Print Inspection: 2KFV

The findings of the re-licensure survey, conducted 05/20/24 through 05/23/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first re-visit to the re-licensure survey of 05/23/24, conducted 01/06/25 through 01/08/25, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

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

During the re-licensure survey, conducted 05/20/24 through 05/23/24, oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number and severity of citations.

Refer to deficiencies in report.

1. Executive director to provide oversight. Including training , supervision and overall conduct for all staff.

2.  Daily review and ED rounds for oversight.

3. Daily.

4. Executive Director.

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

During the survey, multiple non-sampled residents expressed their concerns during a group interview as well as individual interviews regarding complaints being minimized or going unaddressed. Examples given included:

* Food was served cold;

* No resident suggestion box;

* Lack of staff;

* Call light response time was too long;

* Property theft; and

* "They said they would look into it and I never heard back."

On 05/22/24, Staff 1 (Executive Director) 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 which included documenting the response to and resolution of resident complaints.

The need to ensure the facility had an effective method of responding to and resolving resident complaints was discussed with Staff 1 on 05/22/24. She acknowledged the findings.

1. Implementation of resident grievances and complaints through investigation and resolutions.

2. Town Hall meetings will occur monthly with residents addressing grievances and concerns. Follow up meeting minutes including resolutions will be provided to all residents.

3. As grievances and concerns arise as well as monthly.

4. ED, RSD, RN, PD, BOD, CRD, CD, MD and LD

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

During the re-licensure survey, conducted 05/20/24 through 05/23/24, quality improvement oversight to ensure adequate resident care, services, and satisfaction was found to be ineffective.

The need to ensure the facility developed and conducted an ongoing quality improvement program that evaluated services, resident outcomes, and satisfaction was discussed during the exit conference on 05/23/24 with Staff 1 (Executive Director) via telephone, Staff 2 (Resident Services Director), and Staff 4 (Business Office Director). The findings were acknowledged.

Refer to the deficiencies in the report.

1.Development of a quality improvement program to evaluate services, resident outcomes and resident satisfaction.

2. Implantation of Town Hall meetings. Addressing resident concerns Residents will receive copies of Town Hall meeting minutes and resolutions. Placement of suggestion boxes were placed in a public setting which is accessible to all residents.

3. Monthly

4. ED, PD, RSD, MD, CD, RN, BOD, LD, CRD  

Based on observation and interview, it was determined the facility failed to ensure residents were treated with dignity and respect when receiving meal delivery to their apartments. Findings include, but are not limited to:

During meal service observations from 05/20/24 through 05/23/24, meals delivered to resident rooms were served on paper plates, drinks were served in disposable cups, and utensils were plastic. The meals served to residents in the dining room were served on ceramic dishes with stainless steel flatware.  

During an interview on 05/23/24, Staff 6 (Culinary Director) stated all meals delivered to residents in their rooms were served on disposable products. Staff 6 reported that the warmer used for transport held only ten trays and that currently, up to approximately 25 residents were choosing to eat in their rooms. Staff 6 stated meal service to rooms had been attempted with non-disposable products at one point but that logistics had caused the facility to return to disposable products.

Ensuring residents were treated with respect and dignity regarding meal service was discussed on 05/23/24 with Staff 2 (Resident Services Director) and was reviewed during the exit conference on 05/23/24 with Staff 1 (Executive Director) via telephone. The findings were acknowledged.

1.All meals are now being served on glass plates with aluminum foil wrap to secure temps and for presentation. With the exception of residents who prefer paper to go boxes. Preferences will be  captured in service plans.

2. Facility has eliminated all styrofoam containers for meal services.

3. Correction was effective immediately.

4. Culinary Director and food service staff

Based on interview and record review, it was determined the facility failed to ensure resident move-in evaluations addressed all required elements for 1 of 1 sampled resident (#5) whose new move-in evaluation was reviewed. Findings include, but are not limited to:

Resident 5 moved into the facility in 02/2024.

A review of Resident 5's move-in evaluation, dated 02/23/24 and 02/26/24, identified the facility failed to address the following required elements:

* Interests, hobbies, social, and leisure activities;

* Spiritual, cultural preferences and traditions;

* Personality: including how the resident coped with change or challenging situations;

* Pain: non-pharmaceutical interventions, including how s/he expressed pain or discomfort; and

* History of dehydration or unexplained weight loss or gain.

During an interview with Staff 2 (Resident Services Director) on 05/23/24 at 11:30 am, she reviewed the record and acknowledged the findings.

The need to ensure move-in evaluations included all required elements was discussed during the exit conference on 05/23/24 with Staff 1 (Executive Director) via telephone, Staff 2 (Resident Services Director), and Staff 4 (Business Office Director). The findings were acknowledged. No further documentation was provided.

1. Activity profile will be conducted for Resident #5 including hobbies, spirituality, personality, pain, history of dehydration/weight loss and gain. Move-in evaluations will reflect all ADL's plus residents preferences and accommodations.

