The findings of the re-licensure survey, conducted 8/9/21 to 8/11/21, 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

A situation was identified where there was a failure of the facility to comply with the Department's rules that was likely to cause residents serious harm. An immediate plan of correction was requested in the following area:

OAR 411-054-0045 (1)(f)(B) RN Delegation and Teaching

The facility put an immediate plan of correction in place during the survey and the situation was abated.

The findings of the first re-visit to the re-licensure survey of 08/11/21, conducted 11/29/21 through 12/01/21, 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.

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  8/13/21, conducted 03/02/22 through 03/03/22 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 the OARs 411 Division 004 Home and Community Based Services Regulations.

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

On 8/9/21 at 2:00 pm, the facility's kitchen was observed to need cleaning and repair in the following areas:

a. Food spills, splatters, debris, dirt, and black matter was observed on or underneath the following:

* The perimeter of the floors and baseboards in the kitchen and dry food storage area;

* Underneath and behind the ice machine and dry storage shelves;

* Pipes and floor underneath the stove;

* Wall and pipes behind the three compartment-sink and dish machine; and

* Ceiling vents and the ventilation hood above the dish machine.

b. The following areas needed repair:

* Caulking in dish-machine area and around the three-compartment sink;

* Caulking around the back splash in the food prep area;

* Broken plastic corner guard along wall of the kitchen office; and

* Chipped paint and wood on the kitchen doors and frames.

The areas that required cleaning and repair were observed and discussed with Staff 1 (ED) Staff 6 (Dietary Manager) and Staff 5 (Maintenance Director) on 8/10/21. The findings were acknowledged.

1.Deep Clean provided by Healthcare Services Group or designee will conduct a deep clean of Kitchen in following areas: The perimeter of the floors and baseboards in the kitchen and dry food storage area; Underneath and behind the ice machine and dry storage shelves; Pipes and floor underneath the stove; Wall and pipes behind the three compartment-sink and dish machine; and Ceiling vents and the ventilation hood above the dish machine. Areas needing repair will be done by Maintenance as follows Caulking in dish-machine area and around the three-compartment sink; Caulking around the back splash in the food prep area; Broken plastic corner guard along wall of the kitchen office; and Chipped paint and wood on the kitchen doors and frames. 2. HealthCare Services Group Lead Educated on proper kitchen sanitation. 3. Once completed ED and Maintenance will do monthly walk thorough of the Kitchen to look for cleanliness and repairs needed. any area will be completed as needed 4. Maintenance will oversee all is completed and report back to ED.

Based on observation, interview and record review, it was determined the facility failed to provide a social and recreational activity program based upon individual and group interests, physical, mental and psychosocial needs of the residents. Findings include, but are not limited to:

During the survey, 8/9/21 through 8/11/21 the following activities were on the calendar for the assisted living facility:  

*8/9/21 National Book Lovers Day;

*8/10/21 Bingo at 1:00 pm and Sharing recipes & snacking out at 3:00 pm; and

*8/11/21 9:00 am an outing to the store, 10:00 am Walking Club, 1:30 pm another outing to the store and a card game at 3:00 pm.

On 8/9/21 and 8/10/21 an independently organized group of residents were observed to play several card games between 2:00 pm and 3:00 pm.  The scheduled activities on 8/10/21 and 8/11/21 were not observed.

In an interview with the resident council president on 8/10/21 at 10:15 am, s/he stated there were not enough activities and no activity director.  S/he stated there were individuals who got together to play cards, puzzles were set out on tables and s/he wanted to organize a craft activity.  The resident also stated there was a volunteer who came in to call bingo.

In an interview on 8/10/21, Resident 2 disclosed there was no activity program. Resident 2 stated, "there had not been daily activities or outings for quite some time, and we need activities." "Even a walk outside would be nice, we need something."

During an interview with Staff 1 (Executive Director) on 8/10/21 at 3:00 pm, he stated the activity director had been "let go" as well as the employee who was driving for the resident activities. There was a volunteer who assisted with bingo and several residents initiated their own card games.

On 8/10/21, the failure to provide an activity program based on individual and group needs was reviewed with Staff 1 (ED). He acknowledged the findings.

1.Resident 2 was interviewed on what actvities they would like and service plan updated to reflect. Hire on an Activities/life enrichment coordinator to oversee a Resident Services: Activities program that has social and recreational activities that are based on individual and group interests. This Activities director/ Life enrichment coordinator will also take webinar via Oregon Care partners called Life Enrichment.

2.ED or designee will oversee activates are completed with monthly meetings on how and what is needed for Activates/Life enrichment Coordinator to complete their job.

3. Oversite from will be completed monthly with resident interviews via care conferences.

4.ED to over see  

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (# 4) whose move in evaluation was reviewed.  Findings include, but are not limited to:

Resident 4 was admitted to the facility in 4/2021 with diagnoses including major depressive disorder and schizophrenia.

Resident 4's move-in evaluation failed to address the following:

* Mental health issues, including history of treatment, description of how the resident demonstrated behaviors and effective non-drug interventions;

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

* Pain: pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort;

* Recent Losses;

* Unsuccessful prior placements; and

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

The failure to address all required elements in the move-in evaluation was shared with Staff 1 (ED) on 8/10/21 at 3:00 pm.  No additional information was provided.

1.Resident 4's evaluation has been reviewed and updated as necessary Action taken to correct violation is to add missing elements to the move-in evaluation to include Interests, hobbies, social, leisure activities. Spiritual, cultural preferences & traditions. History of treatment; and Effective non-drug interventions. Pain: pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort; Personality: including how the person copes with change or challenging situations fluid preferences List of treatments: type, frequency and level of assistance needed. Review of risk indicators including: Complex medication regimen; Recent losses; Unsuccessful prior placements; Environmental factors that impact the resident's behavior including, but not limited to: noise, lighting, room temperature.

2.The system will be corrected by having the evaluation rewritten to add elements above that were missing and update current residents on upcoming quarterly assessment.

3. Area will be reevaluated with each move-in and with upcoming quarterly evaluation

4. ED and/or RN is responsible to make sure correction are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (# 7) whose move-in evaluation was reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 7 was admitted to the facility in 11/2021 with diagnoses including cellulitis, depression and low back pain.  

