The findings of the change of ownership survey conducted 10/31/22 through 11/04/22 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 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

MCCMemory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first revisit to the re-licensure survey of 11/04/22, conducted 07/25/23 through 07/26/23, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

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 2nd revisit to the re-licensure survey of 11/04/22, conducted 09/21/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

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

The licensee is responsible for the operation of the facility and the quality of services rendered in the facility, including the supervision and training of staff.

During the change of ownership survey, conducted 10/31/22 through 11/04/22, administrative oversight to ensure adequate resident care and services, including the development, implementation and monitoring of systems for responding to resident changes of condition and for updating resident service plans with new care instructions, was found to be ineffective based on the severity and number of citations.

Refer to deficiencies in this report.

Based on interview and record review, it was determined the facility failed to ensure background checks were submitted to the Department for criminal fitness determination for 6 of 6 newly hired employees (#s 3, 18, 19, 20, 21 and 22) in accordance with OAR chapter 407-007-0200 to 407-007-0370, and 407-007-0600 to 0640 and were not being actively supervised at all times by an individual who had been approved without restrictions pursuant to OAR 407-007-0065. Findings include, but are not limited to:

In an interview with Staff 1 (Administrator) and Staff 4 (Business Office Manager) on 11/03/22 at 9:20 am, it was revealed that six recently hired staff members (#s 3, 18, 19, 20, 21 and 22) had not had a background check submitted prior to beginning employment and were not being actively supervised at all times by an individual who had been approved without restrictions pursuant to OAR 407-007-0065. After the interview, the background checks were submitted to the Department for fitness determination for the newly hired employees.

A plan was provided to the survey team on 11/04/22 at 10:30 am by Staff 1 ensuring direct supervision of those staff members who had background checks submitted until final fitness determination was obtained.

The need to ensure the facility had submitted background checks to the Department for a criminal fitness determination for all newly hired employees and received approval to work prior to working unsupervised was discussed with Staff 1, Staff 4 and Staff 8 (Administrative Assistant) on 11/05/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to implement effective methods of responding to and resolving resident complaints. Findings include, but are not limited to:

During a group interview, conducted on 11/02/22 with eleven unsampled residents, multiple complaints or concerns were brought up. The complaints included:

* There were not enough activities or scheduled activities often did not occur;

* The facility van's plates had expired so there were no scheduled outings;

* Residents didn't feel there were any qualified staff available if they had a medical emergency;

* Staff didn't always knock on the resident's door or wait until the resident invited the staff in;

* Multiple issues with meals: food wasn't cooked properly, vegetables were overcooked, the variety/menu was limited, portions were too small; and

* Residents sometimes went without scheduled medications because the facility failed to re-order prescriptions timely.

When asked, the residents stated they did not feel the facility addressed their concerns and made changes to resolve complaints. One resident stated s/he typically got the response, "We're working on it." The residents reported they had ceased having resident council meetings because of low turnout and interest.

In an interview on 11/04/22, Staff 1 (Administrator) acknowledged she was aware residents had a lot of complaints. She stated she felt like even when the facility attempted to resolve resident complaints, the residents were not satisfied and found more things to complain about. She explained that the facility has a "Grievance Form", but residents refuse to fill it out. She also said that rather than approaching her or the Ombudsman with concerns, many residents just called Adult Protective Services. She acknowledged she did not currently have a procedure for documenting resident complaints and how the facility attempted to resolve the complaints.

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

During the survey, conducted 10/31/22 through 11/04/22, quality improvement oversight to ensure adequate resident care, services and satisfaction was found to be ineffective.

Staff 1 (Administrator) and Staff 8 (Administrative Assistant) was asked about the facility's quality improvement program on 11/04/22 at 10:20 am. During the interview, Staff 1 stated the facility did not currently have a Quality Improvement Program. The need to ensure the facility had an effective method to evaluate services, resident outcomes and resident satisfaction was discussed. They acknowledged the findings.

Refer to the deficiencies in the report.

Based on observation, interview and record review, it was determined the facility failed to ensure 1 of 1 sampled resident who was bedbound (#5) was treated with dignity and respect. Findings include, but are not limited to:

Resident 5 was admitted to the facility in 03/2016 with diagnoses including congestive heart failure, cardiomyopathy, Chronic Obstructive Pulmonary Disease (COPD), seizures, diabetes mellitus - type 2, neuropathy and pain. During the entrance conference on 10/31/22, staff reported the resident had a recent overall decline in health, had been hospitalized and was now bedbound.

The record indicated Resident 5 was hospitalized from 09/30/22 through 10/05/22 for exacerbation of seizure activity. Prior to the hospital stay, the resident's 05/13/22 service plan and interviews with staff indicated the resident was independent for most ADLs including transfers, mobility and toileting. Upon return to the facility, the resident had a Foley catheter, and was unable to bear weight, requiring multiple staff and a Hoyer lift for transfers in and out of bed.

In an interview on 11/01/22 at 1:30 pm, the Resident 5 stated s/he felt "neglected" because s/he wanted to be assisted out of bed and use his/her manual wheelchair for mobility in his/her apartment and in the building. The resident stated that care staff reported they were not able to safely lift and transfer him/her out of bed and into the wheelchair. The resident stated s/he had been restricted to his/her bed since returning to the facility on 10/05/22.

In interviews on 11/03/22, Staff 12 (CG) and Staff 15 (CG) confirmed it took two to three staff just to reposition the resident due to the resident's weight, and the facility was unable to physically transfer the resident out of bed.

The resident's status and care needs were discussed with Staff 1 (Administrator) and Staff 8 (Administrative Assistant) on 11/04/22. Staff 1 acknowledged the facility had not been able to transfer the resident out of bed per the resident's preference and request. Staff 1 stated corporate policy prohibited the facility from utilizing a Hoyer Lift to transfer the resident. The surveyors informed Staff 1 and Staff 8 that because they had accepted Resident 5 back to the facility following the hospitalization, the facility was responsible to meet the resident's care needs and preferences, and failure to do so was a violation of the resident's right to be treated with dignity and respect. Staff 1 and 8 acknowledged the findings.

Upon exiting the building on 11/04/22 at 4:45 pm, a caregiver was observed pushing Resident 5 outside the building in his/her wheelchair. The resident told this surveyor "I feel so much better being out of bed."

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

a. Observation of the kitchen on 10/31/22 at 10:05 am revealed an accumulation of food spills, splatters, loose food debris, dirt and/or dust on or underneath the following:

* Cupboards under juice station;

* Small refrigerator near juice station;

* Juice dispenser;

* Coffee machine;

* Ice machine;

* Cupboards under steam table;

* Cupboards across from steam table

* Steam table shelving;

* Steam table sides;

* Industrial toaster;

* Shelving below toaster;

* Ovens;

* Stove;

* Ventilation hood;

* Steamer;

* Industrial mixer;

* Prep sink counter and shelving;

* Clean dish shelving;

* Push carts;

* Flooring of the walk-in refrigerator;

* Cooling racks;

* Warewasher;

* Garbage disposal mechanism;

* Walls throughout the kitchen;

* Flooring and baseboards throughout the kitchen;

* Floor drains throughout the kitchen; and

* Doors throughout the kitchen.

b. The following kitchen items needed repair:

* Laminate on the shelving surrounding the steam table had scrapes and/or gouges with bare wood exposed rendering the surfaces uncleanable; and

* Clean dish shelving had scrapes and/or gouges with bare wood exposed rendering the surfaces uncleanable.

c. The following food items were not stored in a manner to prevent rodent or pest infestation:

* Cornstarch in pantry;

* Noodles in pantry;

* Flour near prep area;

* Sugar near prep area; and

* Cooking oil under steam table.

d. Garbage cans throughout the kitchen were left uncovered when not in use.

The areas that required cleaning and repair were observed and discussed with Staff 1 (Administrator) on 10/31/22 at 11:22 am. She acknowledged the findings. Staff 1 was asked to begin cleaning immediately. Upon re-inspection of the kitchen on 11/01/22, surfaces throughout the kitchen were clean.