2. Detailed evaluations will be completed by RSD, RSC and RN, LD.

3. Upon admission, 30 days, 90 days and chance of conditions.

4. ED, RSD, RSC, LDand RN

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

1. Resident 1 was admitted to the facility in 12/2023 with diagnoses including depression, hypothyroidism, and chronic obstructive pulmonary disease.

The resident's clinical record was reviewed, including service plan dated 05/17/24 and progress notes and temporary service plans dated 03/02/24 through 05/19/24, the resident was observed, and interviews with staff and the resident were conducted.

The resident's service plan was not reflective and/or lacked resident-specific direction for staff in the following areas:

* Activities;

* Oxygen;

* Refusal of care;

* Meals/nutrition; and

* Behaviors.

The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 2 (Resident Services Director) on 05/23/24, and reviewed with Staff 1 (ED) via telephone during the exit conference on 05/23/24. The findings were acknowledged. No further documentation was provided.

2. Resident 4 was admitted to the facility in 01/2023 with diagnoses including anxiety, chronic pain and depression.  

The resident's clinical record was reviewed, including service plan dated 05/12/24 and progress notes and temporary service plans dated 01/01/24 through 05/19/24, the resident was observed, and interviews with staff and the resident were conducted.

The resident's service plan was not reflective and/or lacked resident-specific direction for staff in the following areas:

* Reminders for meal time;

* Behaviors;

* Recommendations from outside providers;

* Location of pain and non-pharmacological interventions;

* Activities; and

* Care of cat.

The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 2 (Resident Services Director) on 05/23/24, and reviewed with Staff 1 (ED) via telephone during the exit conference on 05/23/24. The findings were acknowledged. No further documentation was provided.

1.  Detailed person centered information will be gathered for resident #1 and #4 capturing resident specific and clear direction for staff  to provide proper care needs and implemented into the service plan.  

2. Service plan team will meet with individuals prior to admission providing an evaluation to gather preferences to implement into the service plan.

3.Admission, 30 days, quarterly and change of condition as needed.

4. Service planning team.   

3. Resident 3 was admitted to the facility in 05/2016 with diagnoses including hypertension and a history of UTI's (urinary tract infections).

Observations and interview with the resident, and interviews with staff were completed. The resident's service plan dated 04/10/24, progress notes dated 01/20/24 through 05/20/24, and incident investigations were reviewed. The following was revealed:

a. The following short-term change of condition lacked documentation of resident-specific actions or interventions needed, communication of the determined actions or interventions to staff on all shifts, progress noted at least weekly, and/or documentation of resolution:

* 05/02/24: Increased confusion and possible UTI.

b. The following short-term changes of condition lacked documentation of resident-specific actions or interventions needed and communication of the determined actions or interventions to staff on all shifts:

* 02/15/24: UTI;

* 02/22/24: Buttock wound; and

* 05/12/24: Fall.

The need to ensure actions or interventions for short-term changes of condition were documented and communicated to staff on each shift, and the changes of condition were monitored weekly through resolution was discussed with Staff 2 (Resident Services Director) on 05/21/24 at 10:35 am, and during the exit conference on 05/23/24 with Staff 1 (Executive Director) via telephone, Staff 2 (Resident Services Director), and Staff 4 (Business Office Director). The findings were acknowledged.

4. Resident 2 was admitted 07/2020 with diagnoses which included a history of skin breakdown and diabetes.

Observations and an interview with the resident, interviews with staff, review of the service plan dated 05/17/24, incident investigations, home health documentation, a hospital discharge summary, and progress notes dated 01/24/24 through 05/20/24 were reviewed. The following was revealed:

a. A progress note, dated 04/08/24, indicated the resident was "throwing up" and was sent to the hospital.

A hospital discharge summary revealed the resident had been admitted to the hospital on 04/08/24 for "Sepsis due to Streptococcus ..." S/he was discharged on 04/12/24 (four days later) and returned to the facility.

There was no evidence the facility evaluated the resident's change in condition, referred the change to the facility RN, or monitored the resident consistent with his/her evaluated needs.

In an interview on 05/23/24, Staff 2 (Resident Services Director) reviewed the resident's record and acknowledged the findings. No further information was provided.

b. The following short-term change of condition lacked documentation of progress noted at least weekly, and/or documentation of resolution:

* 02/15/24: Insulin not administered;

* 02/27/24: Insulin not administered;

* 03/15/24: Medication discontinued; and

* 04/14/24: Low blood sugar.

On 05/23/24 at 8:40 am, Staff 2 (Resident Services Director) reviewed the record and acknowledged the findings.

