The findings of the re-licensure survey, conducted 09/12/22 through 09/16/22, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, and OARs 411 Division 004 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 first revisit to the relicensure survey of 09/16/22, conducted 05/08/23 through 05/11/23, 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.

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 09/16/22, conducted on 07/05/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

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

During the survey, conducted 09/12/22 through 09/16/22, quality improvement oversight to ensure adequate resident care, services and satisfaction was found to be ineffective.

On 09/16/22, Staff 1 (Administrator) was interviewed about the facility's quality improvement program. She stated the facility used a "Quality Assurance and Performance Improvement (QAPI) Program," however, she had not implemented the QAPI program for the last nine months. She acknowledged the facility did not have a current quality improvement plan in place.

Refer to the deficiencies in the report.

Please refer to our plan of correction at C240,C260,C270,C280,C290,C303,C305,C325,C361

The communities ED are activley engaged in this process of the plan of corretion to ensure all is corrected and completed.

The ED is implemeting a new comprehensive Quality Improvement program that will provide ongoing audits with examintion of our systems, procedures and processes for continued compliance in areas of cited to renovate systems and processes. The ED will also continue to provide oversight and active Quality Improement Program with weekly 1:1 with management leads and weekly QAPI meetings. The ED is responsible for ensuring each citation on the plan of correction and will strive for daily compliance.

Based on observation and interview, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 03/2014 with diagnoses including dementia.

Observations and interviews with staff revealed s/he was occasionally incontinent of bowel and bladder and relied on one person assistance with transfers and toileting care.

On 09/14/22 at 11:45 am, the surveyor obtained permission and observed one CG provide ADL care for Resident 3. Prior to entering the restroom, the CG was wearing gloves. Toileting assistance was provided, and the CG began to assist the resident to lunch without removing the gloves or the completion of hand hygiene. The CG escorted the resident to the table and started to prepare his/her lunch while still wearing gloves. The surveyor stopped the process and requested the CG remove her gloves and complete hand hygiene.

The need to ensure staff consistently used effective universal precautions was discussed with Staff 1 (Administrator) on 09/15/22 at 3:15 pm. She acknowledged appropriate infection control practices were not implemented.

Training will be provided to all staff  reguarding providing care with universal percautions, dawning and daffing as well as glove use. This training will occur at our next staff meeting on October 21,2022 at 2:00pm. This is a mandatory meeting and all staff will  receive the traning to prevent more occurances. All staff will be required to take the Oregon Care Partners universal precautions and infection control.

All staff will be retrained on the proper guidelines for removing gloves at the appropriate times and hand hygiene. Informaton will also be posted in all break rooms and medication room.

The ED and nurse will provide oversight.  

Based on observation and interview, it was determined the facility failed to ensure residents received services in a manner that protected their privacy and dignity for 4 of 7 unsampled residents and 1 of 5 sampled residents (#3), and were able to send and receive personal mail unopened for 1 of 7 unsampled residents. Findings include, but are not limited to:

1. A group of seven unsampled residents were interviewed on 09/13/22 at 10:30 am and the following was reported:

* Four unsampled residents reported staff didn't always wait for the resident to respond prior to staff entering their room.  

* One resident reported not receiving packages s/he ordered. S/he confirmed the packages were sent by contacting the seller. On one instance, s/he ordered medications through his/her own pharmacy that s/he was responsible to administer independently. S/he didn't receive the medications, and to order them again, s/he had to pay privately due to insurance coverage. Although the facility reimbursed the resident, it was an emotional hardship for him/her. The resident also reported that s/he had received mail and a package that was already opened.

The need to ensure residents received services in a manner that protected privacy and dignity and received their mail unopened was discussed with Staff 1 (Administrator) on 09/15/22. She acknowledged the findings.  

2. Resident 3 was admitted to the facility in 03/2014 with diagnoses including dementia.

Resident 3's service plan was reviewed and indicated CGs were to "knock on door before entering [Resident 3's] room. Call [him/her] by name and identify yourself and why you are there."

Observations were made between 09/12/22 and 09/15/22 and included the following:

* 09/12/22 at 1:22 pm - two CGs knocked on Resident 3's door and immediately entered the room. The CGs did not call the resident by name, announce themselves or state the purpose of their visit; and

* 09/15/22 at 11:43 am - one CG knocked and immediately entered Resident 3's room. The CG did not call the resident by name, announce herself or state the purpose of the visit.

The need to ensure residents received services in a manner that protected privacy and dignity was discussed with Staff 1 (Administrator) on 09/15/22. She acknowledged the findings.

Our community takes residents right every serious.

All staff will be required to attend a in-service training on residents rights.

The Staff will receive all residents rights that list:

(a) To be treated with dignity and

respect.

(b) To be given informed choice and

opportunity to select or refuse service

and to accept responsibility for the

consequences.

(c) To participate in the development of

their initial service plan and any revisions

or updates at the time those changes are

made.

(d) To receive information about the

method for evaluating their service

needs and assessing costs for the

services provided.

(e) To exercise individual rights that do

not infringe upon the rights or safety of

others.

(f) To be free from neglect, financial

exploitation, verbal, mental, physical or

sexual abuse.

(g) To receive services in a manner that

protects privacy and dignity.

(h) To have prompt access to review all

of their records and to purchase

photocopies. Photocopied records must

be promptly provided, but in no case

require more than two business days(excluding Saturday, Sunday and

holidays).

(i) To have medical and other records

kept confidential except as otherwise

provided by law.

(j) To associate and communicate

privately with any person of choice, to

send and receive personal mail

unopened and to have reasonable

access to the private use of a telephone.

(k) To be free from physical restraints

and inappropriate use of psychoactive

medications.

(l) To manage personal financial affairs

unless legally restricted.

(m) To have access to and participate in

social activities.

(n) To be encouraged and assisted to

exercise rights as a citizen.

(o) To be free of any written contract or

agreement language with the facility that

purports to waive their rights or the

facility's liability for negligence.

(p) To voice grievances and suggest

changes in policies and services to either

staff or outside representatives without

fear of retaliation.

(q) To be free of retaliation after they

have exercised their rights provided by

law or rule;

(r) To have a safe and homelike  environment.

(s) To be free of discrimination in regard

to race, color, national origin, gender,

sexual orientation or religion.

(t) To have proper notification if

requested to move out of the facility, and

to be required to move out only for

reasons.

As for some residents their rights have been violated. we have implimented a comprehensive training on this topic as all staff must understand the importance of this has been identified and to ensure the residents feel safe and know their rights. The need to ensure residents received services in a manner that protected

privacy and dignity.

The ED will provide support.

Based on interview and record review, it was determined the facility failed to investigate an injury of unknown cause in order to rule out suspected abuse or neglect for 1 of 1 sampled resident (# 5), who experienced an injury of unknown cause. Findings include, but are not limited to:

Resident 5 was admitted to the facility in 12/2010.

The resident's 06/12/22 through 09/12/22 progress notes, 08/19/22 service plan, Temporary Service Plans (TSP's) and incident reports were reviewed and revealed the resident experienced an injury of unknown cause on 08/25/22.

On 08/25/22 facility staff noted the following:

"[S/he] came to the dispensary for medication this evening when this med aide observed a large amount of blood on [his/her] sock [on left foot]. [Resident] states [s/he] does not know why there is blood on [his/her] sock or what happened."

In an 09/14/22 interview with Staff 1 (Administrator), she stated the resident was susceptible to skin tears due to his/her fragile skin and therefore abuse and neglect had been ruled out for this injury.

A 08/17/22 TSP instructed staff to provide safety checks for Resident 5. The facility failed to thoroughly investigate the injury of unknown cause for suspected abuse and neglect, including whether the service plan was followed at the time of the injury.

The facility lacked documented evidence on how abuse and neglect was ruled for the resident's injury of unknown cause.

The need to thoroughly investigate injuries of unknown cause in order to rule out suspected abuse or neglect was discussed with Staff 1 and Staff 2 (LPN/Supervisor) on 09/16/22. They acknowledged the findings.

Staff 1 was asked to report the incident to the local SPD office and provided confirmation of the report prior to survey exit.

All Staff will be required t9 retake the Oregon Care Partners abuse and nglect traning courses online. Every fall, injury, imjury of unknown cause bat the community will be evaluated using evaluationn toolthat requires a full interview with staff and the resident.

All staff will be provided retraining on completeing incident reports, notification, follow through and monitoring.

The community leadership team will review all incidents each morning during the clinical meetings to assure full investigations have been completed onall incidents and that incidents have been reported to APS as required. The team will also review the 24 hour log each morning during this meeting to assure that there are not notes in the progress notes indicate an incident occurred without and incident repot being completed.

The ED will provide oversight.

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

On 09/12/22 at 9:35 am, the facility kitchen was observed to need cleaning and repair in the following areas:

a. Food spills, splatters, dust or debris were observed on or underneath the following:

* Metal shelves and the top surface and undercarriage of counters and rolling carts throughout the kitchen;

* Glass door of the two door cooler in serving area,

* Glass door and door frame of square cooler in serving area;

* Glass doors of walk-in cooler in kitchen;

* Interior of cabinet above prep table near microwave;

* Shelf containing metal baking pans;

* Convection oven;

* Top of warewasher;

* Exterior door; and

* Entirety of the tile floor throughout the kitchen and food storage areas.

b. The following areas, entrances and equipment were not in good repair:

* Broken floor tile near the oven;

* Interior and exterior doors to the kitchen and the door to the serving area had chipped paint; and

* Four door cooler between the serving area and the kitchen and the convection oven were not in use due to needed repairs.

The areas requiring cleaning and repair were observed and discussed with Staff 1 (Administrator) and Staff 5 (Kitchen Manager) on 09/15/22. They acknowledged the findings.

The kitchen will receive a deep clean by the dining manager and team.

Daily,weekly and monthly cleaning tasks sheets will be implemented to include daily sign off by then kitchen team. The dining manager will assure compliance.

The ED will complete a weekly one on one meeting with the dining manager to assure compliance is met.

The dining manager has received training and will impliment the weekly QA and his own weekly QA.

The dining manager will have two meetings a month and provide training and oversight to general cleaning, food storage and overall kitchen compliance.

This will be evaluated daily at stand up with all managers and the ED. Meal surveys will be implemented, and feedback will be reviewed at the morning stand up and during the weekly one on ones with the ED.

