The findings of the re-licensure survey conducted 09/07/22 through 09/09/22 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

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

Situations were identified where there was a failure of the facility to comply with the Departments rules that were likely to cause residents serious harm. Immediate plans of correction were requested in the following area:

OAR 411-054-0040 (1-2) Change of Condition and Monitoring

OAR 411-054-0045 (1)(A)(C)(D) Resident Health Services

The facility put immediate plans of correction in place during the survey and the situations were abated.

The findings of the first re-visit to the re-licensure survey of 09/09/22, conducted 03/13/23 through 03/17/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the second re-visit to the re-licensure survey of 09/09/22, conducted 07/24/23 through 07/25/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.

Based on interview and record review, it was determined the facility failed to ensure the initial move-in evaluation contained all required elements, and was signed and dated for 1 of 1 sampled resident (#3) who was recently admitted to the facility.  Findings include, but are not limited to:

Resident 3 was admitted to the facility in 08/2022.  

Review of the initial evaluation dated 08/12/22 revealed the following elements were missing:

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

*A review of risk indicators including: recent losses;

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

*The evaluation was not dated and did not indicate who completed the evaluation.

The need to ensure the initial evaluation included all of the required elements and was signed and dated upon completion was discussed with Staff 1 (Administrator). The findings were acknowledged.

1. Facility acknowledges the missing documentation on move-in evaluation. The 30-day service plan was updated with this missing information for resident #3. The missing information was not applicable to this particular resident and therefore not noted on the move-in service plan. Move in evaluation has been signed, signature page scanned into resident record.

2. All residents with move In evaluations are potentially impacted, areas that are not applicable to that resident, based on evaluation, will be clearly stated in the evaluation.  

3. Administrator will inservice facility RSC (Resident service coordinator) and facility RN on completion of move-in evaluation and signatures.

4. Administrator will audit move in evalutaions weekly x4, then monthly x 90 days to ensure continued comliance.   

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 regarding the delivery of services for 1 of 4 sampled residents (# 2) whose service plans were reviewed. Findings include, but are not limited to:

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

Interviews with care staff and observations of Resident 2 during the survey revealed s/he was dependent on staff for ADL care and required meal assistance.  

Resident 2's service plan, dated 05/24/22, revealed it was not reflective of the resident's needs and lacked clear direction regarding the delivery of services in the following areas:

* Dressing/undressing;

* Bathing;

* Grooming;

* Toileting;

* Positioning;

* Assistance with getting food to his/her mouth;

* Hospice services; and

* Use of side rails.

The need to ensure the service plan was reflective of Resident 2's current care needs and provided clear direction to staff was discussed with Staff 1 (Administrator) and Staff 2 (Director of Nursing Services) on 09/07/22 at 12:20 pm.  Staff 1 stated she had not yet updated the residents service plan.

1. The service plan for res #2 was updated 9/7/2022 to reflect current status and clear directions, service plan meeting held with the family member at 5pm.

2. Marquis Clinical Consultant RN will inservice Administrator, RN and RSC on updating service plans.

3. Administrator will audit service plans weekly x4 and monthly x 90 days for updates based on changes identified during morning 24 hour meeings.

2. Resident 9 was admitted to the facility in 2013 with diagnoses which included lymphedema, obesity, and recurrent cellulitis.

Resident 9's service plan dated 03/10/23 included an intervention to use a lymphedema pump every morning for one hour. The pump was integrated into pants that covered all of Resident 9's body below the sternum as they sat in their reclining chair.

In interview on 3/16/23 Resident 9 stated s/he was concerned that there was no plan to clean or sanitize the garment.

Review of the service plan and posted instructions for the pump did not show any cleaning or maintenance instructions.

Interviews with Staff 15 (RN/Clinical Support), Staff 19 (Resident Services Coordinator), and Staff 9 (CG) revealed they were unaware of a process for cleaning or maintaining the lymphedema pump garment, or that anyone had attempted to clean or sanitize the garment.

The need to ensure the service plan included complete instructions for staff was reviewed with Staff 13 (Administrator) and Staff 15 on 03/16/23. They acknowledged the findings.

4. Resident 6 was admitted to the facility in 09/2022 with diagnoses including gastroesophageal reflux disease. The resident was noted to be at risk for weight loss.

The resident's 02/24/23 service plan, 03/01/23 through 03/13/23 MARs, physician's orders and 12/19/22 through 03/12/23 progress notes were reviewed and revealed  the following:

a. The resident was noted to experience difficulty swallowing his/her medications.

A progress note dated 03/10/13 noted: "...resident is just more slow with swallowing [his/her] meds and it can take up to ten minutes to get them all ingested, but letting [him/her] eat food with [his/her] medicine really helps..."

The facility developed the following intervention noted in the instruction area of the MAR: "The resident may have applesauce with [his/her] pills."

On 03/15/23 at 11:35 am, during an interview with Resident 6 and his/her spouse, Staff 18 (CG/MA) was observed administering Resident 6's noon medications with water. The resident was unsuccessful in swallowing the medications after several attempts, stating "it's stuck in there." During a discussion of the intervention for Resident 6 to take medications with applesauce, Staff 18 stated "...I don't think they have any right now." Resident 6 and spouse were asked if they had something on hand the resident could use to aid in taking his/her medications. The resident's spouse offered chocolate pudding which the resident accepted and used to swallow the medications. Resident 6's spouse stated "...[s/he] has had a hard time swallowing those pills for a while now...they rarely offer the applesauce."

The facility failed to follow the interventions for Resident 6's medication administration as noted on the MAR.

b. During the review period the resident was noted to have experienced a significant weight loss. The 02/24/23 service plan noted the following intervention: "I do not need dining assistance but need encouragement to be out of bed for meals."

On 03/15/23 at 12:02 PM, observations were made of Staff 11 (CG) delivering lunch to Resident 6 in his/her unit. Staff 11 set the food on the table, called out to Resident 6 and his/her spouse "...your lunch is here." Staff 11 then left the unit. During the interview Resident 6 acknowledged s/he could have used assistance to sit up for lunch.

The facility failed to follow the intervention for Resident 6's weight loss as noted in the service plan.

The need to ensure Resident 6's service plan was followed was discussed with Staff 1 (Administrator, Marquis Piedmont), Staff 13 (Administrator) and Staff 15 (RN/Clinical Support) on 03/16/23. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure residents' service plans reflected residents' needs, provided clear directions regarding the delivery of services and were implemented for 4 of 5 sampled residents (#s 6, 7, 9 and 10) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 7 moved into the facility in 08/2022 with diagnoses including a history of stroke.

Observations and interviews with the resident and staff and a review of the service plan available to staff, last updated on 11/02/22, revealed Resident 7's service plan was not reflective of the resident's needs or did not provide clear direction to staff in the following areas:

* Dietary needs and preferences;

* Skin conditions; and

* Fall risk and current interventions.

The need to ensure the service plan reflected residents' needs and provided clear direction to staff was reviewed with Staff 13 (Administrator) and Staff 15 (RN/Clinical Support) on 03/16/23. They acknowledged the findings.