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

The facility provided the survey team with the monthly activity calendar for November 2022. Each day, the calendar indicated multiple activities were scheduled from 9:30 am until 3:00 pm. Activities included:

* Morning workout or morning walk;

* Painting;

* Games;

* BINGO;

* Relax with friends;

* Trivia; and

* Movie night.

On 11/01/22 and 11/02/22, residents organized and led their own BINGO activity. On 11/03/22, Staff 6 (Activity Director) led a BINGO activity from 9:30 am until approximately 11:00 am in which nine residents attended and participated. None of the other scheduled activities were observed to occur during the survey.

During a group interview, conducted by the survey team on 11/02/22, multiple unsampled residents reported:

* There weren't many activities;

* Activities often were canceled;

* They didn't feel some activities were age-appropriate;

* Fitness activities didn't occur and they wished the facility had exercise equipment;

* There weren't activities developed specifically for the male residents; and

* The facility van's license plates had not been renewed so the facility could not offer outings as activities for the residents.

The lack of a daily program of social and recreational activities was discussed with Staff 1 (Administrator), Staff 8 (Administrative Assistant) and Staff 6 on 11/04/22. They acknowledged the facility was not providing activities that were scheduled and needed to improve the current activity program.

Based on interview and record review, it was determined the facility failed to ensure resident evaluations were completed before the resident moved into the facility, at least quarterly and following a significant change of condition, that initial evaluations addressed all required elements and that evaluations were reflective of the resident's current status, for 3 of 5 sampled residents (#s 3, 4 and 5) whose evaluations were reviewed. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 06/2022 with diagnoses including chronic respiratory failure, Chronic Obstructive Pulmonary Disease (COPD), anxiety disorder, chronic pain syndrome and long-term use of opiate analgesic medications.

a. In an interview on 11/04/22, Staff 1 (Administrator) acknowledged she did not begin entering Resident 3's initial evaluation information into the facility electronic documentation system until three days after the resident was admitted and did not complete the evaluation until 18 days after admission.

b. The initial evaluation failed to address the following elements with sufficient information to develop an initial service plan:

* Customary routines: sleeping, eating, bathing;

* Interests, hobbies, social and leisure activities;

* Spiritual, cultural preferences and traditions;

* Mental health: history of treatment and effective non-pharmacological interventions;

* Pain: description and non-pharmaceutical interventions;

* Fluid preferences;

* Emergency evacuation ability;

* Complex medication regimen;

* History of dehydration or unexplained weight loss or gain;

* Elopement history or risk; and

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

The need to ensure the initial evaluation addressed all elements and was completed prior to the resident's admission was reviewed with Staff 1 and Staff 8 (Administrative Assistant) on 11/04/22. They acknowledged the deficiencies.

2. Resident 5 was admitted to the facility in 03/2016 with diagnoses including congestive heart failure, cardiomyopathy, COPD, seizures, diabetes mellitus - type 2, neuropathy and pain.

The record indicated Resident 5 was hospitalized from 09/30/22 through 10/05/22 for exacerbation of seizure activity. Prior to the hospital stay, the resident's 05/13/22 service plan and interviews with staff indicated the resident was independent for most ADLs including transfers, mobility and toileting. Upon return to the facility, the resident had a Foley catheter, and was unable to bear weight, requiring multiple staff and a Hoyer lift for transfers in and out of bed.

The resident experienced a significant change of condition in status and care needs following the hospitalization. The resident's evaluation was not updated for staff to reflect the changes in status and care needs until 10/24/22 - 19 days after the changes occurred.

The need to ensure resident evaluations were updated timely following a significant change of condition was reviewed with Staff 1 (Administrator) and Staff 8 (Administrative Assistant) on 11/04/22. They acknowledged the evaluation was not updated timely.

3. Resident 4 was admitted to the facility in 10/2020 with diagnoses including arthritis and gait disorder.

The resident's record indicated that s/he received wound care from an outpatient provider on 08/04/22 who documented the presence of wounds on both the left foot and right toe. Review of the resident's progress notes, dated 07/31/22 through 10/30/22, revealed no documented evaluation of the wound on the resident's right toe.

The resident experienced a significant change of condition following the identification of a right toe wound. The resident's service plan, dated 08/20/22, was not updated with changes to the resident's care needs.

The need to ensure evaluations were completed timely following a significant change of condition was discussed with Staff 1 (Administrator) and Staff 8 (Administrative Assistant) on 11/04/22 at 1:00 pm. They acknowledged the findings.

4. Resident 6 was admitted to the facility in 01/2021.

a. During the acuity interview on 10/31/22, facility staff stated current service plans available to staff were located in a binder at the front desk.

Review of the binder revealed Resident 6's service plan, available to staff, was dated 10/12/21 (a year old).

In an interview with Staff 1 (Administrator) on 10/31/22, she acknowledged the service plan available to staff was not current. She stated the most recent service plan had to be printed from her computer. A copy of the recent service plan, dated 09/19/22, was printed and given to the surveyor.

b. Interviews with care staff, observations and an interview with Resident 6, and review of the clinical record revealed the service plan, dated 09/19/22, was not reflective of the resident's needs and lacked clear direction regarding the delivery of services in the following areas:

* Skin wounds;

* Application of lotion;

* Use of a fall mat;

* Dressing assistance;

* Personal hygiene/grooming assistance;

* Continence care;

* Bathing assistance;

* Daily housekeeping services;

* Oxygen flow rate; and

* Activity participation/socialization.

The need to ensure the current service plan was available to staff, was reflective of Resident 6's care needs, and provided clear direction was discussed with Staff 1 and Staff 8 (Administrative Assistant) during an interview on 11/04/22. They acknowledged the findings. No further information was provided.

Based on observation, interview and record review, it was determined the facility failed to ensure resident service plans were completed before move-in and following quarterly evaluations and significant changes of condition, were reflective of the resident's current status, included a written description of the services to be provided and were readily available to staff, for 6 of 6 sampled residents (#s 1, 2, 3, 4, 5 and 6) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 06/2022 with diagnoses including chronic respiratory failure, Chronic Obstructive Pulmonary Disease (COPD), anxiety disorder, chronic pain syndrome and long-term use of opiate analgesic medications.

Review of the record indicated Resident 3's service plan was not completed until 18 days after s/he was admitted to the facility.

The need to ensure resident service plans were completed prior to move-in was reviewed with Staff 1 (Administrator) and Staff 8 (Administrative Assistant) on 11/04/22. They acknowledged the findings.

2. Resident 5 was admitted to the facility in 03/2016 with diagnoses including congestive heart failure, cardiomyopathy, COPD, seizures, diabetes mellitus - type 2, neuropathy and pain.

The record indicated Resident 5 experienced a significant change of condition that affected his/her status and care needs upon returning from a hospitalization on 10/05/22. The resident's service plan was not updated to reflect the changes in status and care needs until 10/24/22 - 19 days after the changes occurred.

Refer to C 252, example 2.

3. Resident 4 was admitted to the facility in 10/2020 with diagnoses including arthritis.

The resident's current service plan dated 08/20/22 was reviewed, observations were made, and interviews were conducted between 10/31/22 and 11/04/22. Resident 4's service plan was not reflective, did not provide clear instruction to staff and/or was not followed in the following areas:

* Transfer status;

* Fall interventions;

* Toileting status;

* Skin wounds; and

* Alcohol consumption including the need for increased safety checks.

The need to ensure service plans were reflective of the identified needs of the resident, provided clear direction to staff, and were followed by staff was discussed with Staff 1 (Administrator) and Staff 8 (Administrative Assistant) on 11/04/22 at 1:00 pm. They acknowledged the findings.

5. Resident 1 and Resident 2 were admitted to the facility in 09/2017.

Service plans for Resident 1 and Resident 2, available for review to this surveyor and to the staff, were dated 02/15/22. On 11/02/22, updated service plans for Resident 1 and Resident 2, dated 10/31/22, were provided to this surveyor by Staff 1 (Administrator).

