Print Inspection: 0XQ0

The findings of the re-licensure survey, conducted 05/15/23 through 05/17/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 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 first re-visit to the re-licensure survey of 05/17/23, conducted 09/27/23 through 09/28/23 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the second re-visit to the re-licensure survey of 05/17/2023, conducted 12/05/23 are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

2. Resident 1 was admitted to the facility in 04/2023 with diagnoses including left below knee amputation, pain, anxiety and depression.  

The resident's service plan last updated on 05/02/23, observations and interviews with Resident 1 and interviews with care staff between 05/15/23 and 05/17/23 indicated the resident required 2 staff assistance with hoyer transfers, utilized a wheelchair for mobility and had behavioral angry outbursts.  

Review of incident investigations and progress notes from 04/12/23 through 05/15/23 showed the following:

* A progress note dated 05/08/23 indicated the resident had right hand pain with swelling, redness and decreased ability to use.

* A progress note dated 05/10/23 indicated Resident 1's right hand was "very swollen and bruised from index to ring finger and all over the top of the hand. Swelling is about the size of a baseball." The resident refused to be sent to the emergency department for evaluation of the hand.

* On 05/10/23 a progress note indicated a request for mobile x-ray of the right hand was sent to the physician.

No investigation was completed regarding the right hand injury.

During an interview with Staff 1 (Administrator) and Staff 2 (RN) on 05/16/23, Staff 1 reported the facility was waiting to complete the investigation until the resident had an x-ray of the hand to determine if there was a fracture.  They acknowledged there was no documented investigation of the injury, although Staff 1 stated she spoke with Resident 1 on 05/12/23 and was told he/she was angry and hit a hard surface.

The facility was asked to report the 05/08/23 injury to the  right hand which lacked documentation of an investigation, failing to rule out abuse to the local SPD office. Confirmation of the report was received prior to exit.

The need to ensure resident incidents were promptly investigated to rule out abuse and neglect was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 05/16/23. The staff acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure injuries of unknown cause were promptly investigated to rule out abuse and/or neglect and reported to the local SPD office as required for 2 of 3 sampled residents (#s 1 and 4) whose incidents were reviewed. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 06/2022 with diagnosis including spinal stenosis.

Review of Resident 4's clinical record including progress notes dated 02/01/23 through 05/15/23 and incident reports for the same time period identified the following injuries of unknown cause:

04/04/23 - "bruising to right upper arm and right mid back";

05/12/23 - "quarter size bruise to right top of forearm"; and

05/14/23 - "more bruising has appeared to [left] inner arm and [right] inner and outer arm".

There was an incident report for the bruising identified on 04/04/23, however the investigation was not completed until 04/16/23.

On 05/09/23, Staff 8 (MT) documented in a progress note "no signs of bruising or swelling [related to the 05/08/23 fall]; and

On 05/10/23, Staff 1 (Administrator), documented in a progress note "no signs of bruising or injury [related to the 05/08/23 fall].

During an interview on 05/17/23, with Staff 1 and Staff 8, Staff 8 reported she thought the bruises identified on 05/12/23 and 05/14/23 were related to the 05/08/23 fall. Staff 1 acknowledged the lack of an immediate investigation for the bruising and requested Staff 8 to complete an incident report. On 05/17/23, Staff 1 completed an investigation for the bruising and was able to rule out abuse and neglect.

The facility failed to immediately investigate the injuries of unknown cause to rule out abuse or neglect.

The need to ensure all injuries of unknown cause were promptly investigated to rule out abuse and/or neglect, was discussed with Staff 1 on 05/17/23. She acknowledged the findings.

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action:

1. Actions to be taken to correct the rule violation include:

a.Resident #4 Incident report for injuries of unknown cause was completed 5/17/23. Investigation was completed and abuse and neglect was ruled out.

b.Resident #1 injury to right hand that occurred on 5/8/23 was investigated on 5/17/23 and was reported to local SPD office per surveyors request prior to exit.  