Meals will be temperatured checked prior to serving from the steam tables to the residents and tracked on the temperature  charts. The dining manager will implement a QA tool that reqoes tjat cooks taste all meals prior to being served and review all dining feedback cards with the  team. All staff will receive retraining on proper handwashing, and this will be observed by the  dining manager daily and observations tacked on the dining manager weekly QA followed by a weekly one on one meeting with the dining manager.

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 evaluation was reviewed. Findings include, but are not limited to:

Resident 4 admitted to the facility in 09/2022 with diagnoses including anemia, protein-calorie malnutrition and dementia without behavioral disturbances. The move-in evaluation was reviewed and there was no documented evidence the following required elements were addressed:

* Pain relating to pharmaceutical and non-pharmaceutical interventions, including how the resident expressed pain or discomfort;

* Nutrition habits and fluid preferences;

* Fall risk or history; and

* Complex medication regimen.

The need to ensure all required elements were addressed prior to the resident moving into the facility was discussed with Staff 1 (Administrator) on 09/15/22. She acknowledged the findings.

All residents are at risk for this deficient p[ractice. The ED or Designee will inservice the service planning team on the required elements of the evaluation that must at minimum be addressed.

The ED will review all of most recent evaluation and complete any of the required areas that were missing such as;

The Residentg Care Coordinator will perform a audit to quarterly to rnsure that all of the required elements thaty are needed to be addressed within the evaluation process.

The ED will review all move-in evaluations and service plans to enure that all of the required elements are comloeted upon move in.

The residednt care coordinator will bring the results from the audit to QUAPI quarterly for six consercutive quarters or until deficient practice is resolved.  

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs,  provided clear direction to caregiving staff regarding the delivery of services, or were followed for 4 of 5 sampled residents (#s 1, 2, 3 and 6) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 11/2018 with diagnoses including chronic venous hypertension with ulcer of bilateral lower extremities.

Observations of the resident, interviews with staff, review of the current 06/17/22 service plan and clinical records during the survey, revealed Resident 1's service plan was not reflective of the resident's status and did not provide specific directions to staff in the following areas:

* Bed mobility status including level of assistance;

* Use of a raised toileting seat;

* Bathing status including level of assistance; and

* Skin status.

The need to ensure the service plan provided clear instruction to staff and was reflective of Resident 1's needs was discussed with Staff 1 (Administrator) and Staff 2 (LPN/Supervisor) on 09/15/22 and 09/16/22. They acknowledged the findings.

2. Resident 2 was admitted to the facility in 11/2020 with diagnoses including lymphedema.

Observations of the resident, interviews with staff, review of the current 06/17/22 service plan and clinical records during the survey, revealed Resident 2's service plan was not reflective of the resident's status and did not provide specific directions to staff in the following areas:

* Medication management; and

* Resident's preference of staff entering the unit.

The need to ensure the service plan provided clear instruction to staff and was reflective of the resident's needs was discussed with Staff 1 (Administrator) and Staff 2 (LPN/Supervisor) on 09/15/22 and 09/16/22. They acknowledged the findings.

4. Resident 6 was admitted to the facility in 07/2018 with diagnoses including cerebral palsy. The resident's current service plan and temporary service plans were reviewed, and staff were interviewed. The service plan was not accurate or did not provide clear caregiving instructions in the following areas:

* Bathing including preferences and how often;

* Fall interventions;

* Transfer assistance;

* Behavior interventions and what could trigger behaviors;

* PRN use of a psychotropic;

* Direction to staff for using a deeper voice, raising voice levels and stating words clearly due to the resident being hard of hearing; and

* Activity participation in the facility.

The need to ensure service plans were reflective of the current needs of the resident and provided clear caregiving instruction was discussed with Staff 1 (Administrator) on 09/15/22. She acknowledged the findings.

3. Resident 3 was admitted to the facility in 03/2014 with diagnoses including dementia.

The resident's current service plan dated 09/08/22 was reviewed, observations were made and interviews were conducted between 09/12/22 and 09/15/22. Resident 3's service plan was not reflective, did not provide clear instruction to staff and/or was not followed in the following areas:

* Activities and levels of involvement;

* Nail care;

* Oral care assistance;

* Hearing aid assistance and maintenance;

* Assistance required for incontinent care; and

* Routine for CGs entering the resident's room.

The need to ensure service plans were reflective of the identified needs and preferences of the resident, provided clear direction to staff, and were followed by staff was discussed with Staff 1 (Administrator) on 09/15/22 at 3:15 pm. She acknowledged the findings.

ED and Resident Care Coordinator or designee will review Resident #1 service plan to ensure thayt it is reflective of the residents current staus asd well ads ensuring that the following items stated are also noted bed mobility status including level of assistance, use of a raised toileting seat, bathing status including level of asistance and skin status and then have thi updated service plan reviewed by all staff.

Resident #2 service plan  and clinical records to ensure that it is reflective of the residets current status as well as ensuring that the the following items provide more specific directions to medication management and rsidents preference of staff entering the unit, and then have this updated service plan reviewed by all staff.

Resident #3 service plan to ensure that it is reflective of the residents current status a well as including the level of assistance needed to complete ADL'S, Activities and levels of involment,nail care, oral care assistance,hearing aid assistance and nmaintenance, assistance required for incontinent care and routine for Caregivers entering tne residnets room. This service plan will be updated and reviewed by all staff.

Resident #6 service plan to rensure that it is reflective of the residents current status and preferences  as well as ensuring that the following items are provided clear direction to caregivers of Bathing preferences and how often, fall interventions, behavior interventionsand what could trigger behaviors, PRN use of a psychotropic, director to caregivers on using a deeper voice, raising voice levels and stating words clearly due to the resident being hard of hearing and activity participation in the facility. The service plan will be updated and will be reviewed by all staff.

The ED or designee will provide an in-service training on the importance and understanding of service planning and its key role in the communication to the care staff. ED will ensure each service plan asd it comes up to quarterly service plans to ensure that they reflect the residents current status. ED and management team will review 15 residents service plans every Monday to ensure that they are reflective of the residents current status.

3. Resident 6 was admitted to the facility in 07/2018 with diagnosis including cerebral palsy.

Progress notes dated 06/13/22 through 09/12/22, temporary service plans and incident reports were reviewed. The following deficiencies were identified:

a. The resident went to the hospital after one of his/her falls on 08/14/22. There was a progress note dated 08/14/22 at 6:06 am indicating the hospital noted a "small laceration on right leg which was treated with wound care."

There was no documented evidence the laceration was monitored weekly through resolution or that the facility implemented an intervention for wound care.

b. An incident report dated 08/17/22 identified an unwitnessed fall. Resident 6 was found in his/her room, on left side, in-between the motorized wheelchair and the bed. The incident report indicated 911 was called.

There was no documented evidence the facility implemented new interventions or that the resident was monitored for the fall through resolution.

The need to ensure short term changes of condition were evaluated, the service plan was updated as needed and staff documented on the progress of the condition at least weekly until resolution with discussed with Staff 1 (Administrator) on 09/15/22. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to evaluate, determine interventions, communicate interventions to staff on each shift, and monitor conditions through resolution for 3 of 5 sampled residents (#s 3, 5 and 6) who experienced changes of condition. Findings include, but are not limited to:

1.  Resident 5 was admitted to the facility in 12/2010.

Review of the resident's progress notes, dated 06/12/22 through 09/12/22, revealed the resident experienced the following changes in condition:

* 08/26/22- Bleeding scab on the right elbow; and

* 09/05/22- Med changes-methenamine hippurate one gram two times daily and Nitrofurantoin 50 milligrams at bedtime.

The facility lacked documented evidence interventions were determined and communicated to staff on all shifts, and conditions monitored with progress noted at least weekly through resolution.

In an 09/16/22 interview with Staff 1 (Administrator), she confirmed the resident's injury and medication changes were not monitored by the facility.                                                           

The need to ensure short term changes of condition were evaluated, interventions determined, communicated to staff on each shift and monitored with progress noted at least weekly through resolution was discussed with Staff 1 and Staff 2 (LPN/Supervisor) on 09/16/22. They acknowledged the findings.

2. Resident 3 was admitted to the facility in 03/2014 with diagnoses including dementia.

Resident 3's progress notes dated 06/13/22 through 09/12/22, incident reports and temporary services plans (TSPs) were reviewed for changes of condition and revealed the following:

a. Resident 3 was diagnosed with urinary tract infections (UTIs) on 08/05/22 and 08/27/22. On 08/16/22 Resident 3 returned from the hospital with a diagnosis of sepsis due to a UTI. The facility's documentation noted the following:

* Interventions for the UTIs included three different antibiotics - Keflex 500 mg, Ciprofloxacin 500 mg and Amoxicillin 500 mg;

* TSPs for each incident instructed CGs to document on adverse reactions to the medications, resident complaints, tolerance to change and benefits/improvements;

* Progress notes indicated no adverse effects to the three antibiotics; and

* Resolution of monitoring the incidents were documented on 08/10/22, 09/06/22 and 08/22/22 respectively.

There was no documented evidence the facility monitored the antibiotics for effectiveness.

b. Resident 3 had two falls dated 08/20/22 and 09/05/22.

The following interventions were documented on the incident reports and TSPs:

* 08/20/22 - Encourage call light assistance routinely;

* 09/04/22 - Offer water; and

* 09/05/22 - Cue resident to move slowly when changing positions.

The resolution of monitoring the falls were documented on 08/24/22 and 09/08/22 respectively.

There was no documented evidence the facility monitored the fall interventions for effectiveness.

c. Resident 3 had a decline in ADL status on 08/22/22.

A TSP was created on 08/22/22 with staff instruction to check on the resident every two hours and document on changes, complaints, attempted interventions, new levels of assistance provided, potential cause of change, vital signs, poor meal intake, change in mood and increased incontinence. The resolution of monitoring for the change of condition was documented on 09/01/22.

There was no documented evidence the facility checked on the resident every two hours.

The need to ensure the facility monitored changes of condition through resolution and monitored previous interventions was discussed with Staff 1 (Administrator) and Staff 2 (LPN / Supervisor) on 09/15/22. They acknowledged the findings and no additional documentation was provided.

Resident #1 The RN will document a change of condition to inculde a full skin assessment that will be conducted weekly and be monitored until healed, as well as an update on the evaluation an service plan. The rn will also conduct a MAR audit to ensure that medication changes are accurate to the doctors orders. The nurse or designee will have shift huddle to all staff on all shifts for daily communication and conditions ar monitored with progress notes daily until there is  resolved or a new baseline is set.