The need to ensure service plans were completed quarterly after the resident moved into the facility was discussed with Staff 1 and Staff 8 (Administrative Assistant) on 11/04/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that included the resident, the resident's legal representative if applicable, any person of the resident's choice, the Administrator or designee, at least one other staff person who was familiar with or who was going to provide services to the resident for 6 of 6 sampled residents (#s 1, 2, 3, 4, 5 and 6). As applicable, the Service Planning Team must also include local APD or AAA Case Managers and family invited by the resident, and a licensed nurse if the resident shall need or is receiving nursing services or experienced a significant change of condition. Findings include, but are not limited to:

Current service plans for Residents 1, 2, 3, 4, 5 and 6 were reviewed during the survey.

The service plans lacked evidence a Service Planning Team reviewed and participated in the development of the service plans.

The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (Administrator) and Staff 8 (Administrative Assistant) on 11/04/22. They acknowledged the findings.

3. Resident 6 was admitted in 01/2021 and had a history of falls, skin breakdown and congestive heart failure.

During the entrance conference on 10/31/22, staff reported the resident had a recent significant overall decline in health and weight loss.

The clinical record, progress notes, hospital discharge summaries, and facility weights were reviewed from 04/2022 through 10/31/22, and an interview with the resident on 10/31/22 revealed the following:

a. Resident 6, who was alert and oriented, was interviewed on 10/31/22. During the interview, s/he said s/he eats in his/her room, had a poor appetite, often refused meals, and had lost weight.

On 08/13/22, a staff MT documented in progress notes that the resident had "unplanned weight loss suspected ...loss of appetite ..."

On 08/26/22, a progress note written by Staff 24 (former LPN) indicated the resident had "not been eating well and has been losing weight ..."

Facility weight records and hospital discharge summaries revealed the following weights:

* 04/26/22: 159.8 lbs.

* 05/12/22: 147.9 lbs.

* 08/26/22: 124.0 lbs.

* 09/23/22: 135.8 lbs.

* 10/21/22: 139.1 lbs.

Staff obtained the resident's weight on 11/02/22. Resident 6 weighed 140 lbs.

Resident 6 weighed 159.8 pounds in 04/2022. On 10/21/22, the resident's weight dropped to 139.1 pounds, which was a loss of 20.7 pounds or 12.9% loss in six months which constituted a severe loss and significant change in condition.

There was no evidence the facility evaluated the weight loss, referred the significant change to the facility RN, or updated the service plan.  

b. A progress note, written by an MT on 08/13/22, indicated the resident had "shown the following signs of a significant change in condition: uncontrolled pain, fast decline in activities of daily living, unplanned weight loss suspected, level of consciousness change, loss of appetite. Has been put on alert for change in condition."

The facility failed to refer to the facility RN for assessment and update the service plan to reflect the change in condition.

c. Resident 6 fell five times between 08/01/22 and 10/12/22. Review of the record revealed no documented evidence the facility consistently monitored and documented on the progress of the resident's condition at least weekly until resolved. Additionally, the facility failed to consistently evaluate if service-planned interventions were implemented, were effective, or if new interventions were needed.

d. Between 09/01/22 and 10/03/22, Resident 6 was sent to the hospital on four occasions and returned with diagnoses including, but not limited to: foot cellulitis, head trauma, foot pain, pneumonia and decreased level of consciousness. The facility initiated short-term monitoring. However, ongoing monitoring did not continue until resolution for the short-term changes in condition.

The need to ensure the facility monitored and documented on the progress of short-term changes in condition at least weekly until resolved, determined if fall interventions were implemented, effective or if new interventions were needed, ensured significant changes of condition were evaluated, referred to the facility RN for assessment, and the service plan updated was shared with Staff 1 (Administrator) and Staff 8 (Administrative Assistant) on 11/04/22 at 10:20 am. They acknowledged the findings. No further information was provided.

2. Resident 5 was admitted to the facility in 03/2016 with diagnoses including congestive heart failure, cardiomyopathy, Chronic Obstructive Pulmonary Disease (COPD), seizures, diabetes mellitus - type 2, neuropathy and pain.

During the entrance conference on 10/31/22, staff reported the resident had a recent overall decline in health, had been hospitalized and was now bedbound.

The clinical record, progress notes and hospital and PCP visit summaries from 08/01/22 through 10/31/22 were reviewed. Facility staff and the resident were interviewed. The following deficiencies were identified:

a. Between 08/11/22 and 10/18/22, the resident had nine falls in his/her apartment. There was no documented evidence the facility:

* Reviewed each fall to determine whether service-planned fall interventions were being followed, were effective or whether different or additional interventions needed to be implemented to prevent further falls; and

* Ensured staff instructions or interventions were resident-specific and made part of the resident record with weekly progress noted until the condition resolved.

b. The resident sustained several minor injuries from the falls including bruising and skin tears.

* There was no documented evidence the facility determined, documented and communicated to staff what actions or interventions were needed for the resident; and

* The facility failed to monitor the injuries with weekly progress noted until the conditions resolved.

c. The resident was hospitalized three times for reports of chest pains or exacerbation of respiratory conditions.

* For two of the incidents, there was no documented evidence the facility determined, documented and communicated to staff what actions or interventions were needed for the resident and monitored the resident with weekly progress noted until the conditions resolved; and

* The facility failed to make staff instructions or interventions part of the resident record.

d. Resident 5 was hospitalized from 09/30/22 through 10/05/22 for exacerbation of seizure activity. Prior to the hospital stay, the resident's 05/13/22 service plan and interviews with staff indicated the resident was independent for most ADLs including transfers, mobility and toileting. Upon return to the facility, the resident had a Foley catheter, and was unable to bear weight, requiring multiple staff and a Hoyer lift for transfers in and out of bed.

The change in status and care needs following the hospitalization represented a significant change of condition. Though the facility nurse documented some of the resident's changes, the facility failed to update the resident's service plan with specific instructions for staff as to how to meet Resident 5's care needs regarding transfers, mobility, toileting, catheter care and other ADLs.

The need for the facility to develop and implement an effective system for responding to resident changes of condition that included review of service-planned interventions, development, documentation and communication of instructions for staff that were made part of the resident's record and monitoring of conditions until resolved, was discussed with Staff 1 (Administrator) and Staff 8 (Administrative Assistant) on 11/04/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to determine and document what actions or interventions were needed for changes of condition including resident specific instructions communicated to staff on each shift, weekly progress documented until the condition resolved and/or the facility failed to refer significant changes of condition to the facility RN for 3 of 3 sampled residents (#s 4, 5 and 6) who had changes of condition. Resident 4 did not receive consistent and ordered wound care and the resident's wound worsened and caused distress to the resident. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 10/2020 with diagnoses including gait disorder and lichen planus (inflammation of the skin).

During the entrance conference interview on 10/31/22, Resident 4 was identified as receiving home health services for lower leg edema.

Resident 4 was interviewed on 11/01/22 at 9:35 am and reported to have wounds on both his/her left and right feet. The wounds were visualized at that time with the resident's permission. The left foot had approximately a quarter-sized wound on the left side. The right foot had a visible wound on the second toe with a crusty black coating. Neither wound was bandaged. The resident reported the facility did not check on his/her wounds regularly, s/he was not receiving home health services, and the wound clinic frequently canceled appointments due to lack of staff.

a. Resident 4's medical records were examined. The first documentation of a right toe wound occurred on 08/04/22 following an outpatient wound care visit. The clinic identified the location of the wound as the right lateral side of the second toe with orders to "change dressing every other day or as needed for excessive drainage," "cleanse wounds on dressing days with soap and water," "apply Collagen dressing to wound bed as directed," and "Band-Aid applied over Prisma layer."

The service plan, dated 08/20/22, progress notes, dated 07/31/22 through 10/30/22, and MARs, dated 08/2022 through 10/2022, were reviewed and there was no monitoring of the wound, no documentation of when it originated or when the RN was made aware of it.