3. Resident 10 moved into the facility in 12/2021 with diagnoses including chronic kidney disease.

Observations and interviews with the resident and staff and a review of the service plan available to staff, last updated on 01/31/23, revealed Resident 10's service plan was not reflective of the resident's needs, did not provide clear direction to staff, or was not implemented in the following areas:

* Bathing, including schedule and whether the facility or hospice was providing the service;

* Fingernail care, including schedule and whether the facility or hospice was providing the service;

* Toileting needs;

* Dietary needs, including any staff instructions for addressing painful dental implants and for staff to "note the approximate amount of fluids consumed per shift;"

* Pain, including how the resident expresses pain or discomfort and nonpharmaceutical interventions;

* Communication, including the resident's ability to understand;

* Staff assistance with placing glasses and hearing aids; and

* Schedule, including preferred wake up time.

The need to ensure the service plan reflected resident's needs, provided clear instruction to staff and was implemented was reviewed with Staff 1 (Administrator, Marquis Piedmont), Staff 13 (Administrator) and Staff 15 (RN/Clinical Support) on 03/16/23. They acknowledged the findings.

1.) Resident #6,7,9,10 service plans have been updated to provide clear directions for all areas identified as missing, or unclear

             a.) All residents potentially impacted by citation

2. Inservicing completed with IDT team on service plan requirements to include clear directions for care areas as indicated

        a.) all resident's service plans will be reviewed and updated by 5/1 to ensure compliance.

        b.) Care staff inserviced regarding use of kardex for  delivery of care

3. Administrator will audit service plans during service plan meetings every 90 days to ensure that service plans have clear directions for provisions of care to ensure ongoing compliance.

4. Administrator is responsible for ensuring compliance.

Based on observation, interview and record review, it was determined the facility failed to ensure residents who had changes of condition were evaluated, resident-specific instructions or interventions were developed and communicated with staff and the condition was monitored through resolution for 2 of 4 sampled residents (#s 1 and 2) who experienced  changes of condition. Resident 2 experienced severe weight loss. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 2022 with diagnoses including dementia.

The resident's current service plan dated 05/24/22 noted the resident was independent with dressing, grooming, toileting, oral care and at times had difficulty swallowing solid food and "did better with" softer foods.

Review of the facility weight records noted the following:

*06/08/22:  89.4 pounds (standing);

*07/2022:  no weight recorded; and

*08/19/22:  77.2 pounds (standing).

Between 06/2022 and 08/2022 Resident 2 lost 12.2 pounds or 13.64 percentage of his/her total body weight resulting in a severe weight loss and a significant change of condition.

There was no documented evidence the change of condition was evaluated, the facility RN was notified or resident specific instructions were developed. The resident was not able to be weighed during the time of the survey.

Interviews on 09/07/22 and 09/08/22 with caregivers and a medication aide noted the following:

*Resident 2 was receiving hospice services;

*Was not getting out of bed;

*Was not really eating solid foods for the past "3-4 weeks";

*Had safety checks every 1-2 hours to provide incontinent checks and re-positioning;

*Received nutritional supplements and water only;

*Needed assistance to hold onto his/her cup.

During an interview with Staff 9 (CG) on 09/08/22 at 9:15 am, she stated the resident had been refusing food and she "wasn't sure" what the nutritional plan was for the resident.

During an interview with Resident 2 on 09/08/22 at 9:15 am, the resident stated s/he did not get breakfast and thought s/he would like some yogurt. The surveyor requested Staff 9 to provide the resident with yogurt. Staff 9 reported she fed the resident a bowl of yogurt and held the resident's cup so the resident could drink water.

On 09/08/22 at 10:00 am, Resident 2's weight loss was reviewed with Staff 1 (Administrator), Staff 2 (Director of Nursing Services) and Staff 8 (Resident Services Coordinator) and the surveyor requested the facility complete an assessment of the resident's change of condition and update the service plan. Staff 1 provided an updated assessment and service plan and the situation was abated.

During an observation on 09/08/22 at 11:50 am, the resident was offered a fruit and cottage cheese plate. Staff 9 fed the resident and reported the resident ate approximately 25% of the meal.

Resident 2 experienced a severe weight loss without documented evidence of an evaluation, a referral to the facility nurse, documentation related to the change nor was the service plan updated.

2. Resident 1 was admitted to the facility in 6/2021 and had diagnoses including myocardial infarction and pneumonia.

Interviews with the resident and staff on 09/08/22, a review of the service plan updated 07/07/22, alert charting updates 07/14/22, physician's orders and progress notes dated 06/07/22 through 09/06/22 were reviewed.

a. The resident was hospitalized on 07/05/22 and returned to the facility on 07/14/22 with diagnoses of heart attack, pneumonia and a cardiac stent placement. The physician ordered new medications to be administered, including aspirin (for heart attack), atorvastatin (for heart attack), carvedilol (for heart attack), nitroglycerin (as needed for chest pain), and ticagrelor (for blood clot prevention).

On 07/14/22, the service plan was updated by Staff 2 (Director of Nursing Services), and placed the resident on alert charting, instructing staff of "recent heart attack and placement of cardiac stent. Observe for chest pain, shortness of breath, sweating. Observe for adjustment to return to ALF setting, mobility, pain, activity tolerance."

On 07/15/22, a caregiver charted in the progress notes the "resident does need additional assistance while getting up and dressed. Resident does still have bruising on [his/her] right wrist and stated that [s/he] is still feeling stiff and sore."

While the record reflected alert charting notes of monitoring the resident's return from the facility, mobility and general status from 07/14/22 through 07/19/22, the record lacked documented evidence of monitoring and any resolution for the bruising to the wrist area, placement of the cardiac stent, new medications and ADL functioning (transfers, dressing).

b. Resident 1 received the following medication orders from the physician:

* 08/10/22 lamotrigine 12.5 mg daily for mood disorder; and

* 08/22/22 furosemide 20 mg daily for cardiac failure.

The record did not have documented evidence the resident was monitored for any possible side effects of these new medications.

The need to ensure short-term changes of condition had documentation to reflect monitoring at least weekly to resolution, provided clear, resident-specific directions to staff and that interventions were developed was discussed with Staff 1(Administrator) on 09/09/22 and Staff 2 on 09/08/22. They acknowledged the findings.

The service plan for resident #2 has been updated to include instructions and direction on foods to offer and offering supplemental nutrition drinks at each mealtime and bedtime. Tasks have been assigned to the care staff within the allotted times.

RN has completed weight change assessment; service plan review conference was held by phone on 9/8/2022 with administrator, resident services coordinator, and daughter, then reviewed by RN.

100% residents may be affected. 100% of residents will be audited immediately to identify significant weight changes and ensure weight change assessment completed by the RN.

Routine monthly audits of weights will be implemented to identify trends and monitoring for significant changes in weight.

Service plans will be revised as indicated and resident identified will be monitored per assessment and service plan.

Weights are reviewed in stand-up Monday through Friday's.

The RN, RSC and Administrator will conduct the audits monthly.

The immediate instruction and corrective actions related to resident specific concerns have been implemented. Routine audits will be implemented no later than the 15th of each month.