The need to ensure Resident 2's short-term changes of condition had documentation to reflect monitoring at least weekly to resolution, and significant changes in condition were evaluated, referred to the facility RN, and monitored consistent with the resident's evaluated needs was discussed during the exit conference on 05/23/24 with Staff 1 (Executive Director) via telephone, Staff 2 (Resident Services Director), and Staff 4 (Business Office Director). The findings were acknowledged. No further documentation was provided.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents who had changes of condition were evaluated, resident-specific instructions or interventions were developed and reviewed for effectiveness, changes were reported to the RN when needed, and progress was documented weekly until resolution for 4 of 4 sampled residents (#s 1, 2, 3 and 4). Resident 1 experienced a severe weight loss and continued to lose weight. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 12/2023 with diagnoses including depression, hypothyroidism, and chronic obstructive pulmonary disease.

The resident's clinical record was reviewed, including weight records dated 01/25/24 through 05/07/24, service plan dated 05/17/24, 05/2024 MAR, and progress notes, temporary service plans and incident reports dated 02/20/24 through 05/19/24, the resident was observed, and interviews with staff and the resident were conducted.

a. The resident's weight records stated:

* 01/27/24 - 165 pounds; and

* 02/23/24 - 161.2 pounds.

On 03/15/24 Resident 1 was admitted to the hospital due complaint of right arm numbness and tingling and inability to move his/her right hand. S/he returned to the facility 19 days later on 04/03/24 with diagnoses including ischemia of right upper extremity and having undergone a right arm fasciotomy surgery. During interviews on 05/21/24 and 05/22/24, multiple staff stated that upon returning from the hospital the resident appeared to have lost weight and had a significant increase in care needs including wound monitoring and ADL care.

There was no documentation that the facility evaluated the resident, referred to the facility nurse, or updated the service plan upon his/her return from the hospital.

Prior to the resident's hospital admission, his/her weight was recorded as:  

* 01/27/24 - 165 pounds; and

* 02/23/24 - 161.2 pounds.

The resident was weighed on 04/14/24,  11 days after returning from the hospital, and weighed 139.1 pounds. This constituted a severe weight loss of 15.7%, or 25.9 pounds in three months.

There was no documented evidence that the facility evaluated the severe weight loss recorded on 04/14/24, referred to the facility nurse, or updated the service plan as needed.

The resident continued to experience weight loss. On 05/07/24, the resident's weight was recorded as 128.2 pounds. This constituted a severe weight loss of 7.8%, or 10.9 pounds, in one month.  

During an interview on 05/20/24, Staff 2 (Resident Services Director) stated the facility was aware of the resident's weight loss, and that Staff 3 (RN) had completed a significant change of condition assessment on 05/17/24, though she did not currently have access to it as it was on Staff 3's computer which was outside the facility. No new interventions had been put into place or communicated to staff.

On 05/22/24, Staff 3 (RN) acknowledged the multiple severe weight losses and stated she was not able to identify when she was notified of the weight loss.

The facility failed to evaluate Resident 1's severe weight loss, refer to the nurse, and update the service plan as needed, and the resident continued to experience severe weight loss.  

Refer to C 280, example 1.

b. Resident 1 experienced the following changes of condition without interventions or actions determined, documented and communicated to staff on all shifts, and/or monitored weekly through resolution:

* 02/29/24 - Medication change;

* 03/02/24 - Fall with pain and bruising to left knee;;

* 03/07/24 - Medication change;

* 03/07/24 - Fall with pain and bruising to wrist and back;

* 03/10/24 - Fall with lower back pain and return from ER;

* 03/11/24 - Fall, no injury;

* 03/11/24 - Fall with pain to right elbow and ribs;

* 03/12/24 - Altered mental status and return from ER with medication changes;

* 03/13/24 - Fall;

* 04/03/24 - Return from hospital stay 03/15/24 through 04/03/24 with surgery to right elbow, change in medications and ADL participation; and

* 04/19/24 - Fall with report of hitting head.

The need to ensure changes of condition were evaluated, actions or interventions determined, documented and communicated to staff on each shift, and the changes of condition were monitored through resolution was discussed with Staff 1 (ED) and Staff 2 on 05/22/24. They acknowledged the findings.

2. Resident 4 was admitted to the facility in 01/2023 with diagnoses including anxiety, chronic pain and depression.

The resident's clinical record was reviewed, including the service plan dated 05/12/24, 05/2024 MAR, and progress notes, temporary service plans and incident reports dated 01/01/24 through 05/19/24, the resident was observed, and interviews with staff and the resident were conducted.

Resident 4 experienced the following changes of condition without interventions or actions determined, documented and communicated to staff on all shifts, and/or monitored weekly through resolution:

* 01/24/24 - Unwitnessed fall at 3:00 am;

* 01/24/24 - Unwitnessed fall at 8:00 am;

* 01/24/24 - Unwitnessed fall at 1:20 pm;

* 04/24/24 - Behaviors including asking a staff member for pain medication to sell;

* 04/17/24 - Behaviors including verbal aggression towards staff and other residents; and

* 04/22/24 - Behaviors including yelling at staff and walking into another resident's room.