On 11/02/22 at 9:20 am, the resident's wounds were observed with Staff 2 (RN - Wellness Director) and an RN surveyor. Staff 2 documented the assessment on 11/02/22 and indicated the resident had an open 2 cm x 3 cm wound on top and proximally surrounding the right second and third toe with mild clear-yellow discharge.

At 11:09 am on 11/02/22, Staff 2 reported she was not previously aware of the resident's right toe ulcers and her first assessment of the resident's lower extremity wounds was completed by direction of this surveyor on 11/02/22. She also stated there was no documentation by the facility of the resident's right toe wounds, and Staff 11 (CG) completed all basic wound treatments for the resident and home health completed all other wound care. Staff 2 was unaware the resident's wound care clinic appointments had been canceled by the clinic due to lack of staff.

When questioned about her job duties, Staff 2 then stated she was hired to complete delegation tasks only and she was made aware of other nursing issues when caregiving staff or residents told her of problems directly.

The facility's policy was reviewed on 11/04/22. According to the policies and procedures, a "Nursing Comprehensive Evaluation" must be completed by an RN following a significant change of condition. Regarding coordination of care, the RN was responsible to discuss options to address resident's needs with the resident when services could not be provided by the community. Moreover, the RN was responsible for coordination of care and required documentation.

On 11/02/22 at 11:30 am, Staff 11 reported she completed basic wound care for the resident at least every other shift she worked. This included the use of cleanser, antibiotic ointment and covering with a Band-Aid. She went on to state she did not document any wound care she completed, and any concerns about the resident's wounds were reported to the RN or RCC. There was no documented evidence the facility was providing the wound care ordered by the outpatient wound clinic.

Resident 4 was seen on 11/02/22 at his/her primary care physician's office with instructions to start antibiotics for the toe ulcer, directions for wound cleaning and instructions to return to the office for a follow-up visit in one week.

An immediate plan of action to address the resident's wound care, until home health services began, was requested of the facility and approved by this surveyor on 11/04/22.

The facility failed to identify and evaluate the resident's right toe ulcer, refer to the facility RN following a significant change of condition, determine and document interventions regarding the ulcer, communicate the interventions to staff and monitor the resident according to his/her evaluated needs. The resident's right second toe wound worsened to include the third toe.

b. During an interview with Resident 4 on 11/01/22, s/he reported a wound on the left foot.

Resident 4's progress notes, dated 07/31/22 through 10/30/22 were reviewed for changes of condition related to the left foot wound and revealed the following information:

* 08/03/22 - "Remove from Alert Charting...Residents [sic] [left] foot ulcer is being monitored in house by this nurse and treated by this nurse in between [his/her] trips to off-site wound care...Residents [sic] wound continues to improve ...";

* 08/26/22 - "Residents [sic] wound care was canceled again today...at this time this nurse is following orders from the wound care facility";

* 09/27/22 - "Resident was getting upset, because [s/he] wanted to see a doctor or a nurse to do wound care on [his/her] feet...[s/he] requested to go to the ER [emergency room]"; and

* 10/19/22 - "Resident came back from ...ER with diagnosis of Neuropathy and Chronic foot ulcer ..."

On 11/02/22 at 11:30 am, Staff 11 reported she completed basic wound care for the resident at least every other shift she worked, but she did not document any wound care she completed.

There was no documented evidence the facility identified resident specific interventions regarding the left foot wound, communicated the interventions to all staff and then monitored the resident according to his/her evaluated needs.

c. Resident 4's progress notes, dated 07/31/22 through 10/30/22, service plan, dated 08/20/22, and ISP, dated 08/19/22 were reviewed and revealed the following:

The following short-term changes of condition lacked evidence resident-specific actions or interventions were determined, documented and communicated to staff:

* 08/20/22 - Fall with injury; and

* 10/22/22 - Non-injury fall.

The following short-term changes of condition lacked documented evidence the resident's determined actions or interventions were monitored through resolution:

* 08/11/22 - New prescription for meloxicam (for arthritis) and Tylenol #3 (for pain);

* 08/20/22 - Fall with injury;

* 09/15/22 - New prescription for amlodipine (for high blood pressure) and the discontinuation of sertraline (for depression), Zofran (for nausea) and Tylenol PRN (for pain); and

* 10/22/22 - Non-injury fall.

The need to ensure changes of condition were identified, reported to RN if determined to be a significant change of condition, interventions determined, documented and communicated to staff with monitoring occurring per the residents' evaluated needs was discussed with Staff 1 (Administrator) and Staff 8 (Receptionist) on 11/04/22 at 1:00 pm. The findings were acknowledged, and no additional documentation was provided.

3. Resident 6 was admitted in 01/2021 and had a history of skin breakdown and poor appetite.

a. Facility progress notes, weight records, MARs and the current service plan, reviewed from 04/2022 through 10/31/22, revealed the following:

Resident 6 weighed 159.8 pounds in 04/26/22. On 10/21/22, the resident's weight dropped to 139.1 pounds, which was a loss of 20.7 pounds or 12.9% loss in six months which constituted a severe loss and significant change in condition.

There was no documented facility RN assessment to address the weight loss.

Refer to C 270, example 3a.

b. On 08/13/22, a facility MT documented in progress notes that the resident had "shown the following signs of a significant change in condition: uncontrolled pain, fast decline in activities of daily living, unplanned weight loss suspected, level of consciousness change, loss of appetite. Has been put on alert for change in condition."

There was no documented evidence the facility RN conducted an assessment.

During an interview on 11/02/22 at 12:15 pm, Staff 2 (RN - Wellness Director) acknowledged the lack of documented RN assessments for the significant changes in condition.

The need to ensure documented RN assessments for significant changes in condition was discussed with Staff 1 (Administrator) and Staff 8 (Administrative Assistant) on 11/04/22 at 10:20 am. They acknowledged the findings. No further information was provided.

2. Resident 5 was admitted to the facility in 03/2016 with diagnoses including congestive heart failure, cardiomyopathy, Chronic Obstructive Pulmonary Disease (COPD), seizures, diabetes mellitus - type 2, neuropathy and pain.

During the entrance conference on 10/31/22, staff reported the resident had a recent overall decline in health, had been hospitalized and was now bedbound.

The clinical record, progress notes and hospital and PCP visit summaries from 08/01/22 through 10/31/22 were reviewed. Facility staff and the resident were interviewed.

Resident 5 was hospitalized from 09/30/22 through 10/05/22 for exacerbation of seizure activity. Prior to the hospital stay, the resident's 05/13/22 service plan and interviews with staff indicated the resident was independent for most ADLs including transfers, mobility and toileting. Upon return to the facility, the resident had a Foley catheter, and was unable to bear weight, requiring multiple staff and a Hoyer lift for transfers in and out of bed.

The change in status and care needs following the hospitalization represented a significant change of condition. There was no documented evidence the facility RN completed an assessment of the resident which documented findings, resident status, and interventions made as a result of this assessment.

The need to ensure the facility RN completed an assessment of a resident with a significant change of condition was reviewed with Staff 2 (RN - Wellness Director) on 11/02/22 and with Staff 1 (Administrator) and Staff 8 (Administrative Assistant) on 11/04/22. They acknowledged no assessment had been completed by the facility RN as required.

Based on observation, interview and record review, it was determined the facility failed to ensure health services were provided according to the facility's policy and per the resident condition, including ensuring the RN performed an assessment and interventions were developed based on the condition of the resident, and/or providing facility-arranged temporary or intermittent nursing services when services were not available through a third-party provider, for 3 of 3 sampled residents (#s 4, 5 and 6) who experienced significant changes of condition. Resident 4 experienced worsening wounds on the right foot. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 10/2020 with diagnoses including gait disorder and lichen planus (irritation of the skin).