3. Resident 8 was admitted to the facility in 01/2023 with diagnoses including osteoarthritis, low back pain, atrial fibrillation and lower leg edema.

In a progress note dated 01/24/23, staff documented Resident 8 self-reported s/he scraped his/her leg on the bedside table. Staff documented the scrape was bleeding and "then started leaking water." The staff documented she applied a bandage and some gauze to the wound. A progress note dated 01/25/23 indicated a staff changed the bandage for the resident.

The facility did not document for staff what actions or interventions were needed for the resident and the facility did not monitor the resident's wound to ensure it resolved.

The need to ensure the facility determined, documented and communicated to staff what action was needed for a resident in response to a change of condition, and the condition was monitored until resolved, was discussed with Staff 1 (Administrator, Marquis Piedmont), Staff 13 (Administrator) and Staff 15 (RN/Clinical Support) on 03/16/23. They acknowledged the lack of written instructions for staff and lack of monitoring of the resident's condition.

2. Resident 7 moved into the facility in 08/2022 with diagnoses including a history of stroke and UTI's (urinary tract infections). A review of the clinical record revealed the following:

a. Resident 7 experienced a fall on 01/18/23 resulting in "scratches to [his/her] lower back, buttocks and fingers" as documented in facility progress notes, dated 01/18/23. There was no documented evidence the facility monitored and documented the progress of the skin injuries sustained, at least weekly, until resolved.

b. On 01/22/23, progress notes documented the resident was experiencing signs/symptoms of UTI and had agreed to having a urine analysis. There was no documented evidence of monitoring the change of condition or any interventions provided until 02/16/23 (three weeks later) when a physician's assistant ordered a urine analysis.

The need to ensure the facility monitored short term changes of condition with weekly progress noted until resolution was discussed with Staff 13 (Administrator) and Staff 15 (RN) on 03/16/23. They acknowledged the findings.

4.  Resident 9 was admitted to the facility in 2013 with diagnoses including lymphedema, obesity and recurrent cellulitis. Review of the clinical record revealed the following:

a.  The TARs from 01/08/23 to 03/14/23 documented "Pressure ulcer/Wound Care left lateral scrotum" with instructions for wound care by facility staff and home health.

There was no documented monitoring of the wound until resolution.

b.  A progress note dated 01/09/23 documented the discovery of a two inch long scratch on Resident 9's scrotum.

The facility did not document for staff what actions or interventions were needed for the resident and the facility did not monitor the resident's wound to ensure it resolved.

The need to monitor short term changes of condition with weekly progress noted until resolution was discussed with Staff 13 (Administrator) and Staff 15 (RN/ Clinical Support) on 03/16/23. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure resident-specific instructions or interventions were developed and communicated with staff and the condition was monitored through resolution for 4 of 5 residents (#'s 7, 8, 9 and 10) who experienced short-term changes of condition. This is a repeat citation. Findings include, but are not limited to:

1. Resident 10 moved into the facility in 12/2021 with diagnoses including chronic kidney disease. A review of the clinical record revealed the following:

Progress notes and the "Clinical and Order Alerts Listing Report" documented the resident had experienced the following changes of condition:

* 01/27/23: Pain related to a UTI (urinary tract infection) and having COVID;

* 02/09/23: Urinary retention; and

* 02/17/23: Recent onset of anxiety symptoms.

There was no documented evidence the facility monitored and documented weekly progress until resolution for the above changes of condition.

The need to ensure the facility monitored short term changes of condition with weekly progress noted until resolution was discussed with Staff 1 (Administrator, Marquis Piedmont), Staff 13 (Administrator), and Staff 15 (RN/Clinical Support). They acknowledged the findings.

1. Resident #7,8,9, and 10 short term change of conditions have been reviewed, with updates to alert charing and monitoring, implemented as indicated.

Any resident with short term change of condition will be impacted

2. Med tech, RSC and care staff will be in-serviced on alert charting and short term change of condition charting and monitoring.

Admin and RSC will monitor alert charting through stand up meeting Monday-Friday, to ensure compliance. Administrator will ensure that staff have documentation and instruction regarding actions and interventions needed for the facility to monitor the change until it is resolved.

3. Admin will audit for short term changes of condition and proper weekly progress note documentation and monitoring weekly for first 4 weeks then random monthly for 90 days.

4. Adminstrator is responsible for ensuring compliance.

Based on observation, interview and record review, it was determined the facility failed to ensure the RN performed an assessment and interventions were developed based on the condition of the resident for 2 of 2 sampled residents (#s 1 and 2) who experienced  significant changes of condition related to weight loss, overall ADL decline and hospitalization. Resident 2 experienced severe weight loss. Findings include, but are not limited to:

1.  Resident 2 was admitted to the facility in 2022 with diagnoses including dementia.

a.  Resident 2 experienced severe weight loss between 06/2022 and 08/2022. There was no documented evidence the weight loss was assessed by the facility RN including resident specific interventions related to the change.

Refer to C270, example 1.

b.  Resident 2's current service plan dated 05/24/22 noted the resident was independent

with dressing, grooming, toileting and oral care. Resident 2 was noted to have difficulty at times swallowing solid food and "did better with" softer foods.

Review of progress notes dated 08/30/22 indicated a hospice chaplain and social worker had completed an assessment and provided a supportive presence to the resident.

Interviews on 09/07/22 and 09/08/22 with caregivers and a medication aide noted the following:

*Resident 2 was receiving hospice services;

*Was not getting out of bed;

*Was not really eating solid foods for the past "3-4 weeks";

*Was incontinent;

*Had safety checks every 1-2 hours to provide incontinent checks and re-positioning;

*Received nutritional supplements and water only;

*Needed assistance to hold onto his/her cup; and

*Was independent prior to hospice care.

Resident 2 was observed on 09/07/22 at 12:00 pm to be lying on his/her back in a hospital bed, bilateral side rails in the up position and lower extremities elevated with a pillow to float the heels.

Resident 2 had a significant change of condition related to hospice admission and overall decline with ADL care. There was no documented evidence the facility RN had conducted a significant change of condition assessment including findings, resident status, and interventions made as a result of this assessment.

The lack of RN assessment was discussed with Staff 1 (Administrator) and Staff 2 (Director of Nursing Services) on 09/07/22 at 12:20 pm. Staff acknowledged the lack of assessment.

2. Resident 1 was admitted to the facility in 6/2021 and had diagnoses including myocardial infarction and pneumonia.

During the entrance conference it was reported the resident had been hospitalized and returned to the facility.

A review of the clinical record revealed the resident was hospitalized on 07/05/22 and returned to the facility on 07/14/22 following treatment for pneumonia and a heart attack, with placement of a heart stent. This represented a significant change of condition that required an RN assessment.

There was no evidence the facility RN completed an assessment following the resident's return to the facility that documented the resident's current condition, status, findings and interventions made as a result of the assessment. In an interview on 09/08/22, Staff 2 (Director of Nursing Services) confirmed a documented assessment had not been done.

The need to ensure an assessment was completed for significant changes in condition was discussed with Staff 1 (Administrator) and Staff 2. They acknowledged the findings.