Resident 7's move-in evaluation failed to address the following:

* Customary routines: sleeping, eating, bathing;

* Social activities;

* Cultural preferences;

* List of current diagnosis;

* List of medications and PRN use;

* Mental health issues including history of treatment and effective non-drug interventions;

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

* Clear direction on if the facility manages the medication or if the resident manages their own medications;

* Pain relating to pharmaceutical and non-pharmaceutical interventions;

* Fall risk or history of falls;

* Unexplained weight loss or gain;

* Unsuccessful prior placements; and

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

The failure to address all required elements in the move-in evaluation was shared with Staff 1 (ED) and Staff 14 (RN) on 12/01/21. They acknowledged the findings.

1.) Resident #7's move in eval was completed to include customary routines, social activities, cultural preferences, list of current diagnosis, list of medication and PRN use, mental health issues including history of treatment and effective non-drug interventions, personality including how the person copes with change or challenging situations, facility manages medications, pain relating to pharmaceutical and non pharmaceutical interventions, Fall risk, unexpected weight gain or loss, unsucsessful prior placements, and environmental factors which impact behavior, including but not limited to noise lighting, temperature.

2.) Audit will be conducted of  records to ensure that quarterly evaluations and move in evaluations are current.

    Create schedule of upcoming evaluations due to correlate with care conference schedule.

     Audit move in evals and scheduled quarterly evals

weekly x6 weeks then reevaluate process

3.) Audit will be conducted weekly x 6 weeks then reevaluate.

4.) Audits to be conducted by DNS/designee.

2. Resident 1 was admitted to the facility in 3/2020 with diagnoses including major depressive disorder and a bladder obstruction.  

Review of Resident 1's service plan, interviews with Staff 8 (MT/CG) and Staff 11 (CG) and observations of the resident and his/her apartment indicated the service plan was not reflective of, did not provide clear instructions to staff or was not followed in the following areas:

* Smoking;

* Monthly weights;

* Catheter cleaning;

* Home Health; and

* Behavioral expressions.

Resident 1's service plan was reviewed and discussed with Staff 1 (ED) and Staff 2 (RN) on 8/10/21. No additional information was provided.

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

1. Review of Residents 2's service plan, dated 6/29/21 and interviews with staff , indicated the service plan was not reflective of the resident's current health status and lacked clear direction to staff in the following areas:

* Increased leg pain;

* Behaviors related to pain management;

* Emergency room visits; and

* Use of outside services.

The need to ensure resident service plans were reflective and provided directions to staff was discussed with Staff 1 (ED) on 8/11/21. He acknowledged the findings.

1.Residenet 1's and 2's service plan were reviewed and updated as needed.

2.RCC and RN have been educated on person centered service plans via Relias. Service plans will be updated to give clear instructions to staff to care for residents that is person centered. This includes but not limited to change in condition short term, significant, and needs. this also to include but not limit smoking, monthly weights, catheter cleaning, home health/outside providers, leg pain, ER visits, and Behaviors.

3. Facility will perform weekly service plan audits time 5 weeks then as needed to oversee and ensure elements are being captured and added to service plan

4. ED and RCC responsible

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current health status and care needs, and provided clear direction to staff regarding the delivery of services for 2 of 4 sampled residents (#s 8 and 9) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Review of Residents 9's service plan, dated 11/18/21 and interviews with staff,  indicated the service plan was not reflective of the resident's current health status and lacked clear direction to staff in the following areas:

* Oxygen use and maintenance;

* Electric wheelchair;

* Assistance with compression stockings;

* Sleeping routine; and

* Meal escorts.

The need to ensure resident service plans were reflective and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 14 (RN) on 12/01/21. They acknowledged the findings.

2. Review of Residents 8's service plan, dated 11/24/21, observations and interviews with staff, indicated the service plan was not reflective of the resident's current health status and lacked clear direction to staff in the following area:

* Toileting and incontinence care.

The need to ensure resident service plans were reflective and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 14 (RN) on 12/01/21. They acknowledged the findings.

1.) Resident #9's service plan was updated to include oxygen use and maintenance, electric wheelchair, assistance with compression stockings, sleeping routine and meal escorts.

    Resident #8's service plan was updated to reflect current toileting and incontinence care.

2.) Audit service plans to ensure accuracy; update as needed.

    Educate RCC on correct service plan maintenance to ensure service plan matches resident needs.

    Audit service plans to ensure accuracy and completeness.

3.) Audits will be conducted weekly X 6 weeks then process reevaluated for need of continued monitoring.

4.) Audits will be conducted by DNS or designee.

Based on interview and record review, it was determined the facility failed to ensure a service planning team consisting of the resident, the resident's legal representative, if applicable, any person of the resident's choice, the facility administrator or designee and at least one other staff person who is familiar with, or who is going to provide services to the resident, for 2 of 2 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to.

During survey, service plans for Residents 1 and 2 were reviewed. There was no documented evidence of the involvement of a service planning team for either of the residents' service plans.

The need for service plans to be developed by a Service Planning Team was discussed with Staff 1 (ED) and Staff 2 (RN) on 8/10/21 at 3:00 pm.  Staff acknowledged the findings.  

1.Residents 1 and 2 where reviewed and service plan updated to reflect.

2.Correction of system is to have documented evidence of service planning team to include Service Planning Team that consists of the resident, the resident's legal representative, if applicable, any person of the resident's choice, the facility administrator or designee and at least one other staff person who is familiar with, or who is going to provide services to the resident. Involved family members and case managers must be notified in advance of the service planning meeting.

3.Area will be monitored weekly for 5 weeks then monthly

4.RCC, RN, and/or ED be responsible     

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that consisted of the resident, the resident's legal representative if applicable, any person of the residents choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services for 4 of 4 sampled residents (#s 5, 6, 8 and 9). This is a repeat citation. Findings include, but are not limited to:

Residents 5, 6, 8 and 9's most recent service plans lacked evidence that a Service Planning Team reviewed and participated in the development of the service plans.

The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (ED) and Staff 14 (RN) on 12/01/21. They acknowledged the findings.

1.) Residents #5,6,8,and 9's service plans were reviewed by service planning team, including residents and families as willing; and updated as needed.