2.To ensure the system will be corrected so this violation will not happen again:

a.All staff will be provided training on the following topics: Incident report requirements, investigating incident reports, how to appropriately r/o abuse & neglect, implementing new interventions via TSPs, ensuring previous interventions & applicable service planning care were being followed to showcase rule out abuse & neglect secondary to 'as evidenced by' & when to report to local APS.

b. Facility will review incident reports each morning (during working days) to ensure that all incident reports are completed thoroughly, investigations including ruling out abuse and neglect are done timely, that incidents are reported to APS if needed and that the administrator has reviewed and signed all incident reports and investigations.

3. Reporting & investigating abuse & neglect system(s) will be monitored as follows:

a. Administrator & Licensed Nurse will coordinate with HR Manager daily during morning stand up meetings to ensure that all staff have completed the required pre-service & on-going training - 'Abuse & Reporting Requirements.'

b. Administrator & Clinical Team will review all incident reports at least 5 days per week during daily stand up meetings.

4. Administrator, Licensed Nurse or Designee will be responsible for overseeing all systems related to Reporting & Investigating Abuse/Neglect.

2. Resident 1 was admitted to the facility in 04/2023 with diagnoses including left below knee amputation, pain and anxiety.

Interviews with staff, review of the resident's 05/02/23 service plan, and 04/12/23 through 05/15/23 progress notes were completed.

The resident experienced short-term changes without documentation of weekly progress through resolved in the following areas:

* Admission to facility;

* Left and right ischium stage II pressure ulcers;

* Left leg amputation site;

* Medication dose changes to include clonazepam (for anxiety) and gabapentin (for pain); and

* Right heel pressure ulcer.

On 05/16/23 Staff 2 (RN) confirmed there was not consistent weekly progress noted for the changes of condition until resolved in the resident's record.

The need to ensure short-term changes of condition had documentation of weekly progress through resolution was discussed Staff 1 (Administrator) and Staff 2 on 05/16/23. The staff acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure changes of condition were monitored at least weekly until resolved for 2 of 3 sampled residents (#s 1 and 2) who were reviewed for changes of condition. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility 03/2020 with diagnoses including heart failure and hypertension.  

Resident 2's progress notes and facility records dated 02/01/23 through 05/15/23 were reviewed and revealed the following changes of condition:

* Falls on: 02/22/23 and 03/02/23; and

* The resident tested positive for COVID on 04/20/23.

There was no documented evidence the facility monitored the changes of condition at least weekly until resolved.

The need to monitor and document at least weekly until changes of condition were resolved was discussed with Staff 1 (Administrator) on 05/17/23 at 12:15 pm. The findings were acknowledged.  

C270 OAR 411-054-0040 Change of Condition and Monitoring:

1. Actions to be taken to correct the rule violation include the following:

a.Resident #1A comprehensive nursing assessment and appropriate follow up will be completed related to but not limited to, left and right ischium stage II pressure ulcers, left leg amputation site, medication dose changes, and right heel pressure ulcer.

b.  Resident #2 A comprehensive nursing assessment and appropriate follow up will be completed related to but not limited to, falls and positive for Covid.

2. To ensure the system will be corrected so this violation will not happen again, a 24-hour communication system will be in place to include:

Shift to Shift Communication Log

Alert Charting Log / Audit Log

Significant Change of Condition Log

Weekly Skin Monitoring Log

Staff will start short term monitoring / communication system for any resident identified to have an acute change of condition such as skin events, return from the hospital, or fall for example.

a.When a change of condition is identified, staff add the resident name to the alert log to ensure they monitor resident and identify when to report concerns to nursing or physician.

b.The staff will be aware of what to report to the nurse / physician per the temporary service plan (TSP) that has been put in place, which correlates with the resident change of condition. The TSP has specific directions for staff including what to look for, interventions to put in place, signs and symptoms to report and staff signature lines to sign once they have read and understood the TSP.

c. Staff should monitor resident status until resident condition resolves, and they are back to their baseline, 24- hour book / process will be reviewed daily during clinical review as a means of identification of potential significant change that needs to be assessed by the RN.

3. The area needing correction will be evaluated daily during stand up with 24-hour audit system compliance.

Community will also complete a Monthly Continuous Quality Improvement audit to ensure clinical systems follow company policy and Oregon Administrative Rule.