As per immediate plan of correction submitted on 9/8/22 for resident #2: The service plan was immediately updated to include instruction on changes, and the updated changes were discussed and agreed upon with family on 9/7/22.

The service plan for resident #2 has been updated to include instructions and direction on foods to offer and offering supplemental nutrition drinks at each mealtime and bedtime. Tasks have been assigned to the care staff within the allotted times.

RN has completed weight change assessment; service plan review conference was held by phone on 9/8/2022 with administrator, resident services coordinator, and daughter, then reviewed by RN.

100% residents may be affected. 100% of residents will be audited immediately to identify significant weight changes and ensure weight change assessment completed by the RN.

Routine monthly audits of weights will be implemented to identify trends and monitoring for significant changes in weight.

Service plans will be revised as indicated and resident identified will be monitored per assessment and service plan.

Weights are reviewed in stand-up Monday through Friday's.

The RN, RSC and Administrator will conduct the audits monthly.

The immediate instruction and corrective actions related to resident specific concerns have been implemented. Routine audits will be implemented no later than the 15th of each month.

An RN assessment was completed on 7/14/22 during the regularly scheduled service plan meeting, it was determined at that point that no changes to services was needed for Resident #1.

Upon return from hospital residents will continue to be evaluated by RN.

RN and Administrator will be responsible to ensure the RN evaluation is complete.  

Based on observation, interview, and record review, it was determined the facility failed to ensure medications administered by the facility were documented by the same person who administered the medication, and the staff person who administered the medication visually observed the resident take the medication, for 1 of 4 (# 1) sampled residents whose medication records were reviewed . Findings include, but are not limited to:

Resident 1 was admitted to the facility in 06/2021 with diagnoses including myocardial infarction and fibromyalgia.

A review of the resident's 07/07/22 service plan documented that staff would "set up my medications and I will self administer them."

In an interview on 09/08/22, Resident 1 stated the Medication Technicians would open the door and drop off his/her pills, would not stay while s/he took the medication and would leave the medications in his/her room whether s/he was in the room or not. Resident 1 stated concern about not taking the medication at times or spilling it.  

During the interview with Resident 1 on 09/08/22 in the facility dining room at 1:15 pm, Staff 8 (MT) came to the dining room and asked Resident 1 if s/he had taken their morning medications. Resident 1 stated "yes" and Staff 8 stated "I was just checking".

On 09/09/22 at 8:55 am, a cup of pills was observed sitting on the counter in the kitchenette of Resident 1's room.  

In interviews on 09/08/22, with Staff 1 (Administrator) and Staff 2 (Director of Nursing Services), it was confirmed that MT's were instructed to leave the medications in Resident's 1 room without observing him/her taking them. The need to ensure medication technicians visually observed residents take their medications was discussed. They acknowledged the findings and said they would follow up with the resident and staff.

1. All med-tech's immediately trained on the required visual observation of each resident taking medications unless otherwise ordered by provider.

2. An audit will be performed and service plans and physician's orders will be updated to reflect the assessed abilities of independently each residents medication management.

3. This will be completed once and then will be reviewed ongoing with each subsequent quarterly evaluation and new move in evaluations.

4. RSC, Administrator and RN will be responsible to evaluate residents quarterly and as new medications and requests arise.  

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

Resident 4 was admitted to the facility in 03/2022.

A review of the 08/01/22 through 09/06/22 MAR and current physician's orders revealed the following:

Resident 4 had a physician order for metoprolol (to control blood pressure) 25 mg to be given once per day. If the Resident's systolic blood pressure was below 100 or his/her pulse was less than 55, the facility was to hold the medication.

On three occasions in 08/2022 and once during the six days of 09/2022 reviewed, the medication was given outside the parameters.

The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (Administrator) and Staff 2 (Director of Nursing Services) on 09/09/22. They acknowledged the findings.

1. Physician's notified of medication administration outside of parameters for resident #4. Audit will be completed for any other resident in last 30 days of medicaitons given outside of BP parameters, providers will be notified if additional residents are identified.

2. Training will be completed by 10/15/22 for each med-tech on parameters and requirements of following physicians orders.

3 The RN and RSC will monitor medications with parameters weekly for 30 days and then  Spot check quarterly thereafter.

4. The RN and RSC will be responsible to monitor parameter medications and thn spot check the MAR's after initial 30 day period.  

Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 3 of 4 sampled residents (#s 7, 9 and 10) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 9 was admitted to the facility in 2013 with diagnoses which included lymphedema, obesity, and recurrent cellulitis.

1. Resident 9's MAR, dated 03/01/23 through 03/13/23, and corresponding progress notes and prescriber orders were reviewed and revealed the following:

* Signed MD order dated 09/08/2022 "Weight: weekly weights."

* The current service plan, dated 03/13/2022, included the intervention "weight to be obtained weekly... If [resident] refuses, staff to attempt the following day. Explain to resident that daily weights are doctors orders so that edema can be monitored."

Review of Resident 9's weekly weight record showed only two weights in December 2022, only two weights in January 2023, and no weights recorded from 02/12/22 to 03/06/2023.

The need to ensure physician's orders were carried out as prescribed was discussed with Staff 13 (Administrator), Staff 15 (RN/ Clinical Support) on 03/16/23. They acknowledged the findings.

2. Resident 7 moved into the facility in 08/2022 with diagnoses including atrial fibrillation and congestive heart failure.

Resident 7's MAR, dated 03/01/23 through 03/13/23, and corresponding progress notes and prescriber orders were reviewed and revealed the following:

* The resident had an order for daily weights to be obtained. The MAR was blank on four occasions between 03/01 and 03/13/23.

On 03/16/23, the lack of documentation on the MAR was discussed with Staff 15 (RN/Clinical Support) who stated there are codes available for staff to use if a resident refused a weight or the weight was otherwise unable to be obtained. Staff 15 acknowledged the resident's weight was not obtained.

The need to ensure physician's orders were carried out as prescribed was discussed with Staff 13 (Administrator) and Staff 15 on 03/16/23. They acknowledged the findings.

3. Resident 10 was admitted to the facility in 12/2021 with diagnoses including hypertension.

A review of the 03/01/23 through 03/13/23 MAR and current physician's orders revealed the following:

Resident 10 had a physician order for metoprolol (to control blood pressure) 25 mg to be given once per day and for amlodipine (to control blood pressure) 5 mg to be given once per day. If the resident's systolic blood pressure was below 120, the facility was to hold both medications.

On 03/10/23, both medications were administered outside the parameters when they should have been held.

The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (Administrator, Marquis Piedmont), Staff 13 (Administrator), and Staff 15 (RN/Clinical Support) on 03/16/23. They acknowledged the findings.

1. In regards to Residents #9, 7, and 10 weights and holding blood pressure medication per physican order are now in place.

Any resident with daily weights or blood pressure parameters may be possibly impacted.   

2. In-service will be completed during April Caregiver/Med Tech meeting on 4/24/23 with med techs and caregivers on completion of physician orders and administration of medications per parameters.

