The findings of the change of ownership survey, conducted 08/05/24 through 08/08/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Tag numbers beginning with H refer to the Home and Community Based Services rules.

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 change of ownership survey of 08/08/24, conducted 12/30/24 to 01/02/25, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the second re-visit to the change of ownership survey of 08/08/24, conducted 07/15/25 through 07/16/25, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.

Based on observation, interview, and record review, it was determined the licensee failed to provide effective oversight to ensure the quality of care and services that were rendered in the facility. Findings include, but are not limited to:

During the change of ownership survey, conducted 08/05/24 through 08/08/24, oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number of citations.

Refer to deficiencies in report.

1.) Interim ED will provide administrator duties, oversight, and responsibilities until a permanent administrator is hired and trained.

2.) Ongoing oversight and review from vice president of operations.

3.) Weekly meetings to be held with the administrator and operations team to review for compliance and understanding.

4.) The ED and VPO is responsible for ensuring operational responsibilities and oversight are completed and monitored

Based on observation, interview, and record review, it was determined the licensee failed to provide effective oversight to ensure the quality of care and services that were rendered in the facility. This is a repeat citation. Findings include, but are not limited to:

During the first revisit of the change of ownership survey of 08/08/24, conducted 12/30/24 through 01/02/25, oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number of repeat citations and new citations.

Refer to deficiencies in report.

Refer to C 200, C 252, C 260, C 262, C 270, C 280, C303, C 305, C 325, C 420, C 455, C 613

Based on observation, interview, and record review, it was determined the facility failed to ensure residents' right to be treated with dignity and respect, to receive services in a manner that protects privacy and dignity, and to have a homelike environment for multiple sampled and unsampled residents. Findings include, but are not limited to:

1a. On 08/07/24 at 11:30 am, eight unsampled residents attended a group interview. Five of eight residents reported staff had not respected their privacy in their units due to entering units without first knocking and/or knocking and entering without waiting for a response. The following statements were made during the interview:

* "A lot of us want to acknowledge the staff and respond before they come in, but they'll just barge in without waiting.";

* "I don't feel like [the staff] respect us. I've asked several times for them to wait before they come into my apartment and they never do."; and

* "Staff will come right in, they won't even knock."

1b. Resident 1 was observed to have a sign on his/her door, asking staff to knock on the door and wait to be acknowledged prior to entering. During an observation on 08/07/24 at 10:48 am, a caregiver was observed to knock and enter the unit without waiting for the resident to respond.

2. On 08/07/24 at 11:30 am, eight unsampled residents attended a group interview. Four of eight sampled residents reported the Internet and television cable services were frequently down. Sampled Resident 2 also reported during an interview on 08/05/24 at 11:50 am that there was often no Internet or television working because the Internet router needed to be restarted multiple times a week, often in the evenings and on weekends when there was no staff there who had a key to the room the router was in.

Review of the facility's "Uniform Disclosure Statement" indicated that cable television and Internet service were both provided by the facility. During an interview at on 08/07/24, Staff 1 (Interim ED) stated the router was located in the administrative offices and verified it frequently required restarting. She further stated no one had access to the offices in the evening hours after and on the weekends, so residents were often without cable television and Internet services.

3. Observations of meal service to resident rooms indicated the facility used disposable serveware for residents who chose to eat in their rooms.

4. During the group interview held at 1:00 pm on 08/07/24, residents indicated unpleasant odors were present in the hallway near Room 142. Observations of the facility conducted during the survey, from 08/06/24 to 08/08/24, confirmed an unpleasant odor in the hallway outside of Room 142 that did not dissipate.

The need to ensure residents' right to privacy, dignity, respect, and a homelike environment was discussed with with Staff 1, Staff 5 (Regional Vice President of Operations), and Staff 6 (RN Consultant) at 1:30 pm on 08/07/24. They acknowledged the findings.

1.) The community will enforce a policy requiring staff to knock and wait, a voice friend memo and ISP will be used immediately to notify staff with follow up training in an all staff meeting. The internet router has been made accessable to staff at all times to restart it if needed. Non-disposable serveware will be used for resident's that eat in their apartments.  

2.) The community will implement regular audits to ensure staff follow privacy policies, provide staff with consistent access to the router room, and maintain a cleaning schedule to prevent odors.

3.) Privacy adherence will be reviewed monthly, Internet and cable services daily, and odors weekly until resolved, then monthly.

4.) The ED will oversee privacy and staff training, the ESD will ensure router room access and service monitoring, and the Environmental Services team will address and prevent odors.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents' right to be treated with dignity and respect, to receive services in a manner that protects privacy and dignity, and to have a homelike environment for multiple sampled and unsampled residents. This is a repeat citation. Findings include, but are not limited to:  

a. On 12/30/24, three unsampled residents approached the surveyor after finishing their lunch meal. During an interview on 12/30/24 at 12:24 pm, they reported the Internet services were frequently down, and the cable service provider had recently changed. Since the change, one of the unsampled residents reported that cable no longer worked in his/her unit.

During an interview on 12/31/24 at 11:15 am, Staff 26 (ED) indicated that cable television and Internet service were both provided by the facility per their Uniform Disclosure Agreement. He confirmed the facility had recently changed cable providers, and the Internet was scheduled to be upgraded next week.  

b. Observations of meal service to resident rooms indicated the facility used disposable serveware for residents who chose to eat in their rooms.

The need to ensure residents' right to privacy, dignity, respect, and a homelike environment was discussed with Staff 26 (ED) on 01/02/25 at 12:15 pm. He acknowledged the findings.

1.Internet and cable TV outage issues were addressed by procuring a new service provider and new equipment installed on 1/7/2025. Disposable service ware, utilized during construction in the kitchen, has ceased as construction was completed by 1/22/24.

2.Resident grievance policy and procedure will be reviewed with residents and all staff in 2/10/25 meeting. Policy for appropriate use of disposable serve ware will be reviewed with dining services leadership and residents who may be impacted will receive advance notice.

3.Internet service checks will be conducted monthly. Observation of meal delivery and use of appropriate flatware and serve ware to be made during daily walking rounds.

4.Executive Director, Maintenance Director

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 (# 5) and failed to ensure evaluations were performed at least quarterly, to correspond with the quarterly service plan updates, for 2 of 5 sampled residents (#3 and 6) whose evaluations were reviewed. Findings include, but are not limited to:

1. Resident 5 was admitted to the facility in 06/2024 with diagnoses including chronic obstructive pulmonary disease and hypertension.

The resident's 06/28/24 move-in evaluation was reviewed. There was no documented evidence the following elements were addressed:

* Customary Routines: sleeping;

* Visits to health practitioners, emergency room, hospital or skilled nursing facilities;

* Memory, orientation, confusion and decision-making abilities;

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

* Hearing, vision, speech, assistive devices;

* Ability to use call system;

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

* Skin condition;

* List of treatments needed;

* Indicators of nursing needs including potential for delegated nursing tasks;

* Emergency evacuation ability;

* History of dehydration or unexplained weight loss or gain;

* Recent losses;

* Elopement risk or history; and

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

The need to ensure move-in evaluations included all required elements was discussed with Staff 1 (Interim ED), Staff 2 (RN), Staff 3 (RCC), Staff 5 (Regional Vice President of Operations), Staff 6 ( RN Consultant) and Staff 17 (MT/RCC Assistant).  They acknowledged the findings.

2. Resident 3 was admitted to the facility in 08/2017 with diagnoses including macular degeneration and osteoarthritis. A review of the resident's record identified that there were no quarterly evaluations completed between 06/22/23 and 08/01/24.

Staff 3 (RCC) reported in an interview on 08/07/24 that there were no evaluations completed between 06/22/23 and 08/01/24.

The need to ensure resident evaluations were completed quarterly was discussed with Staff 1 (Interim ED), Staff 2 (RN), Staff 3, Staff 5 (Regional Vice President of Operations), Staff 6 (RN Consultant), and Staff 17 (MT/RCC Assistant) on 08/08/24. They acknowledged the findings.

3. Resident 6 was admitted to the facility in 12/2022 with diagnoses including chronic obstructive pulmonary disease and dysphagia (difficulty swallowing) due to Schatzki ring.

The resident's evaluation was dated 06/20/24. The resident's most recent evaluation prior to 06/20/24 was dated 01/10/24.

There was no documented evidence the resident's evaluation had been updated quarterly.

The need to update evaluations quarterly was reviewed with Staff 1 (Interim ED), Staff 2 (RN), Staff 3 (RCC), Staff 5 (Regional Vice President of Operations), Staff 6 (RN Consultant), and Staff 17 (MT/RCC Assistant) on 08/08/24 at 11:34 am. They acknowledged the findings.

1.) Resident #5's service plan will be updated to include customary routines: sleeping, visits to health practitioners, emergency room, hospital or skilled nursing facilities, memory, orientation, confusion and decision making abilities, Personality: including how the person copes with change or challenging situations, hearing vision, speech, assistive devices, ability to use call system, pain: pharmaceutical and non-pharmaceutical interventions including how a person expressing pain and discomfort, skin condition, list of treatments needed, indicators of nursing needs including potention for delegated nursing tasks, emergency evacuation ability, history of dehydration or unexplained weight loss or gain, recent losses, elopement risk or history and environmental factors that impact the resident's behavior including, but not limited to: noise, lighting, room temperature. Resident #3 & #6 service plan will be evaluated quarterly.

2.) All components of move-in evaluations will be completed accurately and will reflect resident prior to moving in. Move-in evaluations to be completed by HSD, ED, and/or RCC. HSD, ED, and RCC to review move-in evaluation together to ensure all components of move-in evaluations are completed. Team to decide together whether resident is appropriate for community's setting based on move-in evaluation. Move in checklist will be completed with each evaluation to ensure completion.

3.) Evaluations will be kept up to date quarterly and as needed. ED and RCC will be responsible to ensure that all components of move-in evaluations are completed efficiently and accurately.