2.) Audit service plans for Service planning team involvement, to include, but not limited to: resident/family if willing, administrator or designee, at least one staff person familiar with or provided service for resident.

    Educate RCC, administrator on need for service plan team review.

    Audit service plan to ensure team review  with quarterly care conference, with admission and with change of condition

3.) Initial audit will happen prior to date of compliance.

Ongoing audit will occur weekly for 6 weeks then reevaluation of system complete to determine ongoing audit.

4.) Audits will be performed by RCC, administrator and/or designee.

2.  Resident 1 was admitted to the facility in 3/2020 with diagnoses including major depressive disorder and a bladder obstruction.

a.  The resident's current evaluation dated 8/4/21, service plan dated 8/8/21, 5/7/21 through 8/9/21 progress notes, emergency department visit summaries and incident reports were reviewed.  Resident 1 experienced multiple short-term changes without documented monitoring at least weekly until resolution and lacked resident specific directions to staff in the following areas:

* Catheter placement;

* Evidence of smoking in the apartment;

* Visits to the emergency room;

* A skin injury; and

* Weight loss.

b.  Resident 1 was noted to be at risk for falls and the current service plan identified multiple fall interventions to help minimize the risk of falls including checking on the resident every two hours.

Progress notes reviewed from 6/2/21 through 8/6/21 noted seven falls one of which was an injury fall that required sutures.  

The incident reports were completed and lacked documented evidence the service planned interventions were reviewed to determine if they were in place at the time of the fall, effective or continued to be appropriate.

The need to ensure short term changes of condition had documentation to reflect monitoring to resolution at least weekly, determining interventions or actions required and/or monitoring interventions to determine if they continued to be effective was discussed with Staff 1 (ED) and Staff 2 (RN) on 8/10/21. Staff acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to determine and document what action or intervention was needed for residents, communicate the interventions to staff, ensure interventions were resident-specific and monitor residents consistent with their evaluated needs and service plan, for 2 of 2 sampled residents (#s 1 and 2) who had documented short term changes of condition. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in in 3/2020 with diagnoses including Congestive Heart Failure and Type 2 Diabetes.

Resident 2's clinical record and progress notes, reviewed from 5/1/21 through 8/9/21, revealed the following:

a. Resident 2 was sent to the emergency room seven times between 5/2/21 and 8/5/21 for increased pain, edema, and falls. Documentation indicated the facility was monitoring after the resident returned from the hospital; however, there was no documented evidence the changes of condition were monitored until resolution.

b. The resident was put on alert charting for behaviors on 7/11/21. There was no description of the behaviors the resident was exhibiting or what behaviors staff should be aware of. There was no documented evidence the facility determined and documented what resident specific interventions were necessary for Residents 2's behaviors, communicated those interventions to staff or monitored the interventions at least weekly through resolution.

c. Resident 2 experienced three falls between 8/1/21 and 8/5/21. The facility failed to complete investigations and determine if service-planned interventions dated 6/29/21 were implemented, were effective or if new interventions were needed following each fall.

The need to ensure the facility consistently evaluated the resident, determined actions or interventions specific to each change of condition, monitored interventions for effectiveness and developed new ones if needed and updated the service plan was reviewed with Staff 1 (ED) and Staff 2 (RN) on 8/11/21. They acknowledged the findings.

1.Resident # 2 no further changes of condition; pain and edema have been controlled with medications. Last fall 8/20 alert charting dc'd 8/31 no injuries behaviors noted 7/11/2021 have since been resolved.

Resident #1 has had Foley Catheter in place and is being by home health. There have not been any more incidents of smoking in apartment and have not had any ER visits since 8/9/2021 Skin injury to chest resolved and skin to be monitored weekly with shower. Registered dietitian to review remotely & recommend nutritionally enhanced meals. Weight will be monitor with showers and review by RN and RCC.

2.Changes in condition to be identified by staff communication, documentation, changed orders, and rounds by RN. Changes Identified will then be evaluated by RN. Resident will be place on alert charting through resolution. Service plans updated as needed. RN, RCC, and Care staff educated on above procedures and deification of short term and significant changes of condition.  

3.Documentation, changes of condition, resolutions will be evaluated weekly and as needed.

4.RN, RCC, and ED to monitor.

Based on interview and record review, it was determined the facility failed to determine and document what action or intervention was needed for the resident, communicate the interventions to staff, ensure interventions were resident-specific and monitor the resident consistent with their evaluated needs and service plan, for 1 of 2 sampled residents (# 9) who had documented short term changes of condition. This is a repeat citation. Findings include, but are not limited to:

Resident 9 was admitted to the facility in 03/2021 with diagnoses including cancer, emphysema and chronic obstructive pulmonary disease.

The resident's current service plan dated 11/18/21, 10/14/21 through 11/28/21 progress notes, hospital discharge summaries, 10/25/21 through 11/22/21 outside provider notes and incident reports were reviewed. Resident 9 experienced multiple short-term changes without documented monitoring at least weekly until resolution, lacked resident specific interventions, and lacked directions to staff in the following areas:

* Return from the hospital;

* Medication changes;

* Diagnosis the cancer had metastasized;  

* Edema;

* An episode of confusion; and

* Two falls.

The need to ensure short term changes of condition had documentation to reflect monitoring to resolution at least weekly, determining interventions or actions required and/or monitoring interventions to determine if they continued to be effective was discussed with Staff 1 (ED) and Staff 14 (RN) on 12/01/21. They acknowledged the findings.  

1.) Resident number 9's service plan was updated to reflect residents current condition, including any short-term changes.

2.) Staff to be educated bu DNS on how to identify change of condion, changes in behavior or falls and who to notify.

   Audit for short term changes of condition using clinical meeting tool, dashboard, 24 hour report, new orders and alerts and update service plan as needed.

3.) Audit of short term changes to be conducted M-F in clinical meeting for 6 weeks the re-evaluate

4,) The DNS or designee will be responsible for these audits

Based on observation, interview and record review, it was determined the facility failed to assess 1 of 1 sampled resident (# 1) who experienced a significant change of condition related to the placement of a catheter.  Findings include, but are not limited to:

Review of Resident 1's progress notes dated 5/7/21 noted the resident was unable to urinate and was experiencing pain to the groin area and s/he was sent to the emergency department.  On 5/9/21 the resident returned to the facility and was noted to have a catheter bag.  Further progress notes revealed:

* 5/20/21 a new catheter was put in place;

* 5/29/21 the resident was sent to the hospital related to genital pain;

* 5/31/21 the resident had returned from the hospital with a "Foley Catheter problem".