Resident #3 The RN will document a short term change of condition to include that the medication technitions and caregivers will monitor the resident when taking new perscribed antibotics for the effectiveness with documenting until there is a resolution or more medical attention is needed. The RN will also include a full fall evaluation and update the evaluation and service plan. The nurse and resident care coordinator will ensure that care staff, medication technitions check on resident every two hours through the change of Condition until there is a resolution at a new baseline.

Resident #6 The RN will document a short term change of condition to inculde full skin assessment that will be conducted weekly and be monitored until healed, as well as an update on the evaluation and service plan. The RN will do weekly monitoring until resolved or more interventions needed.

A new monitoring system will be implemented to  ensure and to help staff to identify short  term change of conditions along with significant changes of status incuding skin issues, medication orders and documentation of residents progress. This system includes observation, reporting, evaluation, service plan updates, referral to the RN as needed and ongoing monitoring. Medication Techs and caregivers are being re-trained and educated on these new processes.

Once our new implementation is completed, monitoring audits will be conducted for contionus follow through that will be conducted by the RN or designee weekly until futher notice. After 6 months we will look into moving the audits process to monthly to ensure ongoing compliance.

The ED and nurse will ensure that each residents status is reflected.   

Based on interview and record review, it was determined the facility failed to communicate interventions to staff on each shift and monitor conditions through resolution for 2 of 3 sampled residents (#s 8 and 9) who experienced changes of condition. This is a repeat citation. Findings include, but are not limited to:

1.  Resident 8 was admitted to the facility in 04/2022.

Review of the resident's progress notes dated 02/07/23 through 05/08/23, and facility weekly skin binder dated 04/2023 through 05/2023, identified the resident experienced the following changes in condition:

* 03/24/23 - Fall in the bathroom;

* 04/10/23 - "L [left] arm with bruising spots, inner Thigh with cluster pimple like bumps and L [left] toe swollen with bruise"; and

* 04/20/23 - Fall with rug burn on left knee 1.5 x 0.5 inches.

There was no documented evidence the resident's conditions were monitored through resolution.

On 05/10/23 and 05/11/23, the above findings were reviewed with Staff 22 (ED). She acknowledged findings.

2.  Resident 9 was admitted to the facility in 11/2016.

Review of the resident's progress notes, dated 02/08/23 through 05/08/23, identified the resident experienced the following changes in condition:

* 02/15/23 - Fall with a bruise on the right knee;

* 03/05/23 - Decreased furosemide medication;

* 03/11/23 - Non injury fall; and

* 04/10/23 - Dark purple bruise on left shoulder and inner left arm.

The facility lacked documented evidence interventions were determined and communicated to staff on all shifts for the falls and the medication dosage change, and the bruises on the right knee, left shoulder and left inner arm were not monitored with progress noted at least weekly through resolution.                                                          

The need to ensure short term changes of condition were evaluated, interventions determined, communicated to staff on each shift and monitored with progress noted at least weekly through resolution was discussed with Staff 22 (ED), Staff 15 (RSC) and Staff 29 (RSC) on 05/10/23. They acknowledged the findings.

*Weekly clinical Drill down.

*RN training with another facility RN

*Administrator audits using COC weekly note audit tool.

*Relias training-"Monitoring Change Of Condition"

*The Role of the RN through OHCA-August 2023 earliest class for RN and Administrator.

Further training for facility RN, Tools to self audit, and weekly clinical drill down to review all alerts, COC's, skins, IR's, and evaluations needed.

Weekly evaluations by Administrator

The RN, RCC's and Administrator are responsible for ensuring the new tools put in place are executed weekly.

Based on interview and record review, it was determined the facility failed to ensure the RN performed an assessment, interventions were developed based on the condition of the resident, and the service plan was updated for 2 of 5 sampled residents (#s 1 and 3) who experienced a significant change of condition in weight loss and a change in ADLs status. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 11/2018 with diagnoses including chronic kidney disease and heart failure.

Resident 1's weight record was reviewed during the survey and revealed the following:

* 07/11/22 - 221. 8 pounds;

* 08/11/22 - 210.4 pounds; and

* 09/12/22 - 198.8 pounds.

From 07/2022 to 08/2022, Resident 1 had weight loss of 11.4 pounds or 5.139 % of his/her body weight in 30 days, which represented a significant change of condition.

A facility RN completed an assessment on 08/17/22 and provided some information of the weight loss, however, there was no documented evidence the RN assessed the resident's condition which included that the weight loss had been evaluated and interventions had been determined to address the weight loss.

During the survey, the former facility RN was not available to interview and the new facility RN had been working approximately two days prior to the survey.

On 09/15/22 and 09/16/22, the above findings and lack of an RN assessment was shared with Staff 1 (Administrator) and Staff 2 (LPN/Supervisor). They acknowledged the findings.

2. Resident 3 was admitted to the facility in 03/2014 with diagnoses including dementia.

a. Resident 3's weight records were reviewed and revealed the following:

* 01/18/22 - 91 pounds

* 06/19/22 - 87 pounds

* 07/19/22 - 79.2 pounds

From 01/18/22 to 07/19/22, Resident 3 had a weight loss of 11.8 pounds or 12.96% of his/her body weight in six months. Additionally, from 06/19/22 to 07/19/22 the resident had a weight loss of 7.8 pounds or 8.96% of his/her body weight in one month. Both weight losses indicated a significant change of condition and required an RN assessment.

b. Resident 3's progress notes dated 06/13/22 through 09/12/22 were reviewed and revealed a decline in ADL status on 08/22/22. Resident 3 transitioned from independent to one person assist for his/her ADLs. This indicated a significant change of condition requiring an RN assessment.

The facility had one RN assessment for both significant changes of condition dated 08/08/22.

The need to ensure all significant changes of condition were assessed by an RN and were completed in a timely manner was discussed with Staff 1 (Administrator) and Staff 2 (LPN / Supervisor) on 09/15/22. They acknowledged the findings and no additional documentation was provided.

Please refer to C270 repeted here.

Resident #1 The RN will document a change of condition to inculde a full skin assessment that will be conducted weekly and be monitored until healed, as well as an update on the evaluation an service plan. The rn will also conduct a MAR audit to ensure that medication changes are accurate to the doctors orders. The nurse or designee will have shift huddle to all staff on all shifts for daily communication and conditions ar monitored with progress notes daily until there is  resolved or a new baseline is set.

Resident #3 The RN will document a short term change of condition to include that the medication technitions and caregivers will monitor the resident when taking new perscribed antibotics for the effectiveness with documenting until there is a resolution or more medical attention is needed. The RN will also include a full fall evaluation and update the evaluation and service plan. The nurse and resident care coordinator will ensure that care staff, medication technitions check on resident every two hours through the change of Condition until there is a resolution at a new baseline.

Resident #6 The RN will document a short term change of condition to inculde full skin assessment that will be conducted weekly and be monitored until healed, as well as an update on the evaluation and service plan. The RN will do weekly monitoring until resolved or more interventions needed.

A new monitoring system will be implemented to  ensure and to help staff to identify short  term change of conditions along with significant changes of status incuding skin issues, medication orders and documentation of residents progress. This system includes observation, reporting, evaluation, service plan updates, referral to the RN as needed and ongoing monitoring. Medication Techs and caregivers are being re-trained and educated on these new processes.

Once our new implementation is completed, monitoring audits will be conducted for contionus follow through that will be conducted by the RN or designee weekly until futher notice. After 6 months we will look into moving the audits process to monthly to ensure ongoing compliance.

The ED and nurse will ensure that each residents status is reflected.   

Based on interview and record review, it was determined the facility failed to ensure the RN performed an assessment, interventions were developed based on the condition of the resident, and the service plan updated for 1 of 2 sampled residents (# 9) who experienced a significant change of condition in weight loss and a change in ADLs status. This is a repeat citation. Findings include, but are not limited to:

Resident 9 was admitted to the facility in 11/2016 with diagnoses including heart failure.

Resident 9's weight record and clinical record were reviewed during the survey and identified the resident had significant changes of condition related to weight and a decline in ADL ability.

a. Weight records were reviewed from 11/27/22 - 05/05/23. The weight records were as follows:

02/05/23 - 313.8 pounds;

03/05/23 - 315.8 pounds;

04/05/23 - 304.4 pounds; and

05/05/23 - 283.2 pounds.

From 04/05/23 - 05/05/23 Resident 9 lost 21.2 pounds or 6.96% total body weight within one month; and from 02/05/23 - 05/05/23, Resident 9 lost 30.6 pounds or 9.75% within three months.

The weight loss represented a significant change of condition.

The RN completed an assessment on 04/17/23, which indicated the resident reported "[s/he] is not trying to lose wt." Interventions documented in the assessment were to "notify provider and continue to monitor wt. [weight] weekly."

The facility failed to ensure the RN assessment documented resident status, findings as a result of the assessment, and updated the service plan for the weight loss plan and interventions.

b. Progress notes reviewed on 04/30/23, 05/03/23 and 05/07/23 identified the resident had a decline in overall health including a decline in ability to self transfer, toileting, and mobility.

During an interview with Staff 10 (CG) on 05/09/23, it was reported Resident 9's increase in care needs included incontinent brief changes, toileting assistance, assistance to put pants, shoes and socks had been happening for the past two to three weeks.

During an interview with Resident 9 on 05/09/23, it was reported s/he had been calling for assistance more frequently for the "past two weeks or so." Resident 9 stated s/he "calls them for help transferring, going to the bathroom, [cleansing after bowel movements] and getting my pants on."

This represented a significant change of condition which required an RN assessment.

There was no documented evidence the RN completed an assessment for Resident 9's decline in health status and ADL ability.

The surveyor attempted to interview with the RN during the survey, but she was unavailable.

The need to ensure an RN assessment was completed and documented resident status, findings and interventions was shared with Staff 22 (ED), Staff 15 (RSC) and Staff 29 (RSC) on 05/10/23. They acknowledged the findings.

*Weekly Clinical Drill Down

*Weekly Administrator Evaluation and Assessment Tool to ensure done correctly by RCC's and RN.

*RN Training by another facility RN to ensure assessments are completed and all information included.

1. This will help the facility RN comprehend the full scope of her responsibility.

2.This puts auditing tools in place.  