Progress notes, dated 05/09/22 through 10/30/22, and MARs, dated 08/2022 through 10/2022, were reviewed. Observations and interviews with staff were completed between 10/31/22 and 11/04/22 and revealed the following:

Resident 4 had open wounds on the left foot and the right second and third toes which indicated a significant change of condition and required an RN assessment.

There was no documented evidence the wounds were assessed by the facility RN with resident specific interventions created related to the change of condition. Additionally, there was no evidence the facility provided temporary nursing services when the resident's care needs could not be met through other third party providers. This resulted in worsening right toe wounds.

The need to ensure documented RN assessments were completed and intermittent nursing services were provided when not available through a third-party provider was discussed with Staff 1 (Administrator) and Staff 8 (Administrative Assistant) on 11/04/22 at 1:00 pm. They acknowledged the findings and no further information was provided.

Refer to C 270, example 1a and 1b.

2. Resident 6 was admitted in 01/2021 and had a history of skin breakdown and weight loss.

During the entrance conference interview on 10/31/22, staff indicated Resident 6 had lost weight and currently had skin breakdown that was being treated by home health nursing services.

a. On 10/31/22 at 1:40 pm, the surveyor observed that Resident 6's left lower leg was wrapped with bandages. S/he explained the wound was bandaged by "home care." During the interview, an RN from home health arrived to perform wound care.

The resident's clinical record revealed the resident sustained a laceration to his/her left lower leg on 06/23/22. Home health was initiated in 07/2022 and continued as of the survey. However, there was no on-going documentation left by home health, no wound care instructions in the event staff needed to provide supplemental care as needed, and no evidence the facility implemented recommendations that were provided by home health.

In an interview on 11/03/22 at 9:50 am, Staff 11 (MT) said she was unsure what to do if she needed to change the dressing on the resident's leg. She reviewed the MAR and stated it lacked wound care instructions in the event the bandages needed to be changed/re-applied.

b. On 10/18/22, home health documented on a facility "Outside Provider Coordination" form that staff should "please give snacks throughout day, trying to increase calorie intake." The document had staff initials, dated 10/25/22, that the recommendation had been reviewed. However, there was no evidence in the resident's record the recommendation had been communicated to staff and implemented.

The need to ensure the facility obtained information from outside providers and ensure recommendations were communicated to staff and/or implemented was discussed with Staff 1 (Administrator), Staff 2 (RN - Wellness Director), Staff 3 (Med Room Manager), and Staff 8 (Administrative Assistant) during interviews on 11/02/22, 11/03/22 and 11/04/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to coordinate on-site health services with outside providers, ensure outside providers left written information in the facility that addressed on-site services being provided, and reviewed and updated the resident's service plan with new interventions, for 2 of 2 sampled residents (#s 5 and 6) who received home health services. Findings include, but are not limited to:

1. Resident 5 was admitted to the facility in 03/2016 with diagnoses including congestive heart failure, cardiomyopathy, Chronic Obstructive Pulmonary Disease (COPD), seizures, diabetes mellitus - type 2, neuropathy and pain.

The record indicated Resident 5 received Physical Therapy services in the facility from 07/14/22 until approximately 09/26/22.

* Review of "Outside Provider Coordination" notes indicated the facility did not review the information provided by PT until 10/09/22.

* On 09/21/22, PT documented, "[Patient] has small wound on [left] heel please monitor daily." There was no documented evidence the facility monitored the wound as instructed by PT.

The need to ensure outside provider information was reviewed timely and instructions/interventions added to the resident's service plan and implemented was reviewed with Staff 1 (Administrator) and Staff 8 (Administrative Assistant) on 11/04/22. They acknowledged the findings.

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

During the change of ownership survey, conducted 10/31/22 through 11/04/22, administrative oversight was found to be ineffective based on deficiencies in the following areas:

C 303: Systems: Medication and Treatment Orders;

C 305: Systems: Resident Right to Refuse;  

C 310: Systems: Medication Administration;

C 325: Systems: Self-Administration of Meds; and

C 330: Systems: Psychotropic Medications.

Failure to ensure adequate professional oversight based on deficiencies related to medication administration was discussed during the exit meeting on 11/04/22.

4.  Resident 6 was admitted in 01/2021 with diagnoses which included heart disease, COPD and constipation.

Physician orders and MARs, reviewed from 10/01/22 through 10/31/22, revealed the following orders were not followed:

* Clopidogrel 75 mg one tablet daily (for heart disease) was not administered on one occasion because it was "unavailable";

* Guaifenesin 1200 mg one tablet twice daily (for congestion) was not given on two occasions because it was "unavailable"; and  

* Miralax (for constipation) 17 grams daily was not documented as given on 10/28/22.

On 11/03/22 at 9:45 am, the surveyor and 11 (MT) observed/checked the MARs and medication supply. Staff 11 was unable to verify if the above orders had been followed.

The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (Administrator) and Staff 8 (Administrative Assistant) on 11/04/22 at 10:20 am. They acknowledged the findings.

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

1. Resident 5 was admitted to the facility in 03/2016 with diagnoses including congestive heart failure, cardiomyopathy, Chronic Obstructive Pulmonary Disease (COPD), seizures, diabetes mellitus - type 2, neuropathy and pain.

a. Review of Resident 5's chart and 10/01/22 through 10/31/22 MAR indicated the following medications were being administered without a signed written physician's order in the resident's record:

* Morphine (for pain and difficulty breathing) TID;

* Basaglar Quickpen (insulin for diabetes mellitus) 30 units at bedtime;

* Basaglar Quickpen 40 units at 5:00 pm;

* Keflex (an antibiotic) for 7 or 10 days BID or TID;

* Cipro (an antibiotic) for 10 days BID;

* Incruse Ellipta inhaler (for respiratory conditions) 1 puff daily;

* PRN Haldol (for psychosis);

* PRN lorazepam (for anxiety or agitation);

* PRN morphine (for pain or breathing difficulty);

* PRN tizanidine (for back spasms);

* PRN Zofran (for nausea/vomiting);

* PRN loparamide (for diarrhea);

* PRN Bisacodyl suppository (for constipation); and

* PRN Senna (for constipation).

b. The facility ceased administering the following medications without a signed, written physician's order to discontinue the medications in the resident's record:

* Amiodarone(for heart health);

* Aspirin (for heart health);

* Basaglar Quickpen (insulin for diabetes mellitus) 40 units daily;

* Carvedilol (for high blood pressure and heart failure);

* Eliquis (a blood thinner);

* Flonase (for seasonal allergies);

* Glipizide (for diabetes mellitus);

* Pantoprazole (for acid reflux);

* Pregabalin (for seizures);

* Simvastatin (to lower cholesterol);

* Spironolactone (for high blood pressure and heart failure);

* Victoza (to lower blood sugar); and

* Benadryl (for allergy and itch relief).

c. The resident was prescribed torsimide (for removing excess fluid) 100 mg every day and an additional 50 mg every other day.

The order was transcribed inaccurately on the MAR. In an interview on 11/04/22, Staff 10 (MT) stated she could not confirm that staff were administering the medication as ordered.  

The facility's failure to have signed, written physician orders in the resident's chart for all medications and treatments it was responsible to administer, and orders to discontinue medications and treatments, was reviewed with Staff 3 (Med Room Manager) on 11/02/22 and with Staff 1 (Administrator) and Staff 8 (Administrative Assistant) on 11/04/22. They were unable to provide copies of the orders.

2. Resident 4 was admitted to the facility in 10/2020 with diagnoses including hypertension and lichen planus (irritation of the skin).

Resident 4's physician's orders, complete MAR, dated 10/01/22 through 10/30/22, and partial MARs, dated 08/2022 through 09/2022, were reviewed and revealed the following:

a. The MAR was blank for the following medications or treatments:

* 10/05/22 - Amlodipine 5 mg (for hypertension);

* 10/28/22 - Clotrimazole 1% cream (for rash); and

* 10/28/22 - Eucerin Advanced Repair Cream (for rash).