4.) It is the responsibility of the ED and RCC to ensure this is monitored and completed

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements and described the current condition of the resident for 1 of 1 sampled residents reviewed for new move in (#7), and failed to be updated within 30 days of move in, quarterly and/or after significant changes of condition for 4 of 4 sampled residents (#s 7, 8, 9, and 10).  This is a repeat citation. Findings include, but are not limited to:

1. Resident 7 was admitted to the facility in 11/2024 with diagnoses including type II diabetes, bacteremia, encephalopathy, and post surgery recovery from an intraspinal abscess.

a. The resident's 11/25/24 move-in evaluation was reviewed. There was no documented evidence the following elements were accurately evaluated:

* Customary Routines: eating, sleeping, bathing;

* Visits to health practitioners, emergency room, hospital;

* Memory, orientation, confusion and decision-making abilities;

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

* Skin condition;

* Indicators of nursing needs including potential for delegated nursing tasks;

* History of dehydration or unexplained weight loss or gain;

* Transfers and assistive devices including use of bilateral side rails;

* To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: Name; Pronouns; and Gender identity.

b. Resident 7's move-in evaluation documented no skin issues.

In interview on 01/02/25, Staff 2 (RN) stated Resident 7 had been admitted with a pressure ulcer, however, there was no documented evidence the wound had been noted on the admission evaluation, the initial service plan, or the MAR.  

c. In interview on 01/02/25 Staff 2 (RN) acknowledged the initial evaluation was not updated and modified as needed during the 30 days following the resident's move into the facility.

The need to accurately evaluate all required areas of the move-in evaluation, and update within 30 days after admission was reviewed with Staff 26 (ED) and Staff 17 (RCC) on 01/02/25. They acknowledged the findings.

2. Resident 10 was admitted to the facility in 07/2023 with diagnoses including suspected lung cancer and severe protein-calorie malnutrition.

Resident 10's quarterly evaluation, due in 11/2024, was not completed.

The need to ensure quarterly evaluations were completed timely was discussed with Staff 26 (ED) and Staff 17 (RCC) on 01/02/25. They acknowledged the findings.

3. Resident 9 moved into the facility in 10/2011 with diagnosis including diabetes mellitus type II, neuropathy, and Binswanger disease.

The resident's record was reviewed, and the following was identified:

a. The resident's most recent evaluation was dated 08/27/24 and was not performed at least quarterly.

b. On 12/09/24, the resident experienced a significant change of condition, related to an ankle fracture, and there was no documented evidence an evaluation was reviewed and completed for the significant change.

The need to ensure evaluations were performed at least quarterly and were reviewed and updated each time a resident experienced a significant change of condition was discussed with Staff 26 (ED) on 01/02/25 at 3:32 pm. He acknowledged the findings.

4. Resident 8 moved into the facility in 06/2024 with diagnoses including prostate cancer, congestive heart failure, and ascites (excessive abdominal swelling).

The resident's record was reviewed, and the following was identified:

On 12/07/24, the resident experienced a significant change of condition, related to significant weight gain, and there was no documented evidence his/her evaluation was reviewed and completed for the significant change, as the resident's most recent evaluation was dated 10/08/24.

The need to ensure evaluations were performed at least quarterly and were reviewed and updated each time a resident experienced a significant change of condition was discussed with Staff 26 (ED) on 01/02/25 at 12:20 pm. He acknowledged the findings.

 1.A checklist for all required evaluation and service plan elements has been obtained. Evaluations for residents 7, 8, and 9 were revised by 1/30/2025 to include missing elements. Resident 10 is no longer in the community.

2.Resident evaluations to be conducted at move-in and updated within 30 days, with significant change of condition, and at least quarterly. An audit to be conducted to ensure that all residents have had an evaluation within the last 90 days. Overdue evaluations will be brought into compliance by 2/16/25.  The community will create, maintain, and follow an evaluation schedule for each resident in Point Click Care. An evaluation checklist to be utilized to ensure all components are addressed.

3.Evaluation due dates to be reviewed in daily clinical meeting. Weekly audit to ensure the schedule is being followed. Evaluations completed as scheduled to be added to QA program agenda.

4.Health Services Director, Care Coordinator(s), Executive Director   

2. Resident 2 moved into the facility in 12/2021 with diagnoses including rheumatoid arthritis, depression, hepatic cirrhosis, and chronic pain.

The current service plan, dated 06/19/24, and interim service plans, progress notes, outside provider visit notes, and incident reports from 05/05/24 through 08/05/24 were reviewed. Observations and interviews with staff and Resident 2 were completed during the survey. The following was identified:

The service plan was not reflective and did not provide clear instructions for staff in the following areas:

* History of significant weight loss;

* Pressure reducing cushion in wheelchair;

* Cigarette smoking; and

* Cat care.

The need to ensure the service plan reflected Resident 2's care needs and included clear directions to staff regarding the delivery of services was discussed with Staff 1 (Interim ED), Staff 2 (RN), Staff 3 (RCC), Staff 5 (Vice President of Clinical Operations), Staff 6 (RN Consultant), and Staff 17 (MT/RCC Assistance) on 08/08/24. They acknowledged the findings.

3. Resident 3 moved into the facility in 08/2017 with diagnoses including macular degeneration, osteoarthritis, and cerebral vascular accident.

Observations and interviews with staff and Resident 3, and a review of the resident's most current service plan, dated 08/01/24, showed the service plan was not reflective, did not provide clear direction to staff, and/or was not implemented in the following areas:

* Edentulous (no teeth or dentures worn);

* Nicotine use (chewing tobacco);

* Divided section plate for meals;

* Preference for all meals in room;

* Dressing;

* Visual impairment with staff instructions;

* Compression stocking compliance;

* Side rails;

* Ambulation assistance;

* Wheelchair use; and

* Preference to sleep in during the morning.

The need to ensure service plans were reflective of current care needs, provided clear direction to staff, and were implemented was discussed with Staff 1 (Interim ED), Staff 2 (RN), Staff 3 (RCC), Staff 5 (Vice President of Clinical Operations), Staff 6 (RN Consultant), and Staff 17 (MT/RCC Assistance) on 08/08/24. They acknowledged the findings.

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

1. Resident 4 moved into the facility in 04/2017 and had diagnoses including delusions and aortic valve stenosis.

The resident's current service plan, dated 07/25/24, was reviewed, observations were made, and interviews were conducted. The service plan was not reflective of the resident's needs and preferences, did not provide clear instruction to staff, and/or was not implemented in the following areas:

* Toileting reminders and assistance needed;

* Safety checks;

* Assistive devices, including use of a bed cane and shower chair;

* Use of emergency pendent and monitoring;

* Outside providers, including home health nursing, PT, and OT;

* Ability to wear glasses independently;

* Skin conditions, including monitoring and instruction to staff;

* Meal reminders and escorts to the dining room;

* Nutritional shakes, including instruction to staff; and

* Self-administration of medication left at bedside.

The need to ensure service plans were reflective of resident needs and preferences, provided clear direction to staff, and were implemented was discussed with Staff 1 (Interim ED), Staff 2 (RN), Staff 3 (RCC), Staff 5 (Regional Vice President of Operations), Staff 6 (RN Consultant), and Staff 17 (MT/RCC Assistant) on 05/08/24. They acknowledged the findings.

1.) Resident #4's service plan will be updated to be reflective of their needs with clear instruction to staff to  include: toileting reminders and assistance needed, assitive devices, including use of a bed cane and shower chair, use of emergency pendant and monitoring, outside providers, including home health nursing, PT and OT, ability to wear glasses independently, skin conditions including monitoring and instructions for staff, meal reminders and escorts to the dining room, nutritional shakes, including instruction to staff, and self-administration of a medication left at bedside. Resident #2's service plan will be updated to be reflective of their needs with clear instruction to staff to include: history of significant weight loss, pressure reducing cushion in wheelchair, cigarette smoking and cat care. Resident #3's service plan will be updated to be reflective of their needs with clear instruction to staff to include: edentulous, nicotine use, divided section plate for meals, preference for all meals in room, dressing, visual impairment with staff instructions, compression stocking compliance, side rails, ambulation assistance, wheelchair use, preference to sleep in during the morning.

2.) The RCC and HSD will receive training on regulations as well as the community's policy and procedure for Service Planning requirements to ensure that service plans are reflective of residents' current status, include clear directions to staff on how to provide care and are readily available to care staff. A Service Plan schedule will be maintained and reviewed at daily morning stand up meeting.

3.) The area needing correction will be audited weekly until in compliance and then monthly ongoing.

4.) It is the responsibility of the ED and RCC to ensure that service plans are up to date and reflective of all needs.

2. Resident 7 was admitted to the facility in 11/2024 with diagnoses including type II diabetes, bacteremia, encephalopathy, and post surgery recovery from an intraspinal abscess.

The resident's initial service plan, dated 11/25/24, was reviewed, observations were made, and interviews were conducted with the resident, resident's family, and caregivers. The service plan was not reflective of the resident's needs, did not provide clear instruction to staff, and/or was not implemented in the following areas:

* Bilateral side rail use; instructions for caregivers and precautions related to the devices;

* Presence of coccyx wound with precautions and monitoring instructions;

* Instructions for caregivers providing catheter care; and

* Home health services and contact information.

The need to ensure service plans were updated quarterly was discussed with Staff 2 (RN, Health Services Director), Staff 26 (ED) and Staff 17 (RCC) on 01/02/25. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were completed following quarterly evaluations, were reflective of the resident's needs, provided clear direction to staff, reviewed and updated as needed when the resident experienced a significant change of condition, and/or were implemented for 4 of 4 sampled residents (#s 7, 8, 9 and 10) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 10 was admitted to the facility in 07/2023 with diagnoses including suspected lung cancer and severe protein-calorie malnutrition.

The current service plan, dated 08/28/24, had not been updated quarterly.

The need to ensure service plans were updated quarterly was discussed with Staff 26 (ED) and Staff 17 (RCC) on 01/02/25. They acknowledged the findings.

3. Resident 8 was admitted to the facility in 06/2024 with diagnoses including prostate cancer, congestive heart failure, and ascites (excessive abdominal swelling).

a. The current service plan, dated 08/16/24, had not been updated quarterly following an evaluation.

b. The resident's current service plan, dated 08/16/24, was reviewed, observations were made, and interviews were conducted with the staff. The service plan was not reflective of the resident's needs, did not provide clear instruction to staff, and/or was not implemented in the following areas:

* Assistive devices and assistance required for mobility;

* Assistance required for ADLs;

* Hospice provider and contact information;

* Bathing services were provided by hospice;

* Recent losses, including death of family members;

* Assistance required with catheter management;

* Assistance required with medication management and administration;

* Use of oxygen;

* Weight changes; and

* History of fluid retention.

c. On 12/07/24, the resident had a significant and severe weight gain, which constituted a significant change of condition. There was no documented evidence the resident's service plan was reviewed and updated to reflect the resident's current care needs.