4. The Administrator and Registered Nurse will be responsible for ensuring the system has been corrected and is monitored

Based on interview and record review, it was determined the facility failed to ensure an RN assessment was completed for significant changes of condition, including findings, resident status and interventions made as a result of the assessment, for 1 of 1 sampled resident (#1) who experienced a significant change of condition related to a pressure wound. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 04/2023 with diagnoses including left below knee amputation and pain.

Interviews with staff, observations and interview with Resident 1, and review of the resident's 05/02/23 service plan and 04/12/23 through 05/15/23 progress notes were conducted.

During interviews with staff, the resident was identified to require two person assist for transfers using a hoyer lift and was independent with mobility using a manual wheel chair.

A progress note dated 05/05/23 identified an intact blister measuring 1 cm x 1 cm to Resident 1's right heel.

During an interview on 05/16/23, Staff 2 (RN) stated the wound was an unstageable pressure ulcer.

Resident 1 experienced a significant change of condition related to an unstageable pressure ulcer. There was no documented evidence an RN assessment was completed for the significant change of condition.

The need to complete an RN assessment for significant changes of condition, to include findings, resident status and interventions, was discussed with Staff 1 (Administrator) and Staff 2 on 05/16/23. They acknowledged the findings.

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services:

1.Actions to be taken to correct the rule violation include:

a.Resident #1 will have a comprehensive significant change of condition assessment specific to unstageable pressure ulcer to right heel. Service plan will be updated to reflect current interventions / needs of the resident.

2. This system will be corrected so this violation does not happen again by the following measures:

a.All resident changes are reported and documented via the 24-hour reporting system.

b.The community nurse will assess the resident and condition change in a timely manner to determine any need for further monitoring.

c.A comprehensive assessment should be completed by RN if the change is significant for the purpose of developing, implementing and evaluating a plan of care.

d.RN will utilize a significant change of condition log to direct who requires a weekly nursing assessment until the resident is back at their baseline health status, or a new baseline can be established. A significant change of condition includes, but is not limited to return from hospital, falls, admission to or change of status with hospice, pain and decline in health status.

3. The area needing correction will be evaluated on a daily basis. Changes of condition are reviewed through the 24-hour process audit in daily standup meeting to provide oversight and follow up by RN when needed.

4. The Administrator and Registered Nurse will be responsible for ensuring the system has been corrected and is monitored.

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 (#5). Findings include, but are not limited to:

Resident 5 was admitted to the facility in 02/2023 and had diagnoses which included acute kidney failure.

Resident 5 had a physician order for PRN Oxycodone, two 5 mg tablets to be given by mouth every 8 hours as needed for severe pain.

Resident 5's 04/01/23 through 05/16/23 Controlled Substance Disposition Logs and MAR were reviewed and revealed the following:

a. Between 04/1/2023 through 04/30/2023 there were three occasions staff signed the drug disposition log that the PRN Oxycodone was removed from the drug card. However, the MAR lacked documentation the resident received the PRN medication.

b. Between 05/01/2023 through 05/16/2023 there were four occasions staff signed the drug disposition log that the PRN Oxycodone was removed from the drug card. However, the MAR lacked documentation the resident received the PRN medication.

Inconsistencies between the MAR and Controlled Substance Disposition logs were reviewed with Staff 10 (MT) and no explanation was offered as to the discrepancy.

The need to ensure narcotic disposition logs accurately reflected the medications administered was discussed with Staff 1 (Administrator) on 05/17/23. The findings were acknowledged.

OAR 411-054-0055 (1) (e.) Systems: Tracking Controlled Substances:

1. Actions to be taken to correct this violation includes,

a.Facility conducted an investigation and was able to correct hole(s) on the MAR for resident #5, who received  PRN oxycodone to ensure that the MAR matches the drug disposition log.

2. This system will be corrected to eliminate further violations,

as follows:

a.RCC will complete a narcotic audit to ensure appropriate documentation of PRN and Scheduled Narcotics, to ensure consistency between drug disposition log and MAR, to ensure all narcotics are destroyed per policy and to identify any trends in narcotic administration.