During an observation on 8/10/21 at 8:45 am, Staff 11 (CG) emptied the contents of the resident leg bag. Staff 11 stated she "believed" home health came to visit the resident regarding the catheter and she checked on the resident multiple times during the day and would offer to empty the catheter bag as needed.

Resident 1 had a significant change of condition related to the insertion of a catheter. There was no documented evidence the facility RN had completed an assessment and documented findings, resident status and interventions made as a result of the assessment.

The lack of RN assessment specific to documenting findings, the resident status and interventions made as a result of the assessment was discussed with Staff 1 (ED) and Staff 2 (RN).  No additional information was provided.

1.Residnet 1 had a complete assessment conducted by RN and is being seen by Home Health Nurse.

2. RN educated regarding significant Change of Condition assessments of residents based on significant change of condition ensuring assessments identifies resident findings, statues, and service plan updates as well as Home Health Documentation changes.

3. Care documentation will be reviewed by RN, RCC, and/or ED Monday-Friday follow up as needed and completed same day.

4. RN, RCC, and ED to monitor.

Based on interview and record review, it was determined the facility failed to ensure the delegation and supervision of special tasks of nursing care was completed in accordance with the Oregon State Board of Nursing (OSBN) Division 47 Rules, for 1 of 1 sampled resident (#2) who received insulin injections by unlicensed facility staff. Resident 2 was at risk for harm related to potential medical complications from the lack of an RN assessment of the resident's condition, unlicensed staff training and supervision to ensure safety and accuracy of insulin administration. Findings include, but are not limited to:

During the acuity interview on 8/9/21, Staff 2 (RN) stated she was the facility RN for the ALF and the MCC license and the delegating nurse for the facility. Resident 2 resided in the ALF and was identified to receive routine insulin daily by non-licensed staff.

Review of Resident 2's record revealed no documented evidence the resident's condition remained stable and predictable, or determination of frequency resident should be reassessed, including rationale.

During an interview and observation of Staff 2's (RN) delegation binder on 8/11/21 at 10:30 am, there was no documented evidence any of the non-licensed staff had been delegated by an RN, including:

* Rationale why the task could be safely delegated;

* Skills, abilities and willingness of non-licensed staff to complete the task;

* Task was taught to the non-licensed staff and they were competent to safely perform task;

* Written instructions available including risks, side effects, response, and risk factors;

* Non-licensed staff were taught the task was client specific and not transferable;

* Determination of frequency the non-licensed staff should be supervised and reevaluated, including rationale; and

* RN takes responsibility for delegating task and ensures supervision will occur for as long as RN was supervising performance.

Staff 1 (Executive Director) and Staff 2 (RN) noted there were three residents residing in the ALF and two residents residing in the MCC that required insulin administration. In addition, 12 staff had the potential to administer insulin and would require delegation.  

On 8/11/21, the need to ensure all staff who administered insulin injections were appropriately delegated and supervised in accordance with OSBN Administrative Rules was discussed with Staff 1 (ED) and Staff 2 (RN). They acknowledged the above findings. The surveyor requested an immediate plan to ensure insulin was administered by licensed or delegated staff in accordance with OSBN Division 47 Rules.

On 8/11/21 at 3:00 pm, a plan to address the delegation issue which included licensed staff administering insulin until delegation was completed was accepted and the situation was abated.  

We have Identified the need for redelegation/retraining on the following residents that have insulin needing delegation from RN.

Using CBC Delegation Review: Division 47 - OSBN Nurse Practice Act Standards for Community-Based Care Registered Nurse Delegation to redelegate/retrain to each resident identified above until each med-tech has been redelgated/retrained the shift they are and will work. Starting afternoon 8/11/2021 until completed Sandra RN will be conducting redelgated/Retraining. Licensed nurse will do insulin for residents until delegation is completed.

New staff member that are hired will also use CBC Delegation Review: Division 47 - OSBN Nurse Practice Act Standards for Community-Based Care Registered Nurse Delegation CBC Delegation Review to do initial and continuing RN delegation

New Residents will use CBC Delegation Review: Division 47 - OSBN Nurse Practice Act Standards for Community-Based Care Registered Nurse Delegation or internal form to document and determine if delegation for staff is needed.

*If an internal form is created for RN delegation is will cover all components presented in CBC Delegation Review: Division 47 - OSBN Nurse Practice Act Standards for Community-Based Care Registered Nurse Delegation. Delegation will be audited monthly for 3 months and every 60 days for 120 day residents will be reviewed and reevaluated and document on with information needed that is provided in CBC Delegation Review: Division 47 - OSBN Nurse Practice Act Standards for Community-Based Care Registered Nurse Delegation at this time RN will determine if resident is still stable and safe to continue to have a delegated task to a non-licensed staff. Then every 60 days but no more than every 180 days residents will be reevaluated and document on with information needed that is provided in CBC Delegation Review: Division 47 - OSBN Nurse Practice Act Standards for Community-Based Care Registered Nurse Delegation or with internal form with all componates laid out in CBC Delegation Review: Division 47 - OSBN Nurse Practice Act Standards for Community-Based Care Registered Nurse Delegation    at this time RN will determine if resident is still stable and safe to continue to have a delegated task to a non-licensed staff.  

2.  Progress notes dated 5/9/21 noted Resident 1 returned to the facility with a catheter.

During an observation on 8/10/21 at 8:45 am, Staff 11 (CG) emptied the contents of the resident's leg bag.  Staff 11 stated she "believed" home health came to visit the resident regarding the catheter.   

Resident 1's current evaluation, service plan and progress notes were reviewed and there was no indication home health had been in the facility or was involved in catheter care for the resident.

During an interview on 8/10/21 Staff 1 (ED) stated HH had recently been in to visit the resident. The surveyor requested documentation related to onsite facility visits and evidence of coordination of care.

