Print Inspection: 2EHY

The findings of the Change of Ownership survey conducted 08/08/22 through 08/11/22 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, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.

Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

Situations were identified where there was a failure of the facility to comply with the Departments rules that were likely to cause residents serious harm. Immediate plans of correction were requested in the following area:

OAR 411-054-0025 (1): Facility Administration: Operation; and

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

The facility put immediate plans of correction in place during the survey and the situations were abated.

The findings of the first revisit to the Change of Ownership survey of 08/11/22, conducted 02/21/23 through 02/22/23 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, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.

Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

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 second re-visit to the re-licensure survey of 08/11/22 conducted 05/01/23 through 05/02/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.

Based on observation, interview and record review, it was determined the licensee failed to ensure adequate administrative oversight of facility operations and supervision and training of staff, which posed a risk to the safety of residents. Findings include, but are not limited to:

During the Change of Ownership survey, conducted 08/08/22 through 08/11/22, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the severity and number of citations.

1. Situations were identified which constituted an immediate plan of correction to residents' health and safety in the following areas:

Situations were identified where there was a failure of the facility to comply with the Departments rules that were likely to cause residents serious harm. Immediate plans of correction were requested in the following area:

OAR 411-054-0025 (1): Facility Administration: Operation; and

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

The facility put immediate plans of correction in place during the survey and the situations were abated.   

2. Refer to deficiencies in the report.

OAR 411-054-0025 - Facility Administration: Operation

Please refer to all citations in this report

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

During the survey, multiple non-sampled residents expressed their concerns with the following:

* Lack of structured activity program;

* Call light times were long;

* Food was served cold;

* There was no resident forum (resident council/suggestion box);

* Residents were not involved in care planning; and

* There was a lack of staff on night shift.

On 08/11/22, Staff 1 (ED) was interviewed about the facility's grievance resolution policy. She stated the facility had a grievance resolution policy, however, she had not yet implemented the system. She acknowledged the facility did not have a system of responding to and resolving resident complaints.  

OAR 411-054-0025 (7) - Facility Administration: Policy & Procedure:

The following resident concerns were noted in recent survey: 1.) Lack of structured activity program, 2.) Call-light times were long, 3.) Food was served cold, 4.) There was no resident forum (resident council/suggestion box),  5.) Residents were not involved in care planning, & 6.) There was a lack of staff on night shift.

1.) Facility has re-structured the resident grievance process, ensuring that grievance forms are available in conspicuous areas, easily accessible to residents and family members. Facility will take items 1-5 above and create grievance forms for each area of concern. Facility will follow the grievance process policy for all items listed above, until each area is resolved.

2.) a. Facility has provided training to all staff on the grievance process, b. Facility has moved grievance forms in common areas that are easily accessible,  

c. Facility is sending out a memo via email to all residents' family members explaining how the grievance process works, & where to find grievance forms, d. Facility is putting the grievance process instructions on each resident's door to ensure they are aware of this process, & e. Facility has moved the barrier of having to get a grievance form from a staff member, and instead leaving them out in the common area, to ensure that each resident feels comfortable expressing concerns.

3.) a. Facility Administrator will review grievance binder daily during morning stand-up and ensure follow-up action happens timely. b. Facility administrator will bring grievance forms to monthly Quality Improvement meetings to discuss with the IDT and identify trending concerns.

4.) Facility Administrator will be responsible for reviewing grievances daily, and monitoring this system monthly during QI meetings.

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

During the survey, conducted 08/08/22 through 08/11/22, quality improvement oversight to ensure adequate resident care, services and satisfaction was found to be ineffective.

On 08/10/22, Staff 1 (ED) was interviewed about the facility's quality improvement program. She stated the facility had a "Quality Improvement (QI) Program" policy, however, she had not yet implemented the QI program. She acknowledged the facility did not have a quality improvement plan in place.

Refer to the deficiencies in the report.

OAR 411-054-0025 (9) Facility Administration: Quality Improvement:

1.) Facility is actively working with the Vanda Consulting team to create the following:

    a. Daily/Weekly/Monthly audit(s)/form(s) for each

        dept to utilize and collect applicable data &

        to analyze any trends,

    b. Clear written processes and expectations for the

        Quality Improvement Program,

    c. A Quality Improvement Binder with tabs for each

        month of the year to store all data/trends

        collected &,

    d. Quality Improvement minutes/form for IDT to

        document findings, staff members present, &

        action plans created during each monthly

        meeting.

2.)

     a. Holi RDO & Vanda Consultant will provide

         mandatory training with IDT to teach/train what a

         Quality Improvement Program is, what each

         dept. will be responsible for auditing, how to

         create an action plan for negative

         trends/outcomes, & why this

         program is crucial to ensuring resident

         satisfaction, safety, and positive outcomes.  

     b. Facility Administrator will be responsible for

         ensuring that audits are completed timely &

         submitted to her, once weekly. Facility

         administrator will also ensure that monthly QI

         meetings are scheduled & the IDT is present.

     c. Facility administrator will send all Quality

         Improvement meeting minutes to Holi RDO, &

         will include any action plans created.

3.) The Quality Improvement Program will be evaluated weekly (ensuring audits are completed & turned in) and monthly, during QI meetings.

4.) Facility Administrator will be responsible for overseeing the Quality Improvement Program, with the help of the facility Director of Wellness who will assist in overseeing clinical audits, trends, and negative outcomes.

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

1. Observations and interviews with staff were conducted to determine adherence to universal precautions for infection control.

On 08/08/22 at 11:15 am, the surveyor obtained permission and observed Staff 5 (CG) and Staff 12 (CG) provide incontinent care for Resident 3. During the observation, Staff 5 failed to change gloves after removing a soiled incontinent product and wiping feces and urine from Resident 3's perineum. Staff 5 applied barrier cream to the resident's bottom and touched the resident's clean blanket and clean incontinent brief while wearing the same soiled gloves.

2. On 08/09/22 at 12:20 pm, observations of the lunch meal being served in the memory care unit revealed direct care staff serving food to residents without the use of an apron or other material to act as a barrier between potentially soiled clothing and resident food. Care staff were observed holding trays of food against their clothing while distributing the meals.

The need to ensure direct care staff consistently used universal precautions and used an apron while serving food was discussed with Staff 1 (ED) and Staff 2 (Director of Wellness) on 08/10/22 and 08/11/22. They acknowledged the findings.

3. During an environmental tour of the facility on 08/08/22 through 08/11/22 multiple observations were made of residents and family members who brought dining room chairs outside to the interior secured courtyard.

The dining room chairs were not of sufficient weight. When the chairs were no longer in use they were not brought back into the facility.

Multiple residents were observed being able to lift or pull the chairs to different locations around the courtyard. The interior courtyard had a black metal gate with openings wide enough to secure a foothold, and with the use of the dining room chairs, had the potential to aid in elopement from the secured area.

During the survey, multiple residents who resided in the MCC verbalized a desire to "get out of here".

Due to the design of the gate and the lack of sufficiently weighted or secured seating in the courtyard, this posed a potential risk to the health and safety of residents.

The above findings were discussed with Staff 1 (ED) and Staff 18 (Maintenance Director) on 08/09/22 at 11:30 am and with Staff 15 (Director of Operations), and Staff 19 (VP of Operations) on 08/11/22. They acknowledged the findings.

OAR 411-054-0025 (4) Reasonable Precautions:

1.) The following actions have been taken to correct each violation, by example/resident:

      a. Universal Precautions secondary to

          incontinence care - Facility leadership team

          provided in-person hand-hygiene, & proper peri-

          care infection precautions training to direct care

          staff on 8/18/22.

      b. Universal Precautions secondary to serving

          food - Facility has ordered enough aprons for

          each universal worker, as well as, provided

          training related to dining service universal

          precautions.

      c. Universal Precautions secondary to a potential

          risk to the health & safety of the residents due

          to courtyard furniture not being weighted or

          secured, creating a possible risk of elopement -

          Facility has removed all furniture in the

          courtyard that is not weighted or secured.

2.)    a. Universal Precautions secondary to

           Incontinence care: Facility is enrolling each

           direct care staff member in the following

           trainings: Peri-Care Training through Relias,

           Proper Hand-Hygiene Training through Relias

           with a return demonstration training with facility

           nurse, and 2hr Infection Control through

           Oregon Care Partners. Facility admin will

             ensure all new-hires are scheduled for new-

             hire orientation, at which time each direct  

             care staff will be given a competency checklist

             to bring with them during on-the-floor training.

             This will ensure all new-hires complete return

             demonstration of resident care tasks.

         b. Universal Precautions secondary to universal

             workers serving food: Facility is providing in-

             person training to all universal workers on

             the importance of infection/universal

             precautions when working as a universal

             worker. Facility will create policies &

             procedures specific to universal workers,

             to include appropriate uniform attire, hand-

             hygiene, and on-going training. This policy will

             be reviewed with current staff at mandatory

             staff meeting, & will be given to all new-hires

             during new-hire orientation. Facility will

             ensure that all care staffs' food handlers cards

             are current.

         c. Universal Precautions secondary to the

             potential risk of the health & safety of

             residents - elopement risk: Facility will include

             weighted &/or secured furniture in the

             courtyard, away from gate exits, to ensure

             appropriate seating for families, and in an

             attempt to prevent further instances of family

             or residents bringing inappropriate furniture

             outside for visits. Facility admin will monitor

             courtyard for unsafe furniture, during

             environmental walk-throughs with

             maintenance director.

3.) The above systems will be evaluated as follows:

          a. Facility will maintain a training grid that is

              reviewed at least once monthly during QI

              meetings, to ensure all care staff are up to

              date on annual infection control,

              provisions of care topics, & hand hygiene

              training. Facility Administrator will coordinate

              with facility B.O.M at least once monthly to

              ensure all new-hires are scheduled for new-

              hire orientation. Facility admin will coordinate

              with B.O.M at least once monthly to audit all

              new direct care staff have completed

              a competency checklist and return

              demonstration of resident care.

          b. Facility will monitor direct care staff food

              handlers expiration dates, & annual trainings

              via the training grid, at least once monthly.

              Facility will ensure that all new direct-care

              staff are given a copy of the 'Universal

              Workers' policies & procedures, once monthly

              during new-hire orientation.  

          c. Facility Administrator & Maintenance Director

              will conduct once weekly environmental walk-

              throughs.

4.) The facility Administrator, B.O.M, & Maintenance Director will be responsible for overseeing all areas related to reasonable precautions.  

Based on observation, interview and record review, it was determined the facility failed to ensure investigations of incidents were thorough and complete in order to rule out neglect for 2 of 3 sampled residents (#s 1 and 3) whose incidents were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 09/2014 with diagnoses including dementia.

a. The resident experienced nine incidents between 05/12/22 and 08/05/22, including falls and sustaining skin injuries. While the documentation of the investigations did include sufficient evidence to rule out abuse, the investigations did not include documentation of whether current interventions were in place or other service planned directions were followed at the time of the incident in order to properly rule out neglect.

b. Incident investigations did not include documentation of the Administrator review and signature.

The need to ensure incident investigations included and documented a review of whether staff were following the provisions of the service plan in order to rule out neglect and include documentation of the Administrator's review was discussed with Staff 1 (ED) and Staff 2 (Director of Wellness) on 08/10/22. They acknowledged the findings.

Surveyor: An, Eun-Suk

2. Resident 3 was admitted to the facility in 11/2020 with diagnoses including dementia and wrist and rib fractures. Resident 3 required a wheelchair for mobility.

Observations of the resident from 08/08/22 to 08/11/22 revealed the resident required staff assistance with transfers and incontinent care.

a. Clinical records reviewed from 05/08/22 to 08/08/22 noted the following:

* The resident's 05/11/22 service plan indicated the resident required staff assistance with bladder and bowel management four times per shift as feasible;

* On 05/25/22 staff documented the resident had a fall on 05/24/22. S/he was incontinent of bowel and was wearing only socks; and

* On 06/20/22 staff documented the resident had a fall. The resident reported s/he wanted to use the bathroom.

There was no documented evidence the facility conducted an investigation to reasonably conclude the above incidents were not the result neglect of care for not receiving timely bladder and bowel management, which constituted abuse.

b. Incident investigations did not include documentation of the Administrator review and signature.

The need to investigate incidents of suspected abuse and neglect and to report the incidents to the local APD when the facility's investigation was unable to rule out abuse was discussed with Staff 1 (ED), Staff 2 (Director of Wellness) and Staff 15 (Director of Operations) on 08/09/22 and 08/10/22.

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

1.) The following actions have been taken to correct each violation as listed in the S.O.D:

         a. Resident #1: Facility has reviewed &/or

             updated resident's service plan/TSP to ensure

             that all previous interventions are in place,

             with the appropriate dates of each intervention

             r/t the incident. Facility conducted a 2nd

                    investigation for all falls from 5/12/22 - 8/5/22

             to ensure that previous interventions were

             being followed, as well as, service planning

             items r/t the fall(s). During the 2nd investigation

             process, the new facility Administrator

             reviewed all above incident reports thoroughly,

             & signed as the administrator on record.

         b.  Resident #3: Facility has reviewed &

              completed a 2nd investigation for incidents on

              5/24/22 & 6/20/22 to ensure that bowel &

              bladder care were provided as stated on

              resident's current care plan. Facility has

              added additional information to these incident

              reports under the abuse & neglect section

              ensuring that abuse & neglect can be r/o

              as evidenced by; staff were providing

              appropriate bowel & bladder care at time of

              incident(s). As part of the 2nd review &

              investigation, the new facility Administrator

             signed above incident reports as the

             administrator on record.

2.) Reporting & Investigating Abuse & Neglect System & procedures will be corrected as follows:

           a. Vanda Consultant is providing a required

                training for all staff on: 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 r/o abuse & neglect secondary to

                'as evidenced by' & when to report to local

                APS. This training is taking place on 9/9/22.

            b. Facility RDO/Regional team has updated

                the current incident report & investigation

                forms to include: What past interventions

                are were in place at time of incident, & were

                past interventions & current care plan being

                followed.

            c. Facility will review incident reports each

                morning (during working days) to ensure

                that all incident reports are completed

                thoroughly, investigations including ruling

                out abuse & neglect are done timely, & that

                the administrator has reviewed & signed all

                incident reports & investigations.

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

            a. Facility Administrator & Facility LN will

                coordinate with B.O.M at least once monthly

                during Quality Improvement meetings

                to ensure that all staff have completed the

                required pre-service & on-going training -

                'Abuse & Reporting Requirements.'

            b. Facility Administrator & Clinical IDT will

                review all incident reports at least 5 days per

                week (during morning stand-up) & will bring

                all data/trends related to incident reports to

                once monthly Quality Improvement

                Meeting(s).

4.) The Facility Administrator, Facility LN, & Facility RCC will be responsible for overseeing all systems related to Reporting & Investigating Abuse/Neglect.

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

On 08/08/22 at 9:30 am, during the entrance conference, the surveyor requested an activity calendar for the current month. At 4:25 pm, the same day, Staff 1 (ED) stated there was no facility activity calendar.

The following observations were made from 08/08/22 to 08/10/22:

* There was no posted activity calendar in the RCF or MCC unit;

* There was no scheduled activity program;

* Residents sat out in the common area for long periods of time watching movies or other TV shows, wandered the halls, or remained in their room; and

* Staff did not provide any individual or group activities to residents in the MCC unit.

During a group interview on 08/09/22, multiple non-sampled residents expressed there were no scheduled activities.  

On 08/09/22 and 08/10/22, the failure to provide an activity program based on individual and group needs was reviewed with Staff 1, Staff 2 (Director of Wellness) and Staff 15 (Director of Operations). They acknowledged the findings.

OAR 411-054-0030 (1) (c-d) Resident Services: Activities:

1.) The following actions have been taken to correct each violation per examples given on the S.O.D:

            a. Facility was unable to provide monthly

                activity calendar: Facility has created a

                current activity calendar for both RCF &

                MCC, as well as an activity calendar

                template for on-going use.

            b. Facility did not have a posted activity

                calendar: The activity calendar(s) have been

                posted for residents and family, in each

                POD.

            c. Facility did not have a scheduled activity

                program: Facility has hired an activities

                coordinator who will provide activity program

                5 days per week. On AC's off days, facility

                staff will ensure that residents are engaged

                in individual and group activities. Facility is

                currently hiring/interviewing for the activity

                director position.

            d. Residents sat out in the common area for

                long periods of time watching TV shows,

                wandered the halls, or remained in their

                room(s): Facility is auditing each resident's

                service plan(s) specifically the social/hobby

                interest section & interviewing residents to

                ensure that all resident's preferred activities

                & hobbies are up to date.

                Facility will reach out to family members for

                those residents in MCC and/or with cognitive

                deficits to obtain a reliable history of social

                interests and hobbies. As the facility obtains

                updated interests & hobbies, resident

                service plans/TSPs will be updated.

            e. Staff did not provide any individual or group

                activities to residents in the MCC unit:

                Facility is working with the Vanda Consulting

                Team to write each MCC resident an

                individual activity plan via TSP, that will be

                entered into the resident's current care plan

                at next evaluation. Facility has hired an

                activity coordinator who will ensure that

                group activities are being offered to all MCC

                residents. Facility is enrolling Activity

                Coordinator in Relias training, titled:

                'Activities: Creating a Well-Rounded

                Program.'

            f. Residents expressed that facility has no

                scheduled activities: Facility has posted a

                current monthly activities calendar in each

                pod. Facility will begin once monthly town-

                hall meetings with residents to get feedback

                on current activities and to suggest new

                activities.

2.) Resident Services: Activities, This system will be corrected as follows:

             a. Facility Administrator will ensure that the

                 monthly activity calendar is turned into her

                 by the 25th of the month prior, for review.