The need to ensure service plans were reflective of resident's current care needs, completed at least quarterly, and were reviewed and updated each time a resident experienced a significant change of condition was discussed with Staff 26 (ED) on 01/02/25. He acknowledged the findings.

4. Resident 9 moved into the facility in 10/2011 with diagnosis including diabetes mellitus type II, neuropathy, and Binswanger disease.

The resident's record was reviewed, and the following was identified:

a. Resident 9's current service plan was dated 08/27/24 and was not updated at least quarterly following an evaluation.

b. The resident's service plan dated 08/27/24 was not readily available to staff.

c. On 12/09/24, the resident experienced a fall that resulted in an ankle fracture which constituted a significant change of condition. There was no documented evidence the resident's service plan was reviewed and updated to reflect the resident's current care needs.

The need to ensure service plans were completed at least quarterly and were reviewed and updated each time a resident experienced a significant change of condition was discussed with Staff 26 (ED) on 01/02/25 at 3:32 pm. He acknowledged the findings.

Surveyor: Cataldo, Debby

1.A checklist for all required evaluation and service plan elements has been obtained. Residents 7, 8, and 9 service plans were reviewed and updated by 1/30/2025 to include missing elements, to reflect each resident's individual needs based on the revised evaluation and to provide clear instructions.  Resident 10 is no longer in the community.

2.Resident service plans will be created move-in and updated within 30 days, with a change of condition, and at least quarterly. An audit to be conducted to ensure that all residents have had a service plan in place that contains all required elements, reflects each resident's individual needs and provides clear instructions to staff. Overdue service plan reviews will be brought into compliance by 2/16/25. The community will create, maintain, and follow a service plan review schedule that corresponds with evaluation reviews for each resident. Consultant team will provide guidance and training on the service plan process and provide a service plan checklist to utilize. All service plans to be reviewed by nursing and clinical team to ensure accuracy of information.

3.Service plan due dates to be reviewed in daily clinical meeting. Weekly audit to ensure the schedule is being followed. SP revisions completed to be added to QA program agenda.

4.Health Services Director, Care Coordinator(s), Executive Director

Based on interview and record review, it was determined the facility failed to ensure the service plan was developed by a service planning team consisting of the resident, the resident's legal representative, if applicable, any person of the resident's choice, the facility administrator or designee, and at least one other staff person who was familiar with, or who was going to provide services to, the resident for multiple sampled and unsampled residents. Findings include, but are not limited to:

* On 08/07/24 at 11:30 am, eight unsampled residents attended a group interview. All eight residents confirmed they had not been involved in developing their service plans; and

* Records for Residents 1, 4, and 6 were reviewed, and residents were interviewed. There was no documented evidence of a service planning team, and the residents confirmed they had not been involved in their service planning.

The need to ensure a service planning team was used to update service plans was discussed with Staff 1 (Interim ED) on 08/07/24. She acknowledged the findings.

1.) Residents #1, #4, and #6 service plans will be updated and developed with a service planning team. Care Conferences will be scheduled and held to include the resident, responsible party or person identified by the resident, the RCC and at least one other staff person who is familiar with or provides services to the resident.

2.) A service plan/care conference schedule will be implemented and reviewed daily at morning stand-up meeting. Department managers will be sent calendar invites for all scheduled care conferences as well as invite to care provider. The RCC will maintain the schedule and assure residents, family or responsible party and outside providers notified by letter and follow up call for confirmation.

3.) Service Plan schedule will be reviewed daily at stand up meeting until compliance is achieved and then weekly ongoing.

4.) It is the responsibility of the RCC and ED to ensure the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure the service plan was developed by a service planning team consisting of the resident, the resident's legal representative, if applicable, any person of the resident's choice, the facility administrator or designee, and at least one other staff person who was familiar with, or who was going to provide services to, the resident for 4 of 4 sampled residents (#s 7, 8, 9, and 10). This is a repeat citation. Findings include, but are not limited to:

Records for Residents 7, 8, 9, and 10 were reviewed. There was no documented evidence of a service planning team. Residents 7, 9, and 10 confirmed they had not been involved in their service planning.

The need to ensure a service planning team was used to update service plans was discussed with Staff 26 (ED) on 01/02/25. He acknowledged the findings.

1.Care conferences were held for residents 7, 8, and 9 on 2/10, 2/11, and 2/12 respectively. Resident 10 is no longer in the community.

2.Care Coordinator(s) to arrange for care conference meetings with administrator and/or a designee and at least one other staff who is familiar with resident, the resident and anyone else of the resident's choosing or who may be providing services to the resident, that correspond with each resident's evaluation and service plan review schedule.

3.Care conference due dates and scheduled meetings to be reviewed in daily clinical meetings. Weekly audit to ensure the schedule is being followed and that meetings are being documented. Care Conference completions to be added to QA program agenda.

4.Executive Director, Health Services Director.

2. Resident 2 was admitted to the facility in 12/2021 with diagnoses including hepatic cirrhosis, depression, and insomnia.

The resident's current service plan dated 06/19/24, progress notes, temporary service plans, and incident reports dated 05/05/24 through 08/05/24 were reviewed.

The following short-term changes of condition lacked monitoring of progress noted at least weekly through resolution:

* 05/05/24 - Ongoing coccyx wound;

* 05/05/24 - New order for multivitamin daily;

* 05/11/24 - Boost drink supplement ordered twice daily;

* 06/09/24 - Symptoms of urinary tract infection;

* 06/17/24 - Fall with head strike;

* 06/17/24 - Fall with skin tear to right arm;

* 06/24/24 - Non-injury fall;

* 06/24/24 - Fall with head strike;

* 07/15/24 - Non-injury fall;

* 07/17/24 - Two non-injury falls;

* 07/24/24 - Fall with skin tear to right upper arm; and

* 07/26/24 - Fall with skin tears to right lower arm.

The need to ensure changes of condition had actions/interventions determined and monitored through resolution was discussed with Staff 1 (Interim ED), Staff 2 (RN), Staff 3 (RCC), Staff 5 (Regional Vice President of Operations), Staff 6 (RN Consultant), and Staff 17 (MT/Assistant RCC) on 08/08/24. They acknowledged the findings.

3. Resident 3 was admitted to the facility in 08/2017 with diagnoses including cerebral vascular accident, hypertension, and macular degeneration.

The resident's 08/01/24 service plan, progress notes, temporary service plans, and incident reports dated 05/05/24 through 08/05/24 were reviewed.

The following short-term changes of condition lacked monitoring of progress noted weekly through resolution:

* 05/07/24 - Re-admit from hospital;

* 05/27/24 - Rash;

* 06/03/24 - Symptoms of urinary tract infection;

* 06/09/24 - Emergency room transport for pain, dysuria. Diagnosis Urinary tract infection. Antibiotic ordered;

* 06/20/24 - Rash with MD order for cream to treat; and

* 07/22/24 - Increase in pregabalin medication.

The need to ensure changes of condition had actions/interventions determined and monitored through resolution was discussed with Staff 1 (Interim ED), Staff 2 (RN), Staff 3 (RCC), Staff 5 (Regional Vice President of Operations), Staff 6 (RN Consultant), and Staff 17 (MT/Assistant RCC) on 08/08/24. They acknowledged the findings.

4. Resident 5 was admitted to the facility in 06/2024 with diagnoses including chronic obstructive pulmonary disease and hypertension.

The resident's 07/28/24 service plan and progress notes dated 06/28/24 through 08/05/24 were reviewed.

The following short-term changes of condition lacked monitoring of progress noted weekly through resolution:

* 06/2024 - Admit to facility; and

* 07/12/24 - Heat rash to right leg and elbow.

The need to ensure changes of condition had actions/interventions determined  monitored through resolution was discussed with Staff 1 (Interim ED), Staff 2 (RN), Staff 3 (RCC), Staff 5 (Regional Vice President of Operations), Staff 6 (RN Consultant), and Staff 17 (MT/Assistant RCC) on 08/08/24. They acknowledged the findings.

5. Resident 4 moved into the facility in 04/2017 and had diagnoses including delusions and aortic valve stenosis.

The resident's 07/25/24 service plan, interim service plans (ISPs), incident reports, and 05/13/24 through 08/05/24 progress notes were reviewed. Observations were made, and staff and the resident were interviewed. The following was identified:

There was no documented evidence resident-specific actions or interventions were determined for short-term changes of condition, the actions or interventions were communicated to staff on all shifts, and/or changes were monitored through resolution, with progress noted at least weekly, for the following:

* 06/14/24 - Positive for COVID, cough, and sore throat;

* 06/14/24 - New medications;

* 07/08/24 - Injury fall in bedroom;

* 07/14/24 - New confusion and diagnosis of pneumonia;

* 07/18/24 - New medications;

* 07/18/24 - Injury fall in resident's living room and new complaints of pain;

* 07/24/24 - Change of condition, updated service plan, change in ADLs;

* 07/29/24 - New medications;

* 07/30/24 - New medications;

* 07/29/24 - New nutritional shake order; and

* 07/29/24 - Medication discontinuation.

On 08/07/24 at 1:50 pm, Staff 3 (RCC) and Staff 17 (MT/RCC Assistant) confirmed there was not a consistent system in place to monitor and ensure actions or interventions were effective through resolution.

The need to ensure there was a system to identify short-term changes of condition, determine and document what actions or interventions were needed, ensure actions or interventions were communicated with staff on all shifts, and ensure changes were monitored, with at least weekly documentation of progress, through resolution was discussed with Staff 1 (Interim ED), Staff 2 (RN), Staff 3, Staff 5 (Regional Vice President of Operations), Staff 6 (RN Consultant,) and Staff 17 on 08/08/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to, determine actions/interventions needed, communicate actions or interventions to staff on all shifts, and monitor changes through resolution, with at least weekly documentation for 5 of 6 sampled residents (#s 2, 3, 4, 5, and 6) reviewed with short term changes of condition? Findings include, but are not limited to:

1. Resident 6 was admitted to the facility in 12/2022 with diagnoses including chronic obstructive pulmonary disease and dysphagia (difficulty swallowing) due to Schatzki ring.

The resident's 06/20/24 service plan, 05/13/24 through 07/29/24 progress notes, and interim service plans (ISPs) were reviewed, and interviews with staff and the resident were completed. The following was identified:

* The resident experienced symptoms of a urinary tract infection on 05/16/24; and

* A progress note written on 05/31/24 indicated the resident had an order for Nystatin suspension (for a fungal infection in the mouth), to be taken four times a day "until lesions have been gone for 2 days" and to notify the prescriber if there was no improvement after 28 days.