Documentation was received on 8/10/21 and noted Resident 1 had been working with HH since 5/26/21.  Between 5/26/21 and 8/9/21 the resident had been seen by HH RN, social worker, speech therapy and physical therapy. There had been no documented evidence onsite visits and pertinent recommendations had been communicated to the facility nor evidence the facility had attempted to coordinate care with the HH agency.

Resident 1's lack of documented evidence notification by an outside service provider was in place to ensure coordination of care was discussed with Staff 1 and Staff 2 (RN) on 8/10/21.  Staff 1 and 2 acknowledged the finding.

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

1. During the entrance conference on 8/9/21, Resident 2 was identified as receiving outside provider services.

A progress note dated 6/20/21 revealed Resident 2 received Home Health services from an off-site provider. Resident 2's clinical records identified the lack of documentation regarding services that had been or were still being provided by the outside service providers.

The need to ensure the facility had a system for coordinating with outside providers was discussed with Staff 1 (ED), Staff 2 (RN), and Staff 3 (RCC) on 8/11/21. They acknowledged the findings.

1.Resident 1 and 2 where reviewed and updated as needed. Med-tech trained on filling out a progress note after home health visits.

2. Contacted Home health and requested notes on resident home health system and RN to update evaluation, RCC or designee to update service plan.

3 Evaluation of Home Health services will be completed weekly  

4. RN to complete and monitor.

Based on interview and record review, it was determined the facility failed to ensure staff are informed of new interventions made by outside providers, the service plan is adjusted if necessary, and reporting protocols are in place to ensure the continuity of care, for 1 of 1 sampled resident (# 9) who received outside services. This is a repeat citation. Findings include, but are not limited to:

During the entrance conference on 11/29/21, Resident 9 was identified as receiving outside provider services. The resident's current service plan dated 11/18/21, 10/14/21 through 11/28/21 progress notes, and 10/25/21 through 11/22/21 outside provider notes were reviewed.

The following outside provider recommendations were made:

* 10/28/21 - staff to assist the resident with donning and doffing compression stockings.

* 10/29/21 - staff to check the resident's skin daily for redness or sores and to use a gait belt with a four wheeled walker for short distances.

* 11/1/21 - the HHRN identified Resident 9 as continuing to have "stage 1 with dry, scaly skin to [left] buttock" and to "try moisture barrier cream."

* 11/17/21 - staff were to help the resident practice using an electric wheelchair.

* 11/22/21 - HHPT listed specific instructions for staff to assist Resident 9 practice using an electric wheelchair.  

There was no documented evidence the facility implemented or communicated the recommendations to staff.   

The need to ensure staff were informed of new interventions made by outside providers, service plan adjusted if necessary, and reporting protocols were in place was discussed with Staff 1 (ED) and Staff 14 (RN). They acknowledged the findings.

1.) Resident #9's service plan was updated to include current HHPT recommendations.

2.) Educate staff to put any home health/ outside provider notes in DNS box. If no note has been left, staff is to follow up with provider requesting documentation; fax copy of request to DNS box.

    Audit resident records to be sure that outside provider and HH have been updated.

    Calendar with home health scheduled visits, appointments and other outside provider to be established.

     Audit comparing calendar visits with resident record to ensure that changes in care have been captured on the service plan; update staff with changes made.

3.)Initial audit will be completed prior to date of compliance.

   Ongoing audit will occur M-F using clinical record, calendar and progress noted from provider for 6 weeks then re-evaluated.

4.) DNS or designee will be responsible for audits.

Based on 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 for 1 of 1 (# 5) sampled resident whose MAR was reviewed. Findings include, but are not limited to:

Resident 5 was admitted to the facility in 06/2019 with diagnoses including type II diabetes.

During a review of the resident's 11/01/21 through 11/29/21 MAR, two staff who were not delegated to administer insulin were recorded as administering insulin in the record.

In interview with Staff 14 (RN) on 11/30/21, it was stated that the staff listed on the MAR were remaining logged into the system while delegated staff from the memory care were coming over to administer. The facility scheduled staff to accommodate delegation needs, but the staff were not correctly recording these occurrences on the MAR.

The need to ensure medications administered were documented by the same person who administered the medication was discussed with Staff 1 (ED) and Staff 14 on 12/01/21. They acknowledged the findings.

1.) Resident #5's record was noted to rectify improper documentation.

2.) Staff educated  on proper documentation to ensure the record reflects who actually provided medication. Staff must log out and allow apprpriate person to log on to complete documentation.

     Staff educated to notify RN and MD of any documentation errors so they can be amended.

     Audit will conducted comparing MAR documentation to staff assignment to ensure that documentation and assigned staff match.

3.) Education provided by RN 12/10; Audits to be performed M-F x 6 weeks then re-evaluated.

4.) Audits will be conducted by RN or designee.

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 and for the disposal of medications, for 1 of 1 sampled resident (# 8) whose MAR and Controlled Substance Disposition logs were reviewed for accuracy. Findings include, but are not limited to:

Resident 8 was admitted to the facility in 12/2007 with diagnoses including spinal stenosis.

On 11/24/21 Resident 8 fell and received a diagnoses of a shoulder fracture.

Resident 8's signed physician orders, dated 11/24/21, included the following orders:

* PRN Hydrocodone 325 mg every six hours for three days for PRN pain; and

* PRN Oxycodone 5 mg tablet every four hours PRN for pain.

Resident 8's Controlled Substance Disposition logs and MARS, reviewed from 11/01/21 through 11/29/21 showed the following:

* 11/24/21 was blank for Hydrocodone administration following the resident's return from the hospital for shoulder fracture;

* The narcotic disposition log recorded a dispensation of Hydrocodone on 11/27/21, the day after the order had been discontinued; and

* The 11/27/21 dose was not reflected on the MAR.

Comparison of the medication dosing cards to the disposition log, showed the amount of medication left was reflected accurately on the log. The staff member who dispensed the discontinued PRN Hydrocodone did not also dispense the PRN Oxycodone.

The need to ensure the narcotic disposition log documentation and MAR documentation were accurate was discussed with Staff 1 (ED) and Staff 14 (RN) during the survey. They acknowledged the findings.

The facility immediately investigated the incident, reported it to APD, and created a plan to educate staff on narcotic medication tracking and the disposal of discontinued medication. A copy of the APD report was provided to survey prior to exit.