3. This system will be evaluated as follows:

a.RCC will complete a narcotic audit at least once a week.

b.RCC will bring all narcotic audits to stand up once a week after they have been completed.

c.Administrator will review all narcotic audits weekly to ensure completion.

              a. RCC will complete a narcotic

4. Administrator and RCC will ensure

         on-going compliance

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 (#5). This is a repeat citation. Findings include, but are not limited to:

Resident 5 was admitted to the facility in 02/2023 with diagnoses including chronic pain and fibromyalgia and was prescribed oxycodone 5 mg tablet - two tablets every six hours as needed.

Resident 5's 09/01/23 through 09/27/23 Controlled Substance Disposition Log and MAR were reviewed and revealed the following:

* Staff documented on the Controlled Substance Disposition Log the oxycodone was dispensed fifteen times between 09/01/23 and 09/27/23.

* The facility failed to document on the MAR the dispensed medication was administered to the resident on five occasions.

The need to ensure a system for accurately tracking controlled substances administered by the facility was reviewed with Staff 1 (Administrator) on 09/27/23. She acknowledged the findings.

OAR 411-054-0055 (1) (e.) Systems: Tracking Controlled Substances:

1. Actions to be taken to correct this violation includes,

a.Facility will correct hole(s) in the MAR for resident   # 5 who received  PRN oxycodone to ensure that the MAR matches the drug disposition log.

2. This system will be corrected to eliminate further violations,

as follows:

a.RCC will complete a narcotic audit to ensure appropriate documentation of PRN and Scheduled Narcotics, to ensure consistency between drug disposition log and MAR, to ensure all narcotics are destroyed per policy and to identify any trends in narcotic administration.

3. This system will be evaluated as follows:

a.RCC will complete a narcotic audit daily.

b.RCC and Administor will review google doc spreadsheet daily to insure drug book matches the MAR.

c.Administrator will also review all narcotic audits weekly to ensure completion.

4. Administrator and RCC will ensure

         on-going compliance

Based on interview and record review, it was determined the facility failed to ensure staff documented non-pharmacological interventions had been tried with ineffective results prior to administering PRN psychotropic medications for 1 of 1 sampled resident (#1) who was prescribed PRN medications for behaviors. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 04/2023 with diagnoses including anxiety.

Review of the record indicated Resident 1 was prescribed clonazepam 0.5 mg every 12 hours as needed for anxiety. Non-drug interventions had been identified on the MAR.

The 05/01/23 through 05/15/23 MAR was reviewed and noted staff administered the PRN lorazepam on six occasions. There was no documented evidence the staff attempted non-drug interventions with ineffective results on four of the six occasions prior to administering the medication.

The need to ensure non-drug interventions had been attempted and documented as ineffective prior to administration was reviewed with Staff 1 (Administrator) and Staff 2 (RN) on 05/16/23. Staff acknowledged the findings.

C330 OAR 411-054-0055 (6) Systems: Psychoactive Medications:

1. Actions to be taken to correct the rule violation include:

a.Completed a comprehensive MAR review for Resident #1 to ensure that resident specific parameters for use of PRN Psychoactive medications as well as adding a trigger for staff to document the resident specific non-pharmacological interventions attempted. Training was provided to all med techs on how to properly document on the MAR non pharmacological intervention attempted.

2. The system will be corrected so this violation will not happen again by:

a.Any new order for PRN psychoactive medication to treat mood or behavior issues will be reviewed by the Licensed Nurse through the triple check process.

b.The Licensed Nurse will ensure appropriate resident specific indicators for use are in place as well as non-pharm interventions staff should offer prior to using.

c.All active PRN psychoactive medications will be reviewed prior to quarterly physician orders sent for signature as well as with scheduled PRN medication audits.

3. This area will be evaluated on a quarterly basis prior to sending quarterly physician orders for signature, on a monthly basis with medication administration record audits and daily with triple check review if a new order is received.

4. Administrator, Licensed Nurse or trained designee will be responsible to ensure the corrections are completed and monitored.

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

The facility was licensed as a Residential Care Facility (RCF) that was home to 26 residents. The RCF had two houses Larch and Tabor that were connected by an interior corridor. The RCF had three floors accessible by stairs and two elevators.  