The need to ensure changes of condition had actions or interventions determined, documented, and communicated to staff on each shift, and the changes of condition were monitored through resolution was discussed with Staff 2 (Resident Services Director) on 05/23/24, and reviewed with Staff 1 (ED) via telephone during the exit conference on 05/23/24. The findings were acknowledged. No further documentation was provided.

1.RN oversight and assessment on all changes of conditions. Residents 1, 2, 3 and 4 the last two weeks were reviewed to rule out any short term change of conditions. Any change of condition identified will further be evaluated and reviewed with staff

2. RN will conduct all significant and short term changes of conditions. Providing oversight, documentation and follow through.

3.  RSD or designee will audit the 24 hour book 5 days a week to ensure all short term COC's and TSP's  are placed on alert. Clinical services team will review documentation weekly to ensure information is documented. Documentation will be reviewed monthly and clinical review meetings until deficient practice is complete. RSC or designee will alert RN of any short term COC's that is not resolving to trigger a comprehensive COC. Any short term COC will be in a 24hr book. RSC/PD will check daily to ensure proper resolution.

4. RN     

2. Resident 2 was admitted 07/2020 with diagnoses which included a history of skin breakdown and diabetes.

Observations and an interview with the resident, interviews with staff, review of the service plan dated 05/17/24, incident investigations, home health documentation, a hospital discharge summary, and progress notes dated 01/24/24 through 05/20/24 were reviewed. The following was revealed:

A progress note, dated 04/08/24, indicated the resident was "throwing up" and was sent to the hospital.

A hospital discharge summary revealed the resident had been admitted to the hospital on 04/08/24 for "Sepsis due to Streptococcus ..." S/he was discharged on 04/12/24 (four days later) and returned to the facility.

The decline in health and hospitalization constituted a significant change in condition for which an assessment by the facility RN was required.

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

During an interview on 05/23/24 at 8:40 am, Staff 2 (Resident Services Director) reviewed the record and acknowledged an RN assessment had not been completed. Staff 3 (RN) was not available for interview.

The need to ensure RN assessments were completed with significant changes in condition was reviewed during the exit conference on 05/23/24 with Staff 1 (Executive Director) via telephone, Staff 2 (Resident Services Director), and Staff 4 (Business Office Director). The findings were acknowledged. No further documentation was provided.

Based on observation, interview, and record review, it was determined the facility failed to ensure a significant change of condition assessment was completed by an RN, including documented findings, resident status and interventions made as a result of the assessment, for 2 of 2 sampled residents (#1 and 2) who experienced significant changes of condition. Resident 1 experienced severe weight loss and continued to lose weight. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 12/2023 with diagnoses including depression, hypothyroidism, and chronic obstructive pulmonary disease.

The resident's clinical record was reviewed, including weight records dated 01/25/24 through 05/07/24, service plan dated 05/17/24 and progress notes dated 02/20/24 through 05/19/24, the resident was observed, and interviews with staff and the resident were conducted.

a. Review of weight records revealed the following:

* 01/27/24 - 165 pounds;

* 02/23/24 - 161.2 pounds; and

* 04/14/24 - 139.1 pounds.

This constituted a severe weight loss of 25.9 pounds, or 15.7%, in three months.

There was no documented evidence a significant change of condition assessment, including findings, resident status, and interventions made as a result of the assessment, was completed by an RN.

The resident continued to experience severe weight loss, as documented by:

* 05/07/24 - 128.1 pounds.

This constituted a severe weight loss of 10.9 pounds, or 7.8%, in one month.

As of survey entrance on 05/20/24, the facility had no documented evidence that a significant change of condition assessment, including findings, resident status, and interventions made as a result of the assessment, was completed by an RN.

At the time of the survey, 05/23/24, the resident weighed 126.0 pounds.

During interviews on 05/21/24 and 05/22/24, staff stated they did not have any observations of how much the resident had been eating recently as the resident ate all meals in his/her room and trashed any remaining food in the Styrofoam containers the food was delivered in.

Resident 1 experienced severe weight loss between February and April of 2024, there was no documented evidence of an RN assessment to include findings, resident status, and interventions made as a result of the assessment and the resident continued to lose weight.

b. Resident 1 was admitted to the hospital 03/15/24 due to change in cognition and right upper extremity numbness, and returned to the facility on 04/03/24. During the hospital stay, the resident underwent fasciotomy surgery to his/her right arm. Upon return, the resident had a surgical wound, changes in multiple medications, new activity restrictions, and an increased need for care assistance.

As of 05/21/24, the facility had no documented evidence a significant change of condition assessment, including findings, resident status, and interventions made as a result of the assessment, was completed by an RN.

During an interview on 05/22/24, Staff 3 (RN) stated she had completed a change of condition assessment on 04/14/24 but had not provided it to the facility until emailing it to Staff 2 (Resident Services Director) on 05/22/24.

The need to ensure a significant change of condition assessment was completed and documented by the RN, including findings, resident status, and interventions made as a result of the assessment, was discussed with Staff 1 (ED), Staff 2 and Staff 3 on 05/22/24. They acknowledged the findings.