Weekly evaluations

RN, RCC's, and Administrator

Based on interview and record review, it was determined the facility failed to coordinate care with outside providers in order to ensure the continuity of care, for 2 of 6 sampled residents (#s 2 and 6) who received outside services. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 11/2020 with diagnoses including lymphedema.

Resident 2's clinical record, dated 08/13/22 through 09/07/22, was reviewed during the survey and revealed the following:

* 08/31/22 home health nursing note indicated to encourage elevation of  both legs and possible protein supplement.

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

On 09/15/22 and 09/16/22, the need to ensure on-going coordination of care was discussed with Staff 1 (Administrator) and Staff 2 (LPN/Supervisor). Staff acknowledged the findings.

2. Resident 6 was admitted to the facility in 07/2018 with diagnoses including cerebral palsy and hypertension.

The resident's service plan, temporary service plans, progress notes dated 06/13/22 through 09/12/22, and outside provider notes were reviewed. The following was identified:

a. A progress note dated 08/14/22 reported the resident fell in the facility's outside courtyard and sustained a fracture. The following recommendations were made from HHPT and HHOT:

* 08/22/22, a HHOT recommended a raised toilet seat with arm rests and a higher level of care relating to being a high fall risk;

* 08/29/22, a HHOT recommended a bedside commode; and

* 09/08/22, a HHPT recommended removing a bottom mattress so the resident's bed would be lower to the ground.

b. On 08/22/22, a facility progress note identified that Resident 6 had "shearing/excoriation" on his/her buttocks. On 08/29/22, a HHOT recommended, "weight shifting for wound management."  

c. On 08/30/22 the resident went to a physician's appointment and was identified as having edema. On 08/30/22, a HHPT recommended the resident be "encouraged to elevate legs in wheelchair."

There was no documented evidence the recommendations had been implemented.

During an interview with Staff 1 (Administrator) on 09/14/22 at approximately 3:00 pm, she reported that the interventions had been refused by the resident, but had no documentation of the refusals.

The need to ensure staff were informed of new interventions, that the service plan was adjusted if necessary, and reporting protocols were in place, including documentation of the resident's refusals to implement the recommendations was discussed with Staff 1 on 09/15/22. She acknowledged the findings.   

All residents are at risk for this deficient practice.

The Nurse and Resident Care Coordinator will review

Resident #2 as 08/31/22 home health nursing note

indicated to encourage elevation of both legs and possible protein supplement. There was no documented evidence the recommendations were communicated to staff or implemented. The residents service plan, out side providers communication will e added into a progress note and TSP's made to ensure it is reflective of the residents current satus and progress.

Resident #6 * 08/22/22, a HHOT recommended a

raised toilet seat with arm rests and a higher level of care relating to being a high fall risk;* 08/29/22, a HHOT recommended abedside commode; and

* 09/08/22, a HHPT recommended removing a bottom mattress so the resident's bed would be lower to the

ground. b. On 08/22/22, a facility progress note identified that Resident 6 had "shearing/excoriation" on his/her buttocks. On 08/29/22, a HHOT recommended, "weight shifting for wound management." c.On08/30/22 the resident went to a physician's appointment and was

identified as having edema. On 08/30/22, a HHPT recommended the resident be "encouraged to elevate legs in wheelchair." There was no documented evidence the recommendations had been

implemented. The residents service plan, outside providers communication will be added into a progress note and TSP's made to ensure it is reflected of te residents current status and progress. All staff will be educated on this at a in-service training and the importance and understanding of an outside provider communication and interventions and its role of communication to the care staff. This will ensure staff were informed of new interventions, that the service

plan was adjusted if necessary, and reporting protocols were in place, including documentation of the resident's

refusals to implement the recommendations.

The ED, Nurse or designee will be responsible for ensuring this and providing support.

Based on observation and interview, it was determined the facility failed to ensure it consistently complied with masking requirements as prescribed in OAR 333-019-1011. Findings include, but are not limited to:

Per Oregon Administrative Rule 333-019-1011(6), (8) and (10), persons employed in an assisted living or residential care facility are required to wear a face mask while they are in the facility except when the employee is alone in a closed room.

Observations of staff during the survey revealed multiple instances where staff failed to wear their face mask properly, exposing their nose, or nose and mouth.

The need to ensure staff consistently wore a face mask was reviewed with Staff 1 (Administrator) on 09/15/22. She acknowledged the findings.

All staff are at risk for this deficiet practice.

The community is conducting an mandatory in-service training for all staff on Infection Prevention and Control.

This will contail maintaing infection prevention and control protocols to provide a safe, sanitary and

comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases as well as compling with masking requirements.

*Observations of staff during the survey

revealed multiple instances where staff

failed to wear their face mask properly,

exposing their nose, or nose and mouth.

The need to ensure staff consistently to  ensure the safety of residents and staff.

This will be monitored daily as we move forward and worn correctly as part of our QA

The ED, Nurse and clinical management team will ensure of this.    

2. Resident 1 was admitted to the facility in 11/2018 with diagnoses including generalized abdominal pain.

Resident 1 had a physician's order, dated 08/09/22, to administer Bisacodyl suppository, docusate sodium enema, and Sodium Phosphate enema as needed for constipation.

Resident 1's 09/01/22 through 09/12/22 MAR revealed there was no indication these orders were transcribed to the MAR.

In interviews on 09/15/22, the physician orders and current MARs were reviewed with Staff 1 (Administrator) and Staff 2 (LPN/Supervisor). They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed, and signed physician orders were documented in the resident's record for all medications and treatments the facility was responsible to administer, for 4 of 4 sampled residents (#s 1, 3, 5 and 6) whose orders were reviewed. Findings include, but are not limited to:

1. Resident 6 was admitted to the facility in 07/2018 with diagnoses including pain and cerebral palsy.

September 1 through 12, 2022 MAR and TAR, physician's orders, and progress notes dated 06/13/22 through 09/12/22 were reviewed. The following was identified:

a. Medications were not administered on the following dates for the documented reasons:

* 08/20/22 - alendronate sodium (for bone strength) was not administered as the medication was not in the facility;

* 08/21/22 - staff took medications to the resident's room at 2:15 pm and documented not administering the medications as s/he was sleeping; and

* 09/05/22 - scheduled ibuprofen (for pain) and acetaminophen (for pain) were not given as staff "could not find resident was outside somewhere."

b. The MAR and TAR had blanks for the following medications without documentation if the resident received the medication or treatment:

* Acetaminophen, scheduled (for pain);

* Ibuprofen, scheduled (for pain); and

* A treatment for skin shearing/excoriation on two occasions.

c. The facility did not have physician orders documented in facility's records for the following medications:

* Antacid/Simethicone suspension (for indigestion);

* Cholecalciferol (for supplement);

* Glycerin adult suppository (for constipation);

* Miralax powder (for constipation); and

* Osybutynin chloride (for bladder incontinence).

The need to ensure medications were carried out as prescribed and signed physician orders were in the resident's facility record was discussed with Staff 1 (Administrator) on 09/15/22. She acknowledged the findings.

4. Resident 5 was admitted to the facility in 10/2010.  

A review of the resident's records, including 08/01/22 through 09/12/22 MAR's, physician's orders and 06/12/22 through 09/12/22 progress notes identified the following:

The resident was noted to have experienced an injury to his/her left ankle on 08/25/22. A temporary treatment order dated 09/02/22 instructed staff to clean and bandage the wound every Monday and Friday until the wound was resolved, or the order was changed by the provider.

The administration record for the treatment on Friday 09/09/22 was blank. The facility lacked documented evidence the treatment order was followed as prescribed.

The need to ensure medications and treatment orders were carried out as prescribed was discussed with Staff 1 (Administrator) and Staff 2 (LPN/Supervisor) on 09/16/22. They acknowledged the findings.

3. Resident 3 was admitted to the facility in 03/2014 with diagnoses including dementia.

Resident 3's MARs dated 08/01/22 through 09/12/22, corresponding progress notes and physician's orders were reviewed and revealed the following:

a. There was no documented evidence the facility had physician's orders to administer the following medications:

* Acetaminophen Suppository 650 mg (for mild pain) - Insert 1 suppository rectally every six hours as needed; and

* Zofran ODT Tablet Disintegrating 4 mg (for nausea or vomiting) - Give one tablet by mouth every four hours as needed.

b. The following medications were documented as not administered on multiple occasions because the resident was sleeping, nauseous or the MAR was blank:

* Acetaminophen Tablet 325 mg (for pain);

* Amlodipine 5 mg (for high blood pressure);

* Amoxicillin Capsule 500 mg (for UTI);

* Aspercreme 10% (for pain);

* Aspirin 81 mg (for heart health);

* Boost Breeze (for weight loss);

* Cephalexin 500 mg (for UTI);

* Cetirizine 10 mg (for allergies);

* Cholecalciferol 2000 Unit (supplement);

* Ciprofloxacin HCl (for UTI);

* Diclofenac Sodium Gel 1% (for pain);

* Famotidine 20 mg (for acid reflux);

* Klor-Con M10 (for low potassium);

* Lisinopril 20 mg (for high blood pressure); and

* Mirtazipine 7.5 mg (for weight loss/appetite).

The need to ensure medications were carried out as prescribed and signed physician orders were in the resident's record was discussed with Staff 1 (Administrator) and Staff 2 (LPN / Supervisor) on 09/15/22. They acknowledged the findings.

Residents 1,3,5 and 6's orders have been reviewed, updated as needed and signed by the physican.

It is our our policy and procedure to follow all physicians orders. No changes are needed within these policies. Although we are reinforcing the policy through our newly developed education training and continuing educaion program. Our training will be performed by out RN prior to orientation with our medication techs. The training includes; reviewing standards fr medication pass administration of oral,eye,topical medciations and inhalers, standards for documentation (PRN, routine, narcotics and time sentive medcations) including how to transcribe orders, follwing all physcian orders for perameters and prn perameters with documentation of any behavioral interventions and standards related to narcotics.

The training will be over a course of 7 days with 3 medication pass competencies conducted by the RN or ED prior to being able to independently pass any medications.

We will be conducting annual medication pass competency conducted with all medication techs. These trainings will be filed in all employee files as well as in our training matrix binder.

The training program will be monitored monthly and qurterly as part of our QA program.