On 11/01/22 at 2:47 pm, the surveyor and Staff 3 (Med Room Manager) observed/checked the MARs and medication supply. Staff 3 was unable to verify if the above orders had been followed.

b. Resident 4 had a physician's order, dated 05/07/22, for amlodipine 5 mg - one tablet daily (for high blood pressure).

The facility documented the medication as given twice daily on the following dates:

* 08/01/22 - 08/31/22;

* 09/01/22 - 09/07/22;

* 09/10/22;

* 09/12/22 - 09/13/22;

* 09/17/22 - 09/18/22;

* 09/20/22 - 09/26/22;

* 09/28/22 - 09/29/22; and

* 10/03/22 - 10/04/22.

c. Resident 4 had a physician's order to administer Acetaminophen 500 mg - two tablets by mouth every four hours as needed for fever greater than 100.1 degrees F.

On 10/04/22, the resident received the PRN Acetaminophen with documentation indicating it was administered for pain.

The need to ensure medications were carried out as prescribed was discussed with Staff 1 (Administrator) and Staff 8 (Administrative Assistant) on 11/04/22. They acknowledged the findings.

3. Resident 1 was admitted to the facility in 09/2017 with diagnoses including Diabetes Mellitus Type 2.

Review of the MAR dated 10/01/22 through 10/31/22 and signed physician orders dated 03/10/22 noted the following:

* Physician's orders requested the facility provide CBG reporting to the PCP monthly; and

* Physician's orders also requested that the facility notify the provider any time Resident 1's CBG was 500 or greater.

a. During an interview on 11/01/22 at 1:40 pm with Staff 11 (MT) it was confirmed the request for the facility to provide CBG reporting to the PCP monthly was not listed on the MAR and had not been completed as of the time of this survey.

b. Based on record review, the facility did not document and could not confirm whether the provider was notified on two occasions that Resident 1's CBG was 500 or greater for the following dates:

* 10/05/22 CBG was noted to be 511; and

* 10/11/22 CBG was noted to be 500.

The need to ensure physician's orders were carried out as prescribed was discussed with Staff 1 (Administrator) and Staff 8 (Administrative Assistant) on 11/04/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure orders were carried out as prescribed for all medications and treatments the facility was responsible to administer for 3 of 5 sampled residents (#s 3, 7, and 10) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 03/2022 with diagnoses which included anxiety disorder, polyneuropathy, chronic obstructive pulmonary disease, and rheumatoid arthritis.

The resident had an order for Azithromycin 250 mg tablet one time per day for prophylaxis.

Resident 3's MAR, reviewed from 07/01/23 - 07/26/23, revealed the medication was not administered on 07/14/23, 07/15/23, and 07/16/23.

During an interview on 07/26/23, with Staff 2 (RN Wellness Director), she reported the agency MT thought the medication had not been ordered in time and that the facility was out of the medication for those three days. She reported the medication was found on an alternate medication cart and administration of the medication was started again on 07/17/23.

Findings were reviewed with Staff 24 (Administrator), Staff 2, Staff 26 (LPN Consultant) and Staff 27 (Regional RN) on 07/26/23. They acknowledged the findings.

2. Resident 10 was admitted to the facility in 06/2018 with diagnoses which included anemia.

The resident had a physician order on 05/15/23 for ferrous sulfate 325 mg tablet, one tablet to be given by mouth twice daily.

Resident 10's MAR, reviewed from 05/01/23 - 07/26/23, revealed the instructions for twice daily administration had been updated, but the medication was only administered once per day, resulting in the resident receiving half of the prescribed daily amount of the medication from 05/16/23 - 07/26/23.

In an interview with Staff 2, Staff 26, and Staff 27 on 07/26/23, they acknowledged the finding and were unable to provide additional information.

The need to ensure all medications were available and administered as prescribed was reviewed with Staff 2, Staff 26, and Staff 27 on 07/26/23. They acknowledged the findings.

3. Resident 7 was admitted to the facility in November 2021 with diagnoses including cerebral vascular disease and history of transient cerebral ischemic attack (TIA).

A review of the resident's current signed physician orders, 05/01/23 through 05/31/23 MAR, temporary service plans and alert charting notes from 04/25/23 through 07/24/23 identified the following medications were not administered as prescribed:

* Aspirin, one tablet daily, was not administered from 05/06/23 through 05/11/23; and

* Trazodone, one tablet daily, was not administered from 05/05/23 through 05/07/23.

The need to ensure medications were administered as prescribed was discussed with Staff 24 (Administrator), Staff 26 (LPN Consultant) and Staff 27 (Regional RN) on 07/26/23. They acknowledged the findings.

1. Resident #3 is receiving all medications as ordered. Resident #10 has had the orderd corrected and is receiving medication as ordered. Resident #7 is receiving medication as ordered.

2. 90 Day orders will be done quarterly by the RN and sent to providers. All new orders, changes, or DC orders will be managed by nursing. Manual imputation of orders will be limited to nursing and only for urgent orders.  Otherwise orders will be entered by the pharmacy and approved in the EHR through the pharmacy link section by nursing or the RCC. Re-training done with RCC and Community Nurse on process to assure scheduled times match order.

3. Quarterly MAR audit while preparing 90 physician orders.

Daily review of Exception report in EHR to identify MAR discrepancies or exceptions for quality assurance. RCC performing weekly ordering until scheduled transition to Cycle Fill in September.

4. Community Nurse & ED

4. Resident 6 was admitted in 01/2021 with diagnoses which included heart disease, COPD and constipation.

Resident 6's MARs were reviewed for the time period of 10/01/22 through 10/31/22.

Staff documented Resident 6 refused:

* Bezetri inhaler (for COPD) on two occasions;

* Lasix (diuretic) on one occasion;

* Oxycodone (for pain) on one occasion;

* Guaifenesin (for congestion) on two occasions; and

* Miralax powder (for constipation) on 16 occasions.

There was no documented evidence the facility notified Resident 6's physician/practitioner of the refusals.

In an interview on 11/04/22, Staff 1 (Administrator) and Staff 8 (Administrative Assistant) acknowledged there was no documented evidence the facility had notified the physician/practitioner of the refusals. No further information was provided.

Based on interview and record review, it was determined the facility failed to have a system to ensure the physician or other practitioner was notified if a resident refused consent to an order, for 4 of 4 sampled residents (#s 3, 4, 5 and 6) who had documented medication or treatment refusals. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 06/2022 with diagnoses including chronic respiratory failure, Chronic Obstructive Pulmonary Disease (COPD), anxiety disorder, chronic pain syndrome and long-term use of opiate analgesic medications.

The MAR, reviewed from 10/01/22 through 10/31/22, indicated Resident 3 refused an order to apply a lidocaine patch for 12 hours daily from 10/01/22 through 10/4/22. There was no documented evidence the facility notified the resident's primary care physician of the refusals.

The need to ensure the physician or other practitioner was notified if a resident refused consent to an order was reviewed with Staff 1 (Administrator) and Staff 8 (Administrative Assistant) on 11/04/22. They acknowledged the facility had not notified the provider of the refusals.

2. Resident 5 was admitted to the facility in 03/2016 with diagnoses including congestive heart failure, cardiomyopathy, Chronic Obstructive Pulmonary Disease (COPD), seizures, diabetes mellitus - type 2, neuropathy and pain.

The MAR, reviewed from 10/01/22 through 10/31/22, indicated Resident 5 refused multiple prescribed medications on multiple occasions including Eliquis (blood thinner), Lyrica (for diabetic nerve pain), Coreg (for high blood pressure and heart disease), Keppra (for seizures), Buspar (for anxiety), Zoloft (for depression) and several different inhaler/nebulizers (to treat respiratory conditions). There was no documented evidence the facility notified the resident's primary care physician of the refusals.

The need to ensure the physician or other practitioner was notified if a resident refused consent to an order was reviewed with Staff 1 (Administrator) and Staff 8 (Administrative Assistant) on 11/04/22. They acknowledged the facility had not notified the provider of the refusals.