1.RN will complete a change of condition assessment for resident number #1. Reflecting on significant weight loss. RSD will modify and capture changes in the Service plan. RN will complete a change of condition evaluation for resident #2 documenting and capturing skin condition.  

2.  RN will complete all assessment for all change of conditions including decline in #1 and #2 weight loss and skin break down.

3. As needs arise RN will complete assessments for changes of conditions.  

4. RN     

Based on interview and record review, it was determined the facility failed to coordinate care with outside providers and ensure service providers leave written information in the facility that addressed the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care if necessary for 1 of 2 sampled residents (#4) who received outside services. Findings include, but are not limited to:

Resident 4 was admitted to the facility in 01/2023 with diagnoses including anxiety, chronic pain and depression.

Resident 4's progress notes, dated 01/01/24 through 05/19/24, were reviewed, as well as all outside provider communications. The following was identified:

a. The facility did not receive or document outside provider notes and recommendations from the resident's primary care provider visits on the following dates:

* 01/18/24;

* 01/30/24;

* 02/27/24;

* 03/12/24;

* 03/26/24;

* 04/09/24; and

* 05/07/24.

b. The resident had biweekly appointments with behavioral support services. The facility did not receive or document outside provider notes and recommendations from January 2024 through April 2024.

The need to coordinate care with outside providers and ensure service providers left written information in the facility that addressed on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care was discussed with Staff 2 (Resident Services Director) on 05/23/24, and reviewed with Staff 1 (ED) via telephone during the exit conference on 05/23/24. The findings were acknowledged. No further documentation was provided.

1.RN and RSD to coordinate care with outside providers as well as ensure written information/instructions on services being provided or requested. Obtain bi-weekly primary care provider notes for resident #4 and monthly documentation for behavioral support services.

2. Daily Monday-Friday clinical reviews.

3. Daily Monday-Friday.

4. RN, RSD, RSC and ED

Based on observation, interview, and record review, it was determined the facility failed to ensure the staff who administered medications visually observed the resident take the medications for 1 of 1 sampled resident (#1) whose records were reviewed. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 12/2023 with diagnoses including depression, hypothyroidism, and chronic obstructive pulmonary disease.

The resident's 04/01/24 through 05/19/24 MARs and physician's orders were reviewed.

During the acuity interview on 05/20/24, Staff 2 (Resident Services Director) and Staff 3 (RN) stated the facility administered all of Resident 1's medications.

During an interview with Resident 1 on 05/21/24, a pill cup with six pills was observed on the resident's bedside table. The resident stated staff "often" left medications without observing him/her take them.

Staff 10 (MT) stated on 05/21/24 that Resident 1 at times had difficulty taking all of his/her medications in the morning. She stated Resident 1 had requested additional time to take medications in the past. Staff 10 stated she did not leave medications in the resident's room, but had observed pill cups in the room in the past.

On 05/23/24, Staff 2 stated she was aware this had occurred in the past. She stated she also had requested an order from Resident 1's physician to allow medications to be left at bedside, as this was Resident 1's preference. She acknowledged there was no current order.  

The need to ensure the staff person who administered medication visually observed the resident take the medication was discussed with Staff 2 (Resident Services Director) on 05/23/24, and reviewed with Staff 1 (ED) via telephone during the exit conference on 05/23/24. The findings were acknowledged. No further documentation was provided.

1.Staff will be retrained and educated on the importance of ensuring all medication is consumed prior to leaving the presence of resident #1. Per resident #1's request fax to PCP for a leave at bedside order has been requested.

2.  Retaining all med techs on proper policy and procedure. Residents with the preference of leaving medications at bedside primary care providers will be contacted to obtain an order clarifying the ability for staff to do so.

3. Per resident request will be reviewed Monday-Friday at daily clinical.

4. RN, RSD and RSC and ED

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

Resident 2 was admitted to the facility in 07/2020 with diagnoses which included high blood pressure.

Resident 2 had an order for clonidine 0.1 mg one tablet three times a day for hypertension (high blood pressure). Staff were instructed to "hold for hypotension [low blood pressure]."

Review of the MARs from 05/01/24 through 05/20/24 revealed the following:

* Lack of clear parameters for hypotension and when the medication should be held; and

* Staff were administering the medication without obtaining a blood pressure to determine if the medication should be held.

In an interview on 05/22/24 at 1:20 pm, Staff 10 (MT) reviewed the resident's MAR. She confirmed the clonidine lacked specific instructions for staff including when the medication should be held.

The need to ensure MARs were accurate and included clear parameters for staff was discussed with Staff 2 (Resident Services Director) on 05/22/24 at 3:45 pm, and during the exit conference on 05/23/24 with Staff 1 (Executive Director) via telephone, Staff 2 and Staff 4 (Business Office Director). The findings were acknowledged. No further documentation was provided.