3. Administrator or designee will audit x4 resident's MARs weekly and monthly to ensure meds are held and weights are obtained per order

4. Administrator is responsible for ensuring compliance.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate, included the initials of who administered the medication and resident-specific parameters for PRN medications for 1 of 4 sampled residents (# 4) whose MARs were reviewed. Findings include, but are not limited to:

Resident 4 was admitted to the facility in 03/2022 with a diagnosis of neuralgia and hip pain.

Resident 4's 09/01/22 through 09/06/22 MAR was reviewed and identified the following:

* Oxycodone (for pain) PRN identified to give 0.5 - 1 tablet, with no clear direction to staff regarding what dose to give;

* PRN bowel medications, bisacodyl, polyethylene glycol and senna without direction to staff which to use first; and

* There were multiple blanks on the MAR for a protein supplement, secura protective cream and wound care.

On 09/09/22, the need to ensure MARs were accurate was discussed with Staff 1 (Administrator) and Staff 2 (Director of Nursing Services). They acknowledged the findings, and no further information was provided.

1. Resident #4's physician faxed to clarify the oxycodone dose; physician faxed to clarify order of bowel medications to be used. Med-Tech's will be inserviced on accurate and complete documentation.

2. Weekly MAR audits for holes will commence immediately.

3. The MAR will continue to be audited weekly for 30 days, then bi-weekly thereafter.  

4. RSC to audit MAR, notify staff of holes in MAR related to them and then will be required to rectify via documentation. The administrator will monitor RSC completing this task.  

3. Resident 10 was admitted to the facility in 12/2021 with diagnoses including chronic kidney disease.

The resident's 02/01/23 through 03/13/23 MAR and progress notes were reviewed. He/She was prescribed the following PRN medications, all to treat pain.

* Acetaminophen 325 mg tab, 1-2 tablets by mouth every 4-6 hours PRN (for pain rated 1-5/10);

* Aleve 220 mg, one capsule by mouth every 8-12 hours PRN (for pain rated 6/10); and

* Morphine sulfate 20 mg/ml, .25 ml by mouth every hour PRN (for pain or shortness of breath).

Progress notes dated 02/03/23, 02/12/23, and 02/25/23 indicated the resident was not able to consistently rate pain using the pain scale.

There were no parameters indicating when to administer one or two acetaminophen, when to administer Aleve every eight or twelve hours, which medication to administer if the resident was unable to rate or verbalize pain and when to administer the morphine sulfate.

The requirement for the MAR to be accurate including resident-specific parameters for PRN medications was discussed with Staff 1 (Administrator, Marquis Piedmont), Staff 13 (Administrator), and Staff 15 (RN/Clinical Support) on 03/16/23. They acknowledged the findings.

3. Resident 9 was admitted to the facility in 2013 with diagnoses including lymphedema, obesity and recurrent cellulitis.

a. The resident's 02/01/23 through 03/13/23 MARs and TARs were reviewed, and identified the following:

* acetaminophen 500 mg "as needed for pain;"

* ibuprofen 400 mg "as needed for pain;" and

* Tramadol 50 mg "as needed for pain."

Three PRN pain medications were listed, all with the same parameter and with no instruction for which to use first.

The requirement for resident specific parameters and instructions for PRN medications was discussed with Staff 13 (Administrator) and Staff 15 (RN/Clinical Support) on 03/16/23. They acknowledged the findings.

b. The resident's TAR included the instruction "dressing changes managed by facility staff Sunday, Wednesdays, and Fridays. Cleanse area with dermal wound cleanser and pat dry. Cut a piece of medihoney with bandage scissors to fit inside the borders of each open area and cover with a 2x2 hydrocolloid patch or band aid, evening shift every Wednesday, Friday, and Sunday, for skin impairment."

In interview with Staff 24 (CG), at 2:05 pm on 3/15/23, she confirmed documenting completing Resident 9's wound care on 2/1/23, 2/8/23, 2/15/23 and 2/22/23, but acknowledged she did not complete any wound care on those dates.

The requirement for MARs to be accurate, including staff documenting that a treatment was being administered or not administered accurately, was discussed with Staff 13 (Administrator) and Staff 15 (RN/Clinical Support) on 03/16/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure accurate MARs were kept for any medications and treatments administered by the facility for 4 of 5 sampled residents (# 6, 7, 9 and 10) whose MARs were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 6 was admitted to the facility in 09/2022 with diagnoses including dementia.

The resident's 03/01/23 through 03/13/23 MARs were reviewed, and identified the following:

* Bisacodyl suppository 10 mg, insert one suppository rectally every 24 hours PRN (for constipation);

* Senna/Docusate 8.5 mg tablets, two tablets by mouth every day PRN (for constipation); and

* Polyethylene glycol powder 17 grams, dissolve 17 grams of powder in liquid and drink by mouth every day PRN (for constipation).

The bowel medications lacked resident-specific parameters on when to administer one versus the other.

The requirement for MARs to be accurate, including resident-specific parameters for PRN medications, was discussed with Staff 1 (Administrator, Marquis Piedmont), Staff 13 (Administrator), and Staff 15 (RN/ Clinical Support) on 03/16/23. They acknowledged the findings.

2. Resident 7 moved into the facility in 08/2022 with diagnoses including a history of stroke.

The resident's 03/01/23 through 03/13/23 MARs were reviewed, and identified the following:

* Chlorhexidine (medicated mouth wash) was prescribed to be used two times a day during teeth brushing. The MAR was blank on five occasions between 03/01 and 03/13/23.

During an interview on 03/15/23, Resident 7 stated s/he performed morning and evening hygiene (brushing teeth and using the mouth wash) independently. Resident 7 stated "they [caregivers] just ask me if I did it".

On 03/16/23, the MAR was discussed with Staff 13 (Administrator) and Staff 15 (RN/Clinical Support) and confirmed staff were initialing the MAR as having "administered" the treatment and left the MAR blank on several occasions.

The requirement for MARs to be accurate, including staff documenting that a treatment was being administered or not administered accurately, was discussed with Staff 13 and Staff 15 on 03/16/23. They acknowledged the findings.

1. Resident #6, #9 and #10 PRN parameters have been reviewed and clarified /updated as indicated.

Resident #7 oral Chlorhexidine to be assessed for self-admin of oral mouth wash.

Any resident unable to self-direct PRN medications or orders on the TAR for oral care may be impacted.

2. Med Techs and caregivers inserviced during caregiver/med tech meeting on 4/24/23 on need for PRN parameters and notify RN of completion of physician orders including skin treatments. Inservice included completion of oral care, per orders on TAR, to notify RN if self admin is requested.

3. RN will complete audit for PRN parameters, weekly x4 then monthly x 90 day, will audit TAR for omissions weekly x4, then monthly x90 days.

4. Administrator is responsible for ensuring compliance.

Based on interview and record review, it was determined the facility failed to ensure  a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications, and an evaluation was completed, at least quarterly, for residents who self-administered medications to assure ability to safely administer for 2 of 2 sampled residents (#s 1 and 5) who self-administered medications. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 06/2021 and had diagnoses including myocardial infarction and fibromyalgia.