1.) Medication log and MAR have been corrected to relect me error. Staff who made error was educated on the 6 rights and the importance of checking medication against order with every administration.

2.) Mar to cart narcotic audit was completed.

    Staff educated in 6 rights, discussing the possible outcomes that could result from a medication error.

    MAR to cart narcotic audit to be conduced weekly and prn.

3.) Initial MAR to cart audit compled by DNS and DDO.

    Staff educated by DNS 12/10/21

    Ongoing audit to be completed weekly and prn for 6 weeks the re-evaluate system.

4.) Education and audits to be completed by DNS or designee.

3. Resident 9 was admitted to the facility in 04/2021 with diagnosis including cancer. The resident's 11/01/21 through 11/29/21 MAR and MD orders were reviewed.

On 08/18/21, the resident had a physician's order directing staff to administer 750 mgs of Tylenol, PRN for elevated temperature and pain. Resident 9 received new signed orders on 10/20/21 that reflected staff were to administer 650 mgs of Tylenol, PRN for temperature and pain. The signed order on 10/20/21 did not include the PRN order for 750 mgs of Tylenol.  

There was no documented evidence of a current order for the 750 mg of Tylenol in Resident 9's record, but it had been administered on ten occasions.

The need to ensure physician's orders were carried out as prescribed was discussed with Staff 1 (ED) and Staff 14 (RN). 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 had current written, signed physician orders documented in residents' facility records for all medications and treatments that the facility is responsible to administer for 3 of 3 sampled residents (#s 5, 8 and 9) whose MARs and orders were reviewed. Findings include, but are not limited to:

1. Resident 5's signed physician orders and 11/01/21 through 11/29/21 MAR was reviewed. The following deficiencies were identified:

a. Resident 5 had orders for the following medications:

* Atorvastin (for hyperlipidemia);

* Losartan (for essential hypertension);

* Gabapentin (for diabetes); and

* Quetiapine (for vascular dementia).

On 11/08/21 and 11/14/21 the MAR reflected that these medications were not administered at 8:00 pm as the resident was sleeping. No documented attempts to administer this medication to follow the order as prescribed could be provided.

b. Resident 5 had orders for Humalog sliding scale twice daily (for type II diabetes), TED hose daily (for edema) and monthly weights.

In the review period there were 13 blanks across the MAR for the above orders.

In interview on 11/30/21 Staff 14 (RN) confirmed the blanks and acknowledged that he could not verify whether the medications and treatments had been provided.

The need to ensure physician orders were followed as prescribed was discussed with Staff 1 (ED) and Staff 14 on 12/01/21. They acknowledged the findings.

2. Resident 8's 11/01/21 through 11/29/21 MAR was reviewed and revealed the following:

The resident had an order for acetaminophen (for pain), 500 mgs four times daily. The MAR was blank for the 8:00 pm dose on 11/19/21 and 11/26/21.

In interview on 11/30/21 Staff 14 (RN) confirmed the dose was not marked on the MAR and could not verify if it had been given to the resident.

The need to ensure physician orders were followed as prescribed was discussed with Staff 1 (ED) and Staff 14 on 12/01/21. They acknowledged the findings.

1.) Residents # 5, 8, and 9 orders and MARS were reviewed and updated accordingly.

2.) Staff educated on the following:

-the importance of reapproach, documentation and physician notification.

-the importance of not leaving holes in MAR

-the importance of verifying order with medication prior to administration.

    MAR to cart audit completed to ensure medications in cart are current and accurate.

    Audit of holes in MAR, meds not given and new medication orders to be conducted daily in morning clinical meeting; staff will be called in to rectify errors.

3.) Education completed 12/10/21

    MAR to cart audit to be completed prior to date of compliance.

    Audit of holes in MAR, meds not given and new medication reviewto be concted Monday through Friday in morning clinical meeting times 6 weeks then system will be re-evaluated.

4.) Education and audits to be completed by DNS or designee.

Based on interview and record review, it was determined the facility failed to notify the physician when a resident refused to consent to orders for 1 of 1 sampled resident (#2) who had documented medication refusals. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 2020 with diagnoses including Type Two Diabetes and Congestive Heart Failure.

Between 5/1/21 and 8/9/21, Resident 2 had multiple medication refusals with no documented evidence the facility notified the physician related to the medication refusals.

On 8/11/21, Resident 2's medication refusals were discussed with Staff 1 (ED). No additional information was provided.

1.Resident 1's refusals where reviewed and Dr. faxed.

2.Med-Tech staff instructed and trained when a refusal happens to fax DR of the refusal and use a medication refusal fax for DR.

3.This will be evaluated weekly.

4.RN to monitor and complete

Based on interview and record review, it was determined the facility failed to notify the physician when a resident refused consent to an order, for 2 of 2 sampled residents (#'s 5 and 8) with multiple medication refusals. This is a repeat citation. Findings include, but are not limited to:

1. Resident 5's MAR from 11/01/21 through 11/29/21 was reviewed. The resident had 27 refusals across multiple medications documented on the MAR during this time. On 11/30/21 Staff 14 (RN) acknowledged that the physician was not notified of the refusals.

2. Resident 8's MAR from 11/01/21 through 11/29/21 was reviewed. The resident was prescribed polyethylene glycol powder (for constipation) once daily. The resident refused 16 times during the review period. On 11/30/21 Staff 14 acknowledged that the physician was not notified of these refusals.

The facility's failure to notify the physician when Residents 5 and 8 refused an ordered medication or treatment was reviewed with Staff 1 (ED) and Staff 14 on 12/01/21. They acknowledged the findings.

1.) Resident #5 and #8 refusals were faxed to the physician.

2.) Refusals will be submitted to physician daily via fax.

    Audit will be completed comparing refusals in MAR to fax receipts and corrected accordingly.

3.) Audit will be completed Monday through Friday for 6 weeks then re-evaluated.

4.) Audits to be completed by RN/designee.

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

1.  Resident 1's 8/1/21 through 8/9/21 MAR's were reviewed and revealed:

* PRN bowel medications (Polyethylene one packet and Senna 8.6 mg) lacked clear instruction to staff regarding what medication to use first for constipation; and

* Two PRN inhalers to assist with shortness of breath lacked clear instruction to staff regarding what inhaler to use first.

2.  Resident 3's 8/1/21 through 8/9/21 MAR's were reviewed and revealed:

* PRN bowel medications (Bisacodyl tablet, bisacodyl suppository, Lactulose and Milk of Magnesia) lacked clear instruction to staff regarding what medications to administer and in what order for constipation; and

* PRN pain medications (Oxycodone, Tylenol and Ibuprofen) lacked clear instruction to staff regarding order of administration.

Resident 1 and 3's MAR's and resident specific parameters for bowel medications, inhalers and pain medications was discussed with Staff 1 (ED) and Staff 2 (RN) on 8/10/21 at 3:00 pm.  No additional information was provided.

2. Residents 2's MARs were reviewed from 7/1/21 through 8/9/21 and the following was noted:

* Resident-specific parameters and instructions for Metoprolol to treat high blood pressure were not transcribed to the August MAR; and

* Two PRN pain medications Acetaminophen and Hydrocodone lacked resident-specific parameters and clear direction to staff regarding when to administer each medication.

The need to ensure  MARs were accurate and included resident-specific parameters and instructions for PRN medications was reviewed with Staff 1 (ED) and Staff 3 (RCC) on 8/11/21. They acknowledged the findings.

1.Resident # 1, 2, and 3 reviewed and PRN medication updated.

2.PRN medication sent to PCP to request resident specified parameters for Bowel medication and if a PRN medication for same class of medication which should be used first.

3.Evaluation will weekly and upon move-in

4. RN to monitor and complete

Based on interview and record review, it was determined the facility failed to ensure resident MAR's were accurate, had documentation of resident specific parameters, and had initials of the person administering the medications for 1 of 3 sampled residents (# 9) whose MAR's were reviewed. This is a repeat citation. Findings include, but are not limited to:

1.  Resident 9's 11/01/21 through 11/29/21 MAR's were reviewed and revealed the following:

a. The resident had an order for Losartan (for hypertension) and parameters to hold the medication for a systolic blood pressure of less than 110. There were seven occasions where the MAR showed "N/A" instead of a blood pressure reading with staff initials the medication was administered.

There was no documented evidence of the blood pressure readings in the resident's clinical record.

In an interview on 12/01/21, Staff 1 (ED) confirmed the staff member took the blood pressure and administered the medication in accordance to the parameters. The staff member was counseled on how to document blood pressures correctly.

b. PRN Bisacodyl tablets (for constipation) lacked resident specific parameters for unlicensed staff of when to administer the medication.

The need to ensure MARs were accurate and included resident-specific parameters and instructions for PRN medications was reviewed with Staff 1 (ED) and Staff 14 (RN) on 12/01/21. They acknowledged the findings.

1.) Resident #9's losartin order requires a BP upon administration; BM protocol parameters added to Biscodyl regimen.

2.) Staff educated 12/10/21 that N/A or see previous are not acceptable choices for parameters on medications with specific parameters.

    Audit of all meds requiring parameters will be conducted and rectified prior to date of compliance.

    Audit of proper documentation of parameters will be conducted using resident record, dashboard and reports.

3.) Initial audit will be conducted prior to date of compliance.

    Ongoing audit will be completed Monday through Friday at clinical meeting for 6 weeks, then system will be re-evaluated.

4.) Education and audits to be conducted by DNS and designees.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 newly hired staff (#s 12 and 13) completed all required pre-service orientation prior to beginning their job responsibilities. Findings include, but are not limited to:

Training records were reviewed on 8/11/21 and revealed the following:

Staff 12 (CG), hired 5/27/21, lacked documented evidence training was received in resident rights and values of CBC care and standard precautions for infection control prior to beginning job duties.  

Staff 13 (MT), hired 7/13/21, lacked documented evidence training was received in standard precautions for infection control and fire safety and emergency procedures prior to beginning job duties.

The need to ensure all required pre-service orientation was completed prior to beginning job responsibilities was reviewed with Staff 1 (ED) on 8/11/21.  Staff 1 acknowledged the findings.

1.Staff #12 and 13 was reviewed and training conducted where needed. 2. System in place orientation will be completed in this order Day Zero (Before New hire papers)- Pre-Service Training via Oregon Care Partners Day Zero (new hire papers)- Resident Rights, Abuse, Pride (Abuse), gait belt, Fire safety walk-through, Emergency prepares, Incident reporting, HIPAA, wandering, Job description, and background check. Day one & two(on computer off floor) - Alternatives to Restraints in Elder Care, Alzheimer's Disease and Related Disorders: Activities of Daily Living, Alzheimer's Disease and Related Disorders: The Physical Environment, Assisting Residents with Activities of Daily Living, Assisting with Medication Administration, Body Systems and the Aging Process, Care of Residents With Dementia In A, Challenging Behaviors in Dementia Care, Communication and People with Dementia, Dementia Care: Caregiver Self-Care, Dementia Care: Normal Aging vs. Dementia/Alzheimers, Dementia Care: Performing ADLs, Dementia Care: Understanding Alzheimer's Disease ,eCOURSE: Point of Care (POC) for Senior Living, Empowering Residents through ADLs, Essentials of Resident Rights, Ethics and the Care of Persons Living with Dementia, First Aid, Food Safety Fundamentals, Principles of Infection Control, PRN Medication Management, Record and Report Condition Changes, Service Plans for ALF, Understanding Dementia. Day three and four: skills check list on the job in MC Day five and six: skills check list on the job in MC or ALF. 3. Every new hire and quarterly. 4. ED, RN and/or RCC.  

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 newly hired caregiving staff (#s 12 and 13) demonstrated satisfactory performance in all job duties, completed Abdominal thrust training, and obtained certification in First Aid within 30 days of hire. Findings include, but are not limited to:

Training records were reviewed on 8/11/21.

There was no documented evidence Staff 12 (CG), hired 5/27/21, and Staff 13 (MT), hired 7/13/21, had demonstrated competency in all required areas within 30 days of hire including:

* Role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Changes associated with normal aging;

* Identification, documentation and reporting of changes of condition;

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

* General food safety, serving, and sanitation;

* Other duties as applicable (including medication administration); and

* First Aid/Abdominal Thrust.

The need to ensure it was documented staff had demonstrated competence in all job duties within 30 days, obtained First Aid certification, and been trained in abdominal thrust was reviewed with Staff 1 (ED). He acknowledged the findings and had recently developed a plan of correction to ensure competencies were demonstrated and documented.  

1. Staff #12 and 13 have been reviewed and 30 day compentices have been completed for those missing and by Day 30 of any new hire will be completed:  Competency demonstrated within 30 days of hire: Role of service plans in providing individualized care, providing assistance with ADLs, Changes associated with normal aging, Identification, documentation and reporting of changes of condition, Conditions that require assessment, treatment, observation and reporting, General food safety, serving and sanitation Other duties as applicable (Med pass, treatments), First Aid/Abdominal Thrust 2. Have a written instruction to complete 30 day compancies and a check/sign-off sheet in this order. 3. Every new hire by 30 days

4. ED, RN and/or RCC to complete and monitor.   

Based on interview and record review, it was determined the facility failed to ensure 1 of 1 long term staff (# 7) completed and documented a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care setting, including training on chronic diseases in the facility population and dementia training. Findings include, but are not limited to:

Staff training records were reviewed with Staff 1 (ED) on 8/11/21.  Staff 7 (MT/CG) was hired 10/1/19. Annual training records were requested and reviewed between 10/2019 and the time of the survey 8/9/21.  

The records indicated Staff 7 had completed a total of four hours of in-service training on topics related to the provision of care for persons in a community-based care setting. None of the training was related to dementia.

The need to ensure direct care staff completed the required annual training was reviewed with Staff 1 on 8/11/21. Staff 1 acknowledged the findings.

1. Staff # 7 traning reviewd and training completed. Annual training will be conducted via Staff meetings and Online computer training. To include a minimum of 12 hours of in-service training annual by hire date and 6 of which will be dementia in topic.

2. The facility will keep an in-service log tracking sheet for each employee. All in-service and training hours will be logged under the appropriate title, month and amount of hours of requirement of 12 hours of training with 6 being dementia in topic.

3. Training will be verfied quarterly.

4.ED, RN, and/or, RCC to monitor.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted and documented all required components in accordance with Oregon Fire Code every other month, and Life Safety instruction was provided to staff on alternating months. Findings include, but are not limited to:

Review of Fire and Life safety records on 8/10/21, for February 2021 through August 2021 lacked documentation of the following:

* Fire and life safety instruction to staff on alternate months;

* Fire drill documentation was lacking or incomplete regarding:

- Escape route used;

- Resident evacuation problems encountered; and

- Number of occupants evacuated.

The requirements regarding fire drills and fire and life safety instruction for staff were reviewed with Staff  5 (Maintenance Director) on 8/10//21. He acknowledged the findings.

1.Actions taken to correct situation is to update fire dill form to included Escape routes used, residents who resisted or failed to participate in drill., Number of occupants evacuated, evidence of alternate routes used during fire drill. This also includes fire safety training in required areas and residents in attendance annually.  

2. Maintenance will conduct fire drills every other month and training of other Fire and life safety instruction to staff on alternate month   

3. Correction will be monitored monthly

4. Maintenances team to complete.  

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

Fire drill and fire and life safety records, reviewed between February 2021 through August 2021, identified the facility lacked documented evidence of the following:

* Alternate exit routes were used during fire drills;

* Residents were instructed on fire and life safety within 24 hours of admission and re-trained at least annually; and

* A written record of fire safety training, including content of the training sessions and the residents attending.

The need to ensure the facility was in compliance with all fire drill and fire and life safety training requirements was discussed with Staff 5 (Maintenance Director) on 8/10/21. He acknowledged the findings.

1. Action taken to correct is have residents be instructed of fire and life safety within 24 hours and then annual.

2.Maintiance team to instruct resident upon move in with documentation evidence.

3.Monthly and with new move-in

4.Maintiance team to monitor.  

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

Refer to C252, C260, C262, C270, C290, C305 and C310.

Refer to C252, C260, C262, C270,

C290, C305 and C310. POC

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

Observations of the smoking area patio on 8/9/21 showed there were multiple drop offs of 2-4 inches along pathway edges.   

The need to ensure pathways in the resident smoking area did not have potential safety hazards was discussed with Staff 1 (ED) on 8/10/21. The staff acknowledged the findings.

1.Action taken to correct rule violation is to fill areas of drop offs that potently cause a safety hazard with material to eliminate drop offs.

2. Drop offs will be filled in as needed.

3 Drop offs will be check monthly by rounds with Maintenance team and fill as needed.

4. Maintenance will be in charge of filling areas and ED/Maintenance for monitoring.     

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 facility was toured on 8/9/21. The following was identified:

* The dining room had cabinets were scuffed and gouged creating non-cleanable surfaces;

* Dark spots and stains on the carpet in the hallways near apartments 141, 241 and 246;

* Couches in the hallways near apartments 202 and 205 had dark marks/stains on the cushion; and

* The laundry room on second floor had lint and insulation in and around the hopper.

The areas needing cleaning were reviewed with Staff 1 (ED) on 8/10/21 at 9:00 am. Staff acknowledged the areas that needed to be cleaned.  

1.Dining room Cabinets will be sanded and refinished to have a smooth cleanable surface. Carpet will be deep cleaned to remove all stains and hopper will/has been cleaned.

2.System will be corrected with ED rounds with Maintenance and HCSG lead doing monthly walk through.

3.These areas will be aduited monthly and touched up as needed.

4.ED, Maintenance, and HCSG lead.

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 8/9/21. Observations and interviews with staff confirmed the doors by which residents could exit the facility did not have a working alarm or other acceptable system to alert staff when residents left the building.

On 8/10/21, the need to ensure exit doors were equipped with an alarming device or other acceptable system was discussed with Staff 1 (ED).  Staff verified the findings.  

1.Doors have been checked in the facility. Made contact with call system company Alert 5(Ialert) on 8/12/2021 to get door transmitters and transmitters where installed and tested on 8/16/2021. This allows caregivers to see when affected doors are opened and it alerts on call light system.

2. Violation corrected by installing door alarm transmitters.

3. Facility will evaluate weekly

4.Maintenance is to monitor