1. Medication procedures will be altered to allow staff to remove from the medication cart and computer from the medication room allowing staff to administer medication resident to resident removing the option to pre-pour/pop medications. RSD revised medication capturing specific parameters and instruction for resident #2's MAR.

2. Medications will no longer be pre popped prior to administration.

All medications will have clear parameters and clear instruction for staff administration.  

3. Per each received medication order.

4. ED, RSD, RSC, and RN

Based on interview and record review, it was determined the facility failed to ensure residents who chose to self-administer their medications were evaluated at least quarterly to ensure their ability to safely self-administer medications for 1 of 1 sampled resident (#4). Findings include, but are not limited to:

Resident 4 was admitted to the facility in 01/2023.

During the acuity interview on 05/20/24, Resident 4 was identified as self-administering his/her own medications.

On 05/22/24, Staff 2 (Resident Services Director) and Staff 3 (RN) acknowledged during separate interviews that Resident 4 did not have a quarterly evaluation completed to ensure s/he could safely self-administer his/her own medications.

The need to ensure residents who chose to self-administer medications were evaluated at least quarterly to ensure their ability to do so safely was discussed with Staff 2 on 05/23/24, and reviewed with Staff 1 (ED) via telephone during the exit conference on 05/23/24. The findings were acknowledged. No further documentation was provided.

1.RN will conduct a quarterly self medication assessment for resident #4 identifying their ongoing ability to self administer medications.

2. The nurse will provide assessment prior to admission if requested as well as quarterly.

3.On admission and quarterly.

4.RN   

Based on interview and record review, it was determined the facility failed to ensure PRN psychotropic medication used to treat resident behaviors had written, resident-specific parameters and non-pharmacological interventions were attempted and documented as not effective prior to administration of the medication for 1 of 1 sampled resident (#1) who had PRN psychotropic medications. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 12/2023 with diagnoses including depression and anxiety.

Review of the resident's 04/01/24 through 05/19/24 MARs and current physician orders revealed the following:

* An order for alprazolam 1 mg tablet to be administered by mouth two times daily as needed for anxiety; and

* The medication was administered 17 times.

The MAR lacked resident-specific parameters for staff describing how the resident presented behaviors such as anxiety. There was no documentation of what non-pharmacological interventions were to be attempted prior to administration of the medication, and during interviews on 05/22/24 and 05/23/24, staff stated they were not aware of any non-pharmacological interventions to attempt prior to administering the medication.  

The need to ensure there were resident-specific descriptions of how the resident behaviors presented, and non-pharmacological interventions were attempted and documented as not effective prior to administration of the medication was discussed with Staff 2 (Resident Services Director) on 05/23/24, and reviewed with Staff 1 (ED) via telephone during the exit conference on 05/23/24. The findings were acknowledged. No further documentation was provided.

1. Provide redirection or less intrusive intervention prior to giving psychotropic medications. Staff to offer resident specific non pharmacologic interventions and redirection. Staff to document effectiveness prior to the utilization of a psychotropic medication. If medications were administered, staff will provide follow up reflecting effectiveness.

2. Education for all staff on redirecting residents when behaviors occur. Follow up by the med tech if the medications are administered for effectiveness.

3. Each occurrence.

4. Med Tech

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

During the relicensure survey, conducted 05/20/24 through 05/23/24, interviews with staff and residents were conducted and staffing schedules were reviewed.

In an interview on 05/20/24, Staff 2 (Resident Services Director) reported the facility was unable to always staff to the level of the posted staffing schedule, but that when this occurred the vacancies were filled by one of four administrative staff.

On 05/21/24 at 5:00 pm Staff 2 reported she was working as a caregiver from 2:00 pm to 6:00 pm to fill in for a caregiver who had called off. Staff 2 was observed conducting administrative work throughout the facility between 2:00 pm and 5:30 pm, when surveyors left the building.

Throughout the survey multiple sampled and unsampled residents and staff reported that the facility was frequently understaffed.

On 05/23/24 staffing schedules for the weeks of 05/05/24 and 05/12/24 were reviewed. Ten of the 14 days reviewed had one or more shifts that were not staffed to the staffing level determined by the facility to meet resident needs.

The facility's failure to ensure it had a sufficient number of caregivers to meet the 24-hour scheduled and unscheduled needs of residents was discussed with Staff 2 on 05/23/24 and was reviewed during the exit conference on 05/23/24 with Staff 1 (Executive Director) via telephone. The findings were acknowledged.

1.Daily review of the ABST. Sufficient number of caregivers to meet the 24hr schedule and unschedule needs of each resident.

2. Daily review of the ABST.

3. Daily at clinical review.

4.Executive Director.