A review of the resident's signed physician orders, the 08/01/2022 through 09/07/22 MARs, the 07/07/22 service plan and an interview with the resident on 09/08/22 revealed the following:

* there was no physician's order in the record for the resident to self-administer medications;

* there was no evaluation to assure the ability to safely self-administer medications;

* the facility medication technician's were marking the MAR on a daily basis that medications had been administered; and

* the resident stated staff were bringing medications to her room and leaving them on her kitchen counter for her to take independently.

During an interview on 09/08/22, Staff 1 (Administrator) and Staff 2 (Director of Nursing Services) confirmed MT's would punch medications for Resident 1 into a cup and leave the medications in the resident's room. A request for a physician's order to leave the prescription medications at the resident's bedside was made, however, no documentation was provided. Staff 2 stated she would discuss the resident's current medication regimen with Resident 1 and communicate with the physician on a plan to address the resident's needs and preferences and obtain physician's orders as appropriate.

2. Resident 5 was admitted to the facility in 07/2015 with diagnoses including chronic pain and diabetes mellitus.

During the acuity interview on 09/07/22, Resident 5 was identified as self-administering his/her medications.

A review of the resident's clinical record revealed there was no evaluation to assure the ability to safely self-administer medications.

The need to ensure the facility evaluated resident's ability to safely self-administer medications and had a corresponding physician's order was discussed with Staff 1 and Staff 2 on 09/08/22. They acknowledged the findings.

1. Resident #5 have self administration evaluations completed. Orders have been updated to reflect specific medications.

Resident #1 has had self med evaluation completed and orders requested from physician for specific medications.

2. RSC, Admin and RN will complete full audit of resident who have been identified to self administer medications and determine wich medications require new orders and wich residents require self-med evaluations, updates will be completed as indicated.

3. Going forward medications to be reviewed at all quarterly service plan evaluations.

4.RSC, RN and administrator will continue to monitor for self-medication preferences of residents with each quarterly evaluation and as needed for requests by resident.  

Based on interview and record review, it was determined the facility failed to ensure 1 of 1 sampled resident (#8) had a physician's or other legally-recognized practitioner's written order of approval for self-administration of prescription medications. This is a repeat citation. Findings include, but are not limited to:

Resident 8 was admitted to the facility in 01/2023 with diagnoses including osteoarthritis, low back pain, atrial fibrillation and major depression-single episode.

During the acuity interview, the facility reported Resident 8 self-administered his/her prescription medications. In an interview on 03/15/23, Resident 8 confirmed s/he self-administered his/her medications.

Staff 15 (RN/Clinical Support) confirmed the facility did not have a physician's written order of approval for Resident 8 to self-administer his/her prescription medications in an interview on 03/15/23.

The need to ensure the facility had a written physician's order of approval for residents who self-administer prescription medications was reviewed with Staff 1 (Administrator, Marquis Piedmont), Staff 13 (Administrator) and Staff 15 on 03/16/23. They acknowledged the lack of the required order.

1. RN and RSC obtained order from physician for resident #8 to self administer medications.

Any resident who self administers medications may be impacted by this citation.

2. Administrator will inservice Med Tech staff to verify self admin on profile, for all residents who wish to administer own meds.

3. Administrator will do random audits for residents who self administer medications weekly for 90 days

4. Administrator will be responsible for ensuring compliance.

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

Observations on 09/07/22, 09/08/22 and 09/09/22 revealed two quarter length side rails in the up position on the resident's bed.

During an interview with Staff 14 (CG) on 09/07/22 at 11:50 am, she stated the resident used the side rails during ADL care to assist with positioning.  

There was no RN, PT or OT assessment for use of the side rails including:

*The resident specifically requested or approved of the device;

*The facility had informed the individual of the risks and benefits associated with the device;

* The facility had documented other less restrictive alternatives evaluated prior to the use of the device; and

*Instructed caregivers on the correct use and precautions related to use of the device.

The need to complete all required elements related to use of an assistive device with restraining qualities was discussed with Staff 1 (Administrator) on 09/07/22 at 12:20 pm. Staff 1 stated the assessment was in process.

Based on observation, interview and record review, it was determined the facility failed to ensure an assessment was completed by the facility RN, PT, or OT prior to the use of a supportive device with restraining qualities for 2 of 3 (#s 2 and 4) sampled residents. Findings include, but are not limited to:

1.  Resident 4 was admitted to the facility in 03/2022 with diagnoses including diabetes.

The resident was identified to have siderails during the acuity interview.

During interview on 09/08/22, Staff 6 (CG) stated the resident had bilateral half siderails on his/her bed that were used for bed mobility.

There was no documented evidence an assessment had been completed by an RN, PT, or OT prior to use of the siderails.

The need to ensure supportive devices with restraining qualities were assessed prior to use was discussed with Staff 1 (Administrator) and Staff 2 (Director of nursing Services) on 09/09/22. They acknowledged the findings.

1. Resident 2's bed rails removed on 9/8/2022; service plan updated. Resident 4 bed rail assessment completed, orders requested from PT/OT evaluation, service plan updated.

2. Administrator and RSC will complete full audit of resident apartments, charts and orders to ensure that any side rails or restraining devices are evaluated.

3. Going forward evaluations will be completed with each quarterly evaluation, all new move-in's as appropriate and/or recommendation from PT/OT or physician.

4. RSC, RN and administrator will be responsible to ensure orders are in place for all residents.  

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 sampled staff completed their Pre-Service Infectious Disease Prevention training prior to beginning their job responsibilities. Findings include, but are not limited to:

There was no documented evidence Staff 7 (CG), hired 08/01/22, and Staff 11 (CG), hired 05/13/22, completed the Infectious Disease Prevention training that included the following:

*Transmission of communicable disease and infections;

*Policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease;

*Respiratory hygiene and coughing etiquette;

*Standard precautions;

*Hand hygiene;

*Use of personal protective equipment;

*Cleaning of physical environment;

*Disinfecting high-touch surfaces and equipment;

*Handling, storing, processing and transporting linens to prevent the spread of infection;

*Isolating and cohorting of residents during a disease outbreak; and

*Rights and responsibilities of employees to report disease outbreaks.  

The need to ensure all staff completed the required Infectious Disease Prevention training was discussed with Staff 1 (Administrator) on 09/08/22 at 1:50 pm. No additional information was provided.

1. Required infectious disease prevention training assigned to all staff, including staff #11 and 7, via Oregon Care Partners. Training will be completed 10/4/22.

2. The required training through Oregon Care Partners has been added to the new-hire required training.

3. Each new-hire will not begin floor training until required training is completed.

4. Administrator, BOM and RSC will be responsible to ensure the training is completed for all new hires going forward.

Based on interview and record review, it was determined the facility failed to ensure all employees completed training addressing the prevention, recognition, control and reporting of the spread of infectious disease, for 4 of 4 sampled newly-hired employees (#s 16, 18, 22 and 23) and all previously-hired employees. This is a repeat citation. Findings include, but are not limited to:

On 03/15/23 at 1:10 pm, Staff 13 (Administrator) was asked to provide documented evidence that four sampled newly-hired employees had completed the required pre-service Infectious Disease Prevention Training.