There was no documented evidence these changes were monitored through resolution, with at least weekly documentation.

The need to monitor short-term changes of condition and document progress at least weekly was discussed with Staff 1 (Interim ED), Staff 2 (RN), Staff 3 (RCC), Staff 5 (Regional Vice President of Operations), Staff 6 (RN Consultant), and Staff 17 (MT/RCC Assistant) on 08/08/24. They acknowledged the findings. No additional information was provided.

1.) Resident #6 progress notes will be updated by the HSD to reflect the following short term changes of condition progress and resolution; urinary tract infection symptoms and fungal infection in the mouth with nurse assessment and notification to provider. Resident #2 progress notes will be updated to reflect the following short term changes of condition; ongoing coccyx wound, order for daily multivitamin, Boost supplement drink, fall with head strike X2, fall with skin tear to right arm, non-injury fall X4, fall with skin tear to right upper arm, and fall with skin tear to right lower arm. Resident #3 progress notes will be updated to reflect  the following short term changes of condition progress/resolution: return from hospital, rash, symptoms of a urinary tract infection, emergency room transport for pain, dysuria and diagnosis of a urinary tract infection with prescribed antibiotic, rash with MD order for cream to treat, and increase in pregabalin. Resident #4 progress notes will be updated by the nurse to reflect the progression/resolution of COVID positive, new medications and medication discontinuation, injury fall in bedroom, new confusion and diagnosis of pneumonia, new medications, injury fall in living room and pain, change of condition with updated service plan and change in ADL's, and nutritional shake order. Resident #5 progress notes will updated by the nurse to reflect progress and resolution of admission to facility and heat rash to right leg and elbow.

2.) Training will be provided to the RCC, HSD, and med techs to ensure systems and policy and procedure are understood and followed. Short-term changes of condition will be evaluated with actions and/or interventions documented and communicated to staff on all shifts with appropriate monitoring by HSD at least weakly until resolution.

3.) The area needing correction will be evaluated weekly during high risk meetings.

4.) It is the responsibility of the ED, HSD and RCC to ensure the corrections are completed and monitored.

2. Resident 7 was admitted to the facility in 11/2024 with diagnoses including type II diabetes, bacteremia, encephalopathy, and post surgery recovery from an intraspinal abscess.

The resident's 11/25/24 service plan, 11/25/24 through 12/30/24 progress and observations notes, and interim service plans (ISPs) were reviewed, and interviews with staff and the resident were completed. The following was identified:

An 11/30/24 progress note documented the discovery of a coccyx wound. An ISP was created on 12/2/24 with the instruction to report changes to the RN, RCC and med tech. The wound was monitored from 12/2/24 until 12/17/24 with no further documentation.

In interview on 1/02/24, Staff 2 (RN) stated the coccyx wound was present at admission, however, there was no documented evidence the wound had been evaluated, interventions developed, and monitored weekly until resolution. Staff 2 stated the wound was now closed, however, there was no documented evidence of wound monitoring after 12/17/24 or when it had resolved.

The need to ensure resident care needs were evaluated, interventions developed and communicated to staff on all shifts, and monitored until resolution was discussed with Staff 2 (RN) and Staff 26 (ED) on 01/02/25. They acknowledged the findings.

3. Resident 8 moved into the facility in 06/2024 with diagnoses including prostate cancer and congestive heart failure.

The resident's 08/16/24 service plan, 10/07/24 through 12/30/24 progress and observations notes, and interim service plans (ISPs) were reviewed, and interviews with staff and the resident were completed. The following was identified:

a. The following short-term changes of condition lacked monitoring of progress noted at least weekly through resolution:

* 10/16/24 - Death of a family member;

* 10/27/24 - Bedroom had flooded;

* 11/01/24 - New medication;

* 11/09/24 - New medication;

* 11/15/24 - Multiple medication changes;

* 11/20/24 - Return from emergency room;

* 11/22/24 - New medication;

* 11/26/24 - Multiple medication changes;

* 12/05/24 - Multiple medication changes;

* 12/07/24 - Blood in catheter bag;

* 12/12/24 - Multiple medication changes;

* 12/19/24 - New wound to the buttocks;

* 12/26/24 - Resident experienced hallucinations; and

* 12/28/24 - Discontinued medications.

b. On 12/07/24, the resident had a significant and severe weight gain. There was no documented evidence the facility evaluated the resident, referred to the facility nurse, documented the change, and updated the service plan as needed.

Refer to C 280, example 1.

The need to ensure changes of condition were monitored through resolution and were evaluated, referred to the facility nurse, and changes documented was discussed with Staff 26 (ED) on 01/02/25. He acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to determine actions/interventions needed, communicate actions or interventions to staff on all shifts, and monitor changes through resolution, with at least weekly documentation for 4 of 4 sampled residents (#s 7, 8, 9, and 10) reviewed with changes of condition and/or failed to refer to the facility nurse, document the change and update the service plan for residents with significant changes of condition. This is a repeat citation. Findings include, but are not limited to:

referred to the facility nurse, documented the change, and updated the service plan as needed

1. Resident 9 moved into the facility in 10/2011 with diagnosis including diabetes mellitus type II, neuropathy, and Binswanger disease.

The resident's 08/27/24 service plan, 10/11/24 through 12/25/24 charting and observation notes, skin monitoring sheets, and Interim Service Plans (ISPs) were reviewed. Observations of the resident were made, and interviews with staff and the resident were conducted.

The following changes of condition were identified:

* 10/07/24: Redness under left breast and groin;

* 10/10/24: Open area on bottom;

* 10/12/24: Received vaccines;

* 10/14/24: New PRN medication;

* 10/18/24: New treatment order;

* 10/18/24: Medication change;

* 10/18/24: Tooth pulled;

* 10/18/24: New medication;

* 10/21/24: Refusals to care between 10:00 pm and 5:00 am;

* 10/23/24: New treatment order;

* 10/24/24: Start antibiotic medication;

* 10/31/24: Start new medication;

* 10/31/24: Medication change;

* 11/05/24: Resident to resident altercation;

* 11/19/24: Medication change;

* 12/09/24: Fall in shower;

* 12/09/24: Fracture to left ankle;

* 12/13/24: Routine wound care and abrasion to ankle;

* 12/17/24: New medication;

* 12/18/24: Resident hygiene; and

* 12/25/24: Pink discharge in brief.

The facility lacked documented evidence the above changes of condition had been identified, had determined actions/interventions, communicated actions or interventions to staff on all shifts, and/or changes were monitored through resolution.

On 01/02/25 at 2:18 pm, Staff 2 (RN) confirmed there was no additional documentation for the above changes of condition.

The need to ensure changes of condition were identified, resident-specific actions or interventions for changes of condition were determined, documented, and communicated to staff on each shift, and were monitored at least weekly through resolution was discussed with Staff 26 (ED) on 01/02/25 at 3:32 pm. He acknowledged the findings.

4. Resident 10 was admitted to the facility in 07/2023 with diagnoses including suspected lung cancer and severe protein-calorie malnutrition.

The resident's 08/28/24 service plan, temporary service plans and progress notes from 10/07/24 to 12/29/24, and weight records from 07/2024 to 12/30/24 were reviewed. Observations of the resident were made, and interviews with staff and the resident were conducted.

The following weights were documented in the resident record:

07/02/24- 132.8 pounds;

10/04/24- 130.2 pounds;

12/04/24- 133.2 pounds;

12/23/24- 120.2 pounds; and

01/02/25- 119.0 pounds (taken during survey).

Between 12/04/24 to 12/23/24 the resident lost 13 pounds, or 9.6 percent of his/her bodyweight, constituting a severe weight loss. The weight loss constituted a significant change of condition for which the facility was required to evaluate, refer to the facility nurse, document the change, and update the service plan. Review of the resident's record revealed no documented evidence the weight loss was evaluated, the facility nurse was notified, the change was documented, and the service plan was updated, and there were no documented interventions for the weight loss.

During an interview at 1:01 pm on 01/02/25, Staff 17 (RCC) confirmed there was no documented evidence the weight loss was referred to the facility nurse. During an interview at 1:16 pm on 01/02/25, Staff 2 (RN) confirmed Resident 6's weight loss had not been evaluated or documented, and the service plan had not been updated.

The need to ensure resident significant changes of condition were evaluated, referred to the facility nurse, documented, and the service plan was updated was discussed with Staff 26 (ED), Staff 17 and Staff 2 on 01/02/25. They acknowledged the findings.

1.A change of condition evaluation was completed, the service plan updated, and weekly monitoring initiated for resident 9 by 1/15/2025. A change of condition evaluation was completed, the service plan updated, and weekly monitoring was initiated for resident 7 by1/15/2025. A change of condition evaluation was completed, the service plan updated, and weekly monitoring was initiated for resident 8 by 1/14/2025.  Resident 10 is no longer in the community.

2.System Corrections:

a.Training to be provided to the RN regarding identification and documentation of temporary and significant changes of condition.

b.Med Techs to receive re-training by HSD on Alert Charting and TSP systems. Consultant RN to review systems and recommend changes to procedures as indicated.

c.Training for all staff necessary notifications to nurse, retrain on completion of 24-hour communication

d.Training to be provided on root-cause analysis for falls and implementing fall interventions. Falls will be tracked and monitored monthly in the quality assurance meeting.

e.Method for skin evaluation and monitoring updated to include use of whiteboard and updated skin tracking system.

f.Alert/TSP to be created for all new or changed medications.

g.Alert/TSP to be created for outside provider treatment and procedures.

h.Alert/TSP to be created when resident experiences a significant loss.

i.Alert/TSP to be created for hospitalization.

j.Alert/TSP to be created for unusual behaviors, hallucinations.

k.Create white-board tracking system for critical clinical issues

l.RN to initiate SCOC assessment within 48 hours and monitor weekly until resolved or becomes the new baseline.

m.RN to complete NurseLearn courses on Change of Condition.

3.Method of evaluation:

a.24-hour, Skin, Fall, Alert charting logs completed every shift

b.Daily clinical meeting to include the above.

c.COC documentation compliance to be added to quality assurance program agenda.

4.Executive Director, Health Services Director

Based on interview and record review, it was determined the facility failed to ensure an RN significant change of condition assessment was completed for 1 of 1 sampled resident (# 2) who had significant weight gain. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 12/2021 with diagnoses including rheumatoid arthritis, depression, and hepatic cirrhosis.