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff (#s 7, 13, 14 and 15) completed all required pre-service orientation training, 3 of 3 newly hired direct-care staff (#s 13, 14 and 15) completed all required pre-service dementia training, and 7 of 7 newly-hired and long term staff (#s 5, 6, 7, 8, 13, 14 and 15) completed the approved Home and Community Based Services (HCBS) course by 03/31/24. Findings include, but are not limited to:

Staff training records reviewed on 05/21/24 at 8:30 am with Staff 4 (Business Office Director) identified the following:

1. There was no documented evidence Staff 7 (Housekeeping), Staff 13 (CG), Staff 14 (CG) or Staff 15 (MT), hired on 02/13/24, 01/31/24, 01/09/24, and 01/03/24, respectively, had completed the following required pre-service orientation topic:

* Department approved infectious disease prevention training.

2. Staff 13, Staff 14 and Staff 15 lacked documented evidence of required pre-service dementia training.

3. Staff 5 (Maintenance Director), Staff 6 (Culinary Director), Staff 7, Staff 8 (Housekeeping), Staff 13, Staff 14 and Staff 15 lacked documented evidence of completing the required HCBS course by 03/31/24.

The need to ensure newly hired staff completed all required pre-service orientation and dementia training prior to beginning their job responsibilities, and all staff completed required HCBS training by 03/31/24 was discussed with Staff 4 on 05/21/24, Staff 2 (Resident Services Director) on 05/23/24, and reviewed with Staff 1 (Executive Director) via telephone during the exit conference. The findings were acknowledged.

1. Staff 7, 13, 14 and 15 will complete pre service, 30 day competency, annual training,dementia training and HCBS by 7/21/24.

2. BOD will require certificate proof of completion.

3.  Upon hire for all new staff and ensure all existing staff obtain a certificate by July 21, 2024.

4. BOD

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired direct care staff (#s 13, 14 and 15) had documented evidence of demonstrated competency in all required areas within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed with Staff 4 (Business Office Director) on 05/21/24. The following was identified:

Staff 13 (CG) hired 01/31/24, Staff 14 (CG) hired 01/09/24, and Staff 15 (MT) hired 01/03/24, lacked documented evidence they had demonstrated competency in all job duties, and had been trained in First Aid and abdominal thrust training within 30 days of hire.    

Staff 4 reported in an interview on 05/22/24 that competency checklists had not been completed for newly hired direct care staff, apart from medication pass duties for MTs. Staff 4 also reported the facility did not have a system in place for training and demonstrating competency in first aid and abdominal thrust.

The need to ensure staff completed all required training and demonstrated competency within 30 days of hire was reviewed with Staff 4 on 05/22/24, Staff 2 (Resident Services Director) on 05/23/24, and during the exit conference on 05/23/24 with Staff 1 (Executive Director). They acknowledged the findings.

1.Staff 13, 14 and 15 will complete all 30 day competency by 7/21/24.

2. Upon hire, the business office director will secure certificates in staff files.

3. Upon hire and prior to expiration.

4. BOD

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

Fire and life safety records were reviewed with Staff 5 (Maintenance Director) on 05/21/24 and 05/22/24.

The facility provided documentation of one fire drill in the last six months, which occurred on 04/30/24. The facility was not relocating residents from the simulated fire area, therefore, there was no documentation of:

* Escape route use;

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

* Evacuation time-period needed; and

* Number of occupants evacuated.

In addition, there was no documentation of fire and life safety instruction for staff consistently being provided on alternate months.

The need to conduct fire drills every other month and provide fire and life safety instruction to staff on alternate months was discussed with Staff 1 (Executive Director) on 05/21/24 and Staff 5 on 05/22/24. They acknowledged the findings.

1.Fire drills will be conducted every other month. Education will be in alternate months.

2. The Maintenance Director will conduct fire drills utilizing Westmont Senior Living form.

3. Every other month for fire drills and training on odd months.

4.Maintenance Director

Based on interview and record review, it was determined the facility failed to re-instruct residents at least annually, in 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. Findings include, but are not limited to:

On 05/22/24, the surveyor discussed the facility's process and documentation for instructing residents on fire and life safety procedures with Staff 5 (Maintenance Director). Staff 5 reported he did not have documented evidence of annual fire and life safety instruction to residents.

The need to ensure residents were re-instructed at least annually, in 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 was reviewed with Staff 2 (Resident Services Director) and Staff 5 on 05/23/24, and during the exit conference on 05/23/24 with Staff 1 (Executive Director). They acknowledged the findings.

1.Residents will be educated upon admission within 24 hrs of admit and annually.

2. Documentation of residents' fire education will be kept in the binder in the maintenance office.

3. Admission and annually

4. Maintenance Director.    

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

Observations on 05/20/24 identified the following areas in need of cleaning or repair:

* Handrails throughout the facility had patches of worn varnish, exposing bare wood;

* Built-in bench surrounding entry living room had large areas of worn varnish and bare wood;   

* Chairs in dining room had chips and gouges on wood surfaces;   

* Double door in dining room leading to outside had black streaks and multiple paint scrapes; and   

* Carpet outside Room 145 had a large black circular stain.