The ED, Nurse and resident care coordiator will bring results of the monthly audit for 6 consecutive quarters or until deficient practice is resolved.

2. Resident 8 was admitted to the facility in 04/2022 with diagnoses including essential hypertension and Type II diabetes.

Review of the 04/26/23 physician order summary, and the 05/01/23 - 05/08/23 MAR and TAR revealed the following:

* Atenolol (a medication to treat high blood pressure) 12.5 mg was ordered to be administered daily. However, it was not being given.

* The MAR indicated Metoprolol 25 mg (for high blood pressure) was administered daily, but there was no current order for this medication.  

* The MAR showed staff checked the resident's blood sugar level two times weekly and documented the result. However, there was no signed physician order for the blood test.

* The TAR showed staff signed they applied Lidocaine ointment to the resident two times daily. However, there was no signed physician order for the treatment.

* The MAR showed staff signed they offered and administered Imodium (a medication to treat loose stool) nightly. However, there was no signed physician order for the medication.

The need to ensure physician orders were carried out as prescribed and signed physician orders were documented in the resident's record was discussed with Staff 15 (RCC), Staff 22 (ED) and Staff 30 (RN) on 05/10/23 and 05/11/23. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed, and signed physician orders were documented in the resident's record for all medications and treatments the facility was responsible to administer, for 2 of 3 sampled residents (#s 8 and 9) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 9 was admitted to the facility in 11/2016 with diagnoses including heart failure.

The 05/01/23 through 05/08/23 MAR and TAR, and physician's orders dated 02/13/23 were reviewed during the survey.

The following medications and treatments were not administered as prescribed:

* Albuterol Sulfate Inhalation Nebulization, as needed every six hours;

* Terbinafine HCL cream apply weekly;

* Polyvinyl Alcohol Solution (eye drops); and

* Apply compression stockings daily.

During an interview and observation with Staff 32 (MT) on 05/09/23 at 1:35 pm, s/he stated the nebulizer supplies and solution, Terbinafine HCL cream and Polyvinyl Alcohol Solution (eye drops) were not available in the med room.

During an observation on 05/08/23 and 05/09/23 the resident wasn't wearing compression stockings and there was no documentation that the resident refused to wear them.

The need to ensure all medication and treatment orders were administered as prescribed was discussed with Staff 22 (ED), Staff 15(RSC) and Staff 29 (RSC) on 05/10/23. They acknowledged the findings.

*Relias Training-Med techs to do the class "Medication Management Assistance"

*Pharmacy cycle fill with monthly cycle fill review required by RCC's to ensure accuracy.

*New medication room with new delivery system to ensure accuracy.

*Training on the 8 Resident Rights as it concerns medications.

*New Stample for all medication orders that includes more "checks" and accountability.

*New process that includes "cart check" with training provided.

*RN training on 3rd check requirements.

This is an ongoing evaluation-Daily process

Med tech's, Rcc's, RN, and Administrator.

3. Resident 6 was admitted to the facility in 07/2018 with diagnoses including cerebral palsy. September 1 through 12, 2022 MAR and TAR, physician's orders, and progress notes dated 06/13/22 through 09/12/2022 were reviewed.

Although Resident 6 was administering his/her own medications, due to the resident incorrectly administering a narcotic, the facility took over administration of medications on 08/15/22.

Facility staff documented the resident refused administration of the following medications:

* All morning medications on 08/21/22, 09/07/22 and 09/08/22;

* Miralax powder (for constipation) on 08/17/22;

* Scheduled acetaminophen (for pain) on 08/25/22, 08/26/22, 08/28/22, 08/29/22 twice, 09/09/22, 09/10/22 and 09/12/22;

* Alendronate sodium (for bone strength) on 09/03/22; and

* Scheduled ibuprofen (for pain) on 09/07/22.

There was no documented evidence the facility notified the prescriber of each refusal.

The need to notify the physician or other legally recognized prescriber each time a resident refused to consent to orders was discussed with Staff 1 (Administrator) on 09/15/22. No additional information was received.

2. Resident 5 was admitted to the facility in 12/2010 with diagnoses including osteoporosis and chronic obstructive pulmonary disease.

The resident's 08/01/22 through 09/12/22 MAR's, and 06/12/22 through 09/12/22 progress notes were reviewed.

Facility staff documented the resident refused administration of the following medications:

* Lidocaine (neuropathic wrist pain) on 08/22/22, 08/24/22, 08/25/22, 08/27/22 and 08/29/22; and

* Fluticasone-salmeterol inhaler (emphysema) on 08/25/22, 08/27/22 and 08/29/22.

There was no documented evidence the facility notified Resident 5's physician of the refusals.

On 09/16/22 the requirement to notify the physician/practitioner when a resident refused to consent to orders was reviewed with Staff 1 (Administrator) and Staff 2 (LPN/Supervisor) who acknowledged the findings.

Based on interview and record review, it was determined the facility failed to notify the physician or prescriber when a resident refused to consent to orders for 3 of 3 sampled residents (#s 3, 5 and 6) who had documented medication and treatment refusals. Findings include, but are not limited to:

1. Resident 3's 08/01/22 through 09/12/22 MARs and corresponding progress notes were reviewed. The resident's record showed multiple medication and treatment refusals.

There was no documented evidence the facility notified the physician each time the resident refused to consent to the orders.  

The need to ensure the facility notified physicians of medication and treatment refusals was discussed with Staff 1 (Administrator) and Staff 2 (LPN / Supervisor) on 09/15/22. They acknowledged the findings.

The community is implimenting new procedures and policies with comprensive training program for the following areas that were identified;

* Resident 3's 08/01/22 through 09/12/22 MARs and corresponding progress notes were reviewed. The

resident's record showed multiple medication and treatment refusals. There was no documented evidence the facility notified the physician each time

the resident refused to consent to the orders.

*Resident #5 Facility staff documented the resident

refused administration of the following

medications:

* Lidocaine (neuropathic wrist pain) on

08/22/22, 08/24/22, 08/25/22, 08/27/22

and 08/29/22; and

* Fluticasone-salmeterol inhaler

(emphysema) on 08/25/22, 08/27/22 and

08/29/22.

There was no documented evidence the facility notified Resident 5's physician of the refusals.*Resident #6 Resident 6 was administering

his/her own medications, due to the resident incorrectly administering a narcotic, the facility took over administration of medications on 08/15/22. Facility staff documented the resident refused administration of the following medications:

* All morning medications on 08/21/22,

09/07/22 and 09/08/22;

* Miralax powder (for constipation) on

08/17/22;

* Scheduled acetaminophen (for pain) on

08/25/22, 08/26/22, 08/28/22, 08/29/22

twice, 09/09/22, 09/10/22 and 09/12/22;

* Alendronate sodium (for bone strength)

on 09/03/22; and

* Scheduled ibuprofen (for pain) on

09/07/22.

There was no documented evidence the facility notified the prescriber of each refusal.

The implementation of this training covers, when to notify Physcian, what to notify physcian about, What was reported and add a progress note in residents chart and any refusal of medications. We are educating all of our medication techs and our RN on the requirements as listed above and out new process on how to notify and the expectations on what to notify PCP about. All of our residents have been checked , updated and PCP notified if anything was needed ensure residents heath safety.

The Nurse will be monitoring the compliance daily during morning shift change and will communicate that during daily stand up with clinical management team as monthly QA.

The ED will provide support.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included clear parameters for administration of prescribed medications for 3 of 4 sampled residents (#s 1, 3 and 6) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 11/2018 with diagnoses including generalized abdominal pain.

Resident 1's 09/01/22 through 09/12/22 MARs were reviewed during the survey and were found to be lacking specific parameters to guide unlicensed staff in the following area:

* Multiple PRN bowel care medications lacked clear parameters for when to administer and which one should be given first.

On 09/15/22 and 09/16/22, the above findings were reviewed with Staff 1 (Administrator) and Staff 2 (LPN/Supervisor). They acknowledged the findings.

3. Resident 6 was admitted to the facility in 07/2018 with diagnoses including cerebral palsy and pain.

September 1 through 12, 2022 MAR and corresponding dates of progress notes were reviewed.

On 09/04/22, the MAR reflected the 2:00 pm doses of scheduled acetaminophen and ibuprofen (both for pain) was marked, "Other / See Progress Note."

There was no documented evidence of a corresponding progress note.

The need to ensure the resident's MARs were accurate and included correct documentation was discussed with Staff 1 (Administrator) on 09/15/22. No further information was received.

2. Resident 3 was admitted to the facility in 03/2014 with diagnoses including dementia and dorsalgia (back pain).

Resident 3's 08/01/22 through 09/12/22 MARs were reviewed. The following PRN medications were found to be lacking resident specific parameters to guide unlicensed staff:

* Acetaminophen Tablet 325 mg (for pain);

* Acetaminophen Suppository 650 mg (for pain);

* Aspercreme/Aloe Cream 10% (for pain);

* Haloperidol Lactate Concentrate 2 mg/ml (for agitation); and

* Morphine Sulfate Solution 100 mg / 5 ml (for pain).

The need to ensure MARs contained resident specific parameters and instructions for PRN medications was discussed with Staff 1 (Administrator) and Staff 2 (LPN / Supervisor) on 09/15/22. They acknowledged the findings.

Residents #1,3 and 6 will throughly be reviewed  by the RN and ED will be thoroughly reviewed and clarifications and training will be provided to all Medication Techs.

We have implememted new processes for physiciam order transcript and check to ensure clear parameters for when to administor and which one should be given first, resident specific paramemters to guide medication techs, ensuring residents MAR are accurate and include correct documentation.

We are educating all Medication techs and our RN as to the requirements and each part in our new process. All residents have been evaluated and updated as needed and signed by their physicians.

The RN and ED will attend the Role of the RN training or get training from the state approved consultant on proper administration and oversight of the MARS. We are also monitoring compliance daily and once satisfied with compliance we will move to monthly monitoring of the Medication Administraton records. If any errors occur, it will result in futher education as well as a analysis to identify the error and if any further actions need to be taken.

The ED will provide oversight.   

Based on interview and record review, it was determined the facility failed to complete quarterly evaluations to assure the ability to safely self-administer medications for 1 of 2 sampled residents (# 3) who self-administered prescription medications. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 03/2014 with diagnoses including asthma.

Resident 3's 08/01/22 through 09/12/22 MARs were reviewed and revealed s/he self-administered Albuterol Sulfate (for shortness of breath).