A review of the resident's clinical record, including progress notes dated 05/05/24 through 08/05/24 and weight records dated 05/01/24 through 07/31/24, was completed, and staff were interviewed. The following was identified:

* On 06/05/24 Resident 2's weight was 119 pounds; and

* On 07/03/24 Resident 2's weight was 130 pounds.

The resident experienced a weight gain of 11 pounds, or 9% of his/her total body weight, in one month. This was considered a severe weight gain and a significant change of condition.

* On 05/01/24 Resident 2's weight was 111.7 pounds; and

* On 07/31/24 Resident 2's weight was 131 pounds.

The resident experienced a weight gain of 12.3 pounds, or 9% of his/her total body weight, in three months. This was considered a significant weight gain and a significant change of condition.

There was no documented evidence an RN assessment was completed for the resident's weight gain.

On 08/07/24, Staff 2 (RN) stated that she had not completed a significant change of condition assessment for Resident 2's significant/severe weight gains, but that the weight gain was positive for the resident.

The resident was observed and reported by staff to eat at all meals in his/her room independently, and s/he received protein supplement drinks twice a day.

The surveyor requested the resident be weighed on 08/07/24. A record of weekly weights was provided, with the most recent being 08/07/24.  Resident 2's weight was 129.5 pounds.

The need for an RN to complete an assessment of all significant changes of condition was discussed with Staff 1 (Interim ED), Staff 2, Staff 3 (RCC), Staff 5 (Regional Vice President of Operations), Staff 6 (RN Consultant), and Staff 17 (MT/RCC Assistant) on 08/08/24. They acknowledged the findings.

1.) RN assessment of resident #2's significant change of condition for 30 & 90 day weight gain.

2.) The HSD will complete change of condition training modules on nuselearn.com immediately as well as attend the role of the nurse in CBC training September 10-12th.Training will also be provided for all direct care staff on how to identify, document and who to notify of resident status changes.

3.) Resident status and need for COC is reviewed daily in clinical meeting to ensure short term and significant changes of condition are identified and RN assessments are completed with appropriate monitoring, documentation, and interventions including clear direction for care staff.

4.) It is the responsibility of the HSD and ED to ensure that the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure an RN significant change of condition assessment was completed for 2 of 2 sampled residents (#s 8 and 9) who experienced significant changes of condition. This is a repeat citation. Findings include, but are not limited to:

1. Resident 8 was admitted to the facility in 06/2024 with diagnoses including congestive heart failure and ascites (excessive abdominal fluid).

A review of the resident's clinical record, including progress and observation notes dated 10/07/24 to 12/30/24 and weight records dated 11/07/24 through 12/07/24, was completed, and staff were interviewed. The following was identified:

* On 11/07/24, Resident 8's weight was 150 pounds; and

* On 12/07/24, Resident 8's weight was 162.8 pounds.

The resident experienced a weight gain of 12.8 pounds, or 8.5% of his/her total body weight, in one month. This was considered a severe weight gain and a significant change of condition.

There was no documented evidence an RN assessment was completed for the resident's weight gain.

On 01/02/25 at 10:30 am, Staff 2 (RN, Health Services Director) stated she was aware of the weight gain. She confirmed she had not completed a significant change of condition assessment for Resident 8's significant and severe weight gain, but that the weight gain was expected due to his/her diagnoses of ascites and congestive heart failure.

The resident was reported by staff to be independent with eating meals. S/he also varied whether s/he ate meals in his/her room or in the dining room.

The resident was unable to be weighed during survey.

The need for a RN to complete an assessment of significant changes of condition was discussed with Staff 2 and Staff 26 (ED) on 01/02/25. The findings were acknowledged.

2. Resident 9 moved into the facility in 10/2011 with diagnosis including diabetes mellitus type II, neuropathy, and Binswanger disease. The resident was identified in the acuity interview as heavy care due to a recent fall on 12/09/24 that resulted in a fractured left ankle. The residents room was observed to have a transfer pole on the left side of a reclining chair and the resident was observed to have a boot on his/her left foot.

The resident's 08/27/24 service plan, 10/11/24 through 12/25/24 charting and observation notes, skin monitoring sheets, and Interim Service Plans (ISPs) were reviewed. Observations of the resident were made, and interviews with staff and the resident were conducted. The following was identified:

An ISP dated 12/09/24 identified Resident 9 had returned from the hospital with a "double fracture in ankle" with interventions that stated the "Resident will be needing extra assistance's [to be determined]" and "Resident need extra assistance with transfers at this time". The following was noted in the resident's record:

* 12/09/24: Emergency Department and resident social worker stated resident is unable to weight bear at this time;

* 12/10/24: Direct-care staff documented the resident required two to three staff assistance to transfer the resident and staff do not feel safe completing transfers; and

* 12/15/24: Resident is a "3 person assist with incontinence changes from [his/her] chair" and "Resident unable to pivot to commode".

On 12/30/24 at 11:28 am, Staff 9 (MT) stated the resident used to be independent with transfers prior to his/her fractured ankle and now required two to three staff to assist with transfers and two to four staff to assist with incontinent care.

On 01/02/24 at 10:05 am, Resident 9 verified s/he initially required three to four staff for transfers and now required one to three staff to assist with transfers and incontinent care.

An RN assessment was initiated on 12/12/24, however it was incomplete and did not include the resident's condition, resident status, or interventions made as a result of the assessment to address the resident's ankle fracture.

The need to ensure the facility RN completed an assessment for the significant change in condition was discussed with Staff 26 (ED) on 01/02/25 at 3:32 pm. He acknowledged the findings.

1.The RN completed a significant change of condition assessment and service plan update for Residents 8 and 9 by 2/10/2025.

2.The RN will evaluate residents who return from the hospital, initiate a SCOC assessment within 48 hours and weekly monitoring as indicated. All-staff training to be completed on conditions that require referral to the RN for significant change of condition. The RN will take the NurseLearn Courses on significant change of condition. Significant changes of condition will be tracked on the whiteboard for weekly progress noted until resolution.

3.Weekly tracking on the whiteboard, monthly review in the quality assurance meeting.

4.Executive Director, Health Services Director

Based on observation, interview, and record review, it was determined the facility failed to ensure it had a trained and designated Infection Control Specialist and failed to establish and maintain effective infection prevention and control protocols. Findings include, but are not limited to:

a. On 08/07/24 at approximately 10:30 am, Staff 1 (Interim ED) reported the facility did not have a trained and designated Infection Control Specialist.

b. Observations of dining services were performed throughout survey. The following was identified:

* On 08/06/24 at 11:55 am, Staff 8 (Dietary Aide) did not perform hand hygiene between tasks and was observed to touch a resident's back, handle dirty and clean glassware by the rim of the glass, remove dirty glassware from a table, and serve beverages to multiple residents.

* On 08/07/24 at 12:50 pm, Staff 7 (Dietary Aide) did not perform hand hygiene between delivering meals to resident rooms. When Staff 7 delivered each meal she also assisted with meal set-up, removed dirty dishes, threw away old meals and beverages, handled residents' personal food and beverages, and assisted with other meal related requests.

On 08/07/24 at 1:14 pm, Staff 7 acknowledged the lack of hand hygiene when delivering resident meals to rooms and stated she had a plan and would address it immediately.

The need to ensure the facility had a designated Infection Control Specialist and to establish and maintain infection prevention and control protocol to provide a safe, sanitary, and comfortable environment was discussed with Staff 1 (Interim ED), Staff 2 (RN), Staff 3 (RCC), Staff 5 (Regional Vice President of Operations), Staff 6 (RN Consultant), and Staff 17 (MT/RCC Assistant) on 08/08/24. They acknowledged the findings.

1.) The HSD has already completed the Infection Control Specialist Training for Community Based Care. A training will be provided to dining staff on hand hygiene and hand sanitizer use while in dining room and delivering meals. Infection control practices reviewed at all staff meeting in August.

2.) Process will be to ensure that upon changes staffing or positions a new Infection Control Specialist is appointed as needed and completes the specialized training within three months of being designated.

3.) The area needing correction will be evaluated upon changes in staffing or positions.

4.) It is the responsibility of the ED and HSD to ensure that the corrections are monitored and completed.

Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 1 of 1 sampled resident (#4) whose MARs and Controlled Substance Disposition logs were reviewed for accuracy. Findings include, but are not limited to:

Resident 4 moved into the facility in 04/2017 and had diagnoses including delusions and aortic valve stenosis.

The resident's physician orders, the Controlled Substance Disposition logs, the 07/01/24 through 08/05/24 MARs, and 05/13/24 through 08/05/24 progress notes were reviewed, and interviews with staff were conducted. The following was identified:

Resident 4 had a physician order for hydrocodone/apap 5-325 mg - one tablet by mouth twice daily for pain.

The MAR and Controlled Substance Disposition logs noted the medication was administered on three occasions between 07/19/24 to 07/20/24. During that time, the resident's progress notes indicated s/he was out of the facility.

The need to ensure the facility had an effective system for tracking controlled substances was reviewed with Staff 1 (Interim ED), Staff 2, Staff 3 (RCC), Staff 5 (Regional Vice President of Operations), Staff 6 (RN Consultant), and Staff 17 (MT/RCC Assistant) on 08/08/24. They acknowledged the findings.

1.) The community will conduct an immediate review of Resident #4's MARs and Controlled Substance Disposition logs. Any discrepancies will be addressed by consulting the physician to ensure proper documentation and administration. Staff involved will receive additional training on the accurate tracking and documentation of controlled substances.

2.) The community will implement a more rigorous system for tracking controlled substances, including cross-checks between MARs and Controlled Substance Disposition logs. This system will be approved by the consulting pharmacist or registered nurse. Regular audits will be conducted to ensure compliance.

3.) The system will be evaluated weekly for the first month to ensure it is functioning effectively. After the first month, evaluations will occur monthly to maintain ongoing compliance.

4.) It is the responsibility of the ED, HSD, and RCC to ensure corrections are monitored and completed.

2. Resident 7 was admitted to the facility on 11/25/24 from a skilled nursing facility (SNF) with diagnoses including type II diabetes, bacteremia, encephalopathy, and post surgery recovery from an intraspinal abscess.

On 12/31/24 Resident 7's current prescriber orders were requested and provided by Staff 17 (RCC).  The orders dated 11/08/24 were Resident 7's admission orders.

The orders instructed wound care: "cleanse bilateral buttocks with normal saline, pat dry. Apply no sting to peri wound. Foam adhesive dressing. Change 1-2 times per week and prn every evening shift every Tuesday, Friday for wound care until resolved".