1. During the entrance conference on 05/15/23, the following was identified regarding resident care needs:

* Six residents needed two-person assist with transfers; and

* One resident was on hospice.

2. During a group interview with six residents on 05/16/23 the following was identified:

* Six residents reported call light response times were often 30 minutes or longer.

3. Review of the call light response times for Larch House and Tabor House from 05/01/23 through 05/16/23 identified the following:

* Larch House had 38 call light response times ranging from 30 minutes to five hours;

* Tabor House had 112 call light response times ranging from 30 minutes to three hours; and

* Seven residents with call light response times that exceeded 30 minutes  had been evaluated as having heavy care needs that included two-person assist for transfers, toileting, and dressing or were receiving hospice services.

The facility's failure to ensure adequate staffing in order to meet the 24 hour scheduled and unscheduled needs of the residents and respond to call lights within a reasonable amount of wait time was shared with Staff 1 (Administrator) on 05/17/23 at 11:30 am. She acknowledged the findings.

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing:

1. Actions to be taken to correct the rule violation include:  

a.Facility has completed the required acuity based staffing tool on the Department's site.

b.The Facility is staffing  per the acuity based staffing tool.                   

c.Facility will run the call light times daily and review it each morning in stand up.

2. The system will be corrected so this violation will not happen again by:

a.Facility will continue to staff based on the most current acuity based staff tool.

b.Maintenance director will audit and pull call times from the last 24 hours and will bring results to morning stand up daily for review on work days.

c.Administrator will update the ABST at each evaluation (Initial, 30 day, Quarterly) and with significant change of condition, to ensure adequate staff to meet the scheduled and unscheduled needs of the residents.

3. This area will be evaluated as follows:

a.Administrator will update the ABST at each evaluation (Initial, 30 day, Quarterly) and with significant change of condition, to ensure adequate staff to meet the scheduled and unscheduled needs of the residents.

b.Administrator will review the staff schedule when a resident has a change of condition, quarterly and update for new admit and 30 days after admit to ensure the schedule is reflective of the staffing requirements based on the ABST.

c.Maintenance director will run and review resident call times at least daily (on work days) and will bring this report to daily stand up.

4. Administrator and the Maintenance Director will oversee and ensure ongoing compliance.

Based on interview and record review, it was determined the facility failed to ensure an Acuity Based Staffing Tool (ABST) assessment was completed for each resident, and was reviewed and amended for each resident at least quarterly. Findings include, but are not limited to:

Review of the facility's online ABST information was reviewed for all residents in the facility's Larch and Tabor houses, and the following was identified:

* One resident residing in the facility's Larch house did not have an ABST assessment completed.

* There were five residents in Larch house whose ABST information had not been updated quarterly.

The need to ensure ABST assessments were completed for all residents and were reviewed and amended for each resident at least quarterly was discussed with Staff 1 (Administrator) on 05/17/23. She acknowledged the findings.

OAR 411-054-0037 (1-8) Acuity-Based Staffing Tool:

1. Actions to be taken to correct the rule violation include:  

a.Facility has completed the Acuity Based Staffing Tool on the Department's site.

b.RCC will receive training related to ABST requirements to ensure the staffing schedule meets requirements.

2. The system will be corrected so this violation will not happen again by:

a.Facility will maintain ABST and update resident care needs in the ABST at time of each resident evaluation (Initial, 30 day and Quarterly)and with any significant change of condition.

b.Administrator will review staffing schedule at move-in, change of ocndition, 30 days after admission and quarterly to ensure the schedule is reflective of staffing requirements based on the ABST.

3. This area will be evaluated as follows:

a.Facility will update the ABST with each resident evaluations (Initial, 30 day and Quarterly) and with significant change of condition.

b.Administrator will review the staffing schedule at move-in, change of condition, 30 days after admission and quarterly to ensure the schedule is reflective of staffing requirements based on the ABST.

4. Administrator and RCC will oversee and ensure ongoing compliance.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 9, 12 and 13) completed all required pre-service training orientation prior to beginning their job responsibilities. Findings include, but are not limited to:

Training records were reviewed on 05/15/23 at 1:04 pm.