In an interview on 09/15/22 at 12:51 pm, Staff 2 (LPN / Supervisor) confirmed Resident 3's most current self-administration evaluation was dated 08/2020.

The need to evaluate the resident's ability to safely self-administer medications quarterly was discussed with Staff 1 (Administrator) and Staff 2 (LPN / Supervisor) on 09/15/22. They acknowledged the findings.

Resident #3's ability to self-administer medications has been evaluated and physicain orders obtained.

As we are implementing new processes for evaluation for that resident who wishes to self-administer that includes a RN assessment to see if resident is competent, obtain physician orders for perscription medications.  if  the assessment done by the RN and the resident is seen fit to self-administer and the physician agrees, it will be updated in residents evaluaion and service plan.

Monitoring will be conducted quarterly wit evaluations and service plans as well as with physician order review by the clinical management team.

The ED and RN will provide support.

2. Resident 10 moved to the facility in 04/2023 with diagnoses Type II diabetes.

Resident 10's 04/03/23 pre-move in initial evaluation indicated the resident self-administered insulin injection.

On 05/09/23 at 1:40 pm, Staff 32 (Med Tech) confirmed that the resident self-administered his/her insulin.

The resident's clinical records were reviewed and the following deficiencies were identified:  

* There was no physician order for self-administration of the insulin injection. Facility obtained the physician order during the survey after survey requested it; and

* The facility initiated an evaluation of self administration of medication on 05/01/23. However, the evaluation lacked documented evidence to determine if the resident could safely self-administered the insulin.

On 05/10/23 and 05/11/23, the failure to obtain a physician's order in a timely manner and evaluate the resident's ability to self-administer medications safely was discussed with Staff 22 (ED). She acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to evaluate a resident's ability to safely self-administer medications for 2 of 3 sampled residents (#s 9 and 10) who self-administered prescription medications. This is a repeat citation. Findings include, but are not limited to:

Resident 9 was admitted to the facility in 11/2016 with diagnoses including heart failure.

Resident 9's 05/01/23 through 05/08/23 MAR and TAR were reviewed and identified s/he self-administered Albuterol Sulfate (for shortness of breath) and polyvinyl alcohol solution (eye drops for dry eyes).

The MAR and physician orders identified staff were to administer an Albuterol Sulfate inhalation nebulization solution every six hours, as needed for wheezing or shortness of breath.

Review of the self administration of medications evaluation completed on 03/02/23 identified the resident was limited to only self administer topical creams, ointments and lotion for affected skin areas.  

Observations and interview with Resident 9 on 05/09/23 at 10:20 am identified the resident had a nebulizer, solution and supplies and an Albuterol inhaler in his/her room.  

During an interview with Staff 32 (MT) on 05/09/23 at 1:35 pm, she indicated the resident didn't have a nebulizer, supplies and solution in the med room. Staff 32 stated she was not aware they were supposed to administer the nebulizer.

The need to evaluate the resident's ability to safely self-administer all medications was discussed with Staff 22 (ED), Staff 15 (RSC) and Staff 29 (RSC) on 05/10/23. They acknowledged the findings.

*RN and RCC's to take c lass on Relias-"Assisting with Self-Administration of Medications; The Guidelines"

*Facility RN trainig on facility self-medication evaluation tool and requirements.

*New outside provider form created that all outside providers must fill out with each visit. These are kept at reception and will be requested from each visit to the facility. There is a warning on the form about checking all medications and equipment in at the med room first.

*Weekly Clinical Drill Down to ensure self med orders are in place and accurate.

*New policy that each self-med assessment must contain the last date the order was written by PCP for self medication ok.

With all of these auditing tools in place we will be able to remain in complinace.

These areas are ongoing evaluations along with a weekly evaluation.

RN, RCC's, and Administrator responsible for moitoring self and each other.

3. On 09/14/22 at 4:00 pm, the survey team requested call response logs from Staff 1. She stated she was not able to generate call response logs due to an old call system. Staff 1 confirmed that there was no system to ensure appropriate call light response times.

4. An unsampled resident's call light was activitated by the surveyor on 09/15/22 at 12:30 pm. Staff knocked on the resident's door at 12:49 pm to assist the resident, which constituted a 19 minute wait time.

The need to ensure there was a sufficient number of caregivers to meet the 24-hour scheduled and unscheduled needs of each resident was discussed with Staff 1 (Administrator) on 09/15/22. She acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to have a sufficient number of caregivers to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to:

1. During the entrance conference and acuity interview on 09/12/22 the following was identified:

* The facility consisted of three floors with resident rooms located on all three floors; and

* The facility had 79 residents.

An interview on 09/13/22 with Staff 1 (Administrator) and the facility's staffing plan for 09/2022 was as follows:

* During the day and swing shift, there were four caregivers; and

* During the night shift, there was one caregiver and one Med-Aide assigned to all three floor.

The facility used an ABST (Acuity Based Staffing Tool) which would determine a staffing plan. However, the facility failed to update the ABST when residents experienced a significant change of condition.

Refer to C 361.

2. A group interview was conducted on 09/13/22 at 10:30 am with seven unsampled residents. The residents were asked how long it took for staff to respond to call lights. The following information was reported:

* One resident waited one hour and 45 minutes for his/her call light to be answered;

* The same resident reported a different instance when s/he waited 45 minutes;

* Another resident always called the dispensary directly to request help due to long call light wait times; and

* A third resident purchased a medical alert system in case CGs did not arrive to help quickly during an emergency.

The facility will initiate the staffing tool provided by the state until an in-house tool is approved for use.

A complete review of resident acuity will be completed by shift to assure appropriate staff schedule to work to meet the scheduled and  unscheduled needs of  the residents.

Staff turnover will be evaluated weekly by the ED and management team at every level. Exit interview will be conducted for all staff that are termed.

The facility will havce a staffing agency contract in place for emergency use.

There will also be training the nurse and resident care coordinator to give update to ED to ensure the updating of the ABST tool when residents experience a singificant change of condition.

The staffing coordinator will have all shifts scheduled and the months schedule posted no later than the 15th of each month and have it approved by the ED to ensure the appropriate staffing levels are correct and covered.

The ED will provide oversite and support.

Based on interview and record review, it was determined the facility failed to update the ABST (Acuity Based Staffing Tool) for 2 of 2 residents (#s 3 and 6) who experienced a significant change of condition as defined in OAR 411-054-0005. Findings include, but are not limited to:

1. Resident 6 was admitted to the facility in 07/2018 with diagnoses including cerebral palsy.

The resident's service plan, temporary service plans, progress notes dated 06/13/22 through 09/12/22, RN assessment dated 08/15/22 and the ABST report was reviewed.

On 08/14/22, Resident 6 was sent to the hospital after a fall in the facility's courtyard that resulted in a fracture. The RN assessment dated 08/15/22 reflected an increase of the resident's care needs.

The ABST report for Resident 6 failed to reflect his/her current care needs and level of assistance in the following areas:

* Personal hygiene;

* Grooming;

* Dressing assistance;

* Assisting with bowel and bladder management;

* Transferring in and out of bed or a chair;

* Medication administration;

* Treatments;

* Monitoring physical conditions or symptoms;

* Responding to call lights;

* Safety checks, fall prevention; and

* Completing housekeeping and laundry tasks.

In an interview on 09/14/22, Staff 1 (Administrator) stated the RN failed to provide information regarding significant changes of condition to the facility's ABST coordinator.

The need to ensure the ABST tool was reviewed following a resident's significant change of condition was discussed with Staff 1 on 09/15/22. She acknowledged the findings.

2. Resident 3 was admitted to the facility in 03/2014 with diagnoses including dementia.

Resident 3's most current service plan, ABST (Acuity Based Staffing Tool) report, RN change of condition assessment dated 08/08/22 and progress notes dated 06/13/22 through 09/12/22 were reviewed and revealed the following:

a. Significant changes of condition were triggered on:

* 07/19/22 for significant weight loss; and

* 08/22/22 for decline in ADL function.

b. Resident 3's ABST report failed to reflect his/her current care needs in the following areas:

* Grooming;

* Dressing assistance;

* Assisting with bowel and bladder management;

* Assisting with ambulation to meals; and

* Monitoring physical conditions or symptoms.

The need to ensure the ABST tool was reviewed following a resident's significant change of condition was discussed with Staff 1 on 09/15/22 at 3:15 pm. She acknowledged the findings.

The community is implimenting a new process and policies to ensure there is a sufficient number of caregivers to meet the 24-hour scheduled and unscheduled needs of each residents.

The community is also getting quotes and having many meetings to get a new call system in our community to ensure that the residents are being helped within minutes of pressing their pendent.

A complete review of resident acuity will be completed by shift to assure appropriate staff are scheduled to work and the scheduled and unscheduled needs of each resident. Also please refer to C360

The RN and ED will be signing up for the class, "the role of the RN" to better understand the ABST when residents experienced a significant change of

condition and when it needs to be updated.

The ABST will be updated anytime there is a change in condition or a new resident moves into the facility. This will be reviewed daily in stand up as well as monthly for our QA,

The ED will provide support.

Based on interview and record review, it was determined the facility failed to ensure pre-service orientation in all required topics was completed and documented for 3 of 4 newly hired staff (#s 13, 18 and 19) and failed to ensure pre-service dementia training in all required topics was completed and documented for 1 of 2 newly hired direct care staff (# 13) . Findings include, but are not limited to:

Facility training records were reviewed on 09/14/22 with Staff 2 (LPN/Supervisor) and Staff 3 (Staffing and Education).

Staff 13 (CG) hired 05/12/22, Staff 18 (Dietary Aide) hired 07/19/22, and Staff 19 (Housekeeping) hired 08/12/22, lacked documented evidence of completing the following required elements of the pre-service orientation:

* Staff 13 lacked documentation of resident rights and values of CBC care, abuse reporting requirements, infectious disease prevention, job description and pre-service dementia training in all required areas;

* Staff 18 lacked documentation of resident rights and values of CBC care and abuse reporting requirements; and

* Staff 19 lacked documentation of resident rights and values of CBC care, abuse reporting requirements, fire safety and emergency procedures and written job description.

The need for new staff to complete the required pre-service orientation training and pre-dementia training before working with residents was reviewed with Staff 1 (Administrator), Staff 2 and Staff 3 on 09/15/22 and 09/16/22. They acknowledged the findings. No additional information was received.