On 03/15/23 at 2:18 pm, Staff 13 reported the facility had not begun providing the required training for newly-hired or previously-hired employees. No further documentation was provided.

The need to ensure all employees completed the required Infectious Disease Prevention Training was reviewed with Staff 1 (Administrator, Marquis Piedmont), Staff 13 and Staff 15 (RN/Clinical Support) on 03/1/23. They acknowledged the findings.

1. Staff members #16, 18, 22, and 23 completed required infection control training. All previously hired employees also completed required infection control training.

2. RSC and Administrator have been in-serviced regarding requirement for pre-service infection control training for all employees

3. Administrator will complete audit for all current employees weekly x 4 weeks and then monthly for 90 days of all new employees for completion as well.

4. Administrator is responsible for auditing and ensuring trainings are complete.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted according to the Oregon Fire Code (OFC), fire and life safety instruction was provided to staff on alternate months and there was documented evidence of changes made to ensure the evacuation standard was being met. Findings include, but are not limited to:

On 09/07/22, review of facility fire drill and fire and life safety instruction records, from 03/2022 through 08/2022, and interviews with staff indicated the facility was not documenting:

* The escape route used;

* Problems encountered and comments related to residents who resisted or failed to participate in the drills;

* Number of occupants evacuated;

* Evidence the facility provided fire and life safety instruction to staff every other month as required;

* Evidence alternate routes were used during fire drills; and

* Evidence evacuation levels were being met.

Additionally there was no documented evidence of the changes the facility made to ensure the evacuation standard was met.

On 09/09/22, the need to ensure fire drills were documented with all required elements, fire and life safety instruction was provided to staff on alternate months and the facility documented the immediate changes they made to meet the evacuation standard was discussed with Staff 1 (Administrator). She acknowledged the findings.

1. Fire drill form updated to reflect additions of escape route used, 'problems encountered and comments related to residents who resisted or failed to participate in the drills, number of occupants evacuated, and detailed training topic to be identified.

2. The updated Fire Drill form will be used for each drill going forward, with the first drill using the updated form being completed on 10/4/2022.

3. Fire Drills and Fire & Life in-services conducted monthly.

4. Maintenance director is responsible for conducting all Fire Drill and Fire & Life Safety in-services. The administrator will ensure drills and in-services are conducted and are thourough and complete to maintain compliance with OAR.

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

On 03/13/23, facility fire drill and fire and life safety instruction records were requested from Staff 13 (Administrator). The facility provided documentation of a fire drill completed on 09/27/22.

On 03/15/22, any additional documentation was requested and Staff 13 provided a copy of a fire drill conducted on 03/15/23 (after the start of the re-visit survey), documentation of a meeting with staff and a new fire drill form, dated 10/25/22, and a copy of a "community meeting" with residents dated 12/28/22. The documents were reviewed and the following was identified:

* The documentation lacked evidence the facility had conducted fire drills every other month; and

* The documentation lacked evidence the facility provided fire and life safety instruction to staff on alternate months as required.

On 03/16/23 at 1:20 pm, the surveyors met with Staff 13, Staff 15 (RN/Clinical Support) and Staff 1 (Administrator, Marquis Piedmont) to discuss the documentation and the process of conducting fire drills. The facility had modified the fire drill form to include the required elements and had addressed resident evacuation needs on their service plans, however, fire drills and staff training had not been conducted on alternating months during the review period.

On 03/16/23 and 03/17/23, the need to ensure fire drills were conducted every other month and fire and life safety instruction was provided to staff on alternate months was discussed with Staff 13 and Staff 15. They acknowledged the findings.

1. Facility has completed fire drill and life safety education in month of April 2023.

Maintenance Director provided Administrator with dates for year of 2023 fire drills and fire and life safety education. Fire drills will be scheduled in May, July, September, and November. Fire and Life safety eduations will be scheduled to occur in April, June, August, October, and Decemeber.

2. Maintenance Director will continue to utilize updated fire drill form.

3. Administrator will complete monthly audits to ensure drills or education were or are scheduled to be completed as required

4. Maintenance director is responsible for ensuring compliance

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements for residents were met. Findings include, but are not limited to:

Fire drill records from 03/2022 through 08/2022 were reviewed on 09/07/22 with Staff 3 (Maintenance Assistant). The facility lacked documentation of the following required elements:

* Evidence residents were being re-instructed on fire and life safety procedures, including designated meeting places inside or outside of the building in the event of an actual fire at least annually.

The need to have documented evidence of all fire and life safety training components was discussed with Staff 1 (Administrator) and Staff 2 (Director of Nursing Services) on 09/09/22. They acknowledged the findings.

1. Full Facility training scheduled for 10/20/2022 for all residents to attend.

2. Fire drills and evacuation protocol are reviewed at each service plan meeting; going forward will discuss in detail.

3. Quarterly with each service plan; and scheduled annually with disaster drills.

4. RSC, RN and administrator will be responsible to review evacuation and fire drill protocol with each service plan going forward; the maintenance director will be responsible to hold the annual fire drill.

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 C 260, C 270, C 303, C 310, C 325, C 370, C 420, C 613, C 630 and C 655.

1. Plan of correction to be implemented by Administrator, RN, and RSC and followed by all staff as indicated throughout this document and per letter of agreeement with the state.

4. Administrator is responsible for ensuring compliance.

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

The interior of the facility was toured with Staff 3 (Maintenance Assistant) on 09/09/22. The following areas needed cleaning or repair:

* Several bench seats in hallways on first and second floors had spots or stains;

* The door jamb and exit door at the end of the hallway, near room 115, had exposed wood, gouges and black scuff marks; and

* The elevator walls had multiple areas of peeling laminate and gouges.

The areas needing cleaning or repair were discussed with Staff 1 (Administrator) and Staff 3 on 09/09/22. They acknowledged the findings.

1. Bench seats cleaned, door jamb and exit door repaired. Elevator wall repair has been requested.

2. Items will be repaired as needed, administrator and maintenance director will perform monthly walk-throughs for overview of facility.

3. Monthly as per TELS by maintenance director, and spot checks from administrator.  

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

The interior of the facility was toured with Staff 3 (Maintenance Assistant) on 03/15/23. The following areas needed cleaning or repair:

* Several bench seats in hallways on first and second floors had spots or stains;

* The carpet in the halls, lobby, and Room 115 had multiple stains;

* Multiple exit doors had gouges and chipped paint; and

* The elevator walls had multiple areas of peeling laminate and gouges.

The areas needing cleaning or repair were discussed with Staff 13 (Administrator) and Staff 3 on 03/15/23. They acknowledged the findings.

1. Apartment 115's carpets were cleaned. Benches in hallway were cleaned and ensured to be free of stains and spots. Exit doors were painted and elevator walls were replaced. Maintenance director conducting bi-weekly facility walk throughs to determine if door jams need to be repaired/painted. Housekeeping conducting bi-weekly facility walk through to determine if carpets need to be cleaned and are cleaning as needed. Maintenance Director will schedule for elevator to be repaired as needed.

2. Maintenance Director and Housekeeping director will continue to complete audits listed above biweekly, ongoing.

3. Administrator will complete audits biweekly for 90 days.

4. Administrator is responsible for ensuring compliance.

Based on observation and interview, it was determined the facility failed to ensure washers had a minimum rinse temperature of 140 degrees Fahrenheit or a chemical disinfectant was used when washing residents' soiled linens and clothing. Findings include, but are not limited to:

During a tour of the facility on 09/07/22, washers utilized by staff to wash soiled linens and clothing were observed in two laundry rooms. The machines had general temperature settings but no device to determine the water temperature. Signs were visible on the cabinets in the laundry room instructing staff to "use resident detergent" for washing laundry. Containers of unmarked laundry detergent were observed in the laundry rooms and in the housekeeping supply room on the second floor, but did not contain a disinfecting agent.

Staff 12 (MT) was interviewed on 09/07/22 about the soiled linen handling process and stated soiled clothing or linens were placed in plastic bags, care staff transported them to the laundry room and washed soiled linens separately from resident clothing, using the resident's own detergent. If the resident had no detergent, staff used the facility detergent.

Staff  1 (Administrator) was interviewed on 09/08/22 about the soiled linen handling process and provided a copy of the facility policy for soil linen handling, which included instructions to use a disinfectant. The need to ensure a disinfectant was used when washing soiled linens, unless the minimum water temperature could be provided, was discussed with Staff 1 on 09/08/22 and 09/09/22. No additional information was provided.

1. Disinfectant was purchased for soiled linen cleaning; training provided for staff on the soiled linen policy.

2. The soiled linen policy will be readily available in the laundry rooms, disinfectant will be available in each laundry room for soiled linens as needed.

3. The housekeeping manager will monitor disinfectant supply available. The soiled linen policy will be reviewed yearly and as needed.

4. Housekeeping director will manage disinfectant supply with routine supply orders. Administrator will monitor.

Based on observation and interview, it was determined the facility failed to ensure washers had a minimum rinse temperature of 140 degrees Fahrenheit or a chemical disinfectant was used when washing residents' soiled linens and clothing. This is a repeat citation. Findings include, but are not limited to:

During a tour of the facility on 03/13/23, washers used by staff to wash soiled linens and clothing were observed in two laundry rooms. The machines had general temperature settings but no device to determine the water temperature.

During an interview on 03/13/23, Staff 20 (Director of Housekeeping) confirmed there was no method of ensuring the minimum rinse temperature of 140 degrees Fahrenheit, and that the facility was not using a chemical disinfectant for residents' soiled laundry.

The need to ensure a disinfectant was used when washing soiled linens unless the minimum rinse temperature was 140 degrees Fahrenheit was discussed with Staff 13 (Administrator) on 03/13/23. She acknowledged the findings.

1. Housekeeping Director obtained disinfectant for facility and is ordering as needed. Instructions hung in laundry room for staff to refer to when adding disinfectant to laundry load to ensure adequate amount of disinfectant is used per load.

2. Product has been purchased and will continue to be ordered as needed

3. Administrator will complete audit 1x weekly for 90 days to ensure facility has disinfectant on hand.

4. Administrator is responsible for ensuring compliance.

Based on observation and interview, it was determined the facility failed to ensure covers, grates, or screens of wall heaters and associated heating elements did not exceed 120 degrees Fahrenheit (F) when they are installed in locations that are subject to incidental contact by individuals or with combustible material. Findings include, but are not limited to:

During a tour of the building with Staff 3 (Maintenance Assistant) on 09/08/22, wall-mounted cadet heaters were observed in multiple resident one-bedroom units. The heaters were located where residents could come into incidental contact with them. When a heater was turned on, the metal surface, measured with the surveyor's digital thermometer, was found to exceed 150 degrees F.

The wall heaters were installed in the following areas:

* Rooms 101, 114, 124, 125, 131, 201, 214, 228, 229 and 235; and

* The foyer at the main front entrance to the lobby.

The heaters were discussed with Staff 3 on 09/08/22 and the heater knobs were removed to disable use of the heaters until a long term plan could be determined by the facility.

The need to ensure heating surfaces did not exceed 120 degrees F when located in areas of incidental contact was discussed with Staff 1 (Administrator) on 09/09/22. She acknowledged the findings.

1. Thermometer knobs were immediately removed as a temporary fix, and will remain in place until long term solution is installed.

2. The maintenance director and the administrator have requested bids for cages to prevent incidental contact with heaters.

3. This will be a need once, however, will need to be inspected quarterly to ensure that the cages/screens have not been tampered with.

4. The maintenance director will be responsible to obtain the screens and install, the administrator will inspect the apartments affected and ensure the screens have been installed.  

Based on observation and interview, it was determined the facility failed to ensure exit doors were equipped with an alarming device or other acceptable system to provide security and to alert staff when residents exited the building. Findings include, but are not limited to:

The building was toured on 09/08/22. Residents were observed exiting the building multiple times through various doors including the front lobby doors and the side door near room 115. Two of the exit doors observed at the end of hallways and near stair well exits had door alarms mounted and visible on the wall. Care staff interviewed verified the audible message would sound on their walkie talkie, alerting staff of the location of the opened door. The door near room 115, however, did not have a door alarm visible on the wall and no audible alert was heard when the door was opened. Another exit door had an alarm installed over the top of the door, however, there was no audible sound and staff were unable to verify if the alarm was working. During the facility tour with Staff  3 (Maintenance Assistant) on 09/09/22, the need to ensure all exit doors had working alarms or other means to alert staff when resident's exited the building was discussed. No further information was provided.

On 09/09/22, the need to ensure all exit doors were equipped with an alarming device or other acceptable system was discussed with Staff 1 (Administrator). No further information was provided.

1. Door alarms purchased and installed by 9/30/22

2. During monthly maintenance inspections door alarms will be monitored and tested for function.

3. Monthly during inspections as guided by TELS.

4. Maintenance director will monitor and manage monthly and document in the TELS system. Administrator will verify completion of monthly inspections.

Based on observation and interview, it was determined the facility failed to ensure exit doors were equipped with an alarming device or other acceptable system to provide security and to alert staff when residents exited the building. This is a repeat citation. Findings include, but are not limited to:

The building was toured on 03/13/23. Observation confirmed that all exit doors had a door alarm visible. During an interview with Staff 21 (MA) near the exit door near room 115, she stated that all exit doors were equipped to send an alarm to staff walkie talkies when residents exited. However, when the exit door near room 115 was opened, no audible alert was heard from Staff 21's walkie talkie.

During the facility tour with Staff  3 (Maintenance Assistant) on 03/13/23, the need to ensure all exit doors had working alarms or other means to alert staff when residents exited the building was discussed. He acknowledged the findings.

The need to ensure all exit doors were equipped with an alarming device or other acceptable system was discussed with Staff 13 (Administrator) on 03/13/23. She acknowledged the findings.

1. Maintenance Director is completing weekly audits to ensure doors are functioning and sounding properly.

2. Weekly audits will continue to ensure proper functioning, if needed alarm will repaired or replaced

3. Administrator will audit weekly to ensure doors are functioning and sounding properly.

4. Administrator is responsible for ensuring compliance