3. Resident 4 was admitted in 10/2020 with diagnoses which included hypertension and lichen planus (irritation of the skin).

Resident 4's MARs, dated 10/01/22 through 10/30/22, were reviewed.

Staff documented Resident 4 refused:

* Amlodipine (for high blood pressure) on one occasion;

* Clotrimazole (for rash) on 30 occasions;

* Eucerin (for rash) on 19 occasions;

* Ketoconazole (for fungal infections) on six occasions; and

* Acetaminophen (for pain) on six occasions

There was no documented evidence the facility notified Resident 4's physician of the refusals.

The need to ensure the physician was notified of medication or treatment refusals was discussed with Staff 1 (Administrator) and Staff 8 (Administrative Assistant) on 11/04/22 at 1:00 pm. They acknowledged the findings, and no additional information was provided.

4. Resident 6 was admitted in 01/2021 with diagnoses which included hypertension, CHF and COPD.

Residents 6's MARs were reviewed from 10/01/22 through 10/31/22 and the following was noted:

* Reasons for use was not indicated for all medications.

On 11/04/22, the need for the facility to ensure MARs were accurate was discussed with Staff 1 (Administrator) and Staff 8 (Administrative Assistant). They acknowledged the findings. No further information was provided.

Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was kept of all medications and treatments ordered by a legal prescriber and administered by the facility, for 4 of 4 sampled residents (#s 3, 4, 5 and 6) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 06/2022 with diagnoses including chronic respiratory failure, Chronic Obstructive Pulmonary Disease (COPD), anxiety disorder, chronic pain syndrome and long-term use of opiate analgesic medications.

Resident 3's 10/01/22 through 10/31/22 MAR was reviewed. The following deficiencies were identified:

* Multiple medications lacked a reason for use or diagnosis;

* Multiple exceptions lacked an explanation of why the medication was not administered as ordered;

* Multiple PRN pain medications (Tylenol, lidocaine patch and naproxen) lacked parameters for unlicensed staff as to when to administer each medication; and

* Multiple PRN medications to treat shortness of breath (albuterol inhaler, combivent inhaler) lacked parameters for unlicensed staff as to when to administer each medication.

The need to ensure MARs were complete and accurate, and included parameters for PRN medications, was discussed with Staff 3 (Med Room Manager) on 11/01/22 and with Staff 1 (Administrator) and Staff 8 (Administrative Assistant) on 11/04/22. They acknowledged the findings.

2. Resident 5 was admitted to the facility in 03/2016 with diagnoses including congestive heart failure, cardiomyopathy, Chronic Obstructive Pulmonary Disease (COPD), seizures, diabetes mellitus - type 2, neuropathy and pain.

Resident 5's 10/01/22 through 10/31/22 MAR was reviewed. The following deficiencies were identified:

* Multiple medications lacked a reason for use or diagnosis;

* Multiple exceptions lacked an explanation of why the medication was not administered as ordered;

* Multiple PRN pain medications (Tylenol, morphine) lacked parameters for unlicensed staff as to when to administer each medication; and

* Multiple PRN medications to treat shortness of breath (albuteral inhaler, Advair inhaler) lacked parameters for unlicensed staff as to when to administer each medication; and

* Multiple PRN medications to treat constipation (Bisacodyl suppository, Senna tablets) lacked parameters for unlicensed staff as to when to administer each medication.

The need to ensure MARs were complete and accurate, and included parameters for PRN medications, was discussed with Staff 1 (Administrator) and Staff 8 (Administrative Assistant) on 11/04/22. They acknowledged the findings.

3. Resident 4 was admitted to the facility in 10/2020 with diagnoses which included hypertension and lichen planus (irritation of the skin).

Resident 4's MARs, dated 10/01/22 through 10/30/22, were reviewed and the following was revealed:

a. The following medications lacked a reason for use or diagnosis:

* Amlodipine (for high blood pressure);

* Ketoconazole (for fungal infections);

* Acetaminophen (for pain);

* Meloxicam (for arthritis);

* Cephalexin (antibiotic);

* Bactrim (antibiotic);

* Triamcinolone (for rash); and

* Tamsulosin (for enlarged prostate).

b. Tylenol #3 (for pain) was administered on 10/27/22 according to the narcotic log and medication card; however, it was not indicated as administered on the MAR.

c. Cephalexin 500 mg (antibiotic) - Resident 4 was ordered to be given four capsules a day for seven days with the medication completed on 10/11/22. The MAR indicated it was administered nine additional times after 10/11/22.

On 11/01/22 at 2:47 pm, the surveyor and Staff 3 (Med Room Manager) observed/checked the MARs and medication supply. Staff 3 and Staff 11 (MT) confirmed the resident had completed the course of antibiotics and the additional medications were not administered.

d. The following medications lacked specific instructions to unlicensed staff:

* Clotrimazole (for rash);

* Eucerin (for rash); and

* Triamcinalone (for rash).

The need to ensure MARs were accurate, included reasons for use and medication specific instructions was discussed with Staff 1 (Administrator) and Staff 8 (administrative Assistant). They acknowledged the findings.

2. Resident 3 was admitted to the facility in 06/2022 with diagnoses including chronic respiratory failure, Chronic Obstructive Pulmonary Disease (COPD), anxiety disorder, chronic pain syndrome and long-term use of opiate analgesic medications.

Interviews with Staff 10 (MT) and Resident 3 on 11/04/22 indicated Resident 3 self-administered multiple prescribed inhalers and nebulizer medications.

* The facility could not provide written, signed physician's orders for the resident to self-administer the medications; and

* The facility had evaluated the resident's ability to safely administer the medications on 6/11/22 but had not re-evaluated the resident quarterly as required.

The need to ensure the facility obtained written, signed orders for the resident to self-administer prescribed medications and evaluated the resident's ability to safely self-administer medications quarterly was reviewed with Staff 1 (Administrator) and Staff 8 (Administrative Assistant) on 11/04/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure residents who self-administered their medications were evaluated at least quarterly, to assure ability to safely self-administer medication, for 2 of 2 sampled residents (#s 2 and 3). Findings include, but are not limited to:

1. Resident 2 was admitted to the facility 09/2017 with diagnoses including hyperlipidemia.

Interviews with Resident 2 on 10/31/22, and Staff 11 (MT) and Staff 17 (MT) on 11/01/22 confirmed the resident administered his/her medications.

Review of the resident's medical records revealed at the time of the survey the last self-medication evaluation had been completed on 05/23/22. A current evaluation was requested and completed by Staff 1 (Administrator) on 11/02/22.

The need to ensure residents who self-administered their medications were evaluated at least quarterly, to assure ability to safely self-administer medications was discussed with Staff 1 and Staff 8 (Administrative Assistant) on 11/04/22. They acknowledged the findings.   

Based on interview and record review, it was determined the facility failed to ensure the specific reasons for use for PRN psychotropic medications were included on the MAR and non-pharmacological interventions had been documented as attempted and ineffective prior to administering the medication, for 2 of 2 sampled residents (#s 3 and 5) who were prescribed and were administered PRN psychotropic medications. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 06/2022 with diagnoses including chronic respiratory failure, Chronic Obstructive Pulmonary Disease (COPD), anxiety disorder, chronic pain syndrome and long-term use of opiate analgesic medications.

Review of the record indicated Resident 3 had orders for, and was administered, PRN Atarax (for anxiety) on 13 occasions from 10/01/22 through 10/31/22. The following deficiencies were identified:

* There were no specific reasons for use documented on the MAR which described how Resident 3 exhibited "anxiety";

* There were no non-pharmacological interventions listed for staff to attempt prior to considering administering the medication; and

* The facility failed to document non-pharmacological interventions were attempted and were ineffective prior to administering the medication.

The need to ensure there were specific reasons for use and non-drug interventions were attempted and ineffective prior to administering a PRN psychotropic medication was reviewed with Staff 1 (Administrator) and Staff 8 (Administrative Assistant) on 11/04/22. They acknowledged the deficiencies.