Please refer to C372

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 sampled newly-hired direct care staff (#s 9, 12, 13 and 16) had documentation of demonstrated competency in all assigned job duties within 30 days of hire. Findings include, but are not limited to:

Review of training records with Staff 2 (LPN/Supervisor) and Staff 3 (Staffing and Education) on 09/14/22, identified Staff 9 (CG), Staff 12 (CG), Staff 13 (MT) and Staff 16 (CG) lacked documented evidence competency was demonstrated in the following required areas:

* The 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; and

* First Aid and abdominal thrust training.

The need to ensure newly-hired direct care staff demonstrated competency in all assigned job duties within 30 days of hire was discussed with Staff 1 (Administrator), Staff 2 and Staff 3 on 09/15/22 and 09/16/22. They acknowledged the findings. No further documentation was provided.

All staff are at risk for this deficiet practice.

The ED or designee will ensure staff#13 pre service orientation training below is completed.

* Staff 13 lacked documentation of

resident rights and values of CBC care,

abuse reporting requirements, infectious

disease prevention, job description and

pre-service dementia training in all

required areas;

The EDor desginee will ensure staff #18's pre- service orientation  training below is completed.

* Staff 18 lacked documentation of

resident rights and values of CBC care

and abuse reporting requirements;

The ED or designee will ensure staff#19's pre-service orientation training below is completed.

* Staff 19 lacked documentation of

resident rights and values of CBC care,

abuse reporting requirements, fire safety

and emergency procedures and written

job description.

The ED or designee will ensure that all pre-srvice orientation is completley completed with their certifications printed and put in the Matrix Binder to ensure completion. After all is completed, staff will be able to progress to on the floor training.

The staffing/education coordinator will bring the updated matrix to monthly QA and weekly 1:1 to complete an audit and ensure all staff are up to date.

The ED will provide support.

Based on interview and record review, it was determined the facility failed to ensure 1 of 3 long-term staff (#17) complete a minimum of 12 hours of annual training related to provision of care for persons in a community-based care setting, including six hours of annual in-service training on dementia care. Findings include, but are not limited to:

Reviewing the facility training records on 09/14/22 with Staff 2 (LPN/Supervisor) and Staff 3 (Staffing and Education), identified the following:

* Staff 17 (Med-Tech) hired 11/29/11, lacked documentation of a minimum of 12 hours of annual in-service training on topics related to provision of care and chronic disease in the Community Based Care population, including six hours of annual training on dementia care.

The need to ensure long-term direct care staff received a minimum of 12 hours of annual training was discussed with Staff 1 (Administrator), Staff 2 and Staff 3 on 09/15/22 and 09/16/22. They acknowledged the findings. No further documentation was provided.

All staff are at risk for this deficient practice.

The ED and staffing coordinator/education coordinator are implemeting a new process for staff's annual in-service training as well as 6 hours of dementia care.

* Staff 17 (Med-Tech) hired 11/29/11,

lacked documentation of a minimum of

12 hours of annual in-service training on

topics related to provision of care and

chronic disease in the Community Based

Care population, including six hours of

annual training on dementia care.

The ED will ensure that six hour dementia care training and in-services will be completed.

The ED or designee will do a full staff audit and dertermine wich staff needs to complete pre service training and have them completed and pulled from the  schedule until completed to ensure staff and resident safety.

From  this point on, all new hires will have to complete the six hour dementia care training and all pre service before on the floor training. All staff will be required to attend a mandortory staff meeting for their monthly 1 hour of in-service training.

The Staffing/Education coordinator will bring the matrix to the weekly QA and one on one with ED to ensure all staff are up to date with all trainings and to ensure long-term direct care staff received a minimum of 12 hours of annual training  

Based on interview and record review, it was determined the facility failed to ensure fire and life safety instruction to staff was provided on alternate months and that documentation reflected all required fire drill components. Findings include, but are not limited to:

On 09/13/22, fire drill and fire and life safety records were reviewed from 03/2022 through 08/2022. The following deficiencies were identified:

1. There was no documented evidence the facility was providing fire and life safety training on alternating months for staff.

2. The evacuation/drill documentation did not contain information on:

* Location of simulated fire origin;

* The escape route used;

* Evidence of alternate escape routes used;

* Residents who resisted or failed to participate in the drills;

* Evacuation time period needed; and

* The number of occupants evacuated.

The need to meet all requirements for fire drills and fire and life safety instruction was reviewed with Staff 1 (Administrator) on 09/13/22. She acknowledged the findings.

All residents are at risk for this  deficient practice.

The maintenance director or designee will be required that the following will be completed monthly;

1. There was no documented evidence

the facility was providing fire and life

safety training on alternating months for

staff

The maintenance director will conduct a fire and life sfety training on alternating months for all  staff and have a documeted training and give to the ED.

2. The evacuation/drill documentation

did not contain information on:

* Location of simulated fire origin;

* The escape route used;

* Evidence of alternate escape routes

used;

* Residents who resisted or failed to

participate in the drills;

* Evacuation time period needed; and

* The number of occupants evacuated.

The Maintance director will ensure that the items above will be documeted and ansered with the approperiate information for record and for futher education purposes and conduct these drills alternating shifts every month.

The maintenance Director or designee will provide an in-service monthly as well as a monthly QA ensuring the life and safety of residents.

The ED will provide support.

Based on interview and record review, it was determined the facility failed to conducted unannounced fire drills every other month and failed to document all required fire drill components in accordance with Oregon Fire Code (OFC). This is a repeat citation. Findings include, but are not limited to:

On 05/08/23, fire drill and fire and life safety records were reviewed from 01/2023 through 04/2023. The following deficiencies were identified:

There was no documented evidence the facility was conducting unannounced fire drill every other month and documenting all required fire drill components including the following:

* Location of simulated fire origin;

* The escape route used;

* Evidence of alternate escape routes used;

* Residents who resisted or failed to participate in the drills;

* Evacuation time period needed; and

* The number of occupants evacuated.

The need to conducted unannounced fore drill every other month and document all required fire drill components was reviewed with Staff 22 (ED) on 05/10/23. She acknowledged the findings.

*A yearly binder of life safety trainings has been created.

*Scheduled fire drills calendar created with ED and Facilities Director to include different times of day and different days of the week.

*The schedule for the next year has been created.

*Training done with all managers of the regulation.

*New documentaion form that includes required information for fire drills.

The schedule will help keep us in compliance, along with accountability. All managers have this calendar now.

This will be evaluated monthly to ensure trainings are complete for each month.

Facilities Director and Administrator responsible to see corrections are made, completed, and monitored.

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

Refer to C 270, C 280, C 303, C 325 and C 420.

To keep each plan in place for each tag. We will be incomplinace with the successful execution of each new  intervention tool.

New systems contain self auditing and auditing of others to help ensure compliance.

These are done daily, weekly, and monthly

Administrator, RN, RCC's, and Facilities Director.

Based on observation and interview, it was determined the facility failed to ensure all exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways were made of hard, smooth material and maintained in good repair, chemicals and toxic materials were maintained in a locked storage unit, and grounds were kept orderly and free of litter and refuse. Findings include, but are not limited to:

Facility grounds were toured from 09/12/22 through 09/14/22 and the following was identified:

* Multiple drop offs were observed throughout the campus grounds;

* An area located outside of the second floor's emergency exit, near Room 208, wing A, had an uneven area on the sidewalk and was a tripping hazard;

* De-icer was being stored in the first foyer of the main entrance of the building, which was accessible to residents; and

* There was refuse observed throughout the facility's grounds, in multiple common-use patios throughout the building and Room 210's patio area on wing D.

The facility grounds were toured with Staff 1 (Administrator) and Staff 6 (Campus Maintenance Manager) on 09/14/22. They acknowledged the above findings.

All resident are at risk for this deficient practice.

Maintenance Director or designee will clean, repair,or replace the following identified areas;

multiple drop offs were observed throughout the campus grounds and now there is one designated drop off. - An area located outside of the second floor's emergency exit near room #208, Wing A has an uneven sidewalk that is a tripping hazard - De-Icer was being stored in the first foyer of the main enterence o the building which was assessible to residents -and there was refuse observed throughout the facilities grounds, in multiple common use patios throughout the bulding and room #210's patio area on Wing D.

The ED or designee will identfy enviormental areas needeing repair,cleaning or replacemet during daily rounds and place these items in the maintenance binder to be addressed as well as discussed during daily stand  up.

The ED, Maintanence Director or designee will bring summary of any findings from the daily rounds and the completed QA quarterly for 6 consecutive quarters or util the deficient practice is resolved.

Based on observation and interview, it was determined the facility failed to ensure all interior and exterior materials and surfaces (e.g., floors, walls, ceilings and furniture) and all equipment necessary for the health, safety, and comfort of the resident was kept clean and in good repair. Findings include, but are not limited to:

The facility was toured from 09/12/22 through 09/14/22 and the following was identified:

1. Exterior

* There was a thick layer of cobwebs observed in the front, outside foyer by a pillar;

* Multiple common use patios throughout the building were in need of cleaning relating to dirt and cobwebs;

* Some of the furniture located in the common use outside patio areas was in disrepair;

* Multiple common use patios throughout the building were in disrepair, had splintering wood and were in need of paint;

* A gazebo located in the courtyard had exposed wood, loose floorboards, and the roof was in disrepair;

* Raised garden beds for resident use were observed to be in disrepair and had areas of splintering wood;

* The area outside the emergency exit located on the second floor, near Room 209 B had splintering wood on the handrails and was in need of painting; and

* The stairs located on the first floor, leading out to a courtyard, were in need of repair including the wood on the handrails was splintering, non-skid strips were coming off, and the bottom stair was loose.

2. First Floor

* Public use bathroom had missing linoleum around the baseboards and door threshold, a crack in the flooring, the wall behind the sink and toilet was in need of repair, and the drain had dark matter around it;

* The elevator closest to B hall was in need of paint around the casing and sides and the handrail located to the left was also in need of painting;

* The laundry room entrance door, the wall to the bottom left of the door and inside the laundry room behind the utility sink was in need of painting;

* There were multiple doors on all halls observed to be scuffed and in need of repair;

* There were multiple areas in need of painting and repair throughout all halls;

* The dining room was observed to have some chipped paint, have scuffing along the walls and the beverage station had areas where the linoleum was chipped;

* A pillar to the right of entering C hall was in disrepair;

* The laundry room on D hall had rust on a back wall;

* Room 107 D had stained carpet and part of the baseboard between the living room and bedroom was missing;

* The elevator located by D hall was observed to have chipped paint on the outside doors, casing and fire doors, and the inside of the elevator was scuffed, in need of paint and the number panel had a quarter sized shatter in the covering; and

* The door near D hall that led to the stairs was in need of painting around the handle.

