It was reported the resident was receiving outside services from hospice. There was no documentation regarding what care the resident was receiving from hospice, if there were any new recommendations, if the service plan required adjustment, and no documented evidence the facility had coordinated care regarding any supplemental care that needed to be provided.

On 06/23/22, the need to coordinate care with on and off-site health care providers was discussed Staff 1 (Administrator), Staff 2 (RCC/MA), and Staff 3 (RN). They acknowledged the findings.

1. New hospice communication process and binder. New whiteboard list in place for who is being seen by outside providers.

2. A new system for home health and hospice communication will be implemented with a new form and place for outside providers to leave instructions. Outside service notes will be reviewed daily and temporary service plans implemented as needed.

3. Weekly.

4. RCC, RN & Administrator.

Based on observation, interview and record review, it was determined the facility failed to ensure a safe medication system with adequate professional oversight. Findings include, but are not limited to:

During the relicensure survey conducted 06/21/22 through 06/23/22, the facility failed to ensure a safe medication and treatment system, and administrative oversight was found to be ineffective, based on deficiencies in the following areas:

C 303: Systems: Medication and Treatment Orders;

C 302: Systems: Tracking Controlled substances

C 310: Systems: Medication Administration;

C 320: Medication Policy;

C 330: Systems: Psychoactive Medications: and

C 372: Staff Training.

On 06/22/22 and 06/23/22, the above information was discussed with Staff 1 (Administrator), Staff 2 (RCC/MA) and Staff 3 (RN). They acknowledged the findings.

See C302, C303, C310, C320, C330, C372.

A pharmacy audit by Omnicare was completed July 15, 2022.   

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

Resident 1 was admitted to the facility in April 2022. Resident 1 had signed physician's orders for PRN oxycodone 5 mg as needed for pain.

Resident 1's Controlled Substance Disposition logs and MARS were reviewed from 06/01/22 through 06/21/22. The following deficiencies were identified:

* A 06/10/22 dose of oxycodone was documented as being removed from storage on the disposition log but was not documented as being administered on the MAR; and

* A 06/15/22 dose of oxycodone was documented as being removed from storage on the disposition log but was not documented as being administered on the MAR.

On 06/23/22, the need to ensure the narcotic disposition log and MAR were maintained and reflective for all controlled substances was discussed with Staff 1 (Administrator), Staff 2 (RCC/MA), and Staff 3 (RN). They acknowledged the findings.

1. A new controlled substance documentation book from Omnicare will be implemented July 19, 2022. Omnicare provided new book of pharmacy policies and procedures. Consultant observed controlled substance count and provided training.

2. Med techs, RCC, and RN will be trained in controlled substance count and disposition. A controlled substance audit will be performed at each consultant visit.

3. Weekly.

4. RN, RCC & Administrator.

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 2 of 3 sampled residents (#s 6 and 7) whose MARs and Controlled Substance Disposition logs were reviewed for accuracy. This is a repeat citation. Findings include, but are not limited to:

1. Resident 6 was admitted to the facility in 07/2016 with diagnoses including chronic back pain.

Resident 6 had physician's orders for Tramadol HCL 50 one tablet twice daily for pain.

Resident 6's Controlled Substance Disposition logs and MARS, reviewed from 04/01/23 through 04/17/23 reflected:

* The MAR documented one tablet as given at 8:00 am and one tablet was given at 8:00 pm on 04/15/23 and 04/16/23; and

* Two tablets were documented as dispensed on the Controlled Substance Disposition log for the 8:00 pm doses on 04/15/23 and 04/16/23.

Comparison of the medication dosing cards to the disposition log, showed the amount of medication left was reflected accurately on the log.   

The need to ensure accurate accounts of narcotic and controlled medications was discussed with Staff 12 (Administrator), Staff 13 (RN), and Witness 1 (RN Consultant). They acknowledged the findings.

2. Resident 7 was admitted to the facility in 08/2014 with diagnoses including anxiety.

Resident 7 had orders for Clonazepam 0.5 mg one tablet as needed for anxiety up to twice daily.

Resident 7's Controlled Substance Disposition logs and MARS, reviewed from 04/01/23 through 04/17/23 reflected:

* On 04/03/23 five tablets were documented as dispensed on the Controlled Substance Disposition log for Resident 7 to take out of the facility; and

* One tablet was documented as administered on the MAR for 04/03/23.

Comparison of the medication dosing cards to the disposition log, showed the amount of medication left was reflected accurately on the log.

The need to ensure accurate accounts of narcotic and controlled medications was discussed with Staff 12 (Administrator), Staff 13 (RN), and Witness 1 (RN Consultant). They acknowledged the findings.

1. The med tech involved with controlled substance documentation deficiency educated on correct medication administration process and follow up with RN. Consultant and RN to do a 3-way audit on controlled substances.

2. Med techs and RN will be trained on controlled substance count and disposition. Consultant and RN will do weekly controlled substance audit.

3. Weekly for the next two weeks then every other week.

4. Administrator and RN

Based on observation, interview and record review, it was determined the facility failed to have signed orders for all medications and failed to ensure orders were carried out as prescribed for 3 of 3 sampled residents (#s 1, 2 and 3) whose orders were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 12/2021 with diagnoses including neuropathy and edema.   