                 Activity calendar & resident feedback from

                 monthly 'town-hall' meeting will be reviewed

                 during monthly QI meeting.

             b. Monthly activity calendar(s) will be posted

                 no later than the 1st of each month, in all

                 three pods.

             c. Facility Administrator will ensure that there

                 are meaningful, resident-centered activities

                 each day. Facility Activities' Coordinator will

                 review daily scheduled activities during

                 morning stand-up with IDT, to ensure

                 on-going activity program.

             d. Facility will limit TV shows & movies as a

                 scheduled activity and instead, ensure that

                 residents are engaged & offered group &

                 individual activities, that support their

                 interests while keeping in mind mental,

                 physical, & psychosocial needs &/or

                 limitations. Facility will create opportunities

                 for all residents to participate in daily

                 activities. Facility Administrator & Facility

                 Activities' Coordinator will ensure that each

                 resident's Service Plan is up-to-date with

                 hobbies & social interests.

             e. Once all MCC residents have updated

                 individual activity plans, facility will ensure

                 that each activity plan is updated &

                 reviewed in a timely manner & in

                 accordance with required service planning

                 schedule. Facility Activity Coordinator will

                 complete on-going continuing education r/t

                 activity program.

              f. Facility is implementing a once monthly

                 'town-hall' meeting for all residents to join,

                 in an attempt to get honest feedback of

                 current activities & to ensure that residents

                 have a place to give suggestions for future

                 activities. 'Town-hall' meeting notes will be

                 reviewed during Quality Improvement

                 meetings.

3.) Facility will evaluate Resident Services: Activities, system, as follows:

             a. Facility Administrator will review monthly

                 calendars at least once monthly, prior to

                 calendar being posted. Facility Admin will

                 ensure that all activity related topics will

                 also be reviewed by the IDT, during monthly

                 Quality Improvement Meetings.

             b. Facility Administrator & Activity Coordinator

               will ensure activity calendar(s) are posted in

               each pod, no later than the 1st of each month

               & Facility Admin will ensure that calendars

               are posted, at least once weekly, when

               conducting weekly environmental walk-

               throughs.

           c. Facility Activities Coordinator will be

               responsible for bringing each days planned

               activities to morning stand-up, to ensure that

               all members of the IDT are aware of

               important scheduled activities for that day, &

               provide assistance as needed.

           d. Facility Administrator & Activities Coordinator

               will review the social interests & hobbies

               sections of all residents' service plans as

               follows: Pre-admission, Admission, 30 days

               after admission, quarterly thereafter, & with

               any significant change of condition. Activities

               Coordinator will be required to be a part of

               the service planning team to ensure

               oversight & accuracy.

           e. Facility Activities Coordinator & Facility

               Admin will ensure all MCC residents have an

               updated, accurate individual activities plan

               during each service plan review, & in

               accordance with required service planning

               schedule: Pre-admission, Admission, 30-

               days after admission, quarterly thereafter, &

               with any significant change of condition.

               Facility Administrator will ensure that AC

               is scheduled on-going education r/t the

               activity program, & will review this once

               monthly.

            f. Facility Administrator & Activities Coordinator

               will ensure that the once monthly resident

               'town-hall' is scheduled & on each months

               activity calendar. Facility Administrator will

               ensure that resident 'town-hall' is scheduled

               every month when reviewing calendar, at

               at least once monthly, prior to it being posted.

4.) The following staff will be responsible for overseeing the Resident Services: Activities, system: Facility Administrator, Facility Activities Coordinator, & Facility LN.

2. Resident 2 was admitted to the facility in 01/2022 with diagnoses including dementia and psoriasis.

The resident's quarterly evaluation, dated 07/04/22, was reviewed and care staff were interviewed. The evaluation was incomplete or inaccurate in the following areas:

* Skin condition (injuries, psoriasis);

* Weight changes; and

* Falls (history and interventions).

The need for quarterly evaluations to be complete and accurate was discussed with Staff 1 (ED) and Staff 2 (Director of Wellness) on 08/10/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure initial move-in evaluations included all required elements, for 2 of 2 sampled residents (#s 4 and 5) and that quarterly evaluations were reflective for 1 of 3 sampled residents (#2). Findings include, but are not limited to:

1. Resident 4 was admitted to the facility on 07/28/22 and Resident 5 was admitted to the facility on 07/01/22. The new move-in evaluations were not signed or dated and lacked information regarding the following required elements:

* Customary routines including eating and bathing preferences;

* Spiritual and cultural preferences and traditions;

* Mental health issues including depression, thought disorders or behavioral or mood problems including history of treatment and non-drug interventions;

* Cognition, including memory, confusion and decision making;

* Communication and sensory abilities including hearing,vision and speech;

* Activities of daily living including toileting, bowel and bladder management, dressing, grooming, bathing, and personal hygiene;

* Eating, dental status, and assistive devices;

* Independent activities of daily living including ability to manage medications, use of call light and transportation;

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

* Skin condition;

* Nutrition habits, fluid preferences, and weight if indicated;

* List of treatments: type, frequency, and level of assistance needed;

* History of dehydration or unexplained weight loss or gain;

* Recent losses;

* Unsuccessful prior placements; and

* Elopement risk or history.

Additionally, Resident 4's evaluation lacked the following required elements:

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

* Mobility: ambulation, transfers, and assistive devices;

* Independent activities of daily living including ability to manage medications, housework, laundry and transportation;

* Review of risk indicators including fall risk or history, emergency evacuation ability;

* Complex medication regimen;

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

Additionally, Resident 5's evaluation lacked the following required elements:

* List of current diagnosis;

* List of medications and PRN use;

* Vital signs if indicated by diagnosis, health problems or medications; and

* Alcohol or drug use.

The move-in evaluation and the need to complete all required components was reviewed with Staff 1 (ED), Staff 2 (Wellness Director), Staff 15 (Director of Operations), Staff 19 (VP of Operations) on 08/09/22 and 08/11/22. They acknowledged the findings.

OAR 411-054-0034 (1-6) Resident Move-In & Eval: Resident Evaluation:

1.) The following actions are being taken for each violation, per examples given on the S.O.D:

           a. Resident #s 4 & 5 lacked required

               information on multiple areas of the

               evaluation(s): Facility is

               currently reviewing & updating above  

               residents' evaluations to ensure all required

               information is included. Facility RDO is

               working with the Vanda Consultant to identify

               areas of the current evaluation in EHR

               system, Yardi, that are missing, structurally.

               Once the missing required areas are

               identified, Facility RDO will work with a Yardi

               representative to restructure the current eval

               to ensure compliance. Upon completion of

               pre-admission, admission, 30-days after

               admission, quarterly, and/or significant

               change of condition evaluations, facility will

               print, sign and date. All current evaluations

               missing a signature & date, will be printed &

               signed & dated by the employee who

               completed them.

           b. Resident #2's evaluation was inaccurate or

               incomplete in the following areas: Skin

               condition (injuries, psoriasis); Weight

               weight changes; and falls (history &

               interventions): Facility will complete a

             thorough review of above inaccurate or

             incomplete areas of this residents' evaluation

             and will update with accurate information.

             Facility Nurse will assess resident's skin &

             weight to ensure proper oversight & accurate

             documentation on the evaluation.

2.) Resident move-in & Eval: Resident Evaluation - Facility will correct this system to eliminate future violations, as follows:

         a. Facility RDO is working with Vanda Consultant

             to audit the current structure of the evaluation

             in EHR system, Yardi, to identify missing

             required elements. Facility RDO will then work

             with a Yardi representative to have the eval

             updated on the back-end to ensure

             compliance. Facility IDT will receive training

             on the required areas needed in each eval,

             as well as, general training on how to & when

             to complete (with date & signature)

             evaluations.

         b. Facility will review current policies and

             processes around completing evaluations, to

             ensure all evaluations are completed

             thoroughly and accurately. Facility will ensure

             that all TSPs from the last quarter are used as

             a tool to build updated evaluation(s). Facility

             will hold a once weekly IDT meeting to discuss

             all evaluations/service plans coming due that

             week, to ensure multiple staff members who

             are familiar with resident care, can assist in

             providing information for updated eval. Facility

             will implement a 24hr audit system to ensure

             that any resident w/ a short-term or significant

             change of condition has appropriate

             documentation, including TSPs, in an attempt

             to ensure weights, skin events, falls, are

             addressed & timely and made a part of

             resident(s) care plans. Audit findings

             will be brought to stand-up meetings to ensure

             appropriate oversight & IDT collaboration.

3.) Resident move-in & Eval: Resident Evaluation - This system will be reviewed as followed:

         a. Facility IDT will review evaluations coming due

             at least once weekly during IDT meeting.

             Facility administrator will review any upcoming

             or overdue evaluations, each morning during

             stand-up, with IDT. All evaluations will be

             completed in accordance to current OARS:

             Pre-admission, Admission, Within 30 days of

             Admission, Quarterly Thereafter, & with any

             significant change of condition.

        b.  Facility will complete 24 hr audit daily on

             Tuesday - Thursday & a 72hr audit on

             Mondays to review with IDT daily during

             stand-up. Facility Administrator will ensure

             that any staff member completing evals will

             have the proper training, and admin will

             monitor this once monthly on training grid.

4.) Facility Administrator, RCC, Facility LN will be responsible for ensuring that evaluations are completed timely, accurately, and are resident-specific.

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

1. Resident 3 was admitted to the facility in 11/2020 with diagnoses including dementia.

Resident 3 was observed to utilize a wheel-chair for mobility and needed to be assisted for food intake during the breakfast and lunch meal.

Observations of the resident, interviews with staff, review of the current 05/11/22 service plan and clinical records during the survey, revealed Resident 3's service plan was not reflective of the resident's status and did not provide specific directions to staff, and was not followed in the following areas:

* Use of air mattress;

* Denture care status;

* Weight changes including plans;

* Oral care status;

* Skin status; and

* Activity status.

The need to ensure the service plan provided clear instruction to staff, was reflective of the resident's needs and was followed was discussed with Staff 1 (ED), Staff 2 (Director of Wellness) and Staff 15 (Director of Operation) on 08/09/22 and 08/10/22. They acknowledged the findings.

2. Resident 2 moved into the facility in 01/2022 with diagnoses including dementia. The most recent service plan available to staff, dated 01/01/22, was not followed or lacked clear instruction for staff in the following areas:

* Obtain daily blood pressure;

* Use of a knee brace;

* The preference to keep room door locked;

* Activity needs and preferences;

* History of falls and current fall interventions; and

* Skin conditions and treatment.

The need to ensure the most current service plans were available to staff, reflective of resident needs and included clear direction to staff was discussed with Staff 1 (ED) and Staff 2 (Director of Wellness) on 08/10/22. They acknowledged the findings.

3. Resident 5 was admitted to the facility in 07/2022. The resident's current service plan, dated 08/03/22, temporary service plans (TSP), observations of the resident's apartment and interviews with staff were completed during the survey.

a. The following care areas were not followed:

* Weekly skin checks;

* Weekly hydration monitoring for dehydration;

* Daily blood pressure checks and PRN hypertension medication;

* Two hour skin checks while wearing prosthetics;

* Staff to order and administer PRN pain medications;

* Weekly weights;

* Apartment floor to be free of clutter;

* Nursing needs including delegated tasks;

* Use of "shrinker" on right amputation;

* Daily HHPT exercises; and

* Two-person transfers.

A TSP was written on 07/26/22 to remind the resident to wear prosthetics after dinner and take them off prior to bed and to assist the resident with exercises. The information was added to the TAR and multiple staff had initialed the TAR, which indicated the treatment had been done.

Observations during the survey from 08/08/22 through 08/11/22 showed the resident's prosthetics were placed at bedside. The resident was not observed to wear the prosthetics or "shrinker" during the survey.

During an interview on 08/10/22, Staff 10 (MT), confirmed she doesn't assist with exercises, use of prosthetics or skin monitoring.

During an interview on 08/10/22, Staff 12 (CG), reported "[s/he] doesn't wear the prosthetics, I don't give him reminders to put them on or help [him/her] do it. I don't help [him/her] with exercises."

During an interview on 08/11/22, Staff 1 (ED), reported "I don't think I have ever seen [him/her] wear them [prosthetics]."

b. The following care areas were not reflective and failed to provide clear direction to staff:

* Urinal use and type of assistance needed; and

* Incontinent care completed in bed.

The need to ensure the service plan provided clear instructions, were reflective of the resident's needs and were followed was discussed with Staff 1 (ED), Staff 15 (Director of Operations), Staff 19 (VP of Operations) on 08/11/22. They acknowledged the findings.

OAR 411-054-0036 (1-4) Service Plan: General:

1.) The following action has been taken for each violation, per examples given on S.O.D:

           a. Resident #3's service plan was not reflective

               of the resident's status and did not provide

               specific directions to staff, and was not being

               following in multiple areas - Facility is

               conducting a thorough review & update of

               resident #3's evaluation & service plan, & will

               ensure that service plan is up to date &

               reflective of residents current needs, with

               specific instructions for staff. Due to resident

               requiring nursing oversight, facility RN will

               be a part of updating this resident's service

               plan & will provide interventions needed.

           b. Resident #2's service plan was not followed

              or lacked clear instruction clear instruction for

              staff in multiple areas - Facility is conducting

              a thorough review & update to resident 3's

              evaluation & service plan. Facility will ensure

              that resident #3's current service plan is up-

              to-date with resident's current needs, & has

              clear instructions for staff to follow.  

          c. Resident #5's service plan was not followed

              or lacked clear instruction in multiple areas -

              Facility is conducting a thorough review of

              resident #5's evaluation & service plan & will

              ensure that resident's service plan is up-to-

              date with resident's needs and has clear

              instructions for staff to follow. Facility LN is

              assessing resident #5 for current skin events,

              risk for skin events, weight loss/gain, use of

              prosthetics, & delegation needs. Facility RN

              will be a part of this resident's service plan

              update to ensure appropriate interventions

              are in place, coordination of care with

              resident's provider, and that staff have clear

              instructions to follow.

2.) Service Plan: General, system: Facility will correct &  evaluate this system to eliminate future violations, as follows:

          a.  Direct care staff are scheduled to receive the

               following training(s): In-Person training on

               short-term change of condition; creating &

               following TSPs, importance of shift-to-shift

               meeting, & when to notify LN for change of

               condition.

               Facility nurse will receive the following

               training(s): Facility nurse will attend OHCA

               'Role of the RN in Community Based Care' &

               will receive training & training materials from

               Vanda Consultant related to; Change of

               condition oversight, service plan review

               within 48hrs of significant change of

               condition, resident specific interventions r/t

               change of condition that are available to staff

               on each shift. Facility will include all change

               of condition(s) as part of the 24/72hr audit, to

               ensure implementation of resident care

               needs/interventions.

           b. Service plans will be reviewed & updated in

               accordance to current OARs: Prior to

               admission, at admission, with updates at 30

               days, quarterly thereafter, & with significant

               change of condition. All other changes to

               resident care needs that occur between

               service plan updates will be written as a TSP

               & will be reviewed by the IDT, as well as, all

               direct care staff. Resident care needs that

               are secondary to a significant change of

               condition will have TSPs written by facility

               RN & will include interventions & clear

               instructions for staff to follow.

           c. Facility Administrator will oversee & ensure

               that all service plans are reflective of resident

               needs as identified in the evaluation. Facility

               Administrator will ensure that the clinical IDT

               review all upcoming service plans for that

               week, during stand-up. Any significant

               change of condition(s) noted, will be

               communicated with facility RN & added to

               the significant change of condition log to

               ensure appropriate service planning.

3.) Service Plan: General - This system will be evaluated as follows:

           a. TSPs will be reviewed daily as part of the 24/

               72 hr process,

           b. Sig-Change log will be evaluated at least

               once weekly by facility RN, with updates

               made to the resident's service plan as

               needed,

           c. Service plans will be reviewed & updated

               prior to admission, at time of admission,

               within 30 days of admission, quarterly, &

               with any significant change of condition,

           d. Facility Administrator will ensure that all staff

               have up-to-date training related to TSPs,

               service plans, and resident care, & will

               review the training grid at least monthly.

4.) The Facility Administrator, Facility RN, & Facility RCC will be responsible for ensuring all corrections to the residents' service plans are made, and overseeing this system as stated above.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were updated after a significant change of condition, were reflective of residents' needs, provided clear direction to caregiving staff regarding the delivery of services and were followed for 1 of 4 sampled residents (#8) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 8 was admitted to the facility in 11/2022 with diagnoses including dementia.

Resident 8 was observed to utilize a wheel-chair for mobility, required 1-2 person assist for transfers, ambulation, bed mobility and needed assistance for food intake during breakfast and lunch meals from 02/21/23 through 02/22/23.

Observations of the resident, interviews with staff, review of the current 01/07/23 service plan, temporary service plans and the clinical record revealed Resident 8's service plan was not updated after a significant change of condition, was not reflective of the resident's status, failed to provide specific directions to staff, and was not followed in the following areas:

* Skin status, including treatments and intervention to float heels;

* 1:1 meal assistance;

* Weight loss intervention to provide preferred foods when meals were refused;

* Hospice provided bathing;

* One-to-two person assist with mobility, including ambulation, transfers and bed mobility;

* Recent falls;

* Toileting status;

* Emergency evacuation status; and

* Activity status.

The need to ensure the service plans were updated following a significant change of condition, provided clear instruction to staff, were reflective of the resident's needs and was followed was discussed with Staff 2 (ED), Staff 8 (Wellness Coordinator) and Staff 22 (Director of Wellness, RN) on 02/22/23. They acknowledged the findings.

OAR 411-054-0036 (1-4) Service Plan: General

1.) Service Plan: The following actions will be taken to correct each violations per examples given on the SOD:  

    a) Resident 8 passed prior to SOD. No corrections to the                  service plan are able to be made at this time.

2.) Service Plan: General: This system is being corrected to eliminate future violations as follows:

  a.) Facility Administrator, Wellness Coordinator, and Director of Wellness will discuss any changes of conditions and interventions or changes to care plan needed as part of the 24/72 hour process.

  b.) One of the three members of the clinical team (ED, RCC, RN) will be decided on to complete the service plan in a timely manor.

  c) Once completed, the service plan will be brought to the next daily clinical meeting where the clinical team members can sign off that it was completed thoroughly and accurately.

3.) Service Plan: General: This system will be evaluated as follows:

  a) At each daily clinical meeting, the ED, RCC, and RN will review any identified changes of condition and ensure the RN has completed a note with interventions and/or changes to care plan. TSP(s) will also be immediately implemented.

  b) Weekly, at each IDT, all TSPs related to the change of condition will be discussed and each department will have an opportunity to provide any further interventions and/or changes needed prior to finalizing the service plan.

4.) The Facility Administrator, Facility RN Director of Wellness, and Facility Wellness Coordinator will be responsible for overseeing the system as stated above.    

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, and at least one other staff person who was familiar with or who was going to provide services to the resident for 5 of 5 sampled residents (#s 1, 2, 3, 4 and 5). Findings include, but are not limited to:

Resident 1, 2, 3, 4 and 5's current service plans were reviewed during the survey.

The service plans lacked evidence the residents or their legal representative's participated in the development of the service plans and that a Service Planning Team was used to develop the service plan.

The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (ED), Staff 2 (Director of Wellness) and Staff 3 (Resident Care Coordinator) on 08/11/22. They acknowledged the findings.

OAR 411-054-0036 (5) Service Plan: Service Planning Team:

1.) The following actions have been taken for each violations, per examples listed on S.O.D:

           a. Resident 1, 2, 3, 4, and 5's service plans

               lacked evidence that the residents or their

               legal representative's participated in the

               development of the service plans & that a

               service planning team was used to develop

               the service plan - Facility is scheduling care-

               conferences with residents 1, 2, 3, 4, & 5, &

               will include applicable family/POA. Facility

               IDT are reviewing these service plans & will

               signing and dating after each respective

               review.

2.) Service Plan: Service Planning Team - This system is being corrected to eliminate future violations, as follows:

           a. Facility is currently working with Vanda

               Consultant to establish policies & procedures

               related to service planning/teams,

           b. Facility IDT will receive training r/t the

               service planning team, care conferences, &

               who needs to be a part of the service plan

               team,

           c. Facility Administrator is actively scheduling

               care conferences with residents and their

               families/POAs.

           d. Facility is developing a once-weekly IDT

               meeting, wherein all completed evaluations &

               service plans will be reviewed by each team

               member, printed, signed and dated.

3.) Service Plan: Service Planning Team - This system will be evaluated as follows:

           a. Upon completion of updated

               policy/procedures, facility IDT will receive

               training related to the requirements of a

               service planning team - facility admin will

               oversee on-going training for applicable staff

               at least once monthly, per new-hires and/or

               employee promotions.

           b. Facility IDT will review all completed service

               plans for that week, during once weekly IDT

               meeting, and will print, sign, and date.

           c. Facility Administrator will collaborate with the

               Administrative assistant at least once

               monthly, to review upcoming service plans &

               to schedule care conferences for the

               upcoming month.

4.) The facility Administrator will be responsible for overseeing and ensuring the correction of above violation(s).

2. Resident 3 was admitted to the facility in 11/2020 with diagnoses including dementia and wrist and rib fractures. Resident 3 required a wheelchair for mobility.

Observations of the resident from 08/08/22 to 08/11/22 revealed the resident required staff assistance with transfers and incontinent care.

a. Resident 3's clinical record dated 05/08/22 through 08/08/22 were reviewed during the survey and revealed the following:

* The resident's 05/11/22 service plan indicated the resident required staff assistance with bowel and bladder management four times per shift as feasible;

* On 05/25/22 staff documented the resident had a fall on 05/24/22. S/he was incontinent of bowel and was wearing only socks; and

* On 06/20/22 staff documented the resident had a fall. Staff further documented the resident wanted to use the bathroom.

There was no documented evidence the facility thoroughly reviewed the incidents to determine if service planned interventions were followed in the area of bowel and bladder management and evaluated for effectiveness or new interventions determined and communicated to staff.

On 08/09/22 and 08/10/22, the above findings were reviewed with Staff 1 (ED), Staff 2 (Director of Wellness) and Staff 15 (Director of Operations). They acknowledged findings.

b. Clinical records reviewed from 05/08/22 to 08/08/22 and staff interview noted the following:

* 05/04/22 - Returned from the hospital;

* 05//18/22 - "blister/diaper rash on the hip"; and

* 06/08/22 - Small red area on coccyx.

There was no documented evidence that the resident's short-term changes of condition were consistently monitored, at least weekly, to resolution.

On 08/09/22 and 08/10/22, the above findings were reviewed with Staff 1 (ED), Staff 2 (Director of Wellness) and Staff 15 (Director of Operations). They acknowledged findings.

Based on observation, interview and record review, it was determined the facility failed to ensure residents who experienced changes of condition were evaluated, necessary actions/interventions were determined, documented, and communicated to staff, and the residents' conditions, including the effectiveness of interventions, were monitored weekly through resolution for 4 of 5 sampled residents (#s 1, 2, 3 and 5) who had documented changes of condition. Resident 1 had repeated falls with injuries. Findings include, but are not limited to:

1. Resident 1 was admitted to the memory care unit in 09/2021 with diagnoses including encephalopathy and dementia. During the survey, s/he was identified as having a history of and recent falls.

Observations of Resident 1 throughout the survey confirmed the resident was often unsteady on his/her feet, had poor safety awareness and was dependent on staff for most ADLs.

Clinical records, including the service plan, temporary service plans (TSP's), incident reports and investigations, provider notes and charting notes were reviewed. The clinical record provided the following information:

a. Resident 1 experienced nine falls between 05/12/22 and 08/05/22 as follows:

* 05/12/22 in common area;

* 05/16/22 in common area resulting in skin tear and bruising;

* 05/18/22 in common area resulting in pain and bruising;

* 05/21/22 in outside courtyard resulting in abrasion;

* 05/25/22 in common area;

* 06/09/22 in room, bruising and swollen lip observed the following day;

* 07/07/22 in common area;

* 07/13/22 in common area, skin tears to head, bruising visible several days later; and

* 08/04/22 in common area.

The records documented information on the falls, how the injuries occurred, treatment provided and that the resident was placed on alert monitoring.

Incident investigations provided, from 05/12/22 through 08/05/22, were reviewed and documented new fall interventions including:

* 05/16/22 staff to assist [the resident] when looking to sit down;

* 05/18/22 guide resident to a chair to sit, re-direct to an activity and ensure resident is wearing non-skid socks or shoes;

* 05/21/22 staff to assist resident when outside for walks, re-direct back inside when outside for walks; and

*07/07/22 present the resident with an activity to keep occupied, re-direct as feasible, keep dining room chairs pushed in.

While the follow-up investigations included documentation of new interventions identified to prevent further falls/injury, the record did not include documented evidence the new interventions were communicated to staff and there was no evidence the interventions were implemented and monitored for effectiveness.

The failure of the facility to ensure interventions were communicated to staff, added to the service plan, were implemented and monitored for effectiveness to prevent future falls or injuries placed the resident at risk and the resident continued to experience falls and/or injuries.

b. Resident 1 sustained multiple skin injuries (as listed above) and included the following:

* 05/26/22 sustained redness and bruising to nose while ambulating in common area;

* 06/20/22 hit chin on a shelf, bruising to chin;

* 06/27/22 hit head on handrail, sustained a cut to the head;

* 08/05/22 bleeding to head, bruising visible two days later.

The skin injuries represented short term changes of condition. The injuries were identified and documented in the alert monitoring charting notes by medication technicians.

While the facility licensed nurse discontinued the alert monitoring of the skin injuries and noted the status of the injury at the time of ending the alert monitoring, there was no documented evidence interventions were developed if needed and staff was monitoring the skin issues, at least weekly, until the injury was resolved.

The monitoring process and need to ensure interventions related to changes of condition were communicated to staff and the conditions were monitored at least weekly until resolved was discussed with Staff 1 (ED) and Staff 2 (Director of Wellness) on 08/10/22. They acknowledged the findings.

2. Resident 2 was admitted to the memory care unit in 01/2022 with diagnoses including dementia and chronic kidney disease.

Clinical records, including the service plan, dated 01/01/22, temporary service plans (TSP's), provider visit notes and charting notes were reviewed. The clinical record provided the following information:

Resident 2 had the following skin injuries identified during the review period from 05/09/22 through 08/01/22:

* 05/19/22 abrasions to left knee and head, skin tear to right hand;

* 05/21/22 bruising to left eye;

* 06/17/22 skin rash to neck, forehead and top of head;

* 06/25/22 bruise to right hand; and

* 07/22/22 open area on neck with drainage.

Resident 2's skin injuries represented short term changes of condition. The clinical record revealed the following:

The skin injuries were identified and documented in the alert monitoring charting notes by medication technicians.

While the facility licensed nurse discontinued the alert monitoring of the skin injuries and noted the status of the injury at the time of ending the alert monitoring, there was no documented evidence the injuries were evaluated at onset, interventions developed, if needed, and the skin issues were being monitored, at least weekly, until the injuries were resolved.

The need to ensure changes of condition were evaluated at onset, interventions developed as needed and monitored, at least weekly, until resolved was discussed with Staff 1 (ED) and Staff 2 (Director of Wellness) on 08/10/22. They acknowledged the findings.

3. Resident 5 was admitted to the facility in 07/2022 with diagnosis of diabetes, CVA (cerebrovascular accident) and hypertension.

a. Review of the clinical record, including progress notes indicated the following short-term changes of condition were not monitored through resolution and monitoring instructions were not communicated to staff:

* On 07/03/22, missed insulin dose at 2:00 pm;

* On 07/16/22, ER visit 07/16/22 and return to facility on 07/17/22 with diagnosis of hyperglycemia;

* On 07/28/22, vomiting and elevated BP 188/81 at 9:14 am, PRN Clonidine was given and BP rechecked at 12:20 pm. Blood pressure (BP) remained elevated at 166/75. No further BP monitoring was completed.

b. Resident 5's new move-in evaluation dated 07/01/22 and physician orders indicated the following evaluated care needs that required monitoring:

* Dehydration monitoring, related to diabetes;

* Weekly skin monitoring; and

* Blood pressure monitoring due to history of CVA and hypertension.

There was no documented evidence the facility monitored the resident per evaluated care needs.

c. A review of the current service plan, dated 08/03/22, temporary service plans (TSP's) and progress notes from 07/02/22 through 08/08/22 noted the following service planned fall risk interventions:

* Two-person transfers;

* Monitor every two hours;

* Provide verbal cues during transfers;

* Keep apartment free of clutter on the floor; and

* Home health PT.

On 07/16/22, staff documented the resident had a witnessed fall in his/her apartment. There was a TSP written for staff to monitor for latent injuries and bruises, however; the facility failed to review the service planned interventions for effectiveness and new interventions determined and communicated to staff.

On 08/05/22, staff documented the resident had an unwitnessed fall in his/her apartment. There was no documented evidence the service planned fall interventions were reviewed for effectiveness and there was no documented evidence monitoring instructions were communicated to staff.

Resident 5 was alert and oriented and able to explain how both falls occurred.

The need to ensure the facility monitored service planned fall interventions for effectiveness, monitor and document on the resident's condition until resolved and communicate changes of condition to staff was discussed with Staff 1 (ED), Staff 15 (Director of Operations), Staff 19 (VP of Operations) on 08/11/22. They acknowledged the findings.

OAR 411-054-0040 (1-2) Change of Condition and Monitoring:

1.) The following actions will be taken for each violation, per the examples written on the S.O.D:

           a. Resident #1 - Facility failed to ensure that the

               monitoring process and need to ensure

               interventions related to change of condition

               were communicated to staff, and that the

               conditions were monitored at least once

               weekly - Facility is reviewing all falls within

               the last 90 days & ensuring all appropriate

               interventions are in place and communicated

               to staff via TSPs. Facility nurse is

               assessing current skin events and the risk

               for skin events, & will document findings, &

               interventions via TSPs. All current skin

               events will be monitored by facility LN at

               at least once weekly, until resolved.

           b. Resident #2 - Facility failed to ensure that

               changes of condition were evaluated at

               onset, interventions developed as needed &

               monitored, at least weekly, until resolved -

               Facility LN is assessing resident for any

               current skin events and the risk for skin

               events. All findings will be documented via

               TSPs, and will include interventions for staff.

               All current skin events will be monitored by

               LN, at least once weekly, until resolved.

           c. Resident #3 - Facility failed to ensure:  

              fall interventions were in place, being

              followed, and were effective, new fall

              interventions were communicated with staff, &

              that short-term changes of condition were

              monitored at least weekly, until resolution -

              Facility is reviewing the last 90 days of falls

              to ensure that appropriate fall interventions

              are in place, effective, and communicated

              with staff via TSPs. Facility will review

              resident records/chart to ensure that any

              recent short-term change of condition is being

              monitored, at least once weekly, until

              resolved.

          d. Resident #5 - Facility failed to ensure fall

              interventions were effective, monitor &

              document on the resident's condition until

              resolved, and communicate changes of

              condition to staff - Facility is reviewing all

              resident falls within the last 90 days to

              ensure that 1.) Current fall interventions are

              effective, 2.) New fall interventions are in

              place and communicated to staff via TSP.

              Facility LN will review resident's chart/record,

              and ensure that any short-term changes of

              condition are being monitored at least once

              weekly until resolved, and communicated to

              staff, via TSP.

2.) Change of Condition - This system is being corrected to eliminate future violations, as follows:

          a. Facility is implementing a 24/72hr audit to

              ensure that all resident changes of condition

              are evaluated at onset, that appropriate

              interventions are put in place via TSP, & that

              all changes of condition are monitored until

              resolution,

          b. Facility is requiring updated training to

              applicable IDT & direct care staff, that will

              focus on change of condition documentation,

              monitoring, and interventions.

          c. Per mandate, facility staff will also receive

              training and training material related to

              incident reports, investigation of incident

              reports, previous & new interventions, when

              to notify the nurse, and ensuring all

              interventions are made a part of the resident

              record & communicated with staff via TSP.

          d. Facility is implementing a skin log as part of

              the 24hr process, to ensure appropriate

              oversight, interventions, and communication

              to staff.

          e. Facility nurse will review skin log, & resident

              alerts, and will ensure that new skin events

              and/or treatments are entered into the

              residents' TAR to ensure monitoring & tx

              interventions, until resolved.

           f. Facility will receive training from Vanda

              Consultant related to the service planning

              process, secondary to changes of condition.

3.) Change of Condition & Monitoring - This system is will be evaluated, as follows:

          a. The clinical IDT will review and complete the

              24/72 hr audit as follows: The 24hr

              report/audit will be completed daily five days,

              and the 72 hr report/audit will be completed

              once weekly, or upon return from two days

              off.

          b. Facility LN will review skin log & resident

              alerts r/t new skin events, daily (5 days a

              week) and will review a 72 hr look back upon

              return from 2 days off.

          c. Facility LN will ensure once weekly oversight

              and documentation on residents with active

              skin events and/or nursing needs, until

              resolved.

          d. Facility will include incident report reviews

              during daily stand-up to ensure appropriate

              interventions are in place, communicated with

              staff, and are effective.

          e. Facility will ensure that all TSPs (Temporary

             Service Plans) are made a part of the

             resident's service plan when completing

             service plans/evaluations as they are updated

             per scheduling requirements: Initial, within 30-

             days of admission, quarterly thereafter, & with

             significant change of condition.

          f. Facility Administrator will ensure that all

             applicable staff (those writing, reviewing, &

             updating TSPs/Service plans will have the

             appropriate training - This system will be

             monitored & reviewed once monthly, via

             the training grid, and upon new-hire

             orientation.

4.) Facility administrator, Facility Licensed Nurse, & Facility RN will ensure that all above corrections are made.

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

1. Resident 3 was admitted to the facility in 11/2020 with diagnoses including dementia.

Observations of the resident on 08/08/22 and 08/09/22 revealed the resident required hands-on assistance to eat meal and nectar thickened liquids to drink.

Resident 3's weight record was reviewed during the survey and revealed the following:

* 04/2022 - 137. 2 pounds;

* 05/2022 - 127.1 pounds; and

* 08/2022 - 116.3 pounds.

From 04/2022 to 05/2022, Resident 3 had weight loss of 10.1 pounds or 7.36 % of his/her body weight, which represented a significant change of condition.

Weights documented after 05/2022 revealed the resident experienced another significant weight loss of 8.49 % in three months from 05/2022 to 08/2022. There were no weights recorded in 06/2022 and 07/2022 to review.

There was no documented evidence the RN completed an assessment of the resident's condition which included that the weight loss had been evaluated, actions or interventions had been determined to address the weight loss.

During the survey on 08/09/22 the following was observed:

* From 9:05 am to 9:40 am, the resident was not observed in common area or in the dining room, the resident was in his/her bed;

* At 10:25 am, Staff 5 (CG) was observed in Resident 5's room to assist the resident with fluid intake. Staff 5 stated s/he complained of being thirsty and offered a cup of thickened orange juice;

* At 12:00 pm, the resident was in the dining room for lunch. S/he was holding a sandwich and s/he ate the sandwich independently with staff cueing. The resident consumed 80 % of lunch.