3. Second Floor

* Room 210 D was observed to have carpet frayed by the door of the balcony and in hallway, the carpet transition plastic piece was lifting, the carpet was stained in the living room and near the kitchen, and there were black marks and gouges on the wall outside of the kitchen;

* Room 208 B was observed to have a hole to the right of the television measuring approximately two feet across by two inches wide, the bedroom door was in disrepair, the right lower area of the closet revealed exposed metal and the baseboard was peeling off, and the right lower side of the shower had exposed dry wall which was sharp to the touch;

* Multiple areas of the ceiling throughout all halls had exposed plumbing pipes, holes and water stains;

* There were stains on some of the furniture located in common areas;

* Common bathroom (sometimes locked for only staff use, but sometimes unlocked making it accessible to residents) had some plaster peeling where the toilet was mounted;

* There were multiple doors in need of repair throughout all halls;

* There were multiple areas in need of paint throughout all areas;

* The sliding door on B hall was difficult to open;

* The handrail to the left of the dispensary was rough to the touch;

* The lower areas of the benches where residents waited for their medications were scuffed and in need of painting;

* The hopper room located in the A hall had holes observed in the wall by the sink and a large rust colored stain was located behind the cold water handle on the hopper;

* The library was observed to have areas of chipped paint and cobwebs were present;

* The blue activity room walls were observed to have splatters and chipped paint, the patio door was dirty and in need of paint, there were dead bugs observed on the window sill, the cabinet under the sink was coming loose, and the drawers in the cabinet located under the sink had debris inside of them; and

* Both elevators had chipped paint, the elevator located by the D hall had an area to the right, lower wall in need of repair, and the fire doors were observed to have chipped paint.

4. Third Floor

* Room 304 D's patio door was difficult to open;

* The common use patio door located by Room 314 D was difficult to open;

* The recreation and multi-purpose room had a large stain on the carpet, two of five skylights had water stains present, and the paint beside the window was raised;

* The elevator casing and fire doors were in need of paint;

* The cove located to the right of the elevator had stains present on two blue chairs; and

* Multiple doors were in need of repair.   

The facility was toured with Staff 1 (Administrator) and Staff 6 (Campus Maintenance Manager) on 09/14/22. They acknowledged the above findings.

All residents are at risk for this deficient practice.

Maintenance director or designee will clean, repair, or replace the following identified areas;

Exterior:

- clean the thick layer of cobwebs observed in the front, outside foyer by a pillar, - multiple common use patios throughout the facility were in need of cleaning relating to dirt and cobwebs, -some of the funiture located in the commmon use outside patio areas was in disrepair, -Multiple common use patios throughout the facility we in disrepair and had splintering wood, and were in need of paint, -A gazebo located in the courtyard had exposed wood, loose floorboards, and the  roof was in disrepair, - The area outside the emergency exit located on the second floor, near room# 209B had splintering wood on the hand rails and was in need of  painting, and - The stairs  located on then first floor, leading out to  a courtyard, were in need of repair including  the wood on the handrails was splintering, non-skid strips were coming off and the bottom stair was loose.

First Floor: * linoleum around the baseboards and door threshold, a crack in the flooring, the wall behind the sink and toilet was in need of repair, and the drain had dark matter around it; * The elevator closest to B hall was in need of paint around the casing and sides and the handrail located to the left was also in need of painting; * The laundry room entrance door, the

wall to the bottom left of the door and inside the laundry room behind the utility sink was in need of painting; * There were multiple doors on all halls

observed to be scuffed and in need of repair; * There were multiple areas in need of painting and repair throughout all halls; * The dining room was observed to have some chipped paint, have scuffing along

the walls and the beverage station had areas where the linoleum was chipped; * A pillar to the right of entering C hall was in disrepair; * The laundry room on D hall had rust on a back wall; * Room 107 D had stained carpet and part of the baseboard between the living room and bedroom was missing; * The elevator located by D hall was observed to have chipped paint on the - Public use bathroom had missing, -outsidedoors, casing and fire doors, andthe inside of the elevator was scuffed, in need of paint and the number panel had a quarter sized shatter in the covering; and * The door near D hall that led to the stairs was in need of painting around the

handle.

Second Floor: * Room 210 D was observed to have

carpet frayed by the door of the balcony and in hallway, the carpet transition plastic piece was lifting, the carpet was stained in the living room and near the kitchen, and there were black marks and gouges on the wall outside of the kitchen; * Room 208 B was observed to have a hole to the right of the television measuring approximately two feet across by two inches wide, the bedroom door was in disrepair, the right lower area of the closet revealed exposed metal and the baseboard was peeling off, and the right lower side of the shower had exposed dry wall which was sharp to the touch; * Multiple areas of the ceiling throughout all halls had exposed plumbing pipes, holes and water stains;

* There were stains on some of the furniture located in common areas; * Common bathroom (sometimes locked for only staff use, but sometimes unlocked making it accessible to residents) had some plaster peeling where the toilet was mounted; * There were multiple doors in need of repair throughout all halls;

* There were multiple areas in need of paint throughout all areas; * The sliding door on B hall was difficult

to open; * The handrail to the left of the dispensary was rough to the touch; * The lower areas of the benches where residents waited for their medications were scuffed and in need of painting; * The hopper room located in the A hall had holes observed in the wall by the sink and a large rust colored stain was located behind the cold water handle on the hopper;

* The library was observed to have areas of chipped paint and cobwebs were present; * The blue activity room walls were observed to have splatters and chipped paint, the patio door was dirty and in

need of paint, there were dead bugsobserved on the window sill, the cabinet under the sink was coming loose, and the drawers in the cabinet located under

the sink had debris inside of them; and * Both elevators had chipped paint, the elevator located by the D hall had an area to the right, lower wall in need of

repair, and the fire doors were observed to have chipped paint.

Third floor:  * Room 304 D's patio door was difficult

to open; * The common use patio door located by

Room 314 D was difficult to open; * The recreation and multi-purpose room had a large stain on the carpet, two of five skylights had water stains present, and the paint beside the window was raised; * The elevator casing and fire doors were in need of paint; * The cove located to the right of the elevator had stains present on two blue chairs; and * Multiple doors were in need of repair.

The ED or designee will identify any enviornmental areas needing any repair, cleaning, or replacement and get quotes with schedule of repair date. Daily rounds will be done with ED and maintanence director weekly and items will be put into the maintance binder and will be adressed. The ED or designee will bring a summary of all findings from the daily and weekly rounds and the completed QA quarterly for six consecutive quarters or until the deficient practice is resolved.    

Based on observation and interview, it was determined the facility failed to ensure all doors that exited the building were equipped with operational alarming devices or other acceptable systems to alert staff when residents exited, and failed to ensure a manually operated emergency call system was provided in each toilet facility used by residents and visitors. Findings include, but are not limited to:

The facility was toured from 09/12/22 through 09/14/22 and the following was observed:

* Sliding glass doors located in common areas were not alarmed;

* Multiple exit doors did not have the alarm activated; and

* The public restrooms located on the first and second floors did not have a call system to alert staff if assistance was needed.

During the tour on 09/14/22, Staff 6 (Campus Maintenance Manager) reported all exit doors (with the exception of the sliding glass doors) were alarmed at night. The Oregon Administrative Rule was discussed and he enabled the alarms to be operable 24 hours a day.

The facility was toured with Staff 1 (Administrator) and Staff 6 on 09/14/22. They acknowledged the above findings.

All residents are at risk for this deficient practice.

The Maintanence director will required to fix the following areas or if not able to repair, The maintanence director will get at least three quotes from outside contractors to schedule the repair of the following;

* Sliding glass doors located in common

areas were not alarmed;

* Multiple exit doors did not have the

alarm activated

* The public restrooms located on the

first and second floors did not have a call

system to alert staff if assistance was

needed.

until the areas above are resolved, there will be more precautions and monitorng being provided by all staff through the building to ensure the safety of all residents during all shifts (24 hours ) until deficeint is resolved.

The Maintenance Director will be required do a daily walk through  of the building with and bring quotes to weekly one on one with ED to perceed with next steps to get these items adressed as soon as possible.

The ED will provide oversight.

Based on interview and record review, the facility failed to ensure each resident had the freedom and support to control their own schedule and activities for 2 of 7 unsampled residents and 1 of 5 sampled residents (#6) who were reviewed for medication schedules.

1. On 09/13/22 at 10:30 am, a group of seven residents were interviewed. Two out of the seven residents who were in the group identified that staff wake them up in order to go to the medication dispensary to receive their morning medications as early as 5:00 am. When asked if that was their choice, both residents confirmed they did not choose to get up that early for their medications.

2. Resident 6 was admitted to the facility in 07/2018 with diagnoses including cerebral palsy. A progress note dated 09/03/22 identified a staff member went into the residents room at 5:00 am with intent to administer the once a week medication alendronate sodium (for bone strength). The progress note quoted Resident 6 as telling the staff member s/he didn't want the medications and to get out of his/her room. A follow up note on the same day revealed the resident went to the medication dispensary at 5:20 am and asked for the medication, but the staff member had destroyed the medication and documented the resident refused to consent to physician's orders. When Resident 6 was told what the staff did, s/he "began to yell at writer and call writer names."

There was no documented evidence the staff member attempted to reapproach the resident relating to his/her refusal of the once weekly medication.

The need to ensure residents could choose what time they would like to wake up to take their medications was discussed with Staff 1 (Administrator) on 09/15/22. No further information was received.

All residents are at risk for this deficient practice.

Resident #6 service plan,evaluation will be updated to include their preferences to ensure the resident on what time they would like to wake up to take their medications.

All resident service plans will be reviewed to ensure residents have their preferences listed for our care staff or if you need to add them and make a TSP.

This will occur quarterly to assure compliance and that the resident preferences is reflected in the service plan.

Weekly interdisciplinary meetings will be implemented to review all residents.

All Staff will receive training on residents preferences and what those expectations look like.

The ED will provide oversight.