Resident 2's 06/01/22 through 06/21/22 MARs and current medication orders were reviewed.

Resident 2 had physician's order for:

* Sodium Polystyrene 15 mg daily, documented as not administered from 06/01/22 through 06/21/22; and

* Hydrochloric 25 mg 1/2 tab daily, documented as not administered from 06/08/22 through 06/21/22.

On 06/22/22, Staff 2 (RCC/MT) explained the medications were not available and acknowledged the medications had not been administered.

On 06/22/22 and 6/23/22 the lack of administering medications as ordered was reviewed with Staff 1 (Administrator) and Staff 3 (RN). They acknowledged the findings.

2. Resident 3 was admitted to the facility in 03/2022 and was receiving hospice services for end of life care.  

Resident 3's 06/01/22 through 06/21/22 MARs and current medication orders were reviewed.

Resident 3 had an order for Cetirizine HCL 10 mg daily (for allergies), documented as not administered from 06/01/22 through 06/14/22.

On 06/22/22, Staff 2 (RCC/MT) explained the medication was not available and acknowledged the medication had not been administered.

On 06/22/22 and 06/23/22, the lack of administering medications as ordered was reviewed with Staff 1 (Administrator) and Staff 3 (RN). They acknowledged the findings.

3. Resident 1 was admitted to the facility in April 2022 with diagnoses including diabetes and congestive heart failure.

Interview and record review indicated the facility failed to have signed physician's orders for any medication that was on Resident 1's MAR. The surveyor requested the facility to obtain signed physician's orders for Resident 1's medications. A copy of Resident 1's signed physician's orders was received on 06/22/22.

Resident 1's MAR and signed physician's orders were reviewed. The following deficiencies were found:

a. The facility failed to transcribe the following medications to the resident MAR and failed to administer the following medications as prescribed:

*Albuterol sulfate HFA 90 mcg: Inhale 2 puffs every 4 hours as needed;

*Ammonium lactate 12% lotion: apply 1 application twice a day by topical route;

*Bisacodyl 10 mg suppository: Insert 1 suppository every day as needed;

*Calcitriol 0.25 mcg: Give by mouth every Mon, Wed, Friday for supplement.

*Fluticasone propionate 50 mcg nasal spray: Use 2 sprays in each nostril every day for allergy symptoms relief;

*Nystop 100,000 unit/gram topical powder: Apply twice daily to rash in skin folds x14 days per occurrence; and

* Triamcinolone acetonide 0.1% topical cream: Apply a thin layer to the affected areas 2 times a day.

b. A physician order for metoprolol tartrate 25 mg lacked reason for use, dosage, and frequency. The facility failed to clarify the signed physician order.

On 06/23/22, the need to ensure written and signed physician orders were documented in resident records for all medications and treatments that were being administered, and that physician's orders were being carried out as prescribed was discussed Staff 1 (Administrator), Staff 2 (RCC/MA), and Staff 3 (RN). They acknowledged the findings.

1. Resident 1, 2 and 3 orders and medications have been reviewed. Omnicare pharmacy audit July 15, 2022. Omnicare pharmacy representative conversation regarding medication not available. New fax machine from Omnicare to facility order processing.

2. QuickMAR electronic documentation system will be implemented. All medication orders have been reviewed by pharmacy and will be reviewed again with QuickMAR implementation. 90-day orders will be reviewed and sent to PCPs. New system for RCC notification of medication not available.

3. Daily, weekly, monthly.

4. RCC, RN & Administrator.

3. Resident 4 was admitted to the facility in 04/2022 with diagnoses including chronic pain and rheumatoid arthritis.

The resident's 01/20/23 through 04/17/23 progress notes, 02/15/23 physician orders, 02/15/23 through 04/17/23 physician communications, and the 04/01/23 through 04/17/23 MAR/TAR were reviewed.

Progress notes dated 04/06/23 through 04/17/23 showed the following:

* On 04/06/23 the resident returned after a six day absence with a skin tear on his/her left buttocks, "3 inches wide/7 inches in length faxed doctor ..." There was no indication of any new orders or treatments that were completed;

* A nursing note on 04/06/23 stated the resident had a skin tear on his/her left buttocks, approximately "3 cm by 5 cm. Will be notifying Dr and getting any new orders ASAP." There was no indication of any new orders or treatments that were completed;

* On 04/07/23 a call was placed to the physician to discuss the skin tear, awaiting return call. There was no indication of any new orders or treatments that were completed;

* On 04/09/23 a nursing note indicated staff requested the resident's left hip be looked at, skin noted to be sheared off. There was no indication of any new orders or treatments that were completed;

* On 04/11/23 it was noted the resident's "bed sore" was improving, "applied cream to buttock." There was no indication of any new orders for the treatment completed or what specific area was treated;

* A nursing note on 04/11/23 indicated the resident was seen by the nurse practitioner who stated the wound was now a stage 2 pressure ulcer. The nurse practitioner would be placing orders for home health wound care, sending supplies with the resident and writing orders. There was no additional information on any new orders received or treatments that were completed;

* Additional notes from 04/12/23 through 04/16/23 indicated the resident had no complaints of pain to the skin tear. There was no additional information on any new orders received or treatments that were completed;

* A note on 04/17/23 at 4:31 am, noted the resident stated the wound on his/her buttocks stung. Staff cleaned the wound. There was no indication of any new orders received or specific treatments that were completed.

Review of the 04/01/23 through 04/17/23 TAR showed no information on any wounds the resident had and no treatments were noted.

A physician order dated 04/17/23 indicated to cleanse the wound with Puracyn, apply skin prep, apply Allevyn or Optifoam dressing every two days and PRN. The TAR was updated with the physician's orders on 04/18/23, no treatments had been documented as completed as of 04/19/23.

In an interview on 04/18/23, Staff 13 (RN) indicated no orders returned with the resident after the first visit with the nurse practitioner. Staff 13 stated minimal supplies were sent back with the resident. Staff were to keep the area as clean and dry as possible and utilize abdominal pads to cover the area. Staff 13 stated she had not included the skin tear on the TAR for monitoring and treatment.

In an interview on 04/18/23, Staff 14 (Agency CG/MT) indicated he never used any pads or other bandages to cover the skin tear. He would "put cream on it," when checking it. Staff 14 stated he checked the spot pretty frequently but did not document on the TAR, he would usually put a note in the progress notes. The area looked "filleted" when the resident first returned but had been getting better.

The need to ensure the facility had orders for all treatments administered was discussed with Staff 12 (Administrator), Staff 13 (RN) and Witness 1 (RN Consultant) on 04/18/23 and 04/19/23. 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, and that orders were in place for all treatments being done,  for 3 of 4 sampled residents (#s 4, 6, and 7) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 6 was admitted to the facility in 07/2016 with diagnoses including diabetes and pain.

Resident 6's current physician's orders and 04/01/23 - 04/17/23 MARs were reviewed.

a. Resident 6 had physician's orders for Tramadol HCL 50 mg one tablet twice daily at 8:00 am and 8:00 pm.

Resident 6 was administered two tablets at 8:00 pm on 04/15/23 and 04/16/23.

b. Resident 6 had physician's orders for blood sugar monitoring before lunch and dinner.

There was no documented evidence on the MAR the blood sugars had been taken as ordered before dinner on April 1st, 4th, 5th, 12th, and 13th.

The need to ensure medication and treatment orders were carried out as ordered was discussed with Staff 12 (Administrator) and Staff 13 (RN), and Witness 1 (RN Consultant) on 04/18/23 and 04/19/23. They acknowledged the findings.

2. Resident 7 was admitted to the facility in 08/2014 with diagnoses including osteoporosis.

Resident 7's current physician's orders and 04/01/23 - 04/17/23 MARs were reviewed.

Resident 7 had a physician's order for Alendronate Sodium (for osteoporosis) 70 mg one tablet on Sundays.  

There was no documented evidence Resident 7 was administered the medication on Sunday April 2nd 2023 as presrcibed.

The need to ensure medication orders were carried out as ordered was discussed with Staff 12 (Administrator) and Staff 13 (RN), and Witness 1 (RN Consultant) on 04/18/23 and 04/19/23. They acknowledged the findings.

1. Resident 6, 7, 4 orders and medication have been reviewed.

2. 90-day orders will be reviewed and sent to PCPs. Will request a pharmacy audit be completed on all medications. 3-check order processing system in place.

3. Order processing daily, monthly review of 90-day orders needed.

4. Admnistrator & RN.

2. Resident 2 was admitted to the facility in 12/2021 with diagnoses including neuropathy and edema.

Review of Resident 2's 06/01/22 through 06/21/22 MARs revealed:

* Sodium Polystyrene 25 mg lacked route and reason for use. The administration record of the medication was circled each day from 06/01/22 through 06/21/22, indicating an exception. There was no documentation of the reason for not administering the medication.

* Hydrochlorothiazide 25 mg 1/2 tablet daily lacked a reason for use. The administration record of the medication was circled each day from 06/08/22 through 06/21/22, indicating an exception. There was no documentation of the reason for not administering the medication. The medication was not documented as administered on 06/03/22 or 06/04/22. Review of the medication blister pack revealed the medication had been given.

* Chlorthalidone 25 mg 1/2 tablet daily lacked a reason for use. The medication was not documented as administered on 06/04/22. Review of the medication blister pack revealed the mediation had been given.

* Acetaminophen 2 tablets every 4-6 hours as needed lacked a dosage information, reason for use and clear parameter for how frequently to administer the medication.

The need to ensure resident MARs were complete and accurate was discussed with Staff 1 (Administrator), Staff 2 (RCC/MT), and Staff 3 (RN) on 06/22/22 and 06/23/22. They acknowledged the findings.

3. Resident 3 was admitted to the facility in 03/2022 and was receiving hospice services for end of life care.

Review of Resident 3's 06/01/22 through 06/21/22 MARs and current medication orders revealed:

*Carvedilol one tab twice daily lacked dosage information and a reason for use. The medication was not documented as administered on 06/10/22. Review of the medication blister pack revealed the medication had been given.

*Cetirizine HCL 100 mg daily lacked a reason for use and route information. The administration record of the medication was circled each day from 06/01/22 through 06/14/22, indicating an exception. There was no documentation of the reason for not administering the medication.

*Furosemide 20 mg daily lacked a reason for use and route. The administration record of the medication was circled on 06/08/22 and 06/09/22, indicating an exception. There was no documentation of the reason for the exception.

* Omeprazole 20 mg 2 times daily lacked a reason for use and route. The administration record of the evening dose of medication was circled each day from 06/01/22 through 06/10/22, indicating an exception. There was no documentation of the reason for the exception.

* Rifixine 550 mg two tablets twice daily lacked a reason for use and route. The medication was not documented as administered on 06/21/22. Review of the medication blister pack revealed the mediation had been given.  The administration record of the medication was circled for the evening dose on 06/19/22, both doses on 6/20/22, and the morning dose on 06/21/22, indicating an exception. There was no documentation of the reason for the exception.

* Senna 8.6 mg two tablets daily lacked a reason for use and route.

* Spironolactone two tablets twice daily lacked dosage information, reason for use, and route. The order for the medication was for one tablet twice daily. Review of the medication blister pack revealed one tablet was administered. The medication was not documented as administered on 06/21/22. Review of the medication blister pack revealed the medication had been given.

* Acetaminophen liquid 10 - 20 cc every 4 hours and Acetaminophen lacked reason for use, clear dosage and route information, and specific parameters for which form of the medication to administer.

* Morphine Syringes as needed every two hours for pain lacked dosage and route information and parameters for which pain medication to use.

* Lorazepam 0.5 mg one to two tablets every two hours for anxiety lacked route information and clear direction to staff for which dose to administer. The medication was administered eight times in 06/2022 with no documented evidence of effectiveness.

Resident 3 had signed orders for:

* Acetic Acid 2% eye drops;

* Calcium Carbonate -vitamin D3 500 mg mcg;

* Melatonin 5 mg tablet as needed for sleep; and

* Tramadol 50 mg.

The medications were not included on Resident 3's MAR for use.

The need to ensure resident MARs were complete and accurate was discussed with Staff 1 (Administrator) , Staff 2 (RCC/MT), and Staff 3 (RN) on 06/22/22 and 06/23/22. They acknowledged the findings.

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

1. Resident 1 was admitted to the facility in April 2022. Review of the residents MAR, between 6/01/22 through 6/21/22, identified the following deficiencies:

a. The following medications failed to have documented reason for use on the MAR:

*Ondansetron 8 mg;

*Polyethylene Glycol 3350 powder;

* Acetaminophen 325 mg;

*Vitamin D3;

*Oxycodone 5 mg;

*Pulmicort flexhaler;

*Metoprolol 25 mg;

*Levothyroxine 137 mcg;

*Aspirin 81 mg;

*Atorvastatin 40 mg;

*Bupropion HCL 300 mg;

*Clopidogrel 75 mg;

*Duloxetine HCL 30 mg;

*Escitalopram 10 mg;

*Ferrous Sulfate 325 mg;

*Furosemide 40 mg;

*Levothyroxine 150 mcg;

*Lisinopril 10 mg;

*Metolazone 5 mg;

*Omeprazole 40 mg;

*Oyster Shell Calcium 500 mg;

*Potassium Chloride 10 MEQ;

*Pregabalin 100 mg;

*Trulicity 3 mg/0.5 ml; and

*Novolog mix 70-30 flexpen 100 unit/ml.

b. Multiple blanks for multiple medications were identified on Resident 1's MAR. On 06/23/22, Staff 2 (RCC/MA) reported Resident 1 received the medications, but the medication aide's failed to sign the medications as administered on the MAR.

c. PRN Acetaminophen 325 mg was administered on 06/11/22 and 06/13/22. The facility failed to document the effectiveness of the PRN administration.

On 06/23/22, the need to ensure residents' MARs were accurate was discussed Staff 1 (Administrator), Staff 2 and Staff 3 (RN). They acknowledged the findings.

1. MARs will be reviewed and updates as needed to reason for use, dosage and route information, clear direction to staff. MARs will be reviewed daily for missing initials. Orders have been reviewed by pharmacy and PCPs contacted.

2. New QuickMAR electronic documentation system will be implemented and all orders reviewed for completeness. Med techs will be trained on medication administration and documentation. MAR audits for exceptions and variances will be daily and weekly. Orders will be reviewed when received and input for completeness.

3. Daily, weekly, monthly.

4. RCC, RN & Administrator.

Based on interview and record review, it was determined the facility failed to have a written policy describing how prescription drugs not prepared as unit dose or blister packs should be dispensed. Findings include, but are not limited to:

A copy of the facility's medication administration policy that addressed how prescription drugs that were not prepared as unit dose or blister packs were dispensed was requested during the entrance conference on 06/21/22. Staff 1 (Administrator) reported the facility did not have a written medications administration policy addressing medications not prepared in blister packs.

On 06/22/22, the need to ensure a written policy describing how prescription drugs that were not prepared as unit dose or blister packs should be dispensed was discussed with Staff 1. She acknowledged the findings.

1. New policy will be in place describing how prescription drugs not prepared as unit dose or blister packs should be dispensed. Consultant will provide.

2. Implement and train med techs on new policy. Communicate with various pharmacies about policy.

3. Monthly.

4. Administrator.

Based on interview and record review, it was determined the facility failed to ensure PRN psychotropic medications used to treat a resident's anxiety had written, resident-specific parameters and non-drug interventions for staff to attempt prior to administering the medication for 1 of 1 sampled resident (#3) who was prescribed PRN medication to address anxiety. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 03/2022 and was receiving hospice services for end of life care.

Review of the resident's 06/01/22 through 06/21/22 MAR and current physician orders revealed an order for Lorazepam 0.5 mg (a psychotropic medication) one to two tablets every two hours as needed for anxiety.

The facility administered the Lorazepam to the resident on eight occasions in June 2022.

The MARs lacked resident specific parameters for staff describing how the resident expressed anxiety. Additionally, there was no documentation of what non-drug interventions were attempted prior to administration of the medications.

The need to ensure there were resident-specific descriptions of how the resident expressed anxiety and that non drug interventions were attempted and documented as not effective prior to administration of the medication was discussed with Staff 1 (Administrator), Staff 2 (RCC/MT), and Staff 3 (RN) on 06/22/22 and 06/23/22. The staff acknowledged the findings.

1. Resident 3 prn parameters and non-pharmacologic interventions  have been updated.

2. Med techs, RCC, and RN will be trained on medical order review and what is required for prn parameters and non-pharmacologic interventions. All MARs will be reviewed and prn parameters and non-pharmacologic interventions updated. New QuickMAR electronic documentation system will be implemented.

3. Daily, weekly, monthly.

4. RCC, RN & Administrator.

Based on observation, interview and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities was assessed thoroughly by an RN, PT or OT prior to use for 1 of 1 sampled resident (#1) who had side rails on their bed. Findings include, but are not limited to:

Resident 3 was observed during the survey and noted to have half-length side rails attached to his/her bed.

Review of the resident's clinical record revealed the following:

* No documented evidence of an assessment completed by an RN, PT or OT for the use of the side rails;

* No documented evidence that other less restrictive alternatives had been attempted prior to use; and

* There was no clear instruction to caregivers on the correct use and precautions related to use of the device.

On 06/23/22, the need to complete an assessment and the required components for the use of devices with potentially restraining qualities was discussed with Staff 1 (Administrator), Staff 2 (RCC/MA) and Staff 3 (RN). They acknowledged the findings.

1. The supportive device assessment for Resident 3 has been completed. A room-to-room audit will be done to identify supportive devices. Resident specific supportive device information will be included on the evaluation and service plan.

2. Consultant provided new form for supportive device assessment. A whiteboard has been ordered and will be used to document dates assessments were completed. The RN will be trained in supportive device assessments.

3. Weekly, monthly.

4. RN & Administrator.

Based on interview and record review, it was determined the facility failed to have a training program that included methods to determine competency of direct care staff through evaluation, observation, or written testing. Findings include, but are not limited to:

During a review of staff training records on 06/22/22, Staff 1 (Administrator) was unable to provide documented evidence the sampled newly hired staff had completed all pre-service orientation, pre-service dementia training, and demonstrated competency in all duties they were assigned. There was no written documentation of initial and annual training completed by each employee.

The need maintain written documentation of training completed by each employee and to have a training program that included methods to determine competency of direct care staff through evaluation, observation, or written testing was discussed with Staff 1 on 06/22/22 and 06/23/22. She acknowledged the findings.

Refer to C370, C372 and C374.

1. All Staff required pre-service training, All staff training files are being audited. Staff are being assigned training. Training files will be created for each employee. An annual inservice schedule will be developed. Consultant provided a list of courses from OCP.

2. A new process will be implemented for new hires and orientation. Pre-service training will be assigned and completed prior to staff being scheduled for on-the-floor training.

3. Weekly, monthly.

4. RCC & Administrator.  

Based on interview and record review, it was determined the facility failed to ensure pre-service orientation and dementia care training had been completed, with certification, prior to staff providing direct care to residents for 4 of 4 newly hired caregiving staff (#s 5, 6, 7 and 10). Findings include, but are not limited to:

Review of the facility's training records on 06/22/22 indicated the following:

Staff 5 (CG), hired 01/16/22, Staff 6 (CG), hired 02/07/22, Staff 7 (CG), hired 02/01/22, and Staff 10 (MT) hired 05/16/22, lacked documented evidence they had completed pre-service orientation and pre-service dementia training prior to providing direct care to residents.

The training program and requirements were discussed with Staff 1 (Administrator) on 06/22/22 and 06/23/22. She acknowledged the findings.

All staff training files are being audited. Staff are being assigned training. Training files will be created for each employee. An annual inservice schedule will be developed. Consultant provided a list of courses from OCP.

2. A new process will be implemented for new hires and orientation. Pre-service training will be assigned and completed prior to staff being scheduled for on-the-floor training.

3. Weekly, monthly.

4. RCC & Administrator.  

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 newly hired staff (#s 17 and 18) had demonstrated competency in all required areas and been trained in First Aid and abdominal thrust within 30 days of hire. This is a repeat citation. Findings include, but are not limited to:

Review of the facility's training records on 004/18/23 indicated:

Staff 17 (CG), hired 01/25/23, and Staff 18 (CG), hired 02/06/23,  lacked documented evidence of demonstrating competence in:

* Role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Changes associated with normal Aging;

* Identification, documentation and reporting changes of condition;

* Conditions that require assessment, treatment, observation and reporting; and

* General Food Safety.

There was no evidence Staff 17 and 18 had been trained in First Aid or abdominal thrust.

The need to ensure staff had documented evidence of demonstrating competence in all assigned duties, and were trained in First Aid and abdominal thrust within 30 days of their hire date, was discussed with Staff 12 (Administrator), Staff 21 (Administrative Coordinator), Staff 13 (RN) and Witness 1 (Consultant RN) on 04/18/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff (#s 5, 6, 7 and 10) had demonstrated competency in all required areas and been trained in First Aid and abdominal thrust within 30 days of hire. Findings include, but are not limited to:

Review of the facility's training records on 06/22/22 and 06/23/22 indicated the following:

1. Staff 5 (CG), hired 01/16/22, Staff 6 (CG), hired 02/07/22, Staff 7 (CG), hired 02/01/22, and Staff 10 (MT), hired 05/16/22, lacked documented evidence of demonstrating competence in:

* Role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Changes associated with normal Aging;

* Identification, documentation and reporting changes of condition; and

* Conditions that require assessment, treatment, observation and reporting.

There was no evidence Staff 5, 6, 7 and 10 had been trained in First Aid or abdominal thrust.

2. Staff 10 lacked documented evidence of demonstrating competence in  Medication Administration.

On 06/23/22, Staff 3 (RN) was notified Staff 10 could not administer medications until she had documented evidence of demonstrating competency. Staff 3 reported she had observed Staff 10 competently administer medications and had not documented the training. She indicated the competence would be reviewed and documented prior to Staff 10 administering medications.

The need to ensure staff had documented evidence of competency demonstration in all assigned duties, and were trained in First Aid and abdominal thrust within 30 days of their hire date, was discussed with Staff 1 (Administrator) on 06/22/22 and 06/23/22. She acknowledged the findings.

1. Training completion is being audited and staff assigned training. Competency observation is in process. All staff are being trained in CPR to include abdominal thrust. New training list provided by consultant.

2. New training files are being created for each staff. A new training process for competency observation and course completion will be developed. Course content will include medication administrator courses from OCP. Med techs will be observed for competency.

3. Weekly, monthly.

4. Administrator & RCC.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 newly hired staff (#s 17 and 18) had demonstrated competency in all required areas and been trained in First Aid and abdominal thrust within 30 days of hire. This is a repeat citation. Findings include, but are not limited to:

Review of the facility's training records on 04/18/23 indicated the following:

Staff 17 (CG), hired 01/25/23, and Staff 8 (CG), hired 02/06/23, lacked documented evidence of demonstrating competence in:

* Role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Changes associated with normal Aging;

* Identification, documentation and reporting changes of condition;

* Conditions that require assessment, treatment, observation and reporting; and

* General food safety, serving, and sanitation.

There was no evidence Staff 17 and 18 had been trained in First Aid or abdominal thrust.

The need to ensure staff had documented evidence of demonstrating competence in all assigned duties and were trained in First Aid and abdominal thrust within 30 days of their hire date was discussed with Staff 12 (Administrator) and Staff 21 (Administrative Coordinator). They acknowledged the findings.

1. Training completion for staff identified in survey is in process. All training files are being audited and staff assigned training as required. Updated training list includes first aid and abdominal thrusts.

2. Administrative coordinator or RCC to complete audit and assign any missing training. Once completed a training audit will be done monthly.

3. Monthly

4. Administrative coordinator, administrator, RCC

Based on interview and record review, it was determined the facility failed to have documented evidence that 12 hours of annual in-service training, including six hours related to the care of residents with dementia, was completed for 2 of 2 long-term staff (#s 2 and 4) whose training records were reviewed. Findings include, but are not limited to:

The annual in-service training records for Staff 2 (RCC/MT), hired 02/26/14, and Staff 4 (MT), hired 11/17/18, were requested 6/22/22.

Staff 1 (Administrator) reported there was no documented evidence of staff completing 12 hours of required in-service training.

The need to ensure staff completed 12 hours of training annually, including six hours related to dementia care, was reviewed with Staff 1 on 06/22/22 and 06/23/22. She acknowledged the findings.

1. An inservice schedule will be developed and assigned to staff.

2. Training files will be created for each staff and be audited monthly and updated.

3. Monthly.

4. Administrator & RCC.

Based on observation, interview and record review, it was determined the facility failed to ensure fire drills were conducted in accordance with Oregon Fire Code and fire and life safety instruction to staff was provided on alternate months. Findings include, but are not limited to:

Review of fire and life safety records on 06/21/22, for December 2021 through May 2022, identified the following deficiencies:

* Lack of documented evidence Fire drills were being conducted every other month; and

* Lack of documented evidence Fire and life safety instruction was being provided to staff on alternate months of fire drills.

In an interview on 06/22/22, Staff 1 (Administrator) acknowledged not having any documented evidence for fire drills or fire and life safety instruction being conducted on alternating months.

Observations of a fire drill conducted on 06/23/22 indicated staff and residents did not know the designated point of safety as evidence by staff and residents evacuating to different points of safety. In an interview approximately 15 minutes after the fire drill, an un-sampled resident reported s/he was told to stay put in a hallway during the fire drill and staff will come back later to further instruct him/her on where to evacuate.

On 06/22/22, the need to ensure fire drills and fire and life safety instruction were completed on alternate months, and that staff and residents knew the designated point of safety was discussed with Staff 1 (Administrator). She acknowledged the findings.

1. Consultant will provide new fire drill form. Staff will be trained by fire chief on fire drill process and designated areas the week of July 25, 2022. The fire chief trained staff on the use of fire extinguishers on July 18, 2022.

2. Fire drills will be scheduled monthly for the next 3 months and then every other month as required. Fire and life safety training will be provided monthly for the next 3 months and then on alternate months as required. A fire drill and training schedule will be developed. A resident evacuation list will be created.

3. Monthly.

4. Administrator & Maintenance Director.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted in accordance with Oregon Fire Code, and fire and life safety instruction to staff was provided on alternate months. This is a repeat citation. Findings include, but are not limited to:

Review of fire and life safety records on 04/17/23, for January 2023 through April 17, 2023, identified the following deficiencies:

* Lack of documented evidence Fire drills were being conducted every other month; and

* Lack of documented evidence Fire and life safety instruction was being provided to staff on alternate months of fire drills.

In interviews on 04/18/23 and 04/19/23, Staff 12 (Administrator) and Staff 21 (Administrative Coordinator) acknowledged not having any documented evidence for fire drills or fire and life safety instruction being conducted on alternating months.

On 04/19/23, the need to ensure fire drills and fire and life safety instruction were completed on alternate months was discussed with Staff 12 (Administrator). She acknowledged the findings.

1. Staff will be trained by fire chief on fire drill process and designated areas by the end of May.

2. Administrator to schedule every other month fire drills with fire chief beginning in May. Fire and life safety training plan to be developed for the other months beginning in June.

3. Monthly.

4. Administrator, administrative coordinator, and maintenance direction.  

Based on interview and record review, it was determined the facility failed to ensure residents were instructed on fire and life safety procedures within 24 hours of admission and annually. Findings include, but are not limited to:

On 06/22/22, facility fire and life safety records were reviewed and lacked documented evidence the following required elements were completed:

* Instruction to residents on fire and life safety procedures within 24 hours of admission; and

* A written record, including content and residents attending, of annual instruction to residents on general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places inside or outside the building in the event of an actual fire.

On 06/22/22, the need to ensure residents were provided instruction per the Oregon Fire Code was discussed with Staff 1 (Administrator). She acknowledged the findings.

1. Consultant will provide resident fire and life safety instruction template. All residents will be trained on fire and life safety procedures including general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places inside and outside the building in the event of an actual fire. The fire chief will be onsite the week of July 25, 2022 to do training.

2. The move in procss will include resident training on fire and life safety procedures. Documentation will be contained in the resident record.

3. Upon move in and annually.

4. Administrator, Maintenance Director & RCC.

Based on interview and record review, it was determined the facility failed to ensure residents were instructed on fire and life safety procedures annually. This is a repeat citation. Findings include, but are not limited to:

On 04/18/23 and 04/19/23, facility fire and life safety records were reviewed.

There was no documented evidence of annual instruction to residents on general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places inside or outside the building, in the event of an actual fire.

On 04/18/23 and 04/19/23, the need to ensure residents were provided instruction per the Oregon Fire Code was discussed with Staff 12 (Administrator). She acknowledged the findings.

1. Consultant will provide resident fire and life safety instruction template. All residents will be trained on fire and life safety procedures including general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places inside and outside the building in the event of an actual fire. The fire chief will be onsite by the end of May to do training.

2. The move in process will include resident training on fire and life safety procedures.

3. Upon move in and annually.

4. Administrator, administrative coordinator, maintenance director.

Based on observation, 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 C240, C260, C270, C280, C302 C303, C372, C420, C 422, C610, C613 and C655.

Refer to C240, C260, C270, C280, C302, C303, C372, C420, C422, C610, C613, C655.

Based on observation and interview, it was determined the facility failed to ensure all exterior pathways and accesses were maintained in good repair, grounds were kept orderly and free of litter and refuse, and garbage was being stored in covered refuse containers. Findings include, but are not limited to:

The exterior of the facility was toured on 06/21/22 and 06/22/22. The following deficiencies were identified:

*Exterior pathways in the courtyard and around the perimeter of the building contained multiple drop-offs up to 2 inches, measured from the concrete to the ground;

*Outside garbage refuse containers were not covered;

*Food scraps were noted on the ground outside on of the side exit doors; and

*The facility courtyard had weeds and vegetation that were overgrown and were approximately three feet high.

On 06/22/22, the building's exterior was toured with Staff 1 (Administrator). She acknowledged the findings.

1. Materials to correct drop offs will be ordered. Outside garbage containers are covered. Residents will be asked to not put food scraps outside side exit doors. The weeds and vegetation was cut/mowed. The outside of the building will be pressure washed.

2. The administrator will do exterior rounds multiple times per week. Consultant will provide an administrator walk-through checklist.

3. Weekly.

4. Administrator & Maintenance Director.

Based on observation and interview, it was determined the facility failed to ensure courtyard surfaces were maintained in good repair. This is a repeat citation. Findings include, but are not limited to:

Observations of facility pathways, courtyard, and seating areas on 04/17/23 and 04/18/23 identified the following:

* Multiple drop-offs of 2-4 inches were noted along pathway edges around the perimeter of the facility and in the courtyard, as well as along the paths at exterior exit doors;

* A section of sidewalk had separated and was lifted up, creating an uneven surface along the back sidewalk of the facility. Additional areas of cracked and lifting concrete and chunks of missing concrete were noted near the seating area at the front of the facility; and

* Multiple pieces of broken furniture, a foam pad, an electric bed frame, damaged window screens, sofa cushions, air conditioner units, metal pieces, and a baking pan were noted around the perimeter of the facility in several locations.

The need to ensure pathways around the facility were in good repair with no potential tripping hazards, and that the facility grounds was free of discarded items was discussed with Staff 12 (Administrator) on 04/18/23. She acknowledged the findings.

1. Materials to correct drop offs on-site. Multiple pieces of broken furniture, a foam pad, an electric bed frame taken to the dump. Screens, air conditioner units, metal pieces, and a baking pan to be taken to the dump. Cracked side walks to be patched.

2. The administrator will do exterior rounds multiple times per week.

3. Weekly.

4. Administrator and Maintenance Director.

Based on observation and interview, it was determined the facility failed to ensure the environment was maintained clean and in good repair. Findings include, but are not limited to:

Observations of the facility on 06/21/22 and 06/23/22 identified the following areas in need of cleaning and repair:

* Multiple areas of the carpet in the corridors and entry ways throughout the facility had stains and black spots;

* Multiple apartment doors, door frames, and walls had significant dings, gouges, scrapes and exposed wood; and

* Multiple pieces of furniture throughout the facility had stains, rips, tears, gouges, and exposed wood.

On 06/22/22, the areas in need of cleaning and repair was discussed with Staff 1 (Administrator). She acknowledged the findings.

1. The carpets will be shampooed July 27, 2022. After cleaning, the carpets will be evaluated to determine what sections may need to be replaced. Quotes have been requested for painting and painting will be scheduled. A quote for furniture replacement has been received and furniture will be replaced as identified. Cleaning of the community scheduled for July 21, 2022. A plan will be developed for repairing apartment doors, door frames, and walls. A Maintenance director has been hired and will start August 1, 2022.

2. Weekly administrator and maintenance director walk through, and place areas of concern on the maintenance log.

3. Weekly, monthly.

4. Administrator & Maintenance Director.

Based on observation and interview, it was determined the facility failed to ensure the environment was maintained clean and in good repair. This is a repeat citation. Findings include, but are not limited to:

Observations of the facility on 04/17/23 and 04/18/23 identified the following areas in need of cleaning or repair:

* Scrapes, dings, and gouges were noted on doors and door frames in Room 201. Baseboards were missing from the resident's bathroom;

* An outer pane of glass had a large broken section with missing glass at the back of the facility;

* Carpet in multiple areas throughout the facility hallways, dining room, and sitting areas had black/red/brown stains of varying sizes. Two sections of carpet had gaps or missing pieces of the carpet; and

* A water fountain near the common area bathrooms was noted to have a brown, opaque liquid which filled the drain area. The fountain was still in use.

The areas in need of cleaning and repair were reviewed with Staff 12 (Administrator) on 04/18/23. She acknowledged the findings.

1. The carpet is in the process of being removed and replaced with luxury vinyl planking throughout the resident rooms and common areas. Each resident apartment is being repaired as the floors are being replaced. The outer pane of glass will be repaired. The water fountain was cleaned out and a plumber is going to fix it.

2. Weekly administrator and maintenance director walk through.

3. Weekly until in compliance then monthly.

4. Administrator & Maintenance Director.

Based on observation and interview, it was determined the facility failed to ensure public and resident restrooms had a manually operated emergency call system, and that exit doors were equipped with an alarming device to alert staff when residents exited the building. Findings include, but are not limited to:

On 06/21/22, a tour of the facility identified the following deficiencies:

* Doors by which residents could exit the facility or exit to the courtyard, did not have a working alarm or other acceptable system to alert staff when residents exited the building; and

* The facility public men's and women's restrooms failed to have a manually operated emergency call system.

On 06/22/22, the need to ensure all exit doors had alarms and all restrooms had a call system was discussed with Staff 1 (Administrator). She acknowledged the findings.

1. Alarms will be installed on all exit doors including courtyard doors. Quote received July 18, 2022. Alarms will be installed in public restrooms unless exception granted.

2. Administrator walk through to ensure alarms are working once installed. Staff training to respond to alarms.

3. Daily, weekly.

4. Administrator.

Based on observation and interview, it was determined the facility failed to ensure public and resident restrooms had a manually operated emergency call system. This is a repeat citation. Findings include, but are not limited to:

A tour of the facility was conducted on 04/17/23 and 04/18/23 and showed:

* The facility public men's and women's restrooms failed to have a manually operated emergency call system.

The need to ensure all common area restrooms had a call system was discussed with Staff 12 (Administrator) on 04/18/23. She acknowledged the findings.

1. Manually operated emergency call system to be installed the week of May 14, 2023 in the public women's and men's restrooms.

2. Administrator walk through to ensure alarms are working once installed. Staff training to respond to alarms.

3. Daily for a week then weekly.

4. Adminstrator.