The areas needing cleaning and repair were reviewed with Staff 5 (Maintenance Director) and Staff 2 (Resident Services Director) on 05/23/24, and during the exit conference on 05/23/24 with Staff 1 (Executive Director). They acknowledged the findings.

1. Wall patching, handrails, and built in bench have been repaired and restrained. Dining chairs wood surfaces scheduled to be repaired and restrained by 7/4/24. Exit door outside of the dining room has been cleaned and received paint touch up. Carpet entering apartment 145 has been shampooed and is now in presentable condition.

All interior and exterior materials and furniture will be kept clean and in good repair.

2. The Maintenance Director will conduct a quarterly walk through of all interior and exterior materials and furniture ensuring all are to quality standards.

3. Quarterly and as needed.

4. The Maintenance Director.

Based on observation and interview, it was determined the facility failed to ensure operable windows were designed to prevent accidental falls when sill heights were lower than 36 inches and above the first floor. Findings include, but are not limited to:

The facility was toured on 05/20/24. Resident unit windows on the second floor opened vertically, and windowsills were lower than 36 inches. The windows in common areas and resident rooms lacked a system which limited how much the windows could be opened to prevent accidental falls.

The need to ensure operable windows were designed to prevent accidental falls was discussed with Staff 5 (Maintenance Director) and Staff 2 (Resident Services Director) on 05/23/24, and was reviewed during the exit conference on 05/23/24 with Staff 1 (Executive Director). They acknowledged the findings.

1. Resident unit windows and common area windows that open vertically will have safety mechanisms installed that limits the amount of opening of the window eliminating falls.  

2. During quarterly exterior walk through. Window clearance will be reviewed.

3. Quarterly and move out inspections.

4. Maintenance Director.

Based on observation and interview, it was determined the facility failed to ensure covers, grates, or screens of wall heaters did not exceed 120 degrees Fahrenheit (F) when they were installed in locations that were subject to incidental contact by residents or with combustible material. Findings include, but are not limited to:

On 05/20/24 at 4:15 pm Room 144, a one-bedroom unit, was observed to have a wall heater in the bedroom. The heater was located where a resident could come into incidental contact with it. When the heater was turned on and allowed to heat up, the metal surface of the heater reached 181.2 degrees F. In an interview on 05/22/24 Staff 5 (Maintenance Director) reported that 12 rooms in Wing E had this type of wall heater.

The risk posed by the hot surface of the wall heaters was discussed with Staff 5 on 05/21/24, and with Staff 1 (Executive Director) on 05/21/24 and 05/22/24. They acknowledged the findings and deactivated the heaters until a long-term solution could be ascertained.

1. All wall heaters in wing E were disconnected immediately after discovery of temperatures exceeding 120 degrees. All discovered units contain a ptack unit which provides sufficient heating and cooling temperatures.

2. All wall heaters in wing E have been permanently disconnected.

3. Move out inspection to ensure the wall heater has stayed disconnected.

4. The Maintenance Director

Based on observation and interview, it was determined the facility failed to ensure water temperatures in residents' units were maintained within a range of 110 and 120 degrees Fahrenheit. Findings include, but are not limited to:

On 05/21/24, water temperatures in resident rooms 105, 215, and 237 measured 102, 103, and 108 degrees Fahrenheit, respectively.

In an interview on 05/22/24, Staff 5 (Maintenance Director) reported that the facility was aware of low water temperatures in rooms 103, 105, 203, and 205, and "many years ago" a plumber had determined that the issue was related to the water being at the end of the line, related to the water heater, in this area of the facility.

The need to ensure water temperatures in resident apartments were maintained within the required range was discussed with Staff 5 on 05/22/24, Staff 2 (Resident Services Director) on 05/23/24, and was reviewed during the exit conference on 05/23/24 with Staff 1 (Executive Director). They acknowledged the findings.

1. Facility will ensure resident Apartments  103, 105, 203, 205, 215 and 237 water temperatures are maintained between 110-120 degrees.

2. Water adjustment will be increased to ensure all listed above units reach temperature between 110-120 while ensuring all facility units do not exceed 120 degrees.

3. Quarterly during interior walk through as well as move in process.

4. The Maintenance Director

Based on observation and interview, it was determined the facility failed to ensure exit doors were equipped with an alarming device or other acceptable system to provide security and to alert staff when residents exited the building. Findings include, but are not limited to:

The building was toured on 05/20/24. Observations and interviews with staff confirmed the doors by which residents could exit the facility did not have a working alarm or other acceptable system to alert staff when residents left the building.

On 05/21/24, the need to ensure exit doors were equipped with an alarming device or other acceptable system was discussed with Staff 5 (Maintenance Director) and Staff 1 (Executive Director). They acknowledged the findings.

1. The Maintenance director implemented alarms on each existing door to the outside public which provides security and to alert staff of any traffic in or out of the building after busy hours.

2. Alert prompts staff of low battery which will be reviewed daily.

3. Prior to daily activation medication tech will sample door alarms ensuring alarms trigger.

4. Maintenance and Med Tech