The failure to complete a RN assessment at the time of the significant weight loss and failure to initiate interventions resulted in further weight loss.

On 08/09/22 and 08/10/22, the above findings and lack of an RN assessment was shared with Staff 1 (ED), Staff 2 (Director of Wellness) and Staff 15 (Director of Operations). They acknowledged the findings.

2. Resident 2 was admitted to the facility in 01/2022 with diagnoses including dementia.

a. Observations of the resident from 08/08/22 to 08/10/22 revealed the resident required hands-on assistance to eat meals. Direct care staff reported the resident ate well with staff assistance and the resident would be unable to eat unless staff assisted. The resident was observed to be able to drink his/her thickened liquids with minimal assistance from staff.

Resident 2's weight record was reviewed during the survey and revealed the following:

* 03/2022 - 156.5 pounds;

* 04/2022 - 160.7 pounds;

* 05/2022 - 174.7 pounds; and

* 08/2022 - 178.4 pounds.

From 03/2022 to 08/2022, Resident 2 had weight gain of 21.9 pounds or 13.09 % of his/her body weight, which represented a significant change of condition.

There were no weights recorded on 06/2022 or 07/2022. On 07/28/22, the facility RN instructed staff to "please take weight monthly" to determine weight changes. The next weight was obtained on 08/04/22 of 178.4 pounds.

There was no documented evidence the RN completed an assessment of the resident's condition, which included whether the weight gain had been evaluated and any actions or interventions determined to address the weight gain.

b. On 07/22/22, charting notes documented the resident had an open wound on his/her neck and a family member cleaned and placed a dressing on the wound. The wound was described as having drainage and a "hole" was visible.

Direct care staff documented cleaning and dressing the wound daily from 07/22/22 through 08/01/22. On 07/28/22, the resident was seen by the facility RN and the assessment described the wound and provided instruction for staff to leave the wound open, monitor and allow it to heal.

The RN assessment, conducted on 07/28/22, was not completed timely for the open wound which represented a significant change of condition.

The need to ensure changes of condition were evaluated and referred to the RN, on a timely basis, for assessment and interventions was discussed with Staff 1 (ED) and Staff 2 (Director of Wellness) on 08/10/22. They acknowledged the findings.

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

1.) The following actions will be taken to correct each violation, per examples written on S.O.D:

           a. Resident #3 - Facility failed to ensure the RN

               performed an assessment, interventions

               developed based on condition of the

               resident, and updated the service plan

               related to significant weight loss: Facility

               is implementing weekly weights for resident

               #3 to ensure oversight on weight status.

               Facility RN will assess resident and begin

               weekly significant change of condition

               assessments, with interventions in place

               via the RN assessment and TSPs. Facility

               RN will coordinate with resident's provider as

               well, to ensure coordination of care.

           b. Resident #2 - Facility failed to ensure that

               changes of condition were evaluated &

               referred to the RN, on a timely basis for

               RN assessment - Facility will implement bi-

               weekly weights for resident #2, to ensure

               appropriate oversight and action for weight

               gain. Facility RN will assess resident #2 to

               identify any concerns r/t weight gain, & r/o

               other symptoms that might be contributing to

               weight gain. Facility RN will add resident #2

               to weekly significant change of condition

               assessments, and will include appropriate

                interventions, as needed, on the

                weekly assessment, as well as, TSPs.

                Facility RN will assess resident #2's wound

                and document once weekly via significant

                change of condition, until resolved. RN will

                add interventions in weekly assessment(s)

                as well as, on TSPs for staff to review.

                Facility RN will add an order for monitoring

                on the TAR of resident #2, and any

                additional treatments needed, until resolved.

2.) Resident Health Service - This system is being corrected to eliminate future violations, as follows:

            a. Facility is implementing a 24/72 hr process

                & audit. As part of this process,

                facility will update the 24hr binder with the

                following: An updated significant change of

                condition log, weekly skin logs, and when to

                notify the nurse. Facility RCC will run the

                24/72 hour audit each morning (on work

                days, 5 days a week, & 72hr audit after

                2 days off) to identify any changes of

                condition noted. This audit will be ran in

                EHR system, QuickMAR, & will allow RCC

                to have a 24/72 hr look back at everything

                that has been happened with that 24-72hr

                timeframe. This audit will ensure that all

                notable changes in a resident's condition is

                identified in a timely manner, & that all

                interventions & assessments are initiated

                and then maintained until resolution. This

                audit will be brought to morning stand-up to

                be reviewed by IDT, and skin log(s),

                significant change of condition log(s), and

                TSPs will be updated as appropriate.

           b. Facility is reviewing & updating weight

               tracking system to ensure appropriate

               oversight & timely assessment. This will be

               done in the EHR system, QuickMAR. Facility

               RN will run the weight(s) report at least once

               weekly, to identify significant weight

               loss/gain.

           c. Facility Administrator will review assessment

               logs at least once weekly to ensure all

               changes of condition, & nursing assessments

               are done timely, thoroughly, and with the

               required components.

3.) Resident Health Services - This system will be evaluated as follows:

            a. The 24/72 hour process/audit will be

                completed daily (5 days a week, on work

                days), & a 72 hour process/audit will be

                completed once weekly (after RCC returns

                from 2 days off.) Skin logs & change of

                condition log will be reviewed at least once

                per week. Alert charting log & TSPs will

                reviewed daily, during Clinical

                stand-up meeting.

            b. Weight tracking report will be ran at least

                once weekly, in an attempt to identify any

                significant weight gain/loss.

            c. To ensure on-going compliance with

                oversight and resident assessments', Facility

                Administrator will review all active

                assessments, at least once weekly.

4.) Facility Administrator, & Facility RN will be responsible for ensuring completion and monitoring of this system.

2. Resident 7's July and August MARs were reviewed, included an order to obtain CBG's twice monthly, and notify the physician for CBG readings above 300.

In an interview on 08/10/22, Staff 9 (MT) stated the facility LPN provided instruction, initially, on how to obtain and record the CBG but there were no written instructions available for how to obtain the resident's CBG's for staff to refer to when performing the task.

The need to have written instructions available for staff to follow when performing a taught task was reviewed with Staff 1 (ED) and Staff 2 (Director of Wellness) on 08/10/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure the teaching, delegation and supervision of special tasks of nursing care was completed in accordance with the Oregon State Board of Nursing (OSBN) Division 47 Rules, for 2 of 2 sampled residents (#s 5 and 7) who were being assisted with insulin injections or CBG readings by unlicensed facility staff. Resident 5 was at risk for harm related to potential medical complications from the lack of an RN assessment of the resident's condition, unlicensed staff training and supervision to ensure safety and accuracy of insulin administration. Findings include, but are not limited to:  

1. Resident 5 was admitted to the facility with diagnoses including diabetes and bilateral below the knee amputation.

Review of Resident 5's clinical record and staff interviews identified the following:

* Blood sugars were documented on the MAR ranging from 102 to 377;

* The resident would take his/her own CBG's, inform the MT who would then advise the resident on how much insulin, including any additional sliding scale dose that was needed;

* The resident would then administer their own insulin injection; and

* The MT's would then initial on the MAR that they had administered the insulin, including documentation of the sliding scale dose administered.

A review of the 07/01/22 through 08/08/22 MAR indicated Staff 7 (MT), Staff 10 (MT), Staff 14 (MT), Staff 20 (MT) and Staff 21 (MT) initialed the MAR for insulin administration.

There was no documented evidence an RN delegation had been completed which included the following:

* RN assessment to determine Resident 5's condition was stable and predictable;

* Determination of frequency resident should be reassessed, including rationale;

* Rationale why the task could be safely delegated;

* Skills, abilities and willingness of unlicensed staff to complete the task;

* Unlicensed staff were taught the task was client specific and not transferable;

* Determination of frequency the unlicensed staff should be supervised and re-evaluated, including rationale; and

* Written instructions available including risks, side effects, response, risk factors, and whom to report the same;

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

In an interview on 08/09/22, Staff 2 (Wellness Director) explained the resident and his/her spouse received teaching and education at another facility prior to moving in. She further stated she was unaware that CBG's and advising on sliding scale insulin dose was a delegated or taught task. Staff 2 confirmed there were no unlicensed staff that had been delegated nor had there been an assessment of the resident's condition.

A review of the 07/01/22 through 08/08/22 MAR indicated 31 occasions where the sliding scale insulin dose was incorrectly documented.

On 08/09/22, Staff 10 (MT) stated she documented insulin administration on the MAR and was confused on how to document the sliding scale dose.

A review of the progress notes dated 07/02/22 through 08/08/22 indicated the following:

* On 07/16/22, Resident 5 went to the ER and returned with a diagnosis of hyperglycemia and a recommendation to increase daily scheduled insulin dose; and  

* On 07/28/22 the MAR indicated Resident 5's CBG was 123 at 5:00 pm and should have been administered 0 units sliding scale dose however, the MAR indicated the resident was administered 6 units. Later in the evening on 07/28/22, Resident 5 called for assistance due to vomiting.

The lack of an RN assessment of the resident's condition, lack of unlicensed staff delegation and supervision to ensure safety and accuracy of insulin administration put Resident 5 at risk for harm related to potential medical complications and an ER visit.

On 08/09/22, the need to ensure all staff who administered insulin injections or performed delegated, taught tasks were appropriately delegated and supervised in accordance with OSBN Administrative Rules was discussed with Staff 1 (ED) and Staff 2. They acknowledged the above findings. The Surveyor requested an immediate plan to ensure insulin was administered by licensed or delegated staff in accordance with OSBN Division 47 Rules.

On 08/09/22 at 4:25 pm, a plan to address the delegation issue was submitted and the situation was abated.

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

1.) The following actions will be taken for each violation, per examples written on the S.O.D:

            a. Facility failed to ensure that teaching,

                delegation, and supervision of special tasks

                of nursing care was completed in

                accordance with the OSBN rules: Facility

                is now administering all insulin for resident

                #5, & obtaining CBGs. Resident has been

                assessed & deemed stable & predictable.

                Facility RN has delegated all medication-

                aides who are required to administer insulin.

                Vanda RN Consultant is working with facility

                RN for further training and training material,

                related to delegations.

            b. Facility failed to ensure that written

                instructions were available for staff to

                follow when performing a taught task:

                Facility has updated the 24hr binder to

                include written instructions for CBGs. All

                applicable staff who are responsible for

                obtaining CBGs were given additional

                training on how to obtain and record CBGs.

                All orders pertaining to blood glucose

                testing will be in EHR system QuickMAR,

                with records recorded as ordered.

2.) RN Delegation and Teaching: This system is being corrected to eliminate future violations, as follows:

            a. Facility RN will implement a delegation

                spreadsheet with all residents requiring

                delegations, and all staff members who will

                be administering insulin. This document will

                have date of initial delegation for each staff

                member, to ensure re-delegation at

                appropriate dates.

            b. Facility RN will be taking the 'Role of The

                RN' through OHCA, at the next training,

                10/11/22.

            c. Facility Administrator will review/audit all

                delegation requirements, to ensure thorough

                and timely assessment.

3.) RN Delegation and Teaching: This system will be evaluated as follows:

            a. Facility RN will review delegation task sheet

                at least bi-weekly, to ensure appropriate

                oversight and assessment.

            b. Facility Administrator will review/audit

                delegations at least once monthly to ensure

                appropriate requirements are in place &

                being followed per the regulations &

                division 47.

4.) Facility Administrator and Facility RN will be responsible for ensuring compliance.  

Based on observation, interview and record review, it was determined the facility failed to coordinate on-site health services with outside providers and ensure outside service providers left written information in the facility that addressed the on-site service being provided, for 2 of 4 sampled residents (#s 3 and 5) who received outside services. Findings include, but are not limited to:

1. Resident 5 was admitted to the facility in 07/2022 with diagnoses of bilateral below the knee amputation and diabetes.

a. The record indicated Resident 5 began receiving HH PT services on 07/07/22. The HH PT service provider had consistently left written information regarding the service provided and the following recommendations:

* On 07/07/22, "needs caregiver assist for all transfers and assist with maintaining hygiene and skin checks";

* On 07/13/22, "please provide assistance with hygiene and skin checks and caregiver assist with all mobility tasks at this time";

* On 07/20/22, "remind pt [patient] to wear "shrinker" on RBK (right below knee) amputation, do [his/her] exercises and to call CG to assist with transfers";

* On 07/21/22, "please monitor for any increase in [his/her] pain and neuropathy"; and

* On 08/01/22, "continue to assist [name] with transfers and home exercise program. Please monitor skin for bruise, wounds."

There was no documented evidence the facility implemented the above recommendations.

b. 07/16/22 ER visit noted a diagnosis of hyperglycemia. Review of the after visit summary indicated the following recommendations were made:

* Increase existing Lantus insulin from 25 units to 30 units;

* New medication, PRN Hydrocodone every four hours;

* New medication, Protonix 40 mg tablet, once daily; and

* Follow up with "PCP" [primary care provider] within two days.

The ER after visit summary was reviewed and signed by three facility staff, however there was no documented evidence the facility followed up to ensure the medication recommendations were implemented and follow up appointment with PCP was scheduled.

The need to ensure the facility had a system for coordinating on-site services with outside providers was discussed with Staff 1 (ED), Staff 15 (Director of Operations) and Staff 19 (VP of Operations) on 08/11/22. They acknowledged the findings.  

2. Resident 3 was admitted to the facility in 11/2020 with diagnoses including dementia.

Resident 3's clinical record, dated 05/08/22 through 08/08/22, was reviewed during the survey and revealed the following:

* 05/06/22 a hospital discharge report, indicated not to use a straw for fluid intake; and

* 06/02/22 a hospice visit note indicated frequent oral care was to be provided to the resident.

Observations of the resident on 08/08/22 revealed the resident was provided thickened liquids with a straw.

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

3. A pharmacy audit was conducted on 05/11/22 through 05/13/22 of multiple non-sampled residents and recommendations were made. There was no documented evidence the recommendations were communicated to staff or implemented.

On 08/09/22 and 08/10/22, the need to ensure on-going coordination of care was discussed with Staff 1 (ED), Staff 2 (Director of Wellness) and Staff 15 (Director of Operations). They acknowledged the findings.

OAR 411-054-0045 (2) Resident Health Services: On and Off-Site Health Services:

1.) Resident Health Services: The following actions have been taken to correct each violation per example written in S.O.D:

            a. Facility failed to have a system for

                coordinating on-site services with outside-

                providers: Facility has updated resident #5's

                care plan with all interventions written by

                HHPT (all current and applicable). Facility

                LN has reviewed ER after visit summary

                from 7/16/22 to ensure all orders are in

                place appropriately, and is coordinating any

                further care needed with provider.

            b. Facility failed to ensure recommendations

                were communicated to staff: Facility LN has

                is reviewing resident # 3's clinical record to

                ensure all recommendations are in place,

                via TSP for staff to review.

            c. Facility failed to ensure on-going

                coordination of care, related to pharmacy

                audit: Facility requested another pharmacy

                audit, which was completed on 8/18/22.

                Facility has followed all recommendations

                & sent out all physician notes from

                Pharmacist.

2.) Resident Health Services: This system is being corrected to eliminate future violations, as follows:

           a. Facility has updated Outside Provider

               Procedure, including creating an outside

               provider binder. All Outside Provider Notes

               will go through the triple check process, with

               the facility LN being the last check. All

               Outside Provider Notes will be processed as

               'orders' to ensure that staff are made aware

               of any new interventions or recommendation,

               that the care plan is adjusted when

               necessary. This process includes writing a

               TSP and placing resident on alert when

               applicable.

           b. All pharmacist audit results &

               recommendations will now be sent to new

               facility administrator, who will coordinate

               with facility nurse and RCC to ensure a

               timely follow for recommendations & notes

               to providers. Facility will document all

               changes made secondary to pharmacy

               recommendations in the EHR system.

3.) Resident Health Services: This system will be evaluated as follows:

          a. Med-Techs will check Outside Provider

              Binder at least once per shift, and process

              all Outside Provider notes prior to their shift

              ending.

          b. Facility LN will review triple checks at least

              once daily, to ensure appropriate follow-up,

              coordination of care, and implementation of

              recommendations and/or interventions.

          c. Facility administrator will review all pharmacy

              audits and recommendations as they are

              sent to the facility, at least quarterly.

4.) Facility Administrator and Facility LN will oversee on-going compliance.

Based on interview and record review, it was determined the facility failed to ensure a safe medication administration system was in place for all residents and failed to ensure adequate professional oversight of the medication and treatment administration systems. Findings include, but are not limited to:

1.  During the survey, conducted 08/08/22 through 08/11/22, administrative oversight of the medication and treatment administration system was found to be ineffective based on deficiencies in the following areas:

* C 282: RN Delegation and Teaching;

* C 302: Tracking Control Substances;

* C 303: Medication and Treatment Orders;

* C 310: Medication Administration;

* C 315: Treatment Administration; and

* C 325: Self-Administration of medications.

The need to ensure the facility had a safe medication administration system and the overall medication and treatment administration system was reviewed with Staff 1 (ED), Staff 2 (Director of Wellness) and Staff 15 (Operation of Director) on 08/09/22 and 08/10/22. They acknowledged the findings.

2. Resident 5 was admitted to the facility in 07/2022 with diagnoses of diabetes, hypertension and pain.

a. A review of the progress notes dated 07/02/22 through 08/08/22 identified the following:

On 07/15/22, Staff 2 (Director of Wellness) received a verbal phone order to "hold Clonidine (for hypertension) PRN, every 6 hours when SBP (systolic blood pressure) was over 155 and PRN Bismuth every 6 hours (for indigestion), due to possible drug interaction with Clopidogrel (blood thinner)" until the physician completed a medication review.

The PRN Bismuth and PRN Clonidine were held from 07/16/22 through 07/22/22. The medication review had not been completed, the facility failed to follow up with the physician and the medications were placed back on the MAR, resulting in the medications being available to administer to the resident. On 07/28/22, the PRN Clonidine was administered.

b. A review of Resident 5's signed physician orders upon move-in indicated the resident was prescribed Oxycodone PRN, every eight hours for pain. The Oxycodone was transcribed onto the July and August 2022 MAR.

During observation and interview on 08/08/22 with Staff 7 (MT) there was no PRN Oxycodone in the medication cart and there was no page for the Oxycodone in the narcotic disposition log for Resident 5. Staff 7 stated she "doesn't believe [she] had ever administered Oxycodone to the resident" and "believed the facility never received the Oxycodone from the pharmacy."

The need to ensure the facility had a safe medication administration system was reviewed with Staff 1 (ED), Staff 2, Staff 15 (Director of Operations) and Staff 19 (VP of Operations) on 08/11/22. They acknowledged the findings.

OAR 411-054-0055 (1)(a) Systems: Medications and Treatments:

Please reference C302, C303, C310, & C315 for plan of correction

2. Resident 1 was admitted in 09/2021 and had diagnoses including dementia and anxiety.

Resident 2 had a physician's order for Lorazepam 0.5 mg, one tablet PRN for severe anxiety.

The Controlled Substance Disposition Log revealed the Lorazepam was administered on 08/01/22, however, the MAR (reviewed from 08/01/22 through 08/08/22) lacked documentation that the resident received the medication.

The inconsistency between the MAR and Controlled Substance Disposition log was reviewed with Staff 1 (ED) and Staff 2 (Director of Wellness) on 08/10/22. They reviewed the documentation and acknowledged the discrepancies.

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 2 of 3 sampled residents (#s 1 and 4) whose MARs and Controlled Substance Drug Disposition logs were reviewed for accuracy. Findings include, but are not limited to:

1. Resident 4 was admitted in 2022 and had diagnoses which included hip replacement.

Resident 4 had an order for oxycodone, one - two tablets (5 - 10 mg) every four hours PRN pain (1 tab for pain 1-5 and 2 tabs for pain 6 - 10).

Resident 4's Controlled Substance Disposition Logs and MARs, reviewed from 8/1/22- 8/10/22, revealed two occasions when staff signed on the drug disposition log that the oxycodone was given. However, the MAR lacked documentation that the resident received the medication.

Inconsistencies between the MARs and Controlled Substance Disposition logs were reviewed with Staff 1 (ED) and Staff 2 (Director of Wellness) on 08/11/22. They reviewed the documentation and acknowledged the discrepancies.

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

1.) Tracking Controlled Substances: The following action will be taken to correct each violation, per example written on the S.O.D:

              a. Facility has corrected hole(s) in the MAR

                  for resident #4, who received PRN pain

                  medication per the narcotic log.

              b. Facility has corrected hole(s) in resident #

                  2's MAR, who received PRN for anxiety

                  per the narcotic book.

2.) Tracking Controlled Substances: This system is being corrected to eliminate further violations, as follows:

              a. Facility RCC is now completing a narcotic

                  audit to: ensure appropriate documentation

                  of PRN & Scheduled Narcotics, ensure

                  consistency between narcotic book and

                  MAR, to ensure all narcotics are destroyed

                  per policy, and to identify any trends in

                  narcotic administration.

3.) Tracking Controlled Substance: This system will be evaluated as follows:

              a. Facility RCC will complete a narcotic

                  audit at least once weekly,

              b. Facility RCC will bring all narcotic audits to

                  once monthly quality improvement

                meetings,

            c. Facility Administrator will review all narcotic

                audits at least once monthly to ensure

                completion.

4.) Facility Administrator and Facility RCC will ensure on-going compliance.

2. Resident 6 was admitted to the facility in 03/2021 with high blood pressure, congestive heart failure and asthma.

a. Resident 6 had a physician's order, dated 03/11/21, to administer Furosemide (for high blood pressure) 60 mg two times daily.

The resident's 08/01/22 through 08/09/22 MAR revealed staff documented 40 mg of the medication was administered to the resident, not 60 mg as prescribed.

b. Resident 6 had a physician's order, dated 03/11/21, to administer lactose, 300 units with meal, for digestion, Symbicort inhaler for asthma two times daily and Systane ultra-solution eye drops daily.

The resident's 08/01/22 through 08/09/22 MAR revealed there was no indication those orders were transcribed to the MAR.

c. Resident 6 had a physician's order, dated 03/11/21, to administer Famotidine, 40 mg with dinner, for indigestion.

The resident's 08/01/22 through 08/09/22 MAR revealed staff documented 40 mg of the medication was administered at 8:00 am in the morning, not with dinner as prescribed.

d. The resident's 08/01/22 through 08/09/22 MAR revealed staff documented Calcium 500 mg was administered two times daily and Breo Elli 100-25 mcg inhaler (for chronic obstructive pulmonary disease) daily was administered to the resident. There was no signed physician order to administer those medications.

On 08/11/22, the physician orders and the MARs were reviewed with Staff 1 (ED) and Staff 15 (Director of Operations). They acknowledged the findings.

3. Resident 1 was admitted to the facility in 09/2021 with diagnoses including dementia and anxiety.

Resident 1 had physician's orders to administer Lorazepam 0.5 mg, every eight hours, PRN for severe anxiety and Risperdone 0.5 mg, three times daily, PRN for physical aggression. Parameters prescribed by the physician included to administer the Risperidone "if not improved with use of PRN Lorazepam first".

The 07/01/22 through 08/08/22 MARs revealed the resident was administered the Risperdone on 07/21/22, however, the Lorazepam had not been administered first and deemed ineffective, as the order instructed.

The need to ensure medications were administered as ordered, including following parameters, was reviewed with Staff 1 (ED) and Staff 2 (Director of Wellness) on 08/10/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to carry out orders as prescribed for 3 of 6 sampled residents (#s 1, 5 and 6) whose orders and MAR/TAR's were reviewed. Resident 5 was not administered blood pressure medications as prescribed which put the resident at risk. Findings include, but are not limited to:

1. Resident 5 was admitted to the facility in 07/2022 with diagnoses including diabetes, stroke and hypertension. Resident 5's current signed physician orders and 07/01/22 through 08/08/22 MAR/TAR's were reviewed during the survey.

a. The following was ordered by the physician:

* Hydration monitoring every day and notify MD weekly, every Friday for signs and symptoms of dehydration;

* Weekly skin audits every Tuesday during showers;

* Weekly weights; and

* Two hour skin checks when wearing prosthetics.

There was no documented evidence the above orders were carried out as prescribed.

b. The following medications were not carried out as prescribed:

* Carvedilol tablet 6.25 mg, give 1 tablet by mouth 2 times per day with meals and hold for SBP (systolic blood pressure) less than 100 and HR (heart rate) less than 55.

The MAR's indicated the resident was administered the medication at 8:00 am and 8:00 pm. The 8:00 pm dose was not given with meals and there was no documentation the SBP and HR were taken prior to administering the medication.

* PRN Clonidine (for hypertension) every six hours, as needed, when SBP was over 155.

The MARs and progress notes reviewed had some recorded blood pressure readings, intermittently, related to alert charting instructions. Resident 5's blood pressure was documented over the SBP of 155 on the following dates:

* 07/02/22 (173/72);

* 07/05/22 (166/84);

* 07/09/22 (173/79);

* 07/16/22 (165/69);

* 07/28/22 (188/81); and

* 08/05/22 (159/68).

On 07/16/22, a progress note at 10:21 pm documented "systolic [blood pressure] number was very high of 165/69. Will recheck in 15 minutes. 183/80 complains of severe numbness and tingling in fingers and does not feel like [him/her] self. The PRN Clonidine was not administered. The resident was sent to the hospital at 11:36 pm.

On 07/28/22 at 9:14 am, a progress note documented the resident's BP was elevated 188/81. The PRN Clonidine was administered. The resident's BP was rechecked at 12:20 pm and was recorded as 166/75. There was no further BP taken at the 6th hour to determine if the SBP was still over 155 which would require another dose of the PRN Clonidine.  

The failure to monitor Resident 5's SBP and administer the PRN Clonidine when systolic blood pressure was elevated above 155, as prescribed, put the resident at serious risk of potential harm.

The need to ensure orders were carried out as prescribed was discussed with Staff 1 (ED), Staff 15 (Director of Operations) and Staff 19 (VP of Operations). They acknowledged the deficiencies.

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders:

1.) Treatment Orders: The following action will be taken to correct each violation per examples given on S.O.D:

               a. Resident #s 1, 5 and 6 medication &

                   treatment orders will be reconciled to

                   ensure all orders are accurate & being

                   administered as prescribed.

               b. All medication aides responsible for

                   administering medications will receive

                   updated training related to medication

                   administration with parameters.

               c. Facility LN will audit all parameters

                   on medications and treatments to ensure

                   clear instructions for staff to follow.

               d. Facility will implement parameter audits to

                   ensure medications are being

                   administered per set parameters, &

                   identify any medications errors secondary

                   to parameters, to ensure appropriate

                   follow-up & monitoring.

2.) Treatment Orders: This system will be corrected to eliminate future violations, as follows:

               a. All residents medications and treatments

                   will be reconciled to ensure accurate &

                   clear orders, via P.O.s at least quarterly.

               b. Facility will complete a parameter audit

                   at least bi-weekly to ensure accurate

                 administration and to identify med-errors.

             c. Facility LN will review triple checks (orders)

                 at least once daily, and will ensure

                 appropriate and clear parameters are in

                 place.

4.) Facility Administrator, and Facility Nurse will ensure on-going compliance.

Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 1 of 4 sampled residents (# 11) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 11 was admitted to the facility in 04/2021 with diagnoses including presenile dementia.

Resident 11's MAR dated 02/01/23 through 02/21/23 and corresponding progress notes were reviewed and revealed the following:

* Resident 11 had a prescriber's order to provide 237 mL of Vanilla Ensure three times a day with meals as a nutritional supplement; and

* The resident's MAR was blank from 02/01/23 through the 8:00 am administration of Ensure on 02/07/23.

On 02/22/23 at 3:10 pm, the surveyor and Staff 10 (MT) observed and checked the resident's MAR. Staff 10 was unable to confirm whether the supplement had been administered as prescribed.

The need to ensure orders were carried out as prescribed was discussed with Staff 2 (ED), Staff 22 (Director of Wellness/RN), Staff 8 (Wellness Coordinator) and Staff 33 (Consultant) on 02/22/23. They acknowledged the findings.

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders

1.) The following action has been taken to correct the rule violation for each example given on S.O.D:

  a.) Wellness Coordinator documented in Resident #11's chart detailing the reason for having holes in the MAR, secondary to the Ensure (Supplement) Order.

  b.) Current Ensure (Supplement) PRN order has been verified with PCP.

2.) Systems: Treatment Orders: Facility will correct this volation to prevent it from happening again as follows:

  a.) Facility Administrator, RN Director of Wellness, and Wellness Coordinator will review holes daily and investigate to correct and ensure proper documentation is completed on a timely basis.

  b.) RN Director of Wellness and Wellness Coordinator will provide training to medication technicians on how to correctly input, correct, and verify orders into the EMAR system.

3.) Systems: Treatment Orders: The system will be evaluated as follows:

  a.) The Missed Meds Report will be audited daily as part of the 24/72 hour process

  b.) Facility Administrator will audit all resident MARs weekly for any holes and ensure it is investigated and the follow-up is documented and/or corrected in the EMAR

4.) The Facility Administrator, Facility RN Director of Wellness, and Facility Wellness Coordinator will be responsible for ensuring all corrections to the resident's chart is made, and overseeing this system as stated above.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included clear parameters for administration of prescribed medications for 3 of 5 sampled residents (#s 1, 3 and 5) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 11/2020 with diagnoses including dementia.

Review of the 08/01/22 through 08/08/22 MARs noted the following as needed medication:

* Tylenol 325 mg tablet, take 2 tablets every 4- 6 hours as needed for pain or fever.

There were no resident-specific parameters regarding whether to administer the medication in 4 hours frame verses a 6 hour time frame. The resident did not receive the medication.

On 08/09/22 and 08/10/22, the above findings were reviewed with Staff 1 (ED), Staff 2 (Director of Wellness) and Staff 15 (Director of Operations). They acknowledged the findings

2. Resident 1 was admitted to the facility in 09/2021 with diagnoses including dementia and anxiety.

Review of the physician's order, dated 03/15/22, and the 08/01/22 through 08/08/22 MAR noted the following discrepancy:

* The resident had a physician's order for Lorazepam 0.5 mg by mouth every 8 hours PRN for severe anxiety;

* Physician's order for Risperdone 0.5 mg by mouth three times daily as needed for physical aggression, paranoid delusional behavior. It included instructions to administer the Risperdone if agitation was not improved with the administration of Lorazepam first;

* 08/01/22  MAR stated to give Risperdone 0.5 mg by mouth three times daily as needed for agitation.

The resident-specific parameters were not transcribed as ordered for the Risperdone. In addition, the parameters did not provide clear instruction to staff regarding which medication to administer when the resident displayed either agitation, anxiety or aggression. The resident had received the Risperdone on 08/01/22.

The need to ensure clear parameters were reviewed and provided for PRN medications was discussed with Staff 1 (ED) and Staff 2 (Director of Wellness) on 08/10/22. They acknowledged the findings

3. Resident 5 was admitted to the facility in 07/2022 with a diagnosis of diabetes.

A review of the MAR/TAR from 07/01/22 - 08/08/22 identified the following deficiencies:

* There were blanks on the MAR for Tylenol and Gabapentin on 07/06/22 at 2:00 pm; and

* Documentation of the sliding scale dosage administered was inaccurately recorded on 31 occasions.

The need to ensure accurate MAR/TAR's were kept was discussed with Staff 1 (ED), Staff 15 (Director of Operations), and Staff 19 (VP of Operations). They acknowledged the deficiencies.

OAR 411-054-0055 (2) Systems: Medication Administration:

1.) Medication Administration: The following action will be taken to correct each violation per examples given on S.O.D:

           a. Resident #s 1, 3, and 5 medications &

               treatments will be reconciled by facility

               nurse to ensure appropriate parameters

               and non-pharm interventions are in place

               and clear, for non-licensed staff to follow.

           b. Facility request Consonus Pharmacy Audit

               1x for the next 3 months to ensure increased

               oversight for medications; systems.

           c. Vanda Consulting team is providing facility

               with a 3-way cart audit to identify areas

               including: parameters, non-pharm

               interventions, updated P.O's w/ MD

               signature.

           d. Facility is correcting all holes to the MAR to

               ensure appropriate documentation.

2.) Medication Administration: The system is being corrected to eliminate future violations as follows:

          a. Facility will ensure that all resident's

              medications & treatments are reconciled,

          b. Facility RCC will complete a daily missed

              medications report to ensure that med-techs

              fix any holes noted, in a timely manner.

          c. All medication-aides will receive updated

            training on the 7 rights of medication

            administration.

3.) Medication Administration: The system will be evaluated as follows:

        a. Facility will complete P.O.s and reconciliation

            at least, quarterly.

        b. Missed medication report will be ran, at least

            daily,

        c. Facility administrator will review all medication

            audits, at least once monthly

4.) Facility Administrator and Facility LN will ensure on-going compliance.

Based on interview and record review, it was determined the facility failed to ensure resident specific parameters and instructions for insulin were followed for 1 of 4 sampled resident (# 13) whose MARs were reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 13 moved into the facility on 01/06/23 with diagnoses which included Diabetes and Alzheimer's disease.

Physician orders and MARs for Resident 13, reviewed from 02/01/23 - 02/21/23, revealed the following:

* A physician's order for Novolog (insulin) 100 units/ml to be injected three times a day with meals; and

* The MAR included "HOLD IF CBG IS <200."

On the following days Novolog was given even though the CBG was less than 200:

* 02/09/23 - 5 pm CBG 145;

* 02/10/23 - 12 pm CBG 69;

* 02/11/23 - 8 am CBG 111;

* 02/11/23 - 5 pm CBG 161;

* 02/12/23 - 5 pm CBG 185;

* 02/16/23 - 5 pm CBG 160;

* 02/19/23 - 5 pm CBG 191; and

* 02/21/23 - 8 am CBG 158.

There was no documented negative outcome to Resident 13.

The need to ensure resident specific parameters were followed was reviewed with Staff 2 (ED) 02/22/23 at 11:00 am. She reviewed the MARs with the surveyor and acknowledged the findings. She stated the MTs would receive additional training on medication administration and documentation. No further information was provided.

OAR 411-054-0055 (2) Systems: Medication Administration

1.) The following action has been taken to correct the rule violation for each example given on S.O.D:

  a.) Director of Wellness provided one-on-one education to the medication technicians who have been identified as having medication errors secondary to insulin administration parameters, on medication administration and documentation.

  b.) Resident #13's Primary Care Provider was faxed of the medication administration errors and that there were no ill effects.

2.) Systems: Medication Administration: Facility will correct this volation to prevent it from happening again as follows:

  a.) Director of Wellness and Wellness Coordinator provided additional training with all medication technicians involving medication administration and documentation in general.

  b.) Specific QuickMAR training will be given by Director of Wellness and Wellness Coordinator to medication technicians and will be required of any newly hired medication technicians. This will include focused training on medication parameters, where to find them in the order & when to notify the community RN.

3.) Systems: Medication Administration: The system will be evaluated as follows:

  a.) Medications with parameters will be audited daily by the clinical team as part of the 24/72 hour process.

 b.) Facility Administrator will audit all resident MARS weekly for any discrepancies involving medications with parameters.

4.) Facility Administrator, RN Director of Wellness, and Wellness Coordinator will be responsible for ensuring all education provided and overseeing this system as stated above.

3. Observations of Resident 3 during the survey and review of his/her records between 06/08/22 and 08/08/22 indicated that facility staff administered treatments, including barrier cream, on bottom area for redness.

The facility failed to document on Resident 3's TAR that the treatment was administered.

The need to ensure all treatments administered by the facility were documented on the TAR was discussed with Staff 1 (ED) and Staff 2 (Director of Wellness) on 08/10/22. Staff acknowledged treatments administered by the facility were not being documented on resident TARs.

Based on interview and record review, it was determined the facility failed to keep an accurate treatment record of all treatments ordered by a legally-recognized practitioner and administered by the facility, for 3 of 4 sampled residents (#s 1, 2 and 3) whose TARs were reviewed. Findings include, but are not limited to:

1. Resident 1's records indicated that between 05/10/22 and 08/08/22, facility staff administered treatments, including first aid and wound care, for the following conditions:

* A cut to the forearm;

* A wound to the elbow;

* A skin tear to the wrist;

* A cut to the top of the head; and

* Skin tears to the forehead.

2. Resident 2's records indicated that between 05/19/22 and 08/08/22, facility staff administered treatments, including wound care, for the following conditions:

* A skin tear to the hand;

* An abrasion to the knee;

* A dry, flaky rash to the top of head, neck and forehead; and

* An open and draining wound to the neck.

The facility failed to document any of the treatments it administered on Resident 1 or Resident 2's TARs.

The need to ensure all treatments administered by the facility were documented on the TAR was discussed with Staff 1 (ED) and Staff 2 (Director of Wellness) on 08/10/22. Staff 2 acknowledged treatments administered by the facility were not being documented on resident TARs.

OAR 411-054-0055 (3) Systems: Treatment Administration:

1.) Treatment Administrations: This system is being corrected for each violation per examples given on S.O.D:

            a. Residents' #1, 2 & 3 will be assessed

                by LN for any current skin event(s) and

                orders for treatment or monitoring will be

                added to the TAR for staff to follow,

            b. Facility has implemented a skin-log sheet

                that will be kept in the 24hr binder, to ensure

                that all active skin events have oversight &

                current interventions and orders for staff to

                follow,

            c. Facility medication-aides will receive further

                training on the change of condition process,

                including placing resident(s) on alert w/skin

                events, writing a TSP, and adding resident

                to the skin log in the 24hr binder.

2.) Treatment Administrations: This system is being corrected to eliminate future violations as follows:

            a. Facility has implemented a skin-log to the

                24hr binder, that facility LN will review

                daily to ensure appropriate oversight,

                interventions, and treatment orders,

            b. Vanda Consultant is working with facility

                LN on the short-term change of condition

                process, related to skin events. This will

              include the process of reviewing alerts daily,

              assessing residents with new skin events

              discontinuing short-term alert &

              implementing interventions via TSP, as well

              as, creating an order in the TAR for tx and/or

              monitoring skin event,

              ensuring staff completed an incident

              report, and adding resident to weekly skin

              assessments, until resolved.

          c. IDT will review 24hr binder/audit, daily during

              clinical drill down, to ensure oversight &

              timely follow-up.

3.) Treatment Administrations: This system will be evaluated as follows:

          a. Skin log and resident alert log will be

              reviewed daily by facility LN (work-days),

          b. Skin logs will be reviewed once monthly by

              facility LN to identify trends/concerns, & IDT

              will review during monthly QI meeting.

          c. Facility RCC will review all skin-events noted

              when completing 24/72hr audit, to ensure

              skin event is on skin log, resident is on alert,

              incident report is completed, and facility LN

              is aware of change(s) of condition.

4.) Facility LN, Facility Administrator, and Facility RCC will ensure on-going compliance.

Based on interview and record review, it was determined the facility failed to ensure a resident who self administered a subcutaneous medication monthly and a resident who had daily insulin injections were evaluated initially and at least quarterly to assure the ability to self administer medications for 2 of 2 sampled resident (#s 4 and 5). Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in July 2022 with diagnoses including arthropathic psoriasis.

A review of Resident 4' clinical information revealed the following:

* Resident 4 was self-administering his/her Taltz subcutaneous solution for psoriasis;

* There was no documented evidence a complete evaluation of the residents' ability to self administer Taltz subcutaneous solution for psoriasis  was completed; and

* There was no documented evidence the facility obtained a written physician order authorizing the resident to self-administer the Taltz subcutaneous solution for psoriasis.

In an interview on 08/08/22 at 2:00 pm, Staff 2 (Director of Wellness) confirmed she was aware the resident required an order to self-administer her/his injection and had not yet completed an evaluation of the resident's ability to self administer medications.

The need to complete evaluations of a resident's ability to self administer medications initially and at least quarterly was discussed with Staff 1 (ED) and Staff 2 on 08/11/22. They acknowledged the findings.

2. Resident 5 was admitted to the facility in 07/2022 with diagnosis including diabetes.

A review of Resident 5's clinical record identified the following:

* Resident 5 was self-administering his/her scheduled insulin, including taking CBG's prior to administering sliding scale dose;

* There was no documented evidence a complete evaluation of the residents' ability to self administer insulin was completed; and

* There was no documented evidence the facility obtained a written physician order authorizing the resident to self-administer the insulin.

During an interview with Staff 2 (Director of Wellness) on 08/08/22 at 2:00 PM, she confirmed there wasn't a physician order that authorized the resident to self-administer insulin.

The need to complete evaluations of a resident's ability to self administer medications and have a signed, written doctor's order for the resident to self-administer medications was discussed with Staff 1 (ED), Staff 15 (Director of Operations), and Staff 19 (VP of Operations) on 08/11/22. They acknowledged the findings.

OAR 411-054-0055 (5) Systems: Self-Administration of Medications:

1.) Self-Administration: This system is being corrected for each violation per examples given on S.O.D:

               a. Resident 4: Facility will obtain a written

                   physician's order for resident to self-

                   administer medication. Facility will

                   complete a self-medication evaluation to

                   ensure resident's ability to self-administer

                   medications/subcutaneous injection,

               b. Resident 5: Facility now administers

                   resident's insulin, and all staff have been

                   delegated.

2.) Self-Administration of Medications: This system is being corrected to eliminate future violations, as follows:

               a. Facility is working with Vanda Consultant

                   to create a self-medication policy that

                   meets Oregon regulations, as well as,

                   an updated self-medication evaluation

                   form,

               b. Facility LN and RCC will be trained on

                   updated self-medication evaluation policy,

               c. Facility LN and RCC are completing an

                   audit to identify any residents who self-

                   administer medications, and will ensure

                   that facility has a written order from MD for

                   that resident to self-administer

                   medications, and will complete a self-

                   medication evaluation.

3.) Self-Medication Administration: This system will be evaluated as follows:

                a. Upon Admission - Facility LN and Facility

                    administrator will identify the desire or

                    request for a resident to self-administer

                    their own medications, as part of the initial

                    evaluation,

                b. Facility will review P.O's at least quarterly,

                    and will ensure that any resident with

                    on-going self-administration of medication

                    is listed on P.O. and sent to provider,

                c. Facility will complete self-medication

                    evaluations, quarterly as required.

4.) Facility LN, and Facility Administrator will oversee and ensure on-going compliance

Based on observation, interview and record review, it was determined the facility failed to ensure an assessment by a PT, OT or RN was completed for assistive devices with potentially restraining qualities for 2 of 2 sampled residents (#s 4 and 5) who had a supportive device. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 07/2022 with diagnoses including hip replacement.

During the entrance conference on 08/08/22, Resident 4 was not identified as having bilateral siderails on his/her bed. An order for a hospital bed with side rails was in Resident 4's chart.

Observations of the resident and the resident's room showed the siderails were on the bed and in the up position. The side rails were not in Resident 4's current service plan.

Review of Resident 4's record revealed there was no documented evidence an assessment of the siderails had been completed by an RN, PT or OT.

In an interview on 08/09/22 at 11:35 am, Staff 2 (Director of Wellness) stated no assessment had been completed for Resident 4's siderails.

The lack of an assessment for the resident's siderails was discussed with Staff 1 (ED) and Staff 2 on 08/11/22. They acknowledged the findings.

2. Resident 5 was admitted to the facility in 07/2022 with diagnoses including bilateral below the knee amputation. During the entrance conference on 08/08/22, Resident 5 was identified as having bilateral siderails on his/her bed.

Observations of the resident and the resident's room on 08/09/22 showed ¼ length bilateral siderails were installed at the head of the hospital bed and were in the up position while the resident was laying in the bed. The side rails appeared intact and in good repair.

During an interview with the resident on 08/09/22, s/he reported the preference to use the siderails for self transferring while using a slideboard and pulling him/herself across the slideboard. The resident further reported s/he used them to assist the caregivers during care that was completed in bed.  

Review of Resident 5's record revealed there was no documented evidence an assessment of the siderails had been completed by an RN, PT or OT.

In an interview on 08/09/22 at 2:00 pm, Staff 2 (Director of Wellness) stated there was no assessment completed for Resident 5's siderails.

The need to ensure the supportive devices with potentially restraining qualities were assessed by an RN, PT or OT was discussed with Staff 1 (ED), Staff 15 (Director of Operations), and Staff 19 (VP of Operations) on 08/11/22. They acknowledged the findings.

OAR 411-054-0060 Restraints and Supportive Devices:

1.) Restraints and Supportive Devices: The following actions are being taken to correct each violation per examples given on S.O.D:

             a. Resident 4: Facility RN will complete

                 a supportive device assessment to address

                 bilateral side-rails, and facility RN will

                 update resident's service plan to include

                 the use of supportive devices, via TSP.

             b. Resident 5: Facility RN will complete a

                 supportive device assessment to address

                 1/4 length bilateral side-rails. Facility RN

                 will ensure that resident has an updated

                 order for side rails, and will ensure that

                 that resident's service plan is reflective of

                 the use of supportive device(s).

2.) Restraints and Supportive Devices: This system is being corrected to eliminate future violations, as follows:

             a. Facility has conducted a facility walk-

                 through to identify all supportive devices in

                 use.

             b. Facility RN will ensure that all current

                 support devices have a valid written order

                 from the provider, are part of the resident

                 service plan, and an assessment that

                 includes the following: (a) The resident

                specifically requests or approves of the

                device and the facility has informed the

                individual of the risks and benefits

                associated with the device; and (b) The

                facility registered nurse, a physical therapist

                or occupational therapist has conducted a

                thorough assessment; and

                (c) The facility has documented other less

                restrictive alternatives evaluated prior to the

                use of the device; and

                (d) The facility has instructed caregivers on

                the correct use and precautions related to

                use of the device.

                (e) Documentation of the use of supportive

                devices with restraining qualities must be

                included in the resident service plan and

                evaluated on a quarterly basis or with a

                significant change of condition.

             c. Facility RN will keep a log of all supportive

                 supportive devices, to ensure that timely

                 assessments are completed, on schedule.

             d. Facility RN will provide training via in-

                 service on proper use of bed-rails &

                 supportive devices.

3.) Restraints and Supportive Devices: This system will be evaluated as follows:

             a. With each new admission, as applicable,

             b. Quarterly,

             c. With significant change of condition.

4.) Facility RN and Facility Administrator will ensure oversight and on-going compliance.

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

1. During the entrance conference and acuity interview on 08/08/22 the following was identified:

* The facility consisted of two floors with resident rooms located on the first floor, in two separate units, for memory care residents and second floor for assisted living residents;

* The facility had 50 residents;

* One resident on the first floor required two-person assistance with transfers; and

* One resident on the second floor required two-person assistance with transfers.

2. The facility's staffing plan for 08/2022 was as follows:

* During the night shift, there was one caregiver assigned to the second floor and on multiple days, there were no staff assigned to the second floor.

3. On 08/08/22, at 9:30 am, at the entrance conference, the surveyor requested the facility staffing tool used to determine the number of caregiving staff needed to provide scheduled and unscheduled needs of the residents. Staff 1 (ED) stated she was aware of the requirement to have an acuity-based staffing tool, but the facility had not implemented it.

4. During the group interview, conducted on 08/09/22 at 11:00 am, multiple alert and oriented non-sampled residents stated the following:

* Residents had made complaints to management related to delayed call light response times, especially on the night shift.

5. On 08/10/22, the survey team requested the call response logs from Staff 1. She stated she was not able to generate the call response logs.

6. During an interview on 08/10/11, Witness 1 stated several residents "on the assisted living unit expressed concern with the lack of staff available on the night shift", long wait times when a call light was initiated and a lack of any activity staff. Witness 1 verified they had previously expressed these concerns to Staff 1.

The failure to ensure adequate staff to meet the scheduled and unscheduled needs of the residents was shared with Staff 1 and Staff 2 (Wellness Director) on 08/09/22 and 08/10/22. They acknowledged the findings.

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

1.) Staffing Requirements and Training: This following action is being taken to correct each violation per examples given on S.O.D:

             a. Facility has increased staffing for NOC shift

                 as follows: 3 Caregivers (1 for each POD)

                 & 2 med-techs,

             b. Facility is currently staffing to staffing

                 requirement as outlined in conditions:

                 Dayshift: 4 caregivers & 3 med-techs,

                 Evening Shift: 4 caregivers & 3 med-techs,

                 NOC shift: 3 caregivers & 2 med-techs,

             c. Facility has completed the required acuity

                 based staffing tool, on The Departments'

                 site,

             d. Facility will identify how to run the report for

                 staff call lights and will review call light

                 times, each morning during stand-up.

2.) Staffing Requirement and Training: This system is being corrected to eliminate future violations, as follows:

             a. Until otherwise directed, facility will maintain

                 staffing requirements set forth in conditions,

             b. Upon removal of staffing requirements,

                 facility will maintain staffing based on the

                 most current ABST,

             c. Facility maintenance director will audit &

               pull all call-times from the last 24hrs and will

               bring results to morning stand-up for IDT to

               review,

           d. Facility Administrator will update the ABST at

               each evaluation (Initial, 30 day, quarterly) &

               with significant change of condition, to

               ensure adequate staff to meet the scheduled

               & unscheduled needs of the residents.

3.) Staffing Requirement and Training: This system will be evaluated as follows:

            a. Facility administrator will update the ABST

                with each resident evaluation completed

                (initial, 30-day, quarterly) and with significant

                change of condition,

            b. Facility administrator will review the staff

                schedule at least once monthly to ensure

                the schedule is reflective of the staffing

                requirements as based on the ABST,

            c. The facility maintenance director will run &

                review resident call times at least daily (on

                work days) and will bring this report to daily

                stand-up.

4.) The Facility Administrator and Facility Maintenance Director will oversee and ensure on-going compliance.

Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) that met the regulation for 5 of 5 sampled residents (#s 1, 2, 3, 4 and 5) whose records were reviewed. Findings include, but are not limited to:

There was no documented evidence the facility was using an ABST which would determine a staffing plan reflective to meet the 24-hour scheduled and unscheduled needs of residents.

On 08/08/22, Staff 1 (ED) reported the facility had not implemented an ABST.

The need to implement an ABST was discussed with Staff 1 and Staff 2 (Wellness Director). They acknowledged the findings.

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

1.) Acuity-Based Staffing Tool: The following action is being taken to correct each violation per examples given on the S.O.D:

              a. Facility has completed the Acuity-Based

                  Staffing Tool on The Department's Site,

              b. Facility RCC will receive training related to

                  ABST requirements, to ensure the

                  staffing schedule meets requirements.

2.) Acuity-Based Staffing Tool: This system is being corrected to eliminate future violations, as follows:

             a. Facility is working with Vanda Consultant

                 to create policies & procedures related to

                 the ABST,

             b. Facility IDT will receive training related to

                 the requirements of the Acuity-Based

                 Staffing Tool,

             c. Facility will maintain ABST and update

                 resident care needs in the ABST at time

                 of each resident evaluation &/or with any

                 significant change of condition

             d. Facility Administrator will review staffing

                 schedule to ensure that the schedule is

                 reflective of staffing requirements based on

                 the ABST.

3.) Acuity-Based Staffing Tools: This system will be evaluated as follows:

             a. Facility will update the ABST with each

                 resident evaluation: initial, 30-days,

                 quarterly, and with significant change of

                 condition,

             b. Facility Administrator will review monthly

                 staffing schedule to ensure that schedule

                 is reflective of staffing needed per the ABST

                 at least once monthly.

4.) Facility Administrator and Facility RCC will oversee and ensure on-going compliance.

Based on interview and record review, it was determined the facility failed to ensure pre-service orientation in all required topics was completed and documented for 4 of 4 sampled staff (#s 3, 4, 5 and 6). Findings include, but are not limited to:

Facility training records were reviewed on 08/08/22 and 08/09/22.

Staff 3 (CG) hired 06/2022, Staff 4 (MT) hired 05/2022, Staff 5 (CG) hired 06/2022 and Staff 6 (Housekeeper) hired 06/2022, lacked documented evidence of completing the following required elements of the pre-service orientation:

* Staff 3, 5 and 6 lacked documentation of resident rights and values of CBC care; and

* Staff 3, 4, 5 and 6 lacked evidence of standard precautions for infection control.

The need for new staff to complete the required pre-service orientation training before working with residents was reviewed with Staff 1 (ED) on 08/09/22. No additional information was received.

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

1.) Caregiver Requirements: The following action is being taken to correct each violation per example given on the S.O.D:

             a. Staff members 3, 4, 5, & 6 will complete all

                 pre-service training as required, with

                 documented evidence of training in

                 their respective training files.

2.) Caregiver Requirements; Training: The following corrections are being made to eliminate future violations:

             a. Facility B.O.M has created an updated

                 training grid, with all required Pre-service,

                 within 30 days, and annual on-going

                 training.

             b. Facility is updating new-hire orientation to

                 include pre-service trainings: Resident

                 Rights, & Values of CBC Care,

             c. Facility is completing an audit on staff

                 staff training, and will ensure each staff

                 member has required training and

                 documents.

3.) Caregiver Requirements; Training: This system will be evaluated as follows:

             a. Facility B.O.M will review training grid at

                 least once monthly,

            b. Facility Administrator will review all new-hire

                orientation and training, at least once

                monthly, to ensure compliance,

            c. Facility B.O.M will bring staff training grid to

                Quality Improvement meetings to review

                with IDT, at least once monthly.

            d. Facility will schedule new-hire orientation at

                least once monthly, to ensure all pre-service

                training is completed.

4.) Facility Administrator and Facility B.O.M will oversee and ensure on-going compliance.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 sampled newly-hired direct care staff (#s 3, 4 and 5) had demonstrated competency in all assigned job duties within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed on 08/08/22 and 08/09/22.

There was no documented evidence Staff 3 (CG), Staff 4 (MT), and Staff 5 (CG), hired 06/17/22, 05/13/22, and 06/17/22, respectively, demonstrated competency in all assigned job duties within 30 days of hire in the following areas:

* Role of service plans in providing individualized care:

* Providing assistance with ADLS;

* Changes associated with normal aging;

* Identification, documentation, and reporting of changes of condition; and

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

The need to ensure newly-hired direct care staff demonstrated competency in all assigned job duties within 30 days of hire was discussed with Staff 1 (ED) on 08/09/22. No further documentation was provided.

OAR 411-054-0070 (6)(9) Training within 30-days: Direct Care Staff:

1.) Training within 30-days: The following actions are being take to correct future violations per examples given on S.O.D:

             a. Facility will complete med-tech and Care-

                 giver competency with staff, #s 3, 4, & 5.

                 Each staff member will show return

                 demonstration with trainer.

2.) Training within 30-days: The following corrections are being made to eliminate future violations:

             a. Facility B.O.M has created an updated

                 training grid, to be reflective of required

                 staff trainings,

             b. Facility has created 2 competency

                 checklists: One for caregivers & one for

                 med-techs,

             c. Facility will ensure that all current staff have

                 appropriate competency checklists,

                 including return demonstration,

             d. All new-hires will be scheduled for new-hire

                 orientation to ensure that all applicable

                 training - including competency checklists,

                 are scheduled and handed out.

3.) Training within 30-days: This system will be evaluated as follows:

            a. B.O.M will review and update training grid

              at least once monthly, with new-hire

              orientation,

           b. All direct-staff will have competency

               checklists with return demonstration

               completed within 30 days of hire,

           c. Facility Administrator and Facility B.O.M

               will review staff training grid, at least once

               monthly during Quality Improvement

               meetings.

4.) The Facility Administrator and Facility B.O.M will ensure oversight and on-going compliance.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 sampled newly-hired direct care staff (#s 26 and 28) had verification of demonstrated competency in all assigned job duties within 30 days of hire. This is a repeat citation. Findings include, but are not limited to:

Staff training records were reviewed on 02/21/23.  

1. There was no documented evidence Staff 26 (MT), hired 12/27/22, demonstrated competency in the topic of changes associated with normal aging.

2. There was no documented evidence Staff 28 (MT), hired 01/10/23, had demonstrated satisfactory performance in all assigned duties, including:

* The role of service plans in providing individualized resident care;

* Providing assistance with the activities of daily living;

* Changes associated with normal aging;

* Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition;

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

* General food safety, serving and sanitation.

There was no documented evidence the facility had observed and evaluated Staff 28's ability to perform safe medication and treatment administration, unsupervised.

The surveyor requested the facility remove Staff 28 from medication and treatment administration until demonstrated competency was documented in all assigned job duties. The facility expressed compliance with the request.

The need to ensure newly-hired direct care staff had verification of demonstrated competency in all assigned job duties within 30 days of hire was discussed with Staff 2 (ED) and Staff 31 (Business Office Manager) on 02/21/23. They acknowledged the findings.

OAR 411-054-0070 (6)(9) Training within 30 days: Direct Care Staff

1.) The following actions will be taken to correct each violation, per examples written on S.O.D:

  a.) Staff 26 was provided training and demonstrated competency with the completion of a new skills checklist including the topic of changes associated with normal aging.

  b.) Staff 28 was pulled off of the floor and has completed their demonstrated competency skills checklist and has provided documentation of all necessary training prior to returning to the medication cart, including:

* The role of service plans in providing individualized resident care;

* Providing assistance with the activities of daily living;

*Changes associated with normal aging;

*Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition;

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

and

*General food safety, serving, and sanitation

2.) Training within 30 days: Direct Care Staff: This system is being corrected to eliminate future violations, as follows:

  a.) All newly hired staff will be given their skills checklists and manuals at orientation. Newly hired staff will be educated on how to complete the checklists, who needs to observe & sign the checklist and where they shall be kept in the community.

  b.) These checklists are to be left here at the community in the hanging file folder near the B.O.M office after each shift and turned in once completed to the same hanging file folder to ensure it is accurately and thoroughly completed.

  c.) Staff will not be able to work independently beyond their 30 days without the competency checklist verified and turned into the Business Office Manager and/or Facility Administrator. If found working on the floor they will be pulled from the schedule until their skills checklist is completed.

3.) Training within 30 days: Direct Care Staff: This system will be evaluated as follows:

  a.) Business Manager and Facility Administrator will check the designated areas for the status of any checklists in the process of completion and/or completed and turned in competency checklists, once daily.

  b.) Business Manager and Facility Administrator will review weekly the upcoming week's schedule to ensure that all staff beyond their 30 days that is working on the floor have a completed skills checklist.  

  c.) Business Office Manager and Facility Administrator will audit monthly that all staff have the necessary trainings needed.

4.) Facility Administrator and Facility Business Office Manager will be responsible for ensuring completion and monitoring of this system as stated above.  

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

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

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

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

* The escape route used;

* Evidence of alternate escape routes used;

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

* Evacuation time period needed; and

* The number of occupants evacuated.

The need to meet all requirements for fire drills and fire and life safety instruction was reviewed with Staff 1 (ED) on 08/09/22. She acknowledged the findings.

OAR 411-054-0090 (1-2) Fire & Life Safety: Safety

1.) Fire & Life Safety: The following actions are being taken to correct each violations per examples given on S.O.D:

             a. Facility is providing an in-service for all

                 staff members to receive fire & life safety

                 training. This training will be documented as

                 required,

             b. Facility is working with Vanda Consultant to

                 create an updated fire drill form, to include

                 the following required information:

                 a) Date and time of day

                 b) Location of simulated fire origin

                 c) The escape route used

                 d) Problems encountered and comments

                     relating to residents who resisted or

                     failed to participate in the drills

                 e) Evacuation time period needed

                 f) Staff members on duty and participating

                 g) Number of occupants evacuated

2.) Fire & Life Safety: This system is being corrected to eliminate future violations, as follows:

             a. Facility Maintenance director is receiving

                 updated training on the requirements for

                 Fire & Life Safety; Fire Drills & on-going

                 training,

             b. Facility Maintenance director will conduct

                 all fire drills and on-going training as

                 required by regulations,

             c. All documentation related to fire-drills &

                 fire & life instructions/trainings, will be filed

                 in the 'Fire Drill/Fire & Life Safety binder,

                 and will be filed by month,

             d. Facility Maintenance director will be

                 required to turn in all fire drills and on-going

                 fire and life safety training, each month

                 during QI meeting.

             e. Facility administrator will review & audit Fire

                 & Life Safety Binder, to ensure compliance.

3.) Fire & Life Safety: This system will be evaluated as follows:

             a. All fire drills and fire & life safety training

                 will be reviewed on a monthly basis.

4.) The Facility Maintenance Director & Facility Administrator will oversee and ensure on-going compliance.

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

On 02/21/23, fire drill and fire and life safety records were reviewed from 11/2022 through 02/2023. The following were identified:

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

2. Written fire drill records did not include information on:

* Location of simulated fire origin;

* The escape route used;

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

* Evacuation time period needed; and

* Number of occupants evacuated.

3. Staff did not evacuate or relocate residents during all fire drills.

4. The fire alarm system was not activated during each fire drill.

The need to ensure staff received fire and life safety instruction on alternate months and the requirements regarding fire drills were discussed with Staff 2 (ED) and Staff 18 (Director of Maintenance) on 02/21/23 at 2:40 pm. They acknowledged the findings.

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety

1.) Fire and Life Safety: Safety: The following action is being taken to correct each violation per examples given on S.O.D.:

  a.) Facility will now be implementing a Fire and Life Safety Binder to include all 12 months and ensure that in each month there is documented evidence of either a fire drill conducted or resources used for Fire and Life Safety training.

  b.) Facility Maintenance Director will be utilizing a fire drill form that has all necessary information, including:

* Location of simulated fire origin;

*The escape route used;

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

*Evacuation time period needed; and

* Number of occupants evacuated.

  c.) Facility Administrator and Maintenance Director will verify and ensure that on each fire drill, residents are either evacuated and/or located and ensure it is documented on the new fire drill form.

  d.) Facility Administrator and Maintenance Director will verify and ensure that on each fire drill, the fire alarm system was activated during each shift and it is documented on the fire drill form.

2.) Fire and Life Safety: Safety: This system is being corrected to eliminate future violations as follows:

  a.) A new fire drill form is being utilized with all of the required documentation needed.

  b.) Facility will be using a Fire and Life Safety binder to show evidence of compliance each month.

3.) Fire and Life Safety: Safety: This system will be evaluated as follows:

  a.) Facility Maintenance Director and Administrator will review monthly the Fire and Life Safety binder to ensure all components of the requirement are met and plan accordingly.

  b.) Fire and Life Safety binder to be audited during each QA monthly meeting and discussed by leadership team on future planning for drills and/or educational topics for the following month.

4.) Facility Administrator and Facility Maintenance Director will be responsible for implementing all new documentation and continued monitoring of this system as stated above.

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

Fire drill records from 02/2022 through 07/2022 were reviewed on 08/09/22 with Staff 1 (ED). The facility lacked documentation of the following required elements:

* Evidence residents were being instructed on fire and life safety procedures, including designated meeting places inside or outside of the building in the event of an actual fire, within 24 hours of admission.

The need to have documented evidence of all fire and life safety training components was discussed with Staff 1 (ED) 08/09/22. She acknowledged the findings.

OAR 411-054-0090 (5) Fire & Life Safety: Training for Residents:

1.) Fire & Life Safety Training for Residents: The following actions are being taken to correct each violation per examples given on the S.O.D:

              a. All residents will be instructed on General

                  safety procedures, Evacuation Methods,

                  responsibilities during fire drills and

                  designated meeting places outside

                  the building or within the fire safe area in          

                  the event of an actual fire, and re-

                  instructed annually. Residents who do not

                  have the mental capability to understand

                  fire & life instructions and/or training, will

                  have clear evacuation instructions in

                  their service plans, for staff to reference.

2.) Fire & Life Safety Training for Residents: This system is being corrected to eliminate future violations as follows:

             a. All new residents will be instructed of fire &

                 life safety, within 24hrs of move-in, and

                 reinstructed annually thereafter.

             b. All resident fire and life safety

                 documentation will be filed and kept on-site,

             c. Facility Maintenance Director will keep an

                 on-going spreadsheet of residents'

                 admission dates, and dates of re-instruction

             d. Facility Maintenance director will bring all

              fire & life safety training for residents, to

              Quality Improvement Meetings for review.

3.) Fire & Life Safety Training for Residents: This system will be evaluated as follows:

           a. Within 24hrs of a new resident admission, &

           b. Annually thereafter,

           c. Facility administrator will review fire & life

               safety for residents, at least once monthly

               to ensure compliance.

4.) Facility Maintenance Director and Facility Administrator will oversee and ensure on-going compliance.

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

Refer to C260, C303, C372 and C420.

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

Please reference C260, C303, C372, and C420 for plan of correction.

Based on observation and interview, it was determined the facility failed to ensure courtyard pathway edges did not have drop-offs and the facility grounds were kept orderly and free from refuse. Findings include, but are not limited to:

1. Observations of the exterior of the facility and interior courtyard on 08/08/22 showed drop-offs along pathway edges in the interior courtyard in excess of 3 inches in multiple areas.

2. An exterior corridor between the buildings had discarded and broken furniture, mobility devices and broken office chairs.

The need to ensure pathways in the resident courtyard did not have drop-offs and the exterior of the facility was kept free of refuse was discussed with Staff 1 (ED) and Staff 18 (Maintenance Director) on 08/09/22 at 11:30 am. They acknowledged the findings.

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

1.) General Building Exterior: The following actions are being take to correct each violation, per the examples given in the S.O.D:

             a. Facility has received a BID for landscaping

                 to fill drop-off areas along the pathway

                 edges, in the courtyard.

             b. All broken furniture, mobility devices, &

                 broken office chairs have been removed

                 from the exterior corridor.

2.) General Building Exterior: The following corrections are being made to eliminate future violations:

             a. Facility has implemented a building walk-

                 through, which will include facility

                 administrator & facility maintenance director

                 to identify any environmental concerns.

3.) General Building Exterior: This system will be evaluated as follows:

              a. Facility Maintenance Director & Facility

                  Administrator will conduct once weekly

                  walk-throughs, using the environmental

                  checklist sheet,

              b. Facility Maintenance director will bring all

                  documents pertaining to environmental

                  concerns or findings, to Quality

                  Improvement meeting, once monthly.

4.) Facility Maintenance Director & Facility Administrator will oversee and ensure on-going compliance.

Based on observation and interview, it was determined the facility failed to ensure the interior environment was kept clean and in good repair. Findings include, but are not limited to:

A tour of the facility was conducted on 08/08/22 through 08/11/22. The facility was comprised of an RCF upstairs and an endorsed memory care downstairs. The MCC units were split into two separate units that were titled MC1 (Memory Care One) and MC2 (Memory Care Two).

a. MC1 required cleaning and repair in the following areas:

* Multiple recliners in common areas were torn, rendering the surface uncleanable;

* Toilet riser in the common use bathroom was rusted, rendering the surface uncleanable;

* Gouges and peeling paint on common use bathroom door, room 128, 134, 135, and 139;

* Splintered and peeling paint on handrail between rooms 124 and 126, and near rooms 129, 135, 138, 141 and 145;

* Multiple wall corners in the dining room and hallway corridors were gouged with exposed sheetrock and metal underneath; and

* Wall gouged and peeling paint (underneath handrail) between fire door and room 135 and around the air return vent (near med room).

b. MC2 required cleaning and repair in the following areas:

* Multiple recliners in common areas were torn, rendering the surface uncleanable;

* Splintered and peeling paint on handrail near room 156;

* Wall gouged with peeling paint approximately 10 feet above couch and drink station in the dining room;

* Multiple wall corners in the dining room, hallway corridors and the wall (with windows) behind the dining room tables were gouged with peeling paint and exposed sheetrock underneath;

* Wall gouged with peeling paint (underneath handrail) near electrical panel labeled 1A and 1B, rooms 102, 106, 115 and 123; and

* Multiple resident room doors had gouged and peeling paint.

c. RCF (upstairs) required cleaning and repair in the following areas:

* Splintered handrail near room 207; and

* Gouged doors on rooms 203, 207, 208 and 234.

The above areas were toured and discussed with Staff 1 (ED) and Staff 18 (Maintenance Director) on 08/09/22 at 11:30 am. They acknowledged the findings.

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

1.) Facility Doors, Walls, Elevators, & Odors: The following action is being taken to correct each violation per examples given on S.O.D:

            a. Facility Maintenance Director is working on

                all environmental deficiencies in MC1, MC2,

                & RCF.

            b. Maintenance Director is working down the

                list of environmental deficiencies in order

                order of priority.

2.) Facility Doors, Walls, Elevators, & Odors: This system is being corrected to eliminate future violations as follows:

            a. Facility has created new procedures

                for environmental walk-throughs, in an

                attempt to identify areas that need

                immediate attention.

            b. Facility Maintenance Director & Facility

                Administrator will document findings on

                weekly environmental checklist. This

                document will have an area for goal of

                completion.

            c. Facility environmental walk-through checklist

                will be filed each week, and then brought to

                Quality Improvement meeting to review

                areas that have not been fixed/corrected.

3.) Facility Doors, Elevators, & Odors: This system will be evaluated as follows:

              a. Facility Maintenance Director & Admin

                  will conduct environmental walk-throughs

                  at least once weekly,

              b. Environmental walk-through checklist will

                  reviewed at least once monthly by IDT to

                  ensure follow-up.

4.) Facility Administrator & Facility Maintenance Director will oversee and ensure on-going compliance.

Based on observation and interview, it was determined the facility failed to ensure washing machines had a minimum rinse temperature of 140 degrees Fahrenheit or used a chemical disinfectant when washing soiled linens and soiled clothing. Findings include, but are not limited to:

The facility laundry room was observed on 08/08/22 with Staff 18 (Maintenance Director). The washing machines were a residential type with no indicator for the water temperature. The detergent the facility used did not include a disinfecting agent.

The need to ensure soiled laundry was properly disinfected was discussed with Staff 1 (ED) and Staff 18 on 08/09/22 at 11:30 am. They acknowledged the findings.

OAR 411-054-0200 (7)(b-d) Housekeeping and Laundry:

1.) Housekeeping and Laundry: The following actions are being taken to correct each violation per example given on S.O.D:

              a. Facility is working with Eco-Labs to obtain

                  the best chemical disinfectant for laundry,

2.) Housekeeping and Laundry: This system is being corrected to eliminate future violations as follows:

              a. Facility Maintenance Director will ensure

                  that all washing machines have approved

                  chemical sanitizer, in stock and in use.

3.) Housekeeping and Laundry: This system will be evaluated as follows:

              a. While conducting environmental

                  walk-throughs, facility maintenance

                  director will ensure that all washers are

                  using chemical sanitizer, & that chemical

                  sanitizer is in stock. Environmental

                  walk-throughs will be conducted weekly.

4.) Facility Maintenance Director and Facility Administrator will oversee and ensure on-going compliance.

Based on observation and interview, it was determined the facility failed to ensure covers, grates, or screens of wall heaters and associated heating elements did not exceed 120 degrees Fahrenheit when installed in locations that were subject to incidental contact by individuals. Findings include, but are not limited to:

During a tour of the facility with Staff 1 (ED) and Staff 18 (Maintenance Director) on 08/09/22, the following observations were made:

* Wall heaters with surface temperatures of 136 - 158 degrees Fahrenheit, were installed under the paper towel dispensers between the sink and toilet in common use bathrooms where residents could potentially come into incidental contact.

Staff 1 and Staff 18 acknowledged the need to ensure wall heater covers did not exceed 120 degrees Fahrenheit. Staff 18 stated the wall heater knobs would be removed which would disable the use of the wall heaters.

On 08/11/22, a random check of the common use bathrooms identified the wall heaters were inoperable.

OAR 411-054-0200 (8) Heating and Ventilation:

1.) Heating and Ventilation: The following actions are being taken to correct each violation, per examples given on S.O.D:

               a. Wall Heaters in common area bathrooms

                   have been disabled.

               b. Facility Maintenance director is working

                   to identify the temperature malfunction

                   in the heaters in the common bathroom.

2.) Heating and Ventilation: This system is being corrected to eliminate future violations, as follows:

               a. Facility Maintenance director will keep

                   a spreadsheet of all temperatures, to

                   ensure compliance,

               b. Facility Maintenance Director will check

                   the temperatures of all common area

                   wall heaters, to ensure temps below

                   120 degrees F.

               c. Facility Maintenance Director will keep a

                   log of all temperature checks and bring it

                   to monthly Quality Improvement meetings

                   to discuss any concerns or follow-up

                   needed.

               d. Facility Administrator will review temp-logs

                   at least once monthly to ensure

                   all temperatures are within required

                   parameters, as well as, conducting

                   random spot-checks for temps.

Based on observation and interview, it was determined the facility failed to ensure exit door alarms were functioning to alert staff when residents exited the RCF. Findings include, but are not limited to:

The facility was toured on 08/09/22 with Staff 1 (ED) and Staff 18 (Maintenance Director) and the following was identified:

* There were two exit doors in the MCC units that opened into the secured courtyard. The doors had alarms installed but the alarms had been manually disabled and the doors were locked.

The need to ensure the facility had operable exit door alarms was discussed with Staff 1 and Staff 18. They acknowledged the findings and Staff 18 activated the door alarms during the facility tour.  

Refer to Z 168.  

OAR 411-054-0200 (11-13) Call System, Exit Door Alarms, Phones, TV, or Cable:

1.) Exit Door Alarms: The following action is being taken to correct each violation per examples given on S.O.D:

             a. Facility has had MCC door alarms fixed as

                 of 8/10/22 - By Davis Lock & Safe Co. MCC

                 Exit doors now have a visual and audible

                 alarm when opened.

2.) Exit Doors: The following corrections have been made to eliminate future violations:

              a. MCC staff to have in-person training

                  related to exit doors in MCC, how the alarm

                  system works, and when to notify facility

                  maintenance director if not working

                  correctly,

              b. Facility Maintenance director will check

                  MCC exit doors to courtyard, when

                  conducting environmental walk-throughs.

3.) Exit Doors: This system will be evaluated as follows:

              a. Maintenance Director will check exit doors

                  in MCC, at least once weekly during

                  environmental walk-through.

4.) Facility Maintenance Director and Facility Administrator will oversee and ensure on-going compliance.

Based on interview and record review, it was determined the facility failed to ensure residents who lived in the facility were provided a key to their units per their evaluated needs. Findings include, but are not limited to:

Review of records for Residents 1, 2, and 3 revealed no documented evidence the residents had been evaluated for the ability to manage keys to their rooms.

On 08/09/22 at 12:25 pm, in an interview with Staff 2 (Wellness Director/LPN), she confirmed there was no documented evidence the residents' ability to manage keys was evaluated and serviced plan if the residents were not able to manage their keys.

On 08/09/22 and 08/10/22, the need to ensure all residents were evaluated for the ability to manage keys to their units and provided keys, based on those evaluations, was discussed with Staff 1 (ED) and Staff 2. They acknowledged the findings.

OAR 411-004-0020(2)(e.) Individual Door Locks: Key Access:

1.) Individual Door Locks: The following actions are being taken to correct each violation per example given on S.O.D:

                 a. Resident #s 1, 2, and 3 will be evaluated

                     for the ability to manage keys to their room.

                 b. Facility is conducting an audit to identify

                     all residents who need Lock & Evaluation

2.) Individual Door Locks: The system is being corrected to eliminate future violations, as follows:

                a. Facility is working with Vanda Consultant

                    to create policies and procedures for

                    individual door locks,

                b. Facility is working with Vanda Consultant

                    to create a Lock and Key Evaluation.

                c. IDT will receive training related to

                    evaluating resident(s) for ability to use

                    a lock and key.

3.) Individual Door Locks: This system will be evaluated as follows:

                a. All new admissions will be evaluated for

                    ability to manage keys, within 24hrs of

                    admission,

                b. Lock and Key evaluations will be

                    completed during quarterly evaluations

                    thereafter.

4.) Facility Administrator and Facility Maintenance Director will oversee and ensure on-going compliance.

Based on observation and interview, the facility failed to ensure residents who lived in the facility had the freedom and support to have access to food at any time.  Findings include, but are not limited to:

Observations of the RCF between 08/08/22 and 08/11/22 showed no snacks were provided to residents and two large glass drink dispensers in the RCF dining area were not filled with any beverages for the resident's consumption.  The residents did not have refrigerators or kitchenettes in their rooms.

In an interview on 08/09/22, an unsampled resident stated sometimes the facility provided snacks if they were requested by residents but sometimes there were none available.

The need to ensure all residents had access to food at any time was discussed with Staff 1 (ED), Staff 2 (Director of Wellness) and Staff 15 (Director of Operations) on 08/11/22. They acknowledged the findings.

OAR 411-004-0020 (2)(j) Individual Freedom: Access to Food Any Time:

1.) Access to Food: The following actions will be taken to correct each violation per example given on S.O.D:

               a.) Facility has created a hydration and

                    nutrition station in each POD that

                    includes snacks and drinks for the

                    residents at any time.

               b.) Facility will ensure that sandwiches and

                    fruit are available at all times as well.

2.) Access to Food: The system is being corrected to eliminate future violations, as follows:

                a.) Facility Activities Coordinator will ensure

                     that nutrition and hydration stations are

                     fully stocked, each morning.

                b.) Facility administrator is speaking with all

                     residents and staff to let them know that

                     sandwiches, fruit, deserts, etc ...are

                     available anytime of the day.

3.) Access to Food: This System will be evaluated each morning by either activities director, or direct care staff, by ensuring all nutrition and hydration carts are fully stocked.

4.) Facility Administrator will oversee and ensure on-going compliance.

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to C 150, C 154, C 156, C 160, C 231, C 242, C 360, C 361, C 370, C 372, C 420, C 422, C 510, C 513, C 530, C 540 and C 555.

OAR 411-057-0140 (2) Administration Compliance:

Please reference C150, C154, C156, C160, C231, C242, C360, C361, C370, C372, C420, C422, C510, C513, C530, C540, and C55 for Plan of Correction.

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to C372 and C420.

OAR 411-057-0140(2) Administration Compliance

Please reference C372 and C420 for plan of correction.

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities.  Findings include, but are not limited to:

Refer to C 252, C 260, C 262, C 270, C 280, C 282, C 290, C 300, C 302, C303, C 310, C 315, C 325 and C 340.

OAR 411-057-0160 (2b) Compliance with Rules Healthcare:

Please reference C252, C260, C262, C270, C280, C282, C290, C300, C302, C303, C310, C315, C325, and C340 for plan of correction.

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities.  Findings include, but are not limited to:

Refer to C260 and C303.

OAR 411-057-0160(2b) Compliance with Rules Health Care

Please reference C260 and C303 for plan of correction.

3. Resident 3 resided on the memory care unit. The current service plan and temporary service plans were reviewed during survey and lacked an individualized nutrition and hydration plan based on his/her needs.

Observations performed during the survey at meal times revealed the resident required hands-on assistance to eat meals, was provided regular texture foods and nectar thickened liquids to drink. The resident ate some of his/her meals with staff assistance. The resident was not observed to be provided with snacks or fluids between the morning and noon meals, during observations on 08/08/22 and 08/09/22.

The resident had experienced a significant weight decline over the past five months and was dependent on staff to meet nutrition and hydration needs. The service plan did not address hydration needs and lacked information on interventions to monitor weight loss.

The lack of an individualized nutritional plan was discussed with Staff 1 (ED) and Staff 2 (Wellness Director) on 08/10/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure individualized nutritional plans for each resident were developed and included in service plans for 3 of 3 sampled residents (#s 1, 2 and 3). Findings include, but are not limited to:

1. Resident 1 resided on the memory care unit and had been identified, in the entrance conference interview, to require meal assistance. The current service plan and temporary service plans were reviewed during survey and lacked an individualized nutrition and hydration plan based on his/her needs.

Observations performed during the survey at meal times revealed the resident required frequent cueing and hands-on assistance to eat meals. The resident was able to eat most of his/her meals with staff assistance. During observations on 08/08/22 and 08/10/22, the resident was not provided with snacks or fluids between the morning and noon meals.

The resident had experienced slow weight decline over the past six months and was dependent on staff to meet nutrition and hydration needs. The service plan did not address hydration needs and lacked information on interventions to monitor weight changes.

2. Resident 2 resided on the memory care unit and had been identified, in the entrance conference interview, to require meal assistance. The current service plan and temporary service plans were reviewed during survey and lacked an individualized nutrition and hydration plan based on his/her needs.

Observations performed during the survey at meal times revealed the resident required hands-on assistance to eat meals, was provided regular textured foods and was able to use a cup to drink nectar thickened liquids independently. The resident ate most of his/her meals with staff assistance. During observations on 08/08/22 and 08/09/22, the resident was not provided with snacks or fluids between the morning and noon meals.

The resident had experienced significant weight increase over the past five months and was dependent on staff to meet nutrition and hydration needs. The service plan did not address hydration needs, the provider recommendation to provide a mechanical soft diet and lacked information on interventions to monitor the weight increase.

The lack of an individualized nutritional plan was discussed with Staff 1 (ED) and Staff 2 (Wellness Director) on 08/10/22. They acknowledged the findings.

OAR 411-057-0160 (2)(c.)(A)(B) Nutrition and Hydration:

1.) Nutrition and Hydration: The following action will be taken to correct each violation per example given on S.O.D:

             a. Facility will write individualized nutrition &

                 hydration plans for resident #s 1, 2, and 3.

                 Individualized nutrition and hydration plans

                 will be written via TSP, and be entered into

                 resident's Service Plan.

2.) Nutrition and Hydration: The following corrections will be made to eliminate future violations:

             a. Facility is working with Vanda Consultant to

                 create a policy and process around

                 Nutrition and Hydration plans,

             b. Facility is conducting an audit to identify any

                 residents who are lacking a nutrition and

                 hydration plan. Facility will ensure all MCC

                 residents have an individualized nutrition &

                 hydration plan.

             c. All direct-care staff will have access to each

                 resident's nutrition and hydration plan, via

                 TSP.

3.) Nutrition and Hydration: This system will be evaluated as follows:

             a. Facility Administrator, LN, and/or RCC will

                 review MCC nutrition and hydration plans

                 during each resident evaluation/SP:

                 Initial, 30-days, quarterly thereafter, and with significant change of condition.

4.) Facility Administrator, Facility LN, and RCC will oversee and ensure ongoing compliance.

Based on observation, interview and record review, it was determined the facility failed to evaluate and develop individualized activity plans for 3 of 3 sampled residents (#s 1, 2 and 3) whose service plans were reviewed. Findings include, but are not limited to:

Residents 1, 2 and 3's service plans offered some information relating to the resident's past interests; however, the facility had not thoroughly evaluated the resident's:

* Current interests;

* Current abilities and skills;

* Emotional and social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for the resident to participate; and

* Identification of activities for behavioral interventions.

Observations of the residents from 08/08/22 through 08/10/22 revealed the lack of activity programs that included the residents in one to one or group interaction.

There was no specific activity plan which detailed what, when, how and how often staff should offer and assist the residents with individualized activities.

The lack of an activity evaluation and individualized activity plan was discussed with Staff 1 (ED) and Staff 2 (Wellness Director) on 08/10/22. They acknowledged the findings.

OAR 411-057-0160 (2d) Activities:

1.) Activities: The following action is being taken to correct each violation per example given on the S.O.D:

             a. Facility is completing individual activity

                 plans for resident #s 1, 2, and 3.

             b. Activity plans will be documented on TSPs,

                 for all staff to review.

2.) Activites: The system is being corrected to eliminate future violations, as follows:

             a. Facility has hired an activities coordinator,

                 who will work 5 days a week,

             b. Facility is conducting interviews with family

                 members, and residents, to get a thorough

                 background on each residents' hobbies and

                 preferences,

             c. Facility will audit all MCC residents to

                 identify any residents who do not have an

                 active activity plan.

             d. Facility will obtain important social interests,

                 hobbies, backgrounds, religion preferences,

                 etc ...during admissions.

             e. Activity Plans will reviewed and updated

                 with each evaluation/SP update.

3.) Activities: This system will be evaluated as follows:

            a. All activity preferences will be obtained

                prior to admission,

            b. All activity plans will be reviewed & updated

               with each evaluation/SP update: Pre-

               admission, initial, within 30 days, quarterly

               thereafter, and with changes of condition.

           c. Activity coordinator will review all upcoming

               nutrition plans that need to be reviewed, at

               at least once weekly during morning stand-up.

4.) Facility Activities Coordinator and Facility Administrator will oversee and ensure on-going compliance.

Based on observation and interview, it was determined the facility failed to provide access to a secured outdoor space and walkways which allowed residents to enter and return without staff assistance, except when indicated by OAR 411-057-0170(5)(e). Findings include, but are not limited to:

The RCF included an endorsed memory care unit on the main level that was split into two units titled Memory Care One (MC1) and Memory Care Two (MC2).

Observations during the survey between 08/08/22 through 08/11/22 of MC1 and MC2, showed the doors to the interior courtyard were locked and did not allow residents to exit and return without staff assistance.

On 08/09/22, Staff 18 (Maintenance Director) was able to disengage the keypad lock to the MC2 door that lead to the courtyard, however, was unable to disengage the lock to the MC1 courtyard door.

During a tour of the building on 08/09/22 at 11:30 am, Staff 1 (ED) and Staff 18 acknowledged the courtyard doors were locked.

OAR 411-057-0160 (g) Outside Area:

1.) Outside Area: The following action will be taken to correct each violation per examples given on S.O.D:

             a. Facility has fixed all MCC door locks and

                 are now open for residents to use the

                 courtyard.

2.) Outside Area: The following corrections are being made to eliminate future violations:

              a. All MCC employees are receiving training

                  related to providing access to residents

                  to a secure outside area,

              b. Facility Maintenance Director will conduct

                  spot-checks to ensure MCC doors to

                  the courtyard remain unlocked.

3.) Outside Area: This system will be evaluated at least once weekly, when facility administrator and maintenance director are completing environmental walk-throughs.

4.) The facility Administrator and Facility Maintenance Director will oversee and ensure on-going compliance.

Based on observation and interview, it was determined the facility failed to have a written facility policy which detailed when doors to the outdoor recreation area may be locked during nighttime hours or during severe weather. Findings include, but are not limited to:

The RCF included an endorsed memory care unit on the main level that was split into two units titled Memory Care One (MC1) and Memory Care Two (MC2).

During the survey, the doors to the MCC unit interior courtyard were observed to be locked during daylight hours with sunny and warm weather on 08/08/22 and 08/09/22.

On 08/09/22, Staff 1 (ED) confirmed the facility did not have a written policy for when the courtyard doors would be locked.

On 08/09/22 at 11:30 am, Staff 1 and Staff 18 acknowledged the above findings.

OAR 411-057-0170(6) Secure Outdoor Recreation Area:

1.) Secure Outdoor Recreation Area: The following action is being taken to correct each violation per examples given on S.O.D:

                 a. Facility is working with Vanda Consultant

                     to create policies & procedures related

                     to secured outdoor area and when to

                     lock/unlock doors.

2.) Secure Outdoor Recreation Area: This system is being corrected to eliminate future violations as follows:

                 a. Upon creation of policy and procedure

                     for secured outdoor area, all staff will

                     receive training on updated policies.

                 b. Facility will ensure that Secure Outdoor

                     Area Policy is being implemented by

                     facility maintenance director conducting

                     random spot-checks, at least once

                     monthly.

3.) Secure Outdoor Recreation Area: This system will be evaluated as follows:

                   a. Facility Maintenance director will do

                       random spot checks at least once

                       monthly.

4.) Facility Administrator and Facility Maintenance Director will oversee and ensure on-going compliance.