Staff 9 (CG), hired 01/04/23, Staff 12 (CG), hired on 02/07/23, and Staff 13 (CG), hired on 02/15/23, lacked documented evidence of completing Infectious Disease Prevention training, as required.

The need to ensure all required pre-service trainings were completed prior to beginning their job responsibilities was reviewed with Staff 1 (Administrator) on 05/15/23 and Staff 3 (HR Manager) on 05/16/23. They acknowledged the findings.

OAR 411-054-0070 (3-4) Staffing Requirements and Training: Caregiver Requirements:

1.Actions to be taken to correct the rule violation include:

a.Staff members #9, #12, and #12 will complete infectious Disease Prevention Training with documented evidence of training in their respective training files.

2. The system will be corrected so this violation will not happen again by:

a.HR Manager has updated the training grid with all required preservice, within 30 days and annual ongoing training.

b.Facility is updating new hire orientation to include pre-service training: Infectious Disease Prevention.

c.Facility is completing an audit on staff training and will ensure each staff member has required training and documents.

3. This area will be evaluated as follows:

a.HR Manager will review training grid at least once monthly.

b.Administrator will review all new hire orientation and training at least monthly to ensure compliance.

c.Facility will schedule new hire orientation at least once monthly to ensure all pre-service training is completed.

4. Administrator and HR Manager will oversee and ensure ongoing compliance.

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

Refer to C 302.

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval:

Reference C302 above

Based on observation and interview, it was determined the facility failed to ensure all chemicals and toxic materials were maintained in a locked storage unit. Findings include, but are not limited to:

The interior of Larch House and Tabor House were toured on 05/15/23. The following issues were noted:

Cleaning chemicals were observed under both kitchen sinks in Larch House and Tabor House and in a cabinet covered by a cloth curtain located between the two kitchen sinks.

The need to ensure all toxic materials were maintained in locked storage was discussed with Staff 1 (Administrator) on 05/15/23. She acknowledged the findings.

OAR 411-054-0200 (3) General Building Exterior:

1. Actions to be taken to correct the rule violation include:

a.All cleaning chemicals are now being stored in the locked housekeeping closet on the second floor.

2. The system will be corrected so this violation will not happen again by:

a. Facility has implemented a building walk through, which will include the administrator and the maintenance director to identify any environmental concerns.

3. This system will be evaluated as followed:

a.Administrator and maintenance director will conduct once weekly walk-throughs.

b.Maintenance director will bring all documents pertaining to environmental concerns or finding to daily stand up meetings.

4. Administrator and Maintenance director will oversee and ensure ongoing compliance.

Based on observation and interview, it was determined the facility failed to ensure the facility was clean and free of unpleasant odors. Findings include, but are not limited to:

Observations of Larch House on 05/15/23 through 05/17/23 identified the following:

* Pervasive urine odors were noted on the 3rd floor near rooms 3B and 3C. The odors did not dissipate throughout the survey.

During an interview with Staff 14 (Housekeeping) on 05/17/23, it was reported the issue in both rooms had been ongoing. "I think it is because both rooms have carpet. I have used the [carpet cleaner] on them multiple times. It won't come out. Both rooms have house keeping scheduled once per week. If I have extra time, I always check the rooms again."

The need to ensure the facility was free of pervasive and unpleasant odors was discussed with Staff 1 (Administrator) on 05/17/23. She acknowledged the findings.

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors:

1.  Immediate actions taken to correct the rule violations include the following: The following items will be cleaned and or repaired:

Larch House:

Pervasive urine odors were noted on

the 3rd floor near rooms 3B and 3C. The

odors did not dissipate throughout the

survey.

a.Carpet has been removed from room 3C and has been replaced with laminate flooring.

b.Carpet will be removed in room 3B and laminate flooring will be installed. Date is pending at this time.

2. The system will be corrected so this violation will not happen again by:

a.Facility has implemented a building walk through, which will include the administrator and the maintenance director to identify any environmental concerns including odors in the community.

3. This system will be evaluated as followed:

a.Administrator and maintenance director will conduct once weekly walk-throughs.

b.Maintenance director will bring all documents pertaining to environmental concerns or findings including odors in the community to daily stand up meetings.

4. Administrator and Maintenance director will oversee and ensure ongoing compliance.