2. Resident 5 was admitted to the facility in 03/2016 with diagnoses including congestive heart failure, cardiomyopathy, COPD, seizures, diabetes mellitus - type 2, neuropathy and pain.

Review of the record indicated Resident 5 had orders for PRN Haldol for "severe psychosis" and PRN lorazepam for "anxiety or agitation." The MAR indicated the resident was administered the lorazepam on 12 occasions from 10/01/22 through 10/31/22. The following deficiencies were identified:

* There were no specific reasons for use documented on the MAR which described how Resident 3 exhibited "severe psychosis" or "anxiety or agitation";

* There were no non-pharmacological interventions listed for staff to attempt prior to considering administering the medications; and

* The facility failed to document non-pharmacological interventions were attempted and were ineffective prior to administering the medications.

The need to ensure there were specific reasons for use and non-drug interventions were attempted and ineffective prior to administering a PRN psychotropic medication was reviewed with Staff 1 (Administrator) and Staff 8 (Administrative Assistant) on 11/04/22. They acknowledged the deficiencies.

Based on interview and record review, it was determined the facility failed to ensure all pre-service orientation was completed and documented for 4 of 4 newly-hired staff (#s 10, 14, 17 and 18) and infectious disease prevention training was completed for 1 of 2 veteran staff (#6). Findings include, but are not limited to:

On 11/03/22 and 11/04/22 training records were reviewed with Staff 4 (Business Office Manager). The following deficiencies were identified:

a. Staff 10 (CG) was hired on 06/15/22 and had not completed pre-service training in the following areas required of all employees:

* Resident rights and values of CBC care;

* Infectious disease prevention training; and

* Fire safety and emergency procedures.

b. Staff 14 (Cook) was hired on 07/05/22 and had not completed pre-service training in the following areas prior to performing any job duties:

* Resident rights and values of CBC care;  

* Infectious Disease Prevention; and

* Fire safety and emergency procedures.

c. Staff 17 (MT) was hired on 09/20/22 and had not completed pre-service training in the following areas required of all employees:

* Resident rights and values of CBC care;

* Abuse reporting requirements;

* Infectious Disease Prevention training;

* Fire safety and emergency procedures; and

* Pre-service dementia training.

d. Staff 18 (CG) was hired on 09/21/22 and had not completed pre-service training in the following areas required of all employees:

* Resident rights and values of CBC care;

* Abuse reporting requirements;

* Infections disease prevention training;

* Fire safety and emergency procedures; and

* Pre-service dementia training.

e. Staff 6 (Activity Director) was hired on 05/01/22 and had not completed infectious disease prevention training by 07/01/2022.

The need to ensure all newly hired staff completed pre-service orientation training prior to providing care and services independently, and veteran staff completed infectious disease prevention was discussed with Staff 1 (Administrator) and Staff 8 (Administrative Assistant) on 11/04/22. They acknowledged the findings.  

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired direct care staff (#s 10, 16 and 23) demonstrated competency in all required areas within 30 days of hire.

Review of the facility's training records on 11/03/22 and 11/04/22 revealed the following:

a. Staff 10 (CG) was hired 06/15/22 and did not have documented evidence of competency demonstrated in the following areas:

* Providing assistance with ADLs; and

* Changes associated with normal aging.

b. Staff 16 (CG) was hired 06/13/22 and did not have documented evidence of competency demonstrated in the following areas:

* Providing assistance with ADLs;

* General food safety, serving and sanitation; and

* First Aid/Abdominal Thrust.

c. Staff 23 (CG) was hired 06/06/22 and did not have documented evidence of competency demonstrated in the following areas:

* Providing assistance with ADLs;

* General food safety, serving and sanitation; and

* First Aid/Abdominal Thrust.

The need to ensure all newly hired staff had competency demonstrated in all areas required within 30 days of hire was discussed with Staff 1 (Administrator) and Staff 8 (Administrative Assistant) on 11/04/22. They acknowledged the findings.  

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 veteran direct care staff (#s 11, 12 and 15) completed a minimum of 12 hours of in-service training annually including six hours on dementia care. Findings include, but are not limited to:

Review of the facility's training records on 11/03/22 and 11/04/22 revealed the following:

*Staff 11 (MT) hired 05/14/20 did not have documented evidence of six hours of annual in-service training related to provision of care in CBC; and

*Staff 12 (CG) hired 04/01/09 and Staff 15 (CG) hired 12/14/20, did not have documented evidence of six hours of annual in-service training related to provision of care in CBC and six hours related to dementia care.  

The need to ensure all staff had a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a CBC, including dementia care topics was discussed with Staff 1 (Administrator) and Staff 8 (Administrative Assistant) on 11/04/22.  They acknowledged the findings.

Based on interview and record review, it was determined that the facility failed to conduct fire drills according to the Oregon Fire Code (OFC). Findings include, but are not limited to:

Fire and life safety records from 05/2022 through 10/2022 were reviewed. The fire drill records did not consistently include documentation of the following required components:

* Escape route used;

* Evacuation time-period needed;

* Number of occupants evacuated; and

* Evidence alternate routes were used during fire drills.

On 11/01/22 an interview with Staff 5 (Facility Services Director) revealed the facility was not relocating or evacuating residents as part of the fire drill process.   

The need to ensure the facility conducted and documented fire drills according to the OFC was discussed with Staff 1 (Administrator) and Staff 8 (Administrative Assistant) on 11/04/22.  They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure residents were re-instructed on general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting spaces inside or outside the building in the event of an actual fire at least annually. Findings include, but are not limited to:

On 11/01/22, Staff 5 (Facility Services Director) was asked to explain the process of providing resident instruction on general safety procedures upon admission and re-instruction annually.  Staff 5 stated fire drill and safety procedures were reviewed with residents upon admission, however re-instruction was not provided annually.

The need to ensure residents were instructed on general safety procedures and re-instructed at least annually was discussed with Staff 1 (Administrator) and Staff 8 (Administrative Assistant) on 11/04/22. They acknowledged the findings.

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

Refer to C 303.

1. NA

2. See POC for 303

3. See POC for 303

4. Community Nurse and ED

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 residents was kept clean, in good repair, and free from odors. Findings include, but are not limited to:

Observations of the facility on 10/31/22 and 11/01/22 revealed the following:

* Resident rooms 103, 111, 112, 115, 118, 121, 125, 126, 129, 133, 134, 136, 138, 139, 142, 144, 151 and 153 had scraped doors and/or jambs;

* The front entrance doors had scraped paint in several areas;

* Sitting benches in the hallways had numerous stains on their fabric seats;

* Hallway exit doors throughout the facility had scraped paint on doors and/or jambs, and spiders/webs/dirt/debris around the door frames. Wall heating units adjacent to exit doors had an accumulation spills/splatters on the exteriors and dirt/debris underneath them;

* Windows/sills located next to Rooms 133 and 142 had an accumulation of dead bugs, dirt and debris;

* The resident laundry room had laminate missing from edge of the folding counter, the floor had an accumulation of dirt, lint and debris along the perimeter and around appliances, and the door had scraped paint in several areas;

* The activity room door had scraped paint in several areas;

* Two common hallway bathrooms had urine odors and discolored caulking around toilet bases;

* The employee laundry room had scraped paint on the door and jamb, laminate missing from the edge of the folding counter, a floor basin had an accumulation of black matter and debris, the window sill had peeling paint, and flooring surrounding the floor drain was cracked and peeling away from the drain;

* Several dining chairs had scraped legs, the beverage counter was missing laminate from the edge, the beverage sink had brown matter in the basin and around the faucet, and several windowsills had scraped paint;

* Pervasive odors were noted in halls and common areas during the survey; and

* The exterior walking path to the side and rear of the building had an approximate 2-4-inch drop between the sidewalk and planting bed. Additionally, ground lighting along the path was broken in several areas.

The surveyor toured the environment with Staff 1 (Administrator) and Staff 5 (Facility Services Director) on 11/01/22. They acknowledged the findings.