In interview on 1/2/25 Staff 2 (RN, Resident Health Services Director) stated facility staff had provided wound care, however there was no documented evidence wound care was provided, or the order was discontinued in Resident 7's record. Staff 2 stated the wound was now closed, however, there was no documented evidence of wound monitoring or when it had resolved.

The need to ensure all medications and treatments the facility was responsible to administer were carried out as prescribed and documented in the resident's record was reviewed with Staff 2 RN and Staff 26 (Executive Director) on 1/02/25. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed, and written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record for all medications and treatments the facility was responsible to administer for 2 of 4 sampled residents (#s 7 and 8) whose orders were reviewed. Findings include, but are not limited to:

1. Resident 8 moved into the facility in 06/2024 with diagnoses including prostate cancer.

The resident's 12/01/24 to 12/30/24 MAR and prescriber orders were reviewed and revealed the following:

There were multiple blanks on the resident's MAR for 14 different medications between 12/09/24 and 12/13/24.

On 01/02/25 at 10:20 am, Staff 2 (RN, Health Services Director) stated she was unaware of these occurrences and acknowledged the inaccuracy of the 12/01/24 to 12/30/24 MAR. She was unable to confirm if the medications had been carried out as prescribed.

The need to ensure medication orders were carried out as prescribed was discussed with Staff 26 (ED) on 01/02/25 at 12:20 pm. He acknowledged the findings.

1.Resident 8's MAR was reviewed for holes in the MAR, and wound care orders were reviewed for resident 7 and updated in MAR.

2.Med-pass and exception reports will be reviewed in the clinical meeting to ensure no blanks in the MAR. Wound care orders will be obtained for all skin issues and added to MAR to ensure appropriate documentation when wound care is completed. Treatment orders will be reviewed in the three check-system during the clinical meeting daily.

3.Review of orders in the clinical meeting several times per week. MAR reviews will be conducted at least monthly. Routine pharmacy audits are scheduled quarterly.

4.Executive Director, Health Services Director.

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

Resident 2 was admitted to the facility in 12/2021 with diagnoses including anxiety, depression, and hepatic cirrhosis.

The resident's 07/01/24 through 08/05/24 MARs and signed physician orders were reviewed.

The resident had a signed physician order which included directions for staff to notify the physician after refusal of any medications.

Medications documented as refused multiple times between 07/01/24 and 08/05/24 included:

* Furosemide 20 mg two times daily (for edema); and

* Varenicline Tartrate 0.5 mg two times daily for 90 days (for smoking cessation).

There was no documented evidence the physician was notified after each refusal for the above medications.

The need to notify the practitioner of resident medication refusals was discussed with Staff 1 (Interim ED), Staff 2 (RN), Staff 3 (RCC), Staff 5 (Vice President of Operations), Staff 6 (RN Consultant), and Staff 17 (MT/RCC Assistant) on 08/08/24. They acknowledged the findings.

1.) For Resident #2, the physician will be notified of the medication refusals immediately. Staff will be retrained on the requirement to report refusals.

2.) The facility will enforce a system where medication refusals are documented and reported to the physician immediately per physician order, with clear steps in place.

3.) The system will be reviewed weekly for two months, then monthly.

4.) It is the responsibility of the ED, HSD and RCC to ensure corrections are monitored and completed.

Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused to consent to orders for 1 of 1 sampled resident (# 8) who had documented medication and treatment refusals. This is a repeat citation. Findings include, but are not limited to:

Resident 8 moved into the facility in 06/2024 with diagnoses including prostate cancer, hypertension, congestive heart failure, and ascites (excessive abdominal fluid).

The resident's 12/01/24 through 12/30/24 MAR and signed prescriber orders were reviewed.

The following medications and a treatment were documented as refused multiple times between 12/01/24 and 12/30/24:

* Acetaminophen 500 mg two times daily (for pain);

* Acyclovir 400 mg two times daily (no reason listed);

* Diphenhydramine/zinc cream twice daily (for rash);

* Lactulose 15 ml by mouth four times daily (for constipation);

* Morphine sulfate 0.25 ml three times daily (for pain);

* Morphine sulfate 0.25 ml daily at bedtime (for pain);

* Omeprazole 40 mg daily (no reason listed);

* Potassium chloride ER 20 milliequivelents once daily (no reason listed);

* Senna 8.6-50 mg twice daily (no reason listed);

* Spironolactone 100 mg daily (for edema);

* Torsemide 20 mg daily (for edema); and

* Barrier cream three times daily (for wound care).

On 01/02/25 at 10:22 am, Staff 2 (RN, Health Services Director) confirmed medication and treatment refusals were either to be faxed to the practitioner, or the practitioner was to be called and documented in the progress notes.

There was no documented evidence the prescriber was notified after each refusal for the above medications and treatment.

The need to notify the physician or other practitioner of resident medication refusals was discussed with Staff 26 (ED) on 01/02/25. He acknowledged the findings.

1.Resident 8's physician was notified by Fax on 1/31/2025 of their refusal to take prescribed medications on multiple dates.

2.Policy and procedure has been reviewed and is appropriate. Med tech retraining to be conducted by HSD on2/03/2025. All PCPs will be asked for their preference regarding notification of refusal and, upon receipt, preference will be added to physician orders and followed by staff.

3.Resident refusals to be reviewed and followed up with during daily clinical meetings. Medication variance reports reviewed weekly and correlated with documentation of physician notification. Missed medications to be added to QA program agenda.

4.Executive Director, Health Services Director

3. Resident 2 admitted to the facility in 12/2021 with diagnoses including chronic pain. Resident 3 admitted to the facility in 08/2017 with diagnoses including osteoarthritis. Resident 2 and 3's 07/01/24 through 08/03/24 MARs were reviewed and noted the following:

* The MARs for Residents 2 and 3 each included multiple prn bowel care medications which lacked parameters and clear instruction to staff for administration.

The need to ensure medications had resident-specific parameters for PRN medications and clear instructions to staff was reviewed with Staff 1 (ED), Staff 2 (RN), Staff 3 (RCC), Staff 5 (Regional Vice President of Operations), Staff 6 (RN Consultant), and Staff 17 (MT/Assistant RCC) on 08/08/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure MARs were accurate, included medication-specific instructions, and had resident-specific parameters and instructions for PRN medications for 4 of 6 sampled residents (#s 1, 2, 3, and 4) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 4 moved into the facility in 04/2017 with diagnoses including delusions and aortic value stenosis.

The resident's 07/01/24 to 08/05/24 MAR and prescriber orders signed 03/18/24 were reviewed and revealed the following:

a. Three scheduled medications lacked reasons for use.

b. One treatment administered four times daily lacked medication-specific instructions for administration, including the amount of gel to apply and where to apply.

c. Two medications with blood pressure parameters were documented as administered on 12 occasions where the blood pressure was not documented.

On 08/06/24 at 10:40 am, Staff 2 (RN) stated she was unaware of these occurrences and acknowledged the need to have reasons for use and medication-specific instructions for administration, and to ensure parameters were documented and followed.

The need to ensure MARs were accurate and included all required elements was discussed with Staff 1 (Interim ED), Staff 2, Staff 3 (RCC), Staff 5 (Regional Vice President of Operations), Staff 6 (RN Consultant), and Staff 17 (MT/RCC Assistant) on 08/08/24. They acknowledged the findings.

2. Resident 1 was admitted to the facility in 05/2004 with diagnoses including chronic heart failure and chronic kidney disease.

The resident's 07/01/24 through 08/05/24 MARs and physician orders were reviewed, and interviews with staff and the resident were conducted. The following was identified:

* The resident self-administered his/her medication, with the exception of insulin injections and application of a fentynal patch (for pain).

* The resident received two insulin injections before breakfast (one fast-acting and one long-acting), and one injection of fast-acting insulin before lunch and dinner. The physician order for the fast-acting insulin stated to "hold" the injection if the resident was skipping a meal.

* Between 07/18/24 and 07/31/24 there were multiple blanks on the resident's MAR for his/her insulin injections. The greatest number of blanks was for the 11:00 am insulin injection.

* Interviews with multiple staff between 08/05/24 and 08/07/24 indicated the resident did not each lunch, only breakfast and dinner, and had a health shake at lunch time.

In an interview on 08/07/24, Staff 15 (MT) reported MTs were not delegated until they had been in their position for 90 days. She stated during the time period in July when there were blanks on the resident's MAR that there was a newer MT who was not delegated, so he would ask another MT on duty to administer the resident's insulin. Staff 15 reported if the MT requested to give the insulin injection to Resident 1 was busy, the administration would not always get documented.

In an interview with the resident on 08/07/24 at 10:40 am, s/he verified they did not eat lunch so did not receive the insulin injection scheduled for 11:00 am. The resident reported s/he received all of his/her insulin injections during the month of July, with the exception of the 11:00 am administration.

The need for the MAR to be accurate was discussed with Staff 1 (Interim ED), Staff 2 (RN), Staff 3 (RCC), Staff 5 (Regional Vice President of Operations), Staff 6 (RN Consultant), and Staff 17 (MT/RCC Assistant) on 08/08/24. They acknowledged the findings.

1.) Resident #4's MAR will be updated to include reasons for use, specific instructions for medication administration, and ensure blood pressure parameters are documented. Resident #1 Ensure all insulin injections are properly documented on the MAR, especially when meals are skipped. Resident #2 and #3 Add specific parameters and clear instructions for PRN bowel care medications on their MARs.

2.) RCC and HSD reviewing the MAR's for any missed administrations. During the order review process, the HSD will ensure that specific instructions and parameters are added for every medication.

3.) The MAR system will be evaluated weekly for the first two months, then monthly to ensure ongoing compliance.

4.) It is the responsibility of the ED, HSD, and RCC to ensure corrections are monitored and completed.    

Based on observation, interview, and record review, it was determined the facility failed to ensure residents who chose to self-administer their medications had a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications and were evaluated at least quarterly, to assure their ability to safely self-administer medications for 1 of 1 sampled residents (#9) who was reviewed for self-administration. Findings include, but are not limited to:

1. Resident 9 moved into the facility in 10/2011 with diagnosis including diabetes mellitus type II, neuropathy, and Binswanger disease.

The resident's current physician orders and self-administration evaluations were reviewed, observations of the resident were made, and interviews with staff and the resident were conducted. The following was identified:

On 12/30/24 at 11:28 am, Staff 9 (MT) stated the resident self-administered all his/her medications.

On 12/31/24 at 11:14 am, Staff 17 (RCC) stated there was no documented evidence a self-administration evaluation had been completed since 07/22/24 and she could not find a physician's order for the self-administration of medications.

On 01/02/25 at 10:05 am, Resident 9 was observed in his/her room and reviewed his/her current medications with this surveyor and identified the resident self-administered tramadol 50 mg tablet, two times daily, however the medication was discontinued 12/09/24.

On 01/02/25 at 11:08 am, Staff 2 (RN) confirmed there was no additional documentation available.

The need to ensure residents who chose to self-administer their medications had a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications and the resident was evaluated at least quarterly, was reviewed Staff 26 (ED) on 01/02/25 at 3:32 pm. He acknowledged the findings.

1.Resident 9 received a self-administration of medications evaluation by a licensed nurse as of 1/20/2025 and was deemed to be safe to continue per their physician's order.

2.Residents who wish to self-administer their medications will be evaluated upon admission, with change of condition and at least quarterly.

3.Self-administration of medication evaluations for residents who do so, will be completed by 2/10/2025.Evaluation due dates will coincide with move-in, change of condition and quarterly evaluations to maintain compliance. Evaluation audits will include self-administration of medication evaluations when applicable.

4.Health Services Director, Executive Director

Based on interview and record review, it was determined the Administrator failed to show documented evidence of a current Residential Care Facility Administrator license. Findings include, but are not limited to:

Upon survey entry on 12/30/24 at 10:15 am, Staff 26 (ED) confirmed he was the acting administrator of the facility.

On 01/02/25 at 2:00 pm, Staff 26 was asked to provide documentation of his Residential Care Facility Administrator license. Staff 26 revealed his license had expired.

The requirement to have a current Residential Care Facility Administrator was discussed with Staff 1 on 01/02/25 at 2:00 pm. He acknowledged the findings.

1.The Administrator's license renewal became available by 1/22/25.

2.The administrator of record will ensure that the required continuing education is completed and that their license renewal application and fee are submitted to the Board timely.

3.Submit renewal application to the Department on or before the deadline printed in the notification received.

4.Executive Director

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly-hired staff (#s 16, 19, 20, and 21) completed all required pre-service orientation training and 3 of 3 newly-hired direct care staff (#s 16, 19, and 20) completed required pre-service dementia training. Findings include, but are not limited to:

Staff training records were reviewed on 08/07/24 with Staff 1 (Interim ED), and the following was identified:

a. There was no documented evidence Staff 16 (CG), Staff 19 (CG), Staff 20 (MT), or Staff 21 (Dietary Aide), hired 04/13/24, 05/16/24, 02/13/24, and 06/28/24, respectively, had completed one or more of the following required pre-service orientation topics prior to beginning their job responsibilities:

* Resident rights and values of CBC care;

* Abuse reporting requirements;

* Fire safety and emergency procedures;

* Written job description;

* Infectious disease prevention training; and

* Home and Community-Based Services training.

b. There was no documented evidence Staff 16, Staff 19, and Staff 20 had completed one or more of the following pre-service dementia care training topics:

* Dementia disease process including progression, memory loss, psychiatric and behavioral symptoms;

* Techniques for understanding, communicating and responding to behaviors; reducing use of antipsychotics;

* Strategies for addressing social needs and engaging them in meaningful activities; and

* Specific aspects of dementia including addressing pain, providing food/fluids, preventing wandering, use of person-centered approach.

The need for staff to complete all required pre-service orientation training and for direct care staff to complete required pre-service dementia training was discussed with Staff 1, Staff 5 (Regional Vice President of Operations), and Staff 6 (RN Consultant) at 1:30 pm on 08/07/24. They acknowledged the findings.

1.) Each employee will complete the specific pre-service training they missed immediately: Staff 16 (CG), Staff 19 (CG), Staff 20 (MT), and Staff 21 (Dietary Aide) will complete:

    - Resident rights and values of CBC care.

    - Abuse reporting requirements.

    - Fire safety and emergency procedures.

    - Written job description.

    - Infectious disease prevention training.

    - Home and Community-Based Services (HCBS) training.

Additionally, Staff 16, Staff 19, and Staff 20 will complete:

    - Dementia disease process training.

    - Techniques for understanding, communicating, and responding to behaviors.

    - Strategies for addressing social needs and engaging residents in meaningful activities.

    - Training on specific aspects of dementia care, including addressing pain, providing food/fluids, preventing wandering, and using a person-centered approach.

2.) All new employees will complete onboarding process which includes completing the state required trainings prior to beginning their perspective jobs, training s to include all identified in OAR 411-054-0070 as well as required certifications and licenses pertaining to specific job descriptions and positions. Tracking tool for all onboarding, training, licenses, and certifications has been implemented.

3.) Areas needing correction will be evaluated weekly until compliance is achieved and then will be audited monthly and as needed.

4.) It is the responsibility of the ED and BOM to see that the corrections are monitored and completed.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly-hired staff (#s 16, 19, and 20) demonstrated competency in assigned duties within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed on 08/07/24 with Staff 1 (Interim ED), and the following was identified:

* There was no documented evidence Staff 16 (CG), Staff 19 (CG), of Staff 20 (MT), hired 04/13/24, 05/16/24, and 02/13/24, respectively, completed training in changes associated with normal aging and in first aid and abdominal thrust within 30 days of hire; and

* There was no documented evidence Staff 19 and 20 completed training in general food safety, serving, and sanitation within 30 days of hire.

The need for staff to complete all required training within the specified time frames was discussed with Staff 1, Staff 5 (Regional Vice President of Operations), and Staff 6 (RN Consultant) at 1:30 pm on 08/07/24. They acknowledged the findings.

1.) Staff 16 (CG), Staff 19 (CG), and Staff 20 (MT) will immediately complete the required training they missed within the first 30 days of hire, including:

  - Changes associated with normal aging.

  - First aid and abdominal thrust.

  - Staff 19 and Staff 20 will also complete training in general food safety, serving, and sanitation.

2.) A new-hire checklist will be implemented that includes pre-service training and orientation and additional trainings and competencies that are to be completed in the initial 30 days of employment. A job specific competency checklist will be maintained by the RCC until completed. The job specific skills checklist will identify competencies that must be completed pre-service and those that must be completed within 30 days of hire. The job specific skills check list will include dates of observation and skills check and will be signed by the trainer and trainee. The RCC will not schedule new employees until the pre-service items and the items required within 30 days have been completed. Upon completion the documentation will be given to the BOM for placement in the employees training record.

3.) The area needing correction will be evaluated weekly until compliance is met and then monthly and as needed.

4.) It is the responsibility of the ED, BOM, and RCC to ensure the corrections are monitored and completed.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 long-term staff (#s 13, 22, and 23) completed 12 hours of annual in-service training, including at least six hours of dementia care, and failed to ensure 2 of 2 long-term non-care staff (#s 24 and 25) completed infectious disease training. Findings include, but are not limited to:

Staff training records were reviewed on 08/07/24 with Staff 1 (Interim ED), and the following was identified:

a. There was no documented evidence Staff 13 (CG), Staff 22 (CG), and Staff 23 (CG), hired 01/01/13, 06/18/20, and 03/10/21, respectively, completed at least 12 hours of training based on their anniversary date of hire related to the provision of care in CBC, including a minimum of six hours of training on dementia care topics.

b. There was no documented evidence Staff 24 (Housekeeper), hired 01/01/13, or Staff 25 (Dietary Aide), hired 09/25/17, completed annual training on infectious disease outbreak and control.

The need to ensure and document that long-term direct care staff completed the required number of hours of annual in-service training and that long-term non-care staff completed annual infectious disease training was discussed with Staff 1 (Interim ED), Staff 5 (Regional Vice President of Operations), and Staff 6 (RN Consultant) at 1:30 pm on 08/07/24. They acknowledged the findings.

1.) Staff 13, 22, and 23 will immediately complete the required 12 hours of annual in-service training, including the mandatory six hours on dementia care. Staff 24 and 25 will complete the necessary infectious disease training.

2.) The Relias system will be used for tracking all training requirements and updating records. Automated reminders will be set up in Relias to alert staff and the BOM of upcoming training deadlines. Monthly compliance reports will be reviewed in Relias by the BOM to ensure adherence to training requirements.

3.) Training compliance will be reviewed monthly through Relias, with quarterly audits conducted to verify the accuracy of training records.

4.) It is the responsibility of the BOM and ED to ensure the corrections are monitored and completed.

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

Six months of fire drill and fire and life safety training records were requested on 08/07/24. The following was identified:

a. Fire drill documentation failed to address the following:

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

* Evacuation time period needed; and

* Number of occupants evacuated.

During an interview at 11:00 am on 08/07/24, Staff 4 (Environmental Director) confirmed that the facility was not evacuating residents during fire drills.

b. There was no documented evidence the facility was providing fire and life safety training to staff on alternating months from fire drills.

The need to ensure fire drills were conducted in accordance with the Oregon Fire Code and fire and life safety instruction was provided to staff on alternate months was discussed with Staff 1 (Interim ED), Staff 5 (Regional Vice President of Operations), and Staff 6 (RN Consultant) at 1:30 pm on 08/07/24. They acknowledged the findings.

1.) Annual calendar has been implemented. Fire drill conducted in August with monthly fire drills scheduled to follow until compliance is met. ESD to perform and document Fire and Life Safety trainings with staff monthly with documentation of drills and meeting minutes/attendance records.

2.) Education and Training has been provided to the ESD utilizing OAR 411-054-0090 and community's Policy and Procedure to ensure understanding of requirements including escape route, evacuation time, number of occupants, and alternate escape routes used. Annual schedule is implemented for fire drills and alternating trainings.

3.) The area needing correction will be evaluated monthly.

4.) It is the responsibility of the ED and ESD to ensure fire drills and trainings are completed.

Based on interview and record review, it was determined the facility failed to conduct fire drills in accordance with the Oregon Fire Code. This is a repeat citation. Findings include, but are not limited to:

Fire drill records were requested and reviewed on 12/30/24. The following was identified:

Fire drill documentation lacked the following required components:

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

* Evacuation time period needed; and

* Number of occupants evacuated.

On 12/31/24 at 12:34 pm, Staff 4 (Maintenance) confirmed the facility was not evacuating residents during fire drills.

The need to ensure fire drills were conducted in accordance with the Oregon Fire Code was discussed with Staff 26 (ED) on 01/02/25 at 4:06 pm. He acknowledged the findings.

1.Fire drill documentation form was revised to include required components, including problems encountered and comments from residents who resisted or failed to participate, the evacuation time period needed, and the number of occupants evacuated.  The drill conducted on 1/31/2025 included an evacuation of residents.

2.Fire drill form has been revised to ensure compliance. Staff re-training on expectation to evacuate residents to take place on 2/10/2025 by Maintenance Director. Fire drill to be completed each shift utilizing new form.

3.Fire drills schedule in place every other month implemented with required trainings.

4.Executive Director, Maintenance Director

Based on interview and record review, it was determined the facility failed to ensure residents were instructed on general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places inside or outside the building within 24 hours of admission; and failed to re-instruct residents on fire and life safety at least annually, with a written record of the content of the training sessions and the residents attending, per the Oregon Fire Code (OFC). Findings include, but are not limited to:

Fire and life safety records were reviewed on 08/07/24.

During an interview on 08/07/24 at approximately 11:00 am, Staff 4 (Environmental Director) reported residents had not been receiving fire and life safety training on admission, nor had the facility been re-instructing residents at least annually.

The need to instruct and re-instruct residents on fire and life safety training per the OFC requirements was discussed with Staff 1 (Interim ED), Staff 5 (Regional Vice President of Operations), and Staff 6 (RN Consultant) at 1:30 pm on 08/07/24. They acknowledged the findings.

1.) Resident's will be re-instructed annually on fire and life safety procedures. Facility to hold an all-resident training for immediate compliance

2.) ESD will conduct and document annual review.

3.) ESD to meet with new admissions to instruct and educate on fire and life safety procedures within 24 hours of move-in.

4.) It is the responsibility of the ESD and ED to ensure the corrections are monitored and completed.

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

Refer to C 150, C 200, C 252, C 260, C 262, C 270, C 280, C 305, C 420, and C 613.

Refer to C 150, C 200, C252, C 260, C 262, C 270, C 280, C 305, C 420, C 613

Based on observation and interview, it was determined the facility failed to ensure all interior and exterior materials and surfaces and all equipment necessary for the health, safety, and comfort of the resident were kept clean and in good repair and the interior of the facility was kept free from unpleasant odors. Findings include, but are not limited to:

Observations of the facility from 08/06/24 to 08/08/24 revealed the following:

a. Facility Wide

* Multiple resident rooms and facility doors and doorframes had scrapes, gouges, and scuffs;

* The windows in common areas and resident rooms were dusty;

* The carpets in all common areas, both elevators, and resident rooms 105, 111, 113, 114, 132, 142, 210, 212, and 227 were stained and/or bulging; and

* Ceiling sprinklers and ceiling and wall vents throughout the facility had dust and black matter build-up.

b. First Floor Staff Laundry Hall and Room

* The walls and exit door in the hall to the staff laundry room had splatters, black marks, and spills;

* The doorframe to enter the hall had a piece of metal pulled away from the frame;

* Several ceiling tiles had holes and/or cracks;

* Both doors into the staff laundry room had black scuffs and stains;

* The hopper sink was missing caulk around the base;

* The floors had black matter build-up and stains; and

* A ceiling light was missing a cover.

c. First Floor Activity Room

* The seats of several chairs were torn;

* The oven interior had a build-up of food spills and stains;

* The walls were dented and had chipped wallpaper; and

* An outlet cover was broken.

d. First Floor Resident Lounge and Laundry Room

* The dryers had lint and dust build-up on the vents;

* The walls and baseboards were dented and had black scuff marks; and

* The window screen was torn.

e. Dining Room

* The fabric backs of the dining chairs had stains and splatters;

* The baseboards had chipped paint and black scuffs;

* The hardwood floor in the service station was scuffed and scratched, and had black matter build-up;

* The service station had multiple broken drawers;

* There was moisture and small flying insects in the cupboard below the beverage sink;

* The beverage sink was rusted and stained; and

* The corners of the service station had dents and chipped paint, exposing wood.

f. Second Floor Great Room

* The parquet flooring was scratched; and

* The backs and seats of chairs were stained.

g. Second Floor Fireplace Seating Area

* The couch seats and arms had multiple stains; and

* The fireplace was non-functioning.

h. Second Floor Spa Room

* The spa was non-functioning; and

* The wall next to the wheelchair scale had paint chips and stains.

i. Second Floor Resident Lounge and Laundry Room:

* The walls were dented and had paint chips;

* The door was dented and had black scuffs;

* The dryer vents and back had lint and dust build-up; and

* The window frame had peeling and cracked paint.

j. Second Floor Library

* The arms and seats of the chairs were stained.

k. Resident Rooms 129 and 149 had water damage with sheetrock and bubbled paint on the walls/ceilings in the respective unit bathrooms.

l. Exterior of building

* The gazebo seating in the courtyard and the benches in the courtyard and south and west sides of the building had exposed, rough wood and chipped paint.

m. There was a pervasive unpleasant odor in the hall near Rooms 139, 141, and 142 that did not dissipate during the survey.

The above areas were toured with Staff 1 (Interim ED) at 2:12 pm on 08/07/24. She acknowledged the findings.

1.) The facility will address all identified issues by completing the following actions: Scrapes, gouges, and scuffs on doors and doorframes will be repaired. Windows will be cleaned, and carpets will be cleaned or replaced as necessary. Dust and build-up on ceiling sprinklers and vents will be removed. The damaged walls, doorframes, and ceiling tiles in the staff laundry hall will be repaired, and missing caulk and light covers will be replaced. Upholstered furniture, stained dining chairs, and malfunctioning appliances will be cleaned or replaced. The exterior benches and gazebo will be refinished. The pervasive odor near resident rooms will be addressed through deep cleaning and odor control measures. LUX Hospitality will provide remodel plans for facility upgrades, and ESD will collaborate with a local contractor for cabinetry improvements.

2.) The ESD will receive training on the TELS system and will use it to conduct routine audits to identify and address repairs promptly. Daily audits will ensure timely identification of repair needs and effective communication with the ED for completion.

3.) The area needing correction will be evaluated daily at morning stand-up meetings and weekly until all issues are resolved. Afterward, evaluations will occur monthly and as needed to ensure ongoing compliance.

4.) The ESD and ED are responsible for ensuring that all corrections are monitored and completed effectively.

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

Observations of the facility from 12/30/24 to 01/02/25 revealed the following:

a. Facility Wide

* Multiple resident rooms and facility doors and doorframes had scrapes, gouges, and scuffs; and

* The carpets in resident rooms 105, 113, 114, 142, 210 and 212 were stained and/or bulging.

b. First Floor Staff Laundry Hall and Room

* The doorframe to enter the hall had a piece of metal pulled away from the frame;

* Several ceiling tiles had holes and/or cracks;

* The hopper sink was missing caulk around the base; and

* A ceiling light was missing a cover.

c. First Floor Activity Room

* The seats of several chairs were torn;

* The oven interior had a build-up of food spills and stains; and

* The walls were dented and had chipped wallpaper.

d. First Floor Resident Lounge and Laundry Room

* The dryers had lint and dust build-up on the vents;

* The walls and baseboards were dented and had black scuff marks; and

* The window screen was torn.

e. Dining Room

* The service station had multiple broken drawers;

* There was moisture and black matter in the cupboard below the beverage sink;

* The beverage sink was rusted and stained; and

* The countertop of the service station had missing laminate, exposing wood.

f. Second Floor Spa Room

* The wall next to the wheelchair scale had paint chips and stains.

g. Second Floor Resident Lounge and Laundry Room:

* The window frame had peeling and cracked paint.

h. Second Floor Library

* The arms and seats of the chairs were stained.

i. Exterior of building

* The gazebo seating in the courtyard had exposed, rough wood and chipped paint.

The above areas were toured with Staff 26 (ED) at 10:05 am on 01/02/25. He acknowledged the findings.

1.Facility-wide painting of scrapes, gouges and scuffs on doors, door frames, has begun. Action to address carpet stains, cracked caulking, missing lights, stained or torn upholstery, dented and chipped walls, broken furniture removal, have all begun. Gazebo seating is scheduled to be removed or replaced by 2/16/25.

2.Preventative maintenance program to include routine painting and touch up of scuffs, gouges and scrapes, missing lights, light covers and burned out lights. Routine housekeeping schedules to include carpet and furniture stain removal. Broken furniture removed and furniture is being repaired or replaced.

3.Facility leadership Team/Managers to observe environment during daily walking rounds and add concerns to work order system. Maintenance Director to track concern in work order system through resolution.

4.Executive Director, Maintenance Director

Based on observation and interview, it was determined the facility failed to ensure a lockable storage space was provided for the safekeeping of residents' small valuable items and funds for multiple sampled and unsampled residents. Findings include, but are not limited to:

* On 08/07/24 at 11:30 am, eight unsampled residents attended a group interview. All eight residents interviewed confirmed that although they had a lockable storage space in their apartments, they did not have a key to the space;

* Observations of two unsampled resident units revealed a cabinet with a lock in both unit bathrooms. The two unsampled residents did not have keys for the cabinets; and

* Two of five sampled residents (#s 2 and 6) confirmed during interviews they did not have a key for the lockable storage in their units.

The need to ensure residents had a key to their lockable storage space was discussed with Staff 1 (Interim ED) on 08/07/24. She acknowledged the findings.

1.) To correct the rule violation, the ESD will compile a list of all apartments requiring new locks or keys for lockable cabinets. Each resident will be provided with a key to their lockable storage space. Any necessary new locks will be installed, and residents will be given access to their secure storage.

2.) The ESD will track and manage the distribution of keys and installation of locks through a detailed list. This list will include all apartments, both vacant and occupied, ensuring that every unit's lockable storage has a functioning lock and key.

3.) The area needing correction will be evaluated weekly until all units are compliant. Following the initial resolution, the system will be reviewed monthly to ensure continued adherence to the requirements.

4.) The ESD is responsible for compiling the list of all apartments needing new locks and keys and ensuring that these updates are made. The ED will oversee and monitor the completion of these corrections to ensure they are implemented effectively and maintain compliance.     

Based on observation and interview, it was determined the facility failed to ensure residents rights of privacy in his or her own unit for multiple sampled and unsampled residents. Findings include, but are not limited to:

Refer to C200.

1.) the community will enforce a policy requiring staff to knock and wait.    

2.) The community will implement regular audits to ensure staff follow privacy policies.

3.) Privacy adherence will be reviewed monthly.

4.) The ED will oversee privacy and staff training.