Print Inspection: 3BCJ

The findings of the re-licensure survey, conducted 7/19/22 through 7/22/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCCMemory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first re-visit to the re-licensure survey of 07/22/22, conducted 02/13/23 through 02/14/23, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

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 revisit to the re-licensure survey of 07/22/22, conducted on 05/15/23, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.

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

During the relicensure survey, conducted 07/19/22 through 07/22/22, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the severity, scope and number of citations.

Refer to deficiencies in report.

1.) The following actions will be taken to correct the violation:

a. Executive Director (ED) will be working with Elderwise consultants to review systems and processes and to create systems that ensure quality of care and services.

2.) ED will hold weekly management meetings with department heads to provide effective administrative oversight and ensure compliance in all departments.

3.) Regional VP of Operations, Nursing team, and Human Resource Department will be reviewing biweekly reports completed by the ED through the Performance Improvement Plan to ensure continued effective adminstrative oversight.

4.) Regional VP of Operations will be responsible to ensure that corrections are completed and monitored.  

Based on observation and interview, it was determined the facility failed to ensure food was prepared and served in accordance with OAR 333-150-0000 (Oregon Food Sanitation Rules). Findings include, but are not limited to:

The facility kitchen was inspected on 07/20/22.

1. The following areas needed cleaning or repair:

* The floor drain under the warewasher had black debris;

* The wall to the right of the warewashing area and the wall outside the restroom where a garbage can was positioned had debris splatter;

* Wire wall shelves above the rear prep counter, above the small prep table to the right of the stove, above the toaster where bread was stored and the freestanding wire shelving unit where serveware was stored had grease build-up and dried debris;

* The backsplash above the steamtable had splatter and debris;

* The pan in which plates were being placed prior to serving had debris in the bottom;

* The interior of the microwave had dried debris;

* The top of the heat lamp above the steamtable had debris;

* There was dried debris on the lower portion of the ice machine where a liquid had splashed or dripped;

* The floor tiles around the doorways to the office and dining room had dark-colored debris build-up;

* The plastic lid to a large bin where oats were stored was damaged; and

* The doors to the bathroom and janitor closet were dirty and some paint was chipped, leaving uncleanable surfaces.

2. During meal service on 07/20/22, multiple care staff pushed residents to the dining room in wheelchairs and assisted with meal service.

a. Care staff did not don aprons prior to serving food to residents.

b. On several occasions, staff failed to properly wash or sanitize their hands after touching residents' wheelchairs or other items and prior to serving food, which put residents at risk for cross-contamination.

The areas needing cleaning and repair, and the issues with proper safe food handling practices, were reviewed with Staff 5 (Dining Services Director) on 07/20/22 at 1:45 pm and with Staff 1 (Executive Director) on 07/21/22 at 2:25 pm. They acknowledged the areas needing cleaning and repair and the need to ensure all facility staff who assisted with dining services followed proper food handling practices.

1.) The following actions wil be taken to correct the violations:

a. The community kitchen, including all areas identified that needed cleaning, was professionally serviced by an outside company on 07/28/2022 and 07/29/2022. Kitchen equipment that were identified to need repair were replaced with a brand new equipment or repaired by the Plant Operations Director (POD).

b. All care staff will be provided an in-service training regarding safe food handling practices and infection control procedures, including wearing aprons and proper hand washing/sanitizing to avoid cross-contamination during meal services. Signs will be placed in the kitchen regarding appropriate apron use and in the bathrooms regarding proper hand washing.

2.) The systems will be corrected by the following:

a. The Dining Services Director has created a cleaning checklist, including a daily, weekly, and monthly scheduled tasks, to ensure that food is prepared and served in accordance to the Oregon Food Sanitation Rules. The POD will complete visual checks of the kitchen for potential needs for repair every quarter and as needed.

b. Every care staff will continue to receive biannual trainings on safe food handling practices and infection control procedures. Every newly employed care staff members will receive this training as part of the pre-service requirements, in addition to scheduled biannual trainings.

3.) The systems to ensure that food is prepared and served in accordance with the Oregon Food Sanitation Rules, including cleaning, repairs, proper safe food handling practices, and infection control procedures, will be evaluated by the Executive Director monthly during monthly Management Meetings.

4.) The Executive Director will be responsible for overseeing that the above systems are in place and continuously monitored.

2. Resident 3 was admitted to the facility in 08/2021. The resident's quarterly evaluation, dated 07/12/22 was reviewed during the survey. The evaluation was not reflective of the resident's current health status and care needs in the following areas:  

* Current diagnoses;

* Visits to the ER and hospital;

* Vital signs routinely checked;

* Vision status and use of eyeglasses;

* ADL status, including mobility and use of a two-wheel walker;

* Pain, including pharmaceutical and non-pharmaceutical interventions;  

* Skin condition of the feet;

* Housework and laundry;

* Fall risk or history; and

* History of dehydration or unexplained weight loss or gain.

The need to ensure quarterly evaluations were reflective of the resident's health status and addressed required elements was discussed with Staff 1 (Executive Director) on 07/22/22. She acknowledged the findings.  

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (#1) and failed to ensure 30 day or quarterly evaluations were reflective of residents' current needs or preferences for 2 of 3 sampled residents (#s 1 and 3). Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 05/2022 with diagnoses including type 2 diabetes mellitus, chronic peripheral venous insufficiency and obstructive sleep apnea.

a. Review of Resident 1's move-in evaluation, dated 05/19/22, revealed the following required elements were not addressed:

* Transportation;

* Pain, including how a person expresses pain or discomfort; and

* List of treatments.

b. Review of Resident 1's 30-day evaluation, dated 06/27/22, revealed the following was not reflective of current needs or preferences:

* The evaluation failed to identify that the resident was diabetic and required twice-daily CBGs and insulin injections;

* Vision status and use of eyeglasses;

* Frequency of escort needed to and from meals;

* Fall history;

* Diabetic toenail care;

* Frequency of bathing assistance and preference for same-sex caregiver;

* Diet type;

* Preference for room trays;

* Nursing tasks - delegation for insulin injections;

* Oxygen use;

* Resident history;

* Environmental factors impacting behavior: lighting;

* Weekly housekeeping and daily bed making;

* Complex medication management;

* Designated pharmacy; and

* Resident stores and self-administers several over-the-counter medications in his/her apartment.

The failure to address all required areas in the move in evaluation and the need to ensure the 30-day evaluation was accurate was discussed with Staff 1 (Executive Director) and Staff 2 (Wellness Director) on 07/22/22.  They acknowledged the findings.

1.) The following actions will be taken to correct the violation for each resident:

a. Resident 1's move-in evaluation, dated 05/19/2022, will be updated to address missing items and resident preferences. Resident 1's 30 day evaluation, dated 06/27/2022, will be updated to address missing items and resident preferences. Once the move-in evaluation has been accurately updated, a new copy will be printed out for all facility staff to review and sign. The updated information will be discussed in the upcoming All-Staff Meeting to ensure everyone's awareness of Resident 1's preferences, routine, current status, and care needs to help her function at her optimal level.

b. Resident 3's quarterly evaluation, dated 07/12/2022, will be updated to include identified missing items and resident preferences. Once the service plan has been accurately updated, a new copy will be printed out for all facility staff to review and sign. The updated information, along with clear direction regarding the delivery of services, will be discussed in the upcoming All-Staff Meeting to ensure everyone's awareness of Resident 3's preferences, routine, current status, and care needs to support principles of dignity, privacy, choice, individuality, and independence.

2.)  Move-in evaluations will be thoroughly reviewed by the Executive Director (ED) to ensure completion of all information that identify the residents' preferences, strengths, and relationships, as well as activities that are meaningful to the individual, physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The ED will confirm that all move-in evaluations are complete prior to approving a future resident's move-in date.

Quarterly service plans will be thoroughly reviewed by the Executive Director to ensure completion of all information required to reflect the resident's current needs and health status, including resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. The ED will confirm that all quarterly service plans are complete prior to approving for its distribution to the resident, the resident's family member(s), and facility staff.

3.) The systems to ensure the completion of move-in evaluations and quarterly service plans will be evaluated by the Wellness Director (WD) and the Executive Director monthly during monthly Wellness Management Meetings.

4.) The Executive Director will be responsible for overseeing that the above systems are in place and continuously monitored.

3. Resident 3 was admitted to the facility in 08/2021 with diagnoses including diabetes and diabetic neuropathy.

Observations and interviews with the resident and staff from 07/19/22 to 07/21/22, review of clinical record and most recent service plan, dated 07/12/22, indicated the service plan failed to reflect the resident's current care needs and lacked specific instruction to staff in the following areas:

* Preferred sleeping in a recliner chair;

* Fall with injury on 06/03/22, sustained a compression fracture;

* Recent hospital stay for bacterial pneumonia and iron deficiency anemia;

* Home Health PT and recommendations;

* Use of oxygen including setting and instruction if assistance was needed;

* Eye glasses;

* Use of shower chair;

* Decrease in mobility and use of a two wheel walker;

* Current skin condition on feet;

* Weight loss and interventions;

* Pain and non-pharmaceutical interventions;

* Level of assistance needed with ADL's;

* Staff to do laundry; and

* Fall risk and interventions.

The need to ensure service plans were reflective of residents' current needs and provided specific instruction to staff was discussed with Staff 1 ( Executive Director) on 07/22/22. She acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current needs and provided clear instruction to staff regarding delivery of services for 3 of 3 sampled residents (#s 1, 2 and 3) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 05/2022 with diagnosis including type 2 diabetes mellitus with diabetic polyneuropathy and venous insufficiency.

Interviews with care staff and the resident, and review of the service plan, dated 06/29/22, was conducted during the survey.

The service plan was not reflective of the resident's status, and lacked clear instructions for staff in the following areas:

* Use of eyeglasses;

* Preference for room trays;

* Diabetic toenail care;  

* Frequency of bathing and preference for same-sex caregiver;

* Diet type;

* Delegation: insulin;

* Skin condition;

* Transportation assistance;

* Preferred pharmacy;

* Weekly housekeeping and daily bed making;

* Oxygen use;  

* Environmental factors impacting behaviors: lighting; and

* Emergency evacuation needs.

The need to ensure service plans were reflective of residents' current needs and provided clear instructions to staff was reviewed with Staff 1 (Executive Director) and Staff 2 (Wellness Director) on 07/22/22.  They acknowledged the findings.

2. Resident 2 moved into the facility in 04/2019 with diagnoses including diabetes and hemiplegia. The most recent service plan, dated 06/08/22, was not reflective and lacked clear instruction for staff in the following areas:

* How to re-direct problematic behaviors;

* Activities and leisure time preferences;

* Fall risk related to left sided weakness;

* Grooming, including where grooming was performed (no access to bathroom sink);

* Housekeeping needs;

* Toileting habits and use of urinal;

* Dietary needs (diabetic status) and food preferences;

* Bathing needs and preferences;

* Use of hand splint; and

* Emergency evacuation needs.

The need to ensure service plans were reflective of resident needs and included clear direction to staff was discussed with Staff 1 (Executive Director) on 7/21/22. She acknowledged the findings.

1.) The following actions will be taken to correct the violation for each resident:

a. Resident 1's service plan, dated 06/29/2022, will be updated to reflect resident's current needs, identified missing items, and resident preferences. Additionally, Resident 1's service plan will be updated to include clear instructions to care staff on how to assist resident with her current care needs. Updates to the resident's service plan and directions for staff on how to provide and deliver services will be discussed at the upcoming All-Staff Meeting to allow for a clear understanding of responsibilities and for questions and concerns to be discussed.

b. Resident 2's service plan, dated 06/08/2022, will be updated to reflect resident's current care needs, identified missing items, and resident preferences. Additionally, Resident 2's service plan will be updated to include clear instruction to care staff on how to assist resident with his current care needs. Updates to the resident's service plan and directions for staff on how to provide and deliver services will be discussed at the upcoming All-Staff Meeting to allow for a clear understanding of responsibilities and for questions and concerns to be discussed.

c. Resident 3's service plan, dated 07/12/2022, will be udpated to reflect resident's current care needs, identified missing items, and resident preferences. Additionally, Resident 3's service plan will be updated to include clear instruction to care staff on how to assist resident with her current care needs. Updates to the resident's service plan and directions for staff on how to provide and deliver services will be discussed at the upcoming All-Staff Meeting to allow for a clear understanding of responsibilities and for questions and concerns to be discussed.

2.) Updates to service plans will be discussed weekly during the Management Meetings. Each manager is responsible for communicating each resident's current care needs with their department, for providing clear directions on how to address and provide appropriate care services to each resident, and for ensuring that each individual in their department read, review, and sign the updated service plan in a timely manner. The Resident Services Director (RSD), or designee, will audit signature page weekly to ensure that all facility staff members have read, reviewed, and signed each updated service plan. A portion of the All-Staff Meeting will be set aside to discuss any concerns or questions about how to provide care services to any resident to ensure understanding of staff responsibilities.

3.) The systems to ensure the thorough completion of quarterly service plans, including clear directions to staff, will be evaluated by the Wellness Director (WD) and the Executive Director monthly during monthly Wellness Management Meetings.

4.) The Executive Director will be responsible for overseeing that the above systems are in place and continuously monitored.

Based on interview and record review, it was determined the facility failed to ensure resident service plans were developed by a Service Planning Team that consisted of the resident, the resident's legal representative, if applicable, any person of the resident's choice, the facility administrator or designee, a licensed nurse if the resident shall need or is receiving nursing services or experiences a significant change of condition, and at least one other staff person who is familiar with or who is going to provide services to the resident, for 3 of 3 sampled residents (#s 1, 2 and 3) whose service plans were reviewed. Findings include, but are not limited to:

Resident 1, 2 and 3's most recent service plans were reviewed during the survey. Each service plan lacked documented evidence it was developed and reviewed by the resident and other required members of his/her Service Planning Team.

The need to ensure resident service plans were developed with a Service Planning Team was reviewed with Staff 1 (Executive Director) and Staff 2 (Wellness Director) on 07/22/22. They acknowledged some resident service plans had not been reviewed by a service planning team or the resident, and documentation of who did participate in the service plan review was lacking.

1.) The following actions will be taken to correct the violation for each example:

A service planning team will be identified for Resident 1, 2, and 3 by talking to each resident about their preferences in participating in their own care conferences and in identifying other individuals who they prefer to be invited to their care conferences such as their emergency contact, a family member, or a facility staff member. In addition to the resident and the resident's preferred service planning team members, the resident's legal representative, the Executive Director, and the Resident Services Director will hold a care conference to update each resident's service plan with the whole Service Planning Team. The licensed nurse will be included in the Service Planning Team for Resident 1, 2, and 3, as they each require nursing services or has had a recent significant change of condition.

2.) A service planning team will be identified for all residents by talking to each resident about their preferences in participating in their own care conferences and in identifying other individuals who they prefer to be invited to their care conferences such as their emergency contact, a family member, or a facility staff member. In addition to the resident and the resident's preferred service planning team members, the resident's legal representative, the Executive Director, and the Resident Services Director will hold a care conference to update each resident's service plan with the whole Service Planning Team. The licensed nurse will be included in the Service Planning Team for residents who require nursing services. The registered nurse will be included in the Service Planning Team for residents have had a recent significant change of condition. Each member of the Service Planning Team will be invited to upcoming care conferences each quarter by the Resident Services Director, or designee, and will be offered a copy of the updated service plan.

3.) The system to ensure the identification of a Service Planning Team and their invited participation in the development of each resident's service plan will be evaluated by the Wellness Director (WD) and the Executive Director monthly during monthly Wellness Management Meetings.

4.) The Resident Services Director, or designee, is responsible for ensuring that each resident has an identified Service Planning Team, for inviting each member of the Service Planning Team to each care conference, for documenting each individual in attendance to the care conference, and for offering and providing a copy of the updated service plan to each Service Planning Team member, as desired. The Wellness Director and the Executive Director is responsible for ensuring that there is an identified Service Planning Team for each resident and that each member of each resident's Service Planning team has the chance to assist with developing the resident's service plan.     

Based on observation, interview and record review, it was determined the facility failed to monitor the resident consistent with his or her evaluated needs and service plan, failed to determine, document and communicate what actions/interventions were needed for a resident's short term change of condition and failed to document, evaluate and refer significant changes of condition to the facility nurse, for 3 of 3 sampled residents (#s 1, 2 and 3) who had documented wounds or changes in care needs which required monitoring by the facility. Resident 1's leg wounds worsened and required hospitalization. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 05/2022 with diagnoses including type 2 diabetes mellitus with diabetic polyneuropathy, congestive heart failure and chronic peripheral venous insufficiency.

* Information provided during the acuity interview, and interviews with the resident and care staff, indicated Resident 1 had been admitted with chronic leg wounds on both lower extremities that were treated by home health until that service was discontinued on 06/10/22. The home health physician provided the facility with continuing wound care orders, dated 06/07/22, that included the following instructions for the facility:

- Wound care three times weekly and as needed if the dressings started to fall off or became saturated with fluid from the wounds; and

- Encourage the resident to elevate legs above heart in a supine position.

There was no documented evidence the facility provided the wound care three times per week and as needed as prescribed. The facility failed to add the instructions regarding encouraging the resident to elevate his/her legs to the service plan and communicate those instructions to staff.

* The wound care documented on the TAR was for dressing changes twice per day (for which the facility could provide no written order) from 06/30/22 through 07/06/22. Interviews with Staff 2 (RN) on 07/21/22 and Staff 4 (Resident Services Director) on 07/22/22 indicated the resident frequently asked staff to remove the dressings not long after they had been applied due to pain. Staff 4 stated that for approximately the past two to three weeks he offered to provide wound care multiple times per day "as needed." He stated even when the resident was agreeable to the care, s/he typically asked staff to remove the dressings one to two hours later. Staff 2 and Staff 4 acknowledged there was no documentation on the TAR of wound care that was provided "as needed."

* Between 06/10/22 and 07/19/22, the facility failed to document on the progress of the wounds at least weekly. The facility documented on 06/20/22, 06/22/22 and 06/23/22 and then not again until two weeks later on 07/06/22. The 07/06/22 progress note indicated weeping edema and redness was present on both lower extremities with open areas on the left ankle.

In an interview with Resident 1 on 07/20/22 at 2:25 pm, the resident's wounds were not covered and the surveyors observed redness on both ankles. The resident said the wounds hurt, especially when the wounds were weeping fluid. S/he acknowledged the wounds should be covered to prevent infection and should have compression wrapping but said it caused too much pain. S/he said s/he could tolerate the pain until later in the day when s/he typically requested a PRN pain medication. S/he said currently staff applied a pad to the wounds in the evening or prior to bed and lightly wrapped them with gauze to keep the pads in place.

On 07/20/22 at 3:45 pm, the surveyors requested Staff 6 (Regional RN) conduct an evaluation of the wounds. On 07/20/22 at 4:55 pm, Staff 6 informed the surveyors the wounds were warm to the touch, she suspected cellulitis (a skin infection causing redness, swelling and pain), and the facility was arranging with the family for the resident to be seen in the local hospital emergency department. The resident was transported to the hospital on 07/21/22. When the survey team completed the survey on 07/22/22 at 3:45 pm, the resident was still at the hospital.

The resident's wounds worsened and required hospitalization. The following deficiencies were identified:

* The facility failed to evaluate and document the status of the wounds at the time it took over wound care from home health so it could monitor the progress of the wounds and evaluate the effectiveness of the interventions/treatments;

* There was no documented evidence the facility provided the wound care three times per week and as needed as prescribed;

* There was no documentation as to how often the resident asked for the dressings to be removed;

* The facility failed to add the instructions regarding encouraging the resident to elevate his/her legs to the service plan and communicate those instructions to staff;

* There was no documentation as to whether the facility determined the interventions were effective; and

* The facility failed to document on the progress of the wounds at least weekly.

The facility's failure to monitor Resident 1's condition, treatments and interventions was discussed with Staff 1 (Executive Director) and Staff 2 on 07/22/22. No further information was provided by the facility.

3. Resident 3 was admitted to the facility in 08/2021 with diagnoses including diabetes and diabetic neuropathy.

Resident 3's charting notes, dated 05/08/22 through 07/19/22, service plan, dated 07/12/22, hospital after-visit summaries, and incident reports were reviewed, and caregiving staff and the resident were interviewed.

Resident 3 experienced the following changes of condition:

* On 06/03/22, staff documented Resident 3 fell, was sent to the hospital and diagnosed with a compression fracture of the spine. There was no documented evidence the facility had evaluated the resident's change of condition, referred to the facility nurse, documented the change, updated the service plan to reflect the resident's overall condition, or monitored and documented on the progress of the condition at least weekly until resolved; and

* A hospital after-visit summary indicated the resident was hospitalized from 07/07/22 through 07/11/22 for bacterial pneumonia. The resident returned to the facility on 07/11/22 with supplemental oxygen. Staff 2 (Wellness Director) completed an evaluation of the resident on 07/12/22 and documented the resident was on a continuous flow of oxygen and that the resident could manage independently. Staff was to monitor for increasing difficulty in breathing or ability to manage oxygen and report to the Licensed Nurse; however, the facility failed to update the resident's service plan, communicate monitoring instructions to staff and document on the progress of the condition until resolved.

The need to ensure residents who experienced a change of condition were evaluated, resident specific actions or interventions were developed, communicated to staff, and monitored was discussed with Staff 1 (Executive Director) on 07/22/22. She acknowledged the findings.

2. Resident 2 was admitted to the facility in 04/2019 with diagnoses including diabetes mellitus and hemiplegia.

A review of Resident 2's progress notes, dated 04/17/22 through 07/19/22, current service plan and temporary service plans revealed the following:

* On 04/25/22, home health documented the resident had a pressure ulcer on the upper thigh;

* On 04/27/22, a home health RN made recommendations for interventions to treat the pressure wound;

* On 05/31/22 and 06/07/22, the home health RN documented the wound was healing with the current treatment plan in place; and

* On 06/07/22, the home health RN documented a dressing was placed on the resident's left knee.

There was no documented evidence the facility was monitoring the skin issues at least weekly and communicated interventions or instructions to staff.

In an interview with Staff 2 (Wellness Director) on 07/11/22, it was determined the task of weekly monitoring of skin wounds was assigned to the facility RN. Notes and a skin monitoring flow sheet provided from 04/17/22 through 07/19/22 showed one entry from the RN on 07/13/22 stating "unable to observe resident's skin today due to [his/her] being up in the chair for the day." Staff 2 stated she had looked at the wound on 07/13/22 and it was responding well to the current treatment and documented it in progress notes. No other documentation was provided.

The need to ensure resident-specific instructions or 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 (Executive Director), and Staff 2 on 07/21/22. They acknowledged the findings.

1.) The following actions will be taken to correct the violation for each resident:

a. Resident 1's wound on her bilateral extremities has been assessed by a Registered Nurse and has been addressed by a physician. Her most current wound care orders, along with additional recommendations, will be added to the Treatment Administration Record on QuickMAR and to her service plan. A physical copy of her signed wound care orders will be placed in her chart. Every aspect of her wound care will be documented on QuickMAR as they are provided, including taking off bandages and refusals for wound care. A licensed nurse will continue to evaluate, monitor, and document on Resident 1's wound progression and effectiveness of current interventions and ordered treatments weekly until resolved. A licensed nurse will provide education to all care staff members on what signs and symptoms to monitor for, when to alert a licensed nurse of concerns, how to alert a licensed nurse of concerns, and when the wounds need urgent medical attention. Clear and specific directions will be provided to staff via written documentation in QuickMAR and in the resident's service plan. A licensed nurse will alert the Registered Nurse of any potential signs that the wound has progressed to a significant change of condition.

b. Resident 2's pressure ulcer on his upper thigh will be assessed by a Registered Nurse and will be addressed by a physician. His most current wound care orders, along with additional recommendations, will be added to the Treatment Administration Record on QuickMAR and to his service plan. A physical copy of signed wound care orders will be placed in his chart. Every aspect of his wound care will be documented on QuickMAR as they are provided, including taking off bandages and refusals for wound care. A licensed nurse will continue to evaluate, monitor, and document on Resident 2's wound progression and effectiveness of current interventions and ordered treatments weekly until resolved. A licensed nurse will provide education to all care staff members on what signs and symptoms to monitor for, when to alert a licensed nurse of concerns, how to alert a licensed nurse of concerns, and when the wound needs urgent medical attention. Clear and specific directions will be provided to staff via written documentation in QuickMAR and in the resident's service plan. A licensed nurse will alert the Registered Nurse of any potential signs that the wound has progressed to a significant change of condition.

c. Resident 3's service plan will be updated to include: (1) a previous significant change of condition when she sustained a compression fracture of the spine after a fall on 06/03/2022, and (2) a previous change of condition when she was hospitalized from 07/07/2022 to 07/11/2022 for bacterial pneumonia and discharge back to the facility with oxygen orders, in addition to specific directions to care staff on monitoring and documenting on the progress of her condition until resolved.

2.) A visual list of residents with skin issues, wounds, falls, changes of condition, and re-admission from hospitalization will be placed on a communication board in the Wellness Office, along with the most recent date of evaluation. This list of residents will be discussed during weekly clinical meetings with the licensed nurse(s), Resident Services Director, and Executive Director. Any updates to resident-specific interventions will be communicated to care staff by providing clear instructions via the service plan. Weekly clinical meetings will include reviewing TSPs, outside provider notes, skin sheets, progress notes, and 24-hour alert logs to identify any changes of condition or wounds that have not yet been addressed by the licensed nurse.

3.) The effectiveness of the visual list of residents via a communication board and the discussions of changes of conditions during weekly clinical meetings will be reviewed by the Wellness Director and the Executive Director monthly during monthly Wellness Management meetings.

4.) The Wellness Director and the Executive Director will be responsible for ensuring that the corrections are completed and monitored.

Based on observation, interview and record review, it was determined the facility failed to ensure the RN performed an assessment, developed interventions based on the condition of the resident, and updated the service plan for 1 of 1 sampled resident (#3) who experienced a significant change condition related to a fall with fracture. Findings include, but are not limited to:

Resident 3 was admitted to the facility 08/2021 with diagnoses including diabetes.

Review of the resident's clinical records identified that on 06/03/22, Resident 3 experienced a fall which resulted in a compression fracture of the spine.  

In an interview on 07/19/22, Resident 3 reported s/he was very active and would walk the facility grounds numerous times a day, but since the fall s/he has not been able to move around like s/he used to.

Resident 3 was observed multiple times during the survey sitting in his/her recliner chair.

In an interview on 07/21/22, Staff 14 (CG) stated that prior to the fall, the resident was driving and physically active. Since the fall the resident spent a majority of his/her time sitting in his/her recliner.

The spinal fracture represented a significant change of condition for which an RN assessment was required. There was no documented evidence the RN assessed the status of the resident, documented findings as a result of the assessment, or developed interventions related to the resident's significant change of condition.

The need to complete an RN assessment when residents' experienced a significant change of condition was discussed with Staff 1 (Executive Director) on 07/22/22. She acknowledged the findings.

1.) The following actions will be taken to correct the violation for each resident:

Resident 3's service plan will be updated to include a previous significant change of condition when she sustained a compression fracture of the spine after a fall on 06/03/2022, current care needs, and resident preferences. Care staff will be provided education on what may constitute as a significant change of condition and when/how to alert the licensed nurse of urgent concerns during the MedTech Training and during the upcoming Care Staff Meeting.

2.) A visual list of residents with skin issues, wounds, falls, changes of condition, and re-admission from hospitalization will be placed on a communication board in the Wellness Office, along with the most recent date of evaluation. This list of residents will be discussed during weekly clinical meetings with the licensed nurse(s), Resident Services Director, and Executive Director. Any updates to resident-specific interventions will be communicated to care staff by providing clear instructions via the service plan. Weekly clinical meetings will include reviewing TSPs, outside provider notes, skin sheets, progress notes, and 24-hour alert logs to identify any changes of condition or wounds that have not yet been addressed by the licensed nurse. Once made aware of potential significant changes of condition from weekly clinical meetings and the communication board, the Registered Nurse will: (1) physically assess the resident, (2) document findings via a progress note and by updating the service plan, (3) monitor weekly until significant change of condition has resolved or has become the new baseline, (4) provide resident-specific instructions to care staff on resident's need for assistances services. The RN will communicate identified significant changes of condition on the communication board including date of most recent assessment.

3.) The effectiveness of the visual list of residents via a communication board and the discussions of significant changes of conditions during weekly clinical meetings will be reviewed by the Wellness Director and the Executive Director monthly during monthly Wellness Management meetings.

4.) The Wellness Director and the Executive Director will be responsible for ensuring that the corrections are completed and monitored.

3. Resident 1 was admitted to the facility in 05/2022 with diagnoses including type 2 diabetes, congestive heart failure and chronic peripheral venous insufficiency.

* In an interview on 07/21/22, Staff 2 (Wellness Director) reported Resident 1's chronic bilateral leg wounds had been treated by home health services until the service was discontinued on 06/10/22. No discharge summary or discharge orders were found in the resident's record.

* A home health Visit Summary, dated 06/07/22, included a recommendation to encourage the resident to elevate his/her legs above the heart by laying in a supine position. The facility did not add the recommendations to the resident's service plan or communicate the interventions to staff to implement.

The need to ensure all documentation was obtained, reviewed and orders/recommendations were added to the resident's service plan and implemented was reviewed with Staff 1 (Executive Director) and Staff 2 on 07/22/22. No additional information was provided.

2. Resident 3 had been recently diagnosed with a compression fracture and was recovering from pneumonia.  

A review of the resident's clinical record identified the resident was receiving Home Health Physical Therapy.

An outside service care coordination note dated 07/18/22 instructed staff to encourage the resident to wear his/her TLSO (Thoracic Lumbar Sacral Orthosis) brace with standing activities and to use a front-wheeled walker.

There was no documented evidence the facility updated the resident's service plan, developed a temporary service plan, or communicated the recommendations to staff.

On 07/22/22, the need to ensure recommendations from outside service providers were incorporated in resident service plans and the information was available to staff for the provision of care was discussed with Staff 1 (Executive Director). She acknowledged the findings

Based on interview and record review, it was determined the facility failed to coordinate on-site health services with outside service providers and ensure staff were informed of new interventions for 3 of 3 sampled residents (#s 1, 2 and 3) who received services from outside providers. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 04/2019 with diagnoses including hemiplegia.

A review of the resident's clinical record indicated the following:

* Home Health services were being provided, at least weekly, for wound care from 04/27/22 through 06/17/22, however, the facility was unable to provide any documentation of home health notes for visits between 04/27/22 and 05/31/22;

* There was no documentation that home health treatment instructions for wound care had been provided for staff to follow; and

* OT services provided the resident with a hand splint on 06/17/22, and provided instructions on use and application of the splint. There was no documented evidence the instructions were communicated to staff or being implemented.

In an interview on 07/21/22, Staff 10 (CG) stated they thought a new splint was being ordered, so the resident was not wearing it.

The need to ensure coordination between the facility and outside service providers and that interventions were communicated to staff was reviewed with Staff 1 (Executive Director) and Staff 2 (Wellness Director) on 07/21/22. They acknowledged the findings.

1.) The following actions will be taken to correct the violation for each resident:

a. Home Health notes will be requested for all visits with Resident 2 for wound care and for Occupational Therapy, including an order for and instructions for use and application of a hand splint. The licensed nurse will review all notes, orders, and instructions. The licensed nurse will document outside provider service care coordination note via a progress note on QuickMAR. The licensed nurse will input treatment instructions on QuickMAR and the resident's service plan for use of hand splint including clear instructions for care staff on how to assist with its application and how to monitor for adverse reactions. New information from Home Health notes for Resident 2 will be discussed during end of shift change report and at the next monthly Care Staff Meeting.

b. Home Health notes will be requested for all visits with Resident 3 for Physical Therapy, including an order for his Thoracic Lumbar Sacral Orthosis (TLSO) and instructions for its use and application. The licensed nurse will review all notes, orders, and instructions. The licensed nurse will document outside provider service care coordination note via a progress note on QuickMAR. The licensed nurse will input treatment instructions on QuickMAR and the resident's service plan for use of TLSO including clear instructions for care staff on how to assist with its application and how to monitor for adverse reactions, if appropriate. New information from Home Health notes for Resident 3 will be discussed during end of shift change report and at the next monthly Care Staff Meeting.

c. Home Health notes will be requested for all visits with Resident 1 for wound care, including any orders for wound care and recommendations. The licensed nurse will review all notes, orders, and instructions. The licensed nurse will document outside provider service care coordination note via a progress note on QuickMAR. The licensed nurse will input treatment instructions on QuickMAR and the resident's service plan for wound care. New information from Home Health notes for Resident 1 will be discussed during end of shift change report and at the next monthly Care Staff Meeting.

2.) A visual list of residents receiving services from Home Health providers will be placed on a communication board in the Wellness Office, along with date of latest visit and date of discharge, as appropriate. Outside provider notes will be documented on as a progress note in QuickMAR by the medtech. The Resident Services Director, or designee, will request outside provider care plans and progress notes biweekly. The licensed nurse will review the obtained outside provider care plans and progress notes, in addition to documenting findings as a progress note on QuickMAR and adding treatment orders on QuickMAR as needed. The licensed nurse will update the resident's service plan and will provide education and clear instructions to care staff on what services the resident needs, how to assist with such services, how to and when to monitor for adverse side effects, and how to and when to alert a licensed nurse of concerns. This list of residents receiving Home Health Services will be discussed during weekly clinical meetings with the licensed nurse(s), Resident Services Director, and Executive Director. Weekly clinical meetings will include reviewing TSPs, outside provider notes, skin sheets, progress notes, and 24-hour alert logs to identify any needs for Home Health Service or any current Home Health Services that have not yet been addressed by the licensed nurse.

3.) The effectiveness of the visual list of residents receiving Home Health Services via a communication board and the discussions held during weekly clinical meetings will be reviewed by the Wellness Director and the Executive Director monthly during monthly Wellness Management meetings.

4.) The Wellness Director and the Executive Director will be responsible for ensuring that the corrections are completed and monitored.

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

During the re-licensure survey, conducted 07/19/22 through 07/22/22, the facility failed to ensure a safe medication and treatment system, and administrative oversight was found to be ineffective based on deficiencies in the following areas:

C 302: Systems: Tracking Controlled Substances;

C 303: Systems: Medication and Treatment Orders;

C 305: Systems: Resident Right to Refuse;

C 310: Systems: Medication Administration;

C 315: Systems: Treatment Administration; and

C 325: Systems: Self Administration of Medication.

Failure to ensure a safe medication system and to ensure adequate professional oversight based on deficiencies related to medication administration was discussed with Staff 1 (Executive Director) on 07/22/22.

Please refer to the plan of correction for C302, C303, C305, C310, C315, and C325.

Based on interview and record review, it was determined the facility failed to have a system for effectively tracking controlled substances, for 1 of 2 sampled residents (#1) who was administered a narcotic pain medication by the facility. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 05/2022 with diagnoses including chronic peripheral veinous insufficiency.

Resident 1 had chronic leg wounds for which s/he was prescribed PRN hydrocodone-acetaminophen 5-325 tablets (a narcotic medication to treat pain).

Review of Resident 1's 06/01/22 through 07/18/22 MAR and the Controlled Substance Disposition Record indicated:

* Staff documented on the Controlled Substance Disposition log the Hydrocodone/Acetaminophen 5-325mg was dispensed 50 times between 06/01/22 through 07/18/22.

* The facility failed to document on the MAR the dispensed medication was administered to the resident on 14 occasions.

The discrepancies between the Disposition Record and Resident 1's MAR were reviewed with Staff 1 (Executive Director) and Staff 2 (Wellness Director) on 07/22/22. They acknowledged the discrepancies and Staff 2 stated she would follow up with the medication technician staff.

1.) The following actions will be taken to correct the violation for each resident:

Resident 1's Hydrocodone-Acetaminophen 5-325 tablets for pain PRN will be reviewed by a licensed nurse. The Controlled Substance Disposition Log and the MAR will be audited for this medication by a licensed nurse. Missing medication administration documentation on the MAR will be added as a late entry and a progress note will be documented to explain the late entry documentation for medication administration.

2.) All medtechs for the community attended a 2-day in-person training conducted by the Regional Nurse and the Nurse Consultant on 08/10/2022 and 08/11/2022 regarding policies and procedures, including all aspects of medication administration such a timely and accurate documentation. The Resident Services Director, or designee, will audit the Controlled Subtance Log biweekly and compare the administration records to the MAR to ensure accurate documentation. The RSD, or designee, will immediately alert the licensed nurse of any discrepancies.

3.) The biweekly review of the Controlled Substance Log and the MAR will be reviewed by the Wellness Director and the Executive Director monthly during monthly Wellness Management meetings.

4.) The Wellness Director and the Executive Director will be responsible for ensuring that the corrections are completed and monitored.

Based on observation, interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed, and signed physician orders were documented in the resident's facility record for all medications and treatments the facility was responsible to administer, for 2 of 2 sampled residents (#s 1 and 2) whose orders were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 05/2022 with diagnoses including type 2 diabetes mellitus and chronic peripheral venous insufficiency. The resident had a history of skin breakdown to both lower extremities. At the time of the survey, both legs had open sores.

Resident 1's admission orders, any subsequent orders and the 06/01/22 through 07/19/22 MARs and TARs were reviewed. The following deficiencies were identified:

* In an interview on 07/21/22, Staff 2 (Wellness Director) stated home health services left wound care instructions for the facility to implement, which specified wound care to be provided three times per week and as needed if the dressings started to fall off or became saturated with fluid from the wounds. The wound care orders were not in Resident 1's record at the time of the survey. There was no documented evidence the orders were carried out as prescribed.

* Staff 2 further stated she had received verbal orders from the resident's physician for both routine and PRN wound care and for PRN lidocaine cream (for pain) which were different from the HH order. There was no documented evidence the facility received signed, written orders for the new treatments and lidocaine cream. These orders were documented as discontinued on 07/06/22. There was no order to discontinue the treatments in the resident's record at the time of the survey.

* The resident had signed orders for bacitracin ointment (to prevent minor skin infections) to be applied topically twice daily for redness/blisters around the resident's right ankle. The MAR indicated the order was discontinued 06/30/22. There was no order to discontinue the medication in the resident's record at the time of the survey.

The facility's failure to ensure it had signed, written copies of medication and treatment orders in the resident's record and orders were carried out as prescribed was reviewed with Staff 1 (Executive Director) and Staff 2 on 07/22/22. They acknowledged the issues with the orders.

2. Resident 2 was admitted to the facility in 04/2019 with diagnoses including diabetes mellitus.

Resident 2's MAR dated 07/01/22 through 07/19/22 and current physician's orders were reviewed and revealed the following:

a. Resident 2 had a physician's order, dated 05/17/22, for Metformin 500 mg, give 2 tablets (1000 mg) by mouth once a day.

b. The 07/2022 MAR read Metformin 500 mg, give 1 tablet (500 mg) by mouth once a day. The resident had been receiving the lower dose of the Metformin during the month of July.

The need to ensure that medication orders were carried out as prescribed was discussed with Staff 2 (Wellness Director) on 07/21/22. She acknowledged the findings.

1.) The following actions will be taken to correct the violation for each resident:

a. Resident 1's current orders and Home Health orders for wound care will be reviewed by the licensed nurse to ensure that all medications and treatments being administered has a signed physician's order and that all orders are accurately reflected on QuickMAR.

b. Resident 2's current orders will be reviewed by the licensed nurse to ensure that all medications and treatments being administered has a signed physician's order and that all orders are accurately reflect on QuickMAR.

2.) All medtechs for the community attended a 2-day in-person training conducted by the Regional Nurse and the Nurse Consultant on 08/10/2022 and 08/11/2022 regarding policies and procedures, including requirement for signed physician's orders with all administered medications/treatments and importance of accurate medication administration as prescribed. The Resident Services Director, or designee, will review and audit the "three check system" in the medroom and make changes as needed to continue to make sure that all orders have been processed appropriately. The RSD, or designee, will immediately alert the licensed nurse of any discrepancies.

3.) The audit and review of physician orders will be reviewed by the Wellness Director and the Executive Director monthly during monthly Wellness Management meetings.

4.) The Wellness Director and the Executive Director will be responsible for ensuring that the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to notify the physician or other practitioner when a resident refused consent to an order, for 2 of 2 sampled residents (#s 1 and 2) with documented refusals of medications. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 05/2022 with diagnoses including type 2 diabetes mellitus with diabetic polyneuropathy, congestive heart failure, chronic peripheral veinous insufficiency and obstructive sleep apnea.

Resident 1 had signed physician orders for bacitracin ointment (to prevent minor skin infections) to be applied topically twice daily for redness/blisters around the resident's right ankle.

Review of the MAR from 06/01/22 through 07/18/22 indicated the resident refused the treatment order 14 times over eight days between 06/13/22 and 06/30/22.

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

The need to ensure the facility had a system to ensure it notified a resident's physician if a resident refused consent to an order was reviewed with Staff 1 (Executive Director) and Staff 2 (Wellness Director) on 07/22/22. They acknowledged the findings. No additional documentation was provided.

2. Resident 2 was admitted to the facility in 04/2019 with diagnoses including diabetes.

Resident 2's 06/01/22 through 07/19/22 MARs were reviewed during the survey. Staff documented the resident refused physician-ordered use of Prevident flouride paste and Metformin for diabetes on multiple occasions.

The physician had asked to be updated quarterly for medication refusals. There was no documented evidence the facility notified the physician when the resident refused to consent to the orders.

On 07/21/22, the need to notify prescriber's of refusals was reviewed with Staff 1 (Executive Director). She acknowledged the findings.

1.) The following actions will be taken to correct the violation for each resident:

a. The RSD, or designee, will review Resident 1's MAR/TAR and alert her primary care physician (PCP) of any refusals for medications or treatments for the last quarter. In addition, the PCP's preference will be requested on how often they want to be alerted of medication refusals. This will be added to QuickMAR as an order for MedTechs to fax a list of medication refusals to the PCP at their preferred frequency.

b. The RSD, or designee, will review Resident 2's MAR/TAR and alert his primary care physican of any refusals of medications or treaments for the last quarter. The PCP preference to be alerted of refused medications quarterly will be added to QuickMAR for MedTechs to communicate this information to the PCP at the preferred frequency of once a quarter.

2.) All medtechs for the community attended a 2-day in-person training conducted by the Regional Nurse and the Nurse Consultant on 08/10/2022 and 08/11/2022 regarding policies and procedures, including requirement and importance of notifying the resident's physician if the resident refuses to consent to an order. The Resident Services Director, or designee, will communicate with every resident's PCP to request their preference of when and how often to be alerted of refusals. The RSD will add these preferences for communication on QuickMAR and will audit and review this system biweekly to ensure timely and appropriate communication with physicians. The RSD, or designee, will immediately alert the licensed nurse of any discrepancies.

3.) The audit and review of alerting physicians of resident refusals to ordered medications or treatments will be reviewed by the Wellness Director and the Executive Director monthly during monthly Wellness Management meetings.

4.) The Wellness Director and the Executive Director will be responsible for ensuring that the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to maintain an accurate medication administration record for all medications ordered by a legally-recognized prescriber and administered by the facility, for 1 of 3 sampled residents (#1) whose MARs were reviewed. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 05/2022 with diagnoses including type 2 diabetes mellitus with diabetic polyneuropathy, congestive heart failure, chronic peripheral veinous insufficiency and spinal stenosis - lumbar region.

a. Resident 1 was prescribed four PRN topical pain medications to treat shoulder pain:

* Capsaicin 0.025% cream;

* Capsaicin 0.1% cream

* Diclofenac sodium 1% gel; and

* Lidocaine 5% patch.

The 06/2022 and 07/2022 MARs lacked parameters for unlicensed staff as to when to administer each medication.

b. Resident 1 was prescribed two PRN medications to treat constipation:

* Milk of Magnesia (MOM) as needed for no bowel movement in 3 days; and

* Bisacodyl 10 mg suppository if MOM is ineffective.

The 06/2022 and 07/2022 MARs lacked parameters for unlicensed staff as to how long to wait to administer the suppository if the MOM was determined to be ineffective.

The need to ensure resident MARs included parameters for unlicensed staff when the resident was prescribed multiple PRN medications for the same condition was reviewed with Staff 1 (Executive Director) and Staff 2 (Wellness Director) on 07/22/22. They acknowledged the findings.

1.) The following actions will be taken to correct the violation for each resident:

a. Resident 1's current PRN orders for pain will be reviewed by the licensed nurse (LN). The LN will add clear parameters to provide instructions for unlicesned staff as to when to administer each medication for pain as needed.

b. Resident 2's current PRN orders for constipation will be reviewed by the licensed nurse. The LN will add clear parameters to provide instructions to unlicensed staff of how long to wait to administered the suppository if the Milk of Magnesia was determined to be effective.

2.) All medtechs for the community attended a 2-day in-person training conducted by the Regional Nurse and the Nurse Consultant on 08/10/2022 and 08/11/2022 regarding policies and procedures, including importance of parameters and clear instructions on how to administer PRN medications and treatments that are ordered for the same diagnosis. The licensed nurse will review and audit the MAR/TAR and add clear parameters to multiple PRN orders for the same diagnosis. The licensed nurse will add clear parameters to all PRN medications and treatments as prescribed if needed. The licensed nurse will review all PRN orders and include parameters, if needed, prior to sending out the 90 day physician orders every quarter.

3.) The audit and review of PRN orders to include clear parameters to unlicensed staff will be reviewed by the Wellness Director and the Executive Director monthly during monthly Wellness Management meetings.

4.) The Wellness Director and the Executive Director will be responsible for ensuring that the corrections are completed and monitored.

2. Resident 1 was admitted to the facility in 05/2022 with diagnoses including type 2 diabetes mellitus and chronic peripheral venous insufficiency. The resident had a history of skin breakdown to both lower extremities. At the time of the survey, both legs had open sores.

* In an interview on 07/21/22, Staff 2 (Wellness Director) stated home health services left wound care instructions for the facility to implement, which specified wound care to be provided three times per week and as needed. Staff 2 stated either she or the facility RN provided the wound care.

There was no documented evidence on the 06/2022 or 07/2022 TAR that the facility provided the wound care treatment as prescribed.

* In interviews on 07/20/22 and 07/22/22, Resident 1 and Staff 4 (Resident Services Director) confirmed facility staff were currently providing wound care for the resident's lower extremities as needed. Staff 4 stated he and other MTs offered Resident 1 wound care multiple times per day. Staff 4 also reported that, at times during the past 2 - 3 weeks, the resident required as many as four wound dressing changes per day.

There was no documented evidence on the 06/2022 and 07/2022 TAR that the facility provided PRN wound care as prescribed.

The facility's failure to ensure treatment administration records were accurate and included documentation of all prescribed treatments administered by the facility was discussed with Staff 1 (Executive Director) and Staff 2 (Wellness Director) on 07/22/22. They acknowledged the lack of documentation in the record and could not explain the discrepancies in the TAR.

Based on interview and record review, it was determined the facility failed to ensure an accurate treatment administration record (TAR) was maintained for all treatments the facility provided for 2 of 2 sampled residents (#s 1 and 2) who were receiving wound care treatments. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 4/2019 with diagnoses including diabetes mellitus and hemiplegia.

Review of Resident 2's records indicated the following:

Resident 2 had a re-occurring pressure wound to the left upper thigh on 04/25/22. Outside provider notes and progress notes indicated staff were instructed to provide wound care, a chamosyn barrier cream and bandage changes 04/25/22 - current.

A review of the MAR / TAR for June and July 2022 showed there were wound care instructions for general wound care and a "wound to the left lower leg" abrasion. The wound care recommendations for the pressure wound to the thigh were not documented on the TAR.

In an interview on 07/21/22, Staff 2 (Wellness Director) reported the facility did not include treatments provided by caregivers on the TAR. The facility was unable to provide documentation that the treatments were being provided.

The need to ensure an accurate treatment administration record (TAR) was maintained for all treatments the facility provided was discussed with Staff 1 (Executive Director) and Staff 2 (Wellness Director) on 07/21/22. They acknowledged the findings.

1.) The following actions will be taken to correct the violation for each resident:

a. Resident 2's current wound orders will be reviewed by the licensed nurse to ensure that all treatments ordered by a physician for the resident are accurately reflected on QuickMAR and are being administered and followed as prescribed. The physician will be alerted of and signed orders will be requested for any resident-preferred treatments being requested to be applied to the wound.

b. Resident 1's current wound orders will be reviewed by the licensed nurse to ensure that all and treatments ordered by a physician for the resident are accurately reflected on QuickMAR and are being administered and followed as prescribed. The licensed nurse will review how often PRN wound care has been documented to have been administered and will evaluate this documentation for accuracy. Any previous PRN wound care services administered will be added as a late entry on the TAR in order to refect and accurate treatment adminsitration record.

2.) All medtechs for the community attended a 2-day in-person training conducted by the Regional Nurse and the Nurse Consultant on 08/10/2022 and 08/11/2022 regarding policies and procedures, including importance of abiding by all signed physician orders and requirement for timely and accurate documentation. The Resident Services Director, or designee, will review and audit the "three check system" in the medroom and make changes as needed to continue to make sure that all treatment orders have been processed appropriately. The RSD, or designee, will immediately alert the licensed nurse of any discrepancies. The licensed nurse will review all treatment orders as part of the weekly skin monitoring and will communicate with staff to ensure the accuracy of the administration of PRN wound care treatments.

3.) The system to ensure that an accurate treatment administration record is maintained for all treatments the facility provides will be reviewed by the Wellness Director and the Executive Director monthly during monthly Wellness Management meetings.

4.) The Wellness Director and the Executive Director will be responsible for ensuring that the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure a resident who self-administered medications was evaluated at least quarterly to ensure they were safe to do so, for 1 of 1 sampled resident (#3) who self-administered medications. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 08/2021 with diagnoses including diabetes and hypotension.

During the acuity interview on 07/19/22, Resident 3 was identified as self-administering his/her medications.

Review of the resident's 10/28/21 signed physician orders and the 07/2022 MAR , and interview with the resident, confirmed the resident was self-administering all of his/her medications.

There was no documented evidence a self-medication evaluation had been completed by the facility.

The need to ensure the facility evaluated Resident 3's ability to safely self-administer his/her medications quarterly was discussed with Staff 1 (Executive Director) on 07/22/22. She acknowledged the findings.  

1.) The following actions will be taken to correct the violation for each resident:

a. Resident 3 will be evaluated by the RSD, or designee, to identify if they are able to appropriately and accurately self-administer their medications. Resident 3's physicians will be alerted of the result of the evaluation and orders will be requested for the resident to be able to self-administer all medications, if found appropriate to do so. The self-administration evaluation will be added to the resident's service plan to be updated once a quarter or when there has been a significant change of condition. In addition, a progress note will be added on QuickMAR regarding the evaluation and the MAR/TAR will be changed to accurately reflect resident's current status.

2.) A visual list of residents that have been evaluated to be able to appropriately self-administer all medications will be placed on a communication board in the Wellness Office, along with date of latest evaluation. This list will be discussed during weekly clinical meetings with the licensed nurse(s), Resident Services Director, and Executive Director. Weekly clinical meetings will include reviewing TSPs, outside provider notes, progress notes, and 24-hour alert logs to identify any needs for an evaluation of a resident's ability to appropriately self-administer their medications.

3.) The system to ensure current evaluations of a resident's ability to self-administer their medications will be reviewed by the Wellness Director and the Executive Director monthly during monthly Wellness Management meetings.

4.) The Wellness Director and the Executive Director will be responsible for ensuring that the corrections are completed and monitored.

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

1. During the acuity interview on 07/19/22, the following was identified:

* The facility consisted of a one-story building with four corridors of resident units, connected by a common area dining room and living rooms;

* The facility had 39 residents;

* Six residents needed two-person assistance with transfers or a mechanical lift; and

* Seven residents needed frequent staff assistance with activities of daily living.

The facility's posted staffing plan on 07/19/22 was as follows:

* During the night shift, there was one caregiving staff and one MT scheduled to be on duty. Staff 1 (Executive Director) confirmed the night shift staffing plan.

2. On 07/20/22 at 11:00 am, during a group interview, multiple residents reported that the facility was not able to respond to calls for assistance in a timely manner on the night shift. Resident's reported they often decided not to call for assistance due to "the staff are too busy." Multiple residents who required two-person assistance with their care stated the facility needed "at least one more staff on night shift" to help with care.

3. Service plans reviewed during the survey did not include information on the number of staff and assistance needed to evacuate residents in the case of an emergency.

Refer to C 260 and C 420 in the report.

The need to ensure an adequate number of staff to meet the scheduled and unscheduled needs of residents was discussed with Staff 1 on 07/22/22. She acknowledged the facility had been working to increase staffing levels.

1.) The following actions will be taken to correct the violation:

a. NOC shift staffing has been increased to 2 care associates and 1 MedTech to address the acuity of the community during NOC hours. Additional NOC care associates have been added to the schedule as 07/25/2022.

b. The community has updated the posted staffing plan at the front desk to reflect the increase in staffing during NOC hours.  

c. The service plans for residents 1, 2, and 3 have been updated with information regarding need for evacuation assistance.

2.) The community will be using an Acuity-Based Staffing Tool that will accurately reflect current staffing needs per shift based on information from each resident's service plan. The posted staffing plan will be updated with changes in staffing.

3.) The Executive Director will evaluate the use of the Acuity-Based Staffing Tool to define staffing needs once a month.

4.) The Executive Director will be responsible in ensuring that corrections are completed and monitored.

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 3 of 3 sampled residents (#s 1, 2, and 3) whose records were reviewed. Findings include, but are not limited to:

There was no documented evidence the facility was using an ABST that would determine a staffing plan reflective to meet the 24-hour scheduled and unscheduled needs of residents, updated the tool as required and included all the required ABST elements.

The requirements of the ABST were discussed with Staff 1 (Executive Director) on 07/20/22 and 07/21/22. She acknowledged the current system of ABST tools the facility was using did not include all the required information.

1.) The following actions will be taken to correct the violation for each resident:

The community is working on implementing the use of an updated ABST system that would determine accurate staffing plan reflective to meet the 24hr scheduled and unscheduled needs of residents and all the required ABST elements.

2.) The Executive Director will review the updated ABST system monthly to ensure compliance with all the required ABST elements.

3.) The Wellness Director and Executive Director will review the accurate staffing plan based on the ASBT monthly during monthly Wellness Meetings.

4.) The Executive Director will be responsible to ensure that the above corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure pre-service orientation training was completed prior to providing services to residents for 2 of 3 newly hired staff (#s 9 and 12) whose training records were reviewed. Findings include, but are not limited to:

Staff training records were requested on 07/20/22.

Staff 9 (CG), hired 03/03/22, and Staff 12 (MT), hired 05/18/22, lacked documented evidence of having completed all of the required pre-service training including:

* Resident's rights and values of CBC care; and

* Fire safety and emergency procedures.

The need for staff to complete required pre-service training before working with residents was reviewed with Staff 1 (Executive Director) on 07/22/22. She acknowledged the findings.

1.) The following actions will be taken to correct the violation:

a. Staff #9 and #12 will have all required pre-service trainings completed before working with residents.

2.) Pre-service training for all current employees will be completed. For the newly-hired employees,all pre-service trainings including pre-service dementia (6hr training), pre-service infection disease (2hr), resident rights and values of CBC, abuse reporting requirements, Fire & Safety emergency procedure, and food handler's certification, will be required prior to being placed on the schedule and working with residents. The appropriate department head will be responsible for reviewing completed training certifications for newly-hired employees in their department prior to adding them to the schedule to provide direct care to residents.

3.) The system to ensure that all employees have completed all required pre-service trainings prior to working with residents will be evaluated monthly during the monthly Management Meetings. The Executive Director will be sending copies of employee  trainings monthly  to Home Office Human resources to ensure compliance.

4.) The Executive Director will be responsible for ensuring that the above corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 newly hired direct care staff (#s 9 and 12) demonstrated satisfactory performance in required job duties within 30 days of hire. Findings include, but are not limited to:

Training records were reviewed on 07/20/22.

There was no documented evidence Staff 9 (CG), hired 03/03/22, and Staff 12 (MT), hired 05/18/22, had demonstrated competency in the following areas:

* Role of service plans in providing individualized care;

* Changes associated with normal aging;

* Identification, documentation and reporting changes of condition;

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

* General food safety, serving and sanitation.

Staff 9 reportedly had completed first aid and abdominal thrust training but the facility was unable to locate the documentation.

The need to ensure documentation of demonstrated competence in required job duties within 30 days of hire was reviewed with Staff 1 (Executive Director) on 07/22/22. She acknowledged the findings.

1.) The following actions will be taken to correct the violation:

a. Staff #9 and #12 will have all required 30-day trainings completed and have demonstrated satisfactory performance in their required job duties.

b. Documentation of Staff #9's first aid and abdominal thrust trainings will be obtained and placed in their employee file.

2.) All current employees will be required to complete all the 30-day training requirements immediately. For newly-hired employees, all 30-day training requirements will be completed prior to their 30th day of hire. The Business Office Manager (BOM) and the RSD will be monitoring the 30-day training checklist for each employee. Those who have been unable to complete the 30-day training checklist prior to their 30th day of hire will be taken off the schedule until all required trainings have been completed.

3.) The system to ensure that all employees have completed all required trainings prior to their 30th day of hire will be evaluated monthly during the monthly Management Meetings. The Executive Director will be sending copies of employee trainings monthly to Home Office Human Resources to ensure compliance.

4.) The Executive Director will be responsible for ensuring that the above corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to have documented evidence that 12 hours of annual in-service training, including six hours of dementia-related training, was completed for 2 of 2 long-term staff (#s 10 and 13) whose training records were reviewed. Findings include, but are not limited to:

The annual in-service training records for the year 2021 were requested on 07/20/22.  A review of the records provided revealed the following:

* Staff 10 (CG) and 13 (MT) failed to have documented evidence of completing 12 hours of required in-service training, including six hours of dementia related training.

The need to ensure the facility had a tracking system of annual required training and that staff received the required number of training hours was discussed with Staff 1 (Executive Director) on 07/22/22. She acknowledged the findings.

1.) The following actions will be taken to correct the violation:

a. Staff #10 and #12 will have all required annual in-service trainings, including 6 hours of dementia-related training, completed.

2.) All current employees will be required to immediately complete all 12 hours of annual in-service training requirements, including 6 hours of dementia-related training. For newly hired employees, monthly in-services through Relias and through scheduled in-person trainings will be tracked and monitored by the BOM and the RSD monthly. The BOM/RSD, or designee, will review certificates of trainings once a month and will provide assistance through a plan of action for those employees who have not yet fulfilled the monthly training requirement.

3.) The system to ensure that all employees have completed all 12 hours of annual in-service trainings will be evaluated monthly during the monthly Management Meetings. The Executive Director will be sending copies of employee trainings monthly to Home Office Human Resources to ensure compliance.

4.) The Executive Director will be responsible for ensuring that the above corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure fire drill records included documentation of all required elements and fire and life safety instruction to staff was provided on alternate months from fire drills. Findings include, but are not limited to:

Fire and life safety records from February 2022 through June 2022 were reviewed. The following deficiencies were identified:

a. Fire drill records did not include the following required elements:

* Escape route used;

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

* Staff members on duty and participating;

* Evidence alternate routes were used during fire drills; and

* Number of occupants evacuated.

In an interview on 07/20/22, Staff 3 (Plant Operations Director) acknowledged the facility was not relocating residents as part of the fire drill process

b. There was no documented evidence fire and life safety instruction was provided to staff on alternate months.

The requirements regarding fire drills and fire and life safety instruction for staff was reviewed with Staff 1 (Executive Director) on 07/22/22. She acknowledged the findings.  

1.) The following actions will be taken to correct the violation:

a. The fire drill record form will be updated to include all required elements including escape route, problems encountered, comments, related to residents who are resisted or failed to participate in the drills; staff members on duty & participating, evidence of alternate routes used during the fire drill and number of occupants evacuated.

b. Staff were provided with fire and life safety instructions for August 2022. Documentation of these instructions and each staff they were provided to will be kept in the Fire and Life Safety binder.

2.) Fire drills will include the practice of relocating identified residents to safe points/horizontal exits. Fire drills will be documented on the updated Fire and Life Safety form that will include all required elements. The POD, or designee, will be responsible for properly completing and documenting fire drills as required every other month. Additionally, a schedule has been developed by the POD to provide  instructions and documentation of fire and life safety trainings, including emergency disaster preparedness, earthquakes, flooding, active shooter, ice storms, and electric outages, provided for all staff on alternate months from fire drills.

3.) The system to provide proper documentation of all required elements during a fire drill and proper documentation of safety instructions provided to staff on alternate months from the fire drill will be reviewed once a month during the monthly Management Meetings.

4.) The Executive Director will be responsible in ensuring that the above corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to provide fire and life safety instruction for residents, at least annually, in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to:

Fire and life safety records were reviewed. There was no documented evidence the facility provided annual fire and life safety instruction for residents, as required.

During an interview on 07/20/22, Staff 3 (Plant Operations Director) confirmed there were no records that the facility provided annual fire and life safety training to residents.  

On 07/22/22, the need to provide and document annual fire safety instruction for residents, in accordance with the OFC, was discussed with Staff 1 (Executive Director). She acknowledged the findings.

1.) The following actions will be taken to correct the violation:

a. All current residents will receive training on the facility's Fire and Life Safety Policies.

2.) All newly admitted residents will receive training on the facility's Fire and Life Safety Policies within 24 hours of admission - this task will be added on the new resident checklist for the POD, or designee, to complete during the admission process. The POD, or designee, will complete the annual training for fire and life safety procedures with all residents once a year - presently scheduled on January 31st through the TELS system. Residents who are unable to attend the annual training will be provided the information for fire and life safety procedures one-on-one. The POD will keep a record of annual tranings provided for each resident and when they were completed in the Fire and Life Safety Binder.

3.) The system to complete annual tranings and provide proper documentation of fire and life safety policies and procedures to all residents within 24 hours of admission and annually will be reviewed once a month during the monthly Management Meetings.

4.) The Executive Director will be responsible in ensuring that the above corrections are completed and monitored.

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

Refer to C613.

1.Plant Operations Director & Executive Director will identify source of odors from affected apartment; educate resident on need to remediate; get permission from resident/responsible party to remediate; remediate as needed (including cleaning, repair, and/or replacement as indicated).  Ionizer will be utilized when residents are out of the room to remove temporary smells as needed. Will work with Wellness Department to determine if any care needs should be added/amended to the service plans to address any odor sources from resident(s).

2. Staff will be inserviced on observing and reporting resident room needs including malodorous situations at the March All-Staff meeting; service plans will be updated as needed; assigned staff will check the room on a regular basis to assure odors are controlled.

3. Assigned staff will check room weekly (initially) to ensure source of odors has been remediated.  Ongoing, assigned staff will check room monthly or as new odors are reported.

4.  Plant Operations Director and Executive Director will be responsible to ensure corrections are implemented & monitored.  

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:

The interior of the facility was toured on 07/19/22 at 12:00 pm. The following areas needed cleaning or repair:

* The carpet in resident rooms 1, 9, 17, 21, 22, 28, 30, 37 and 38 had darks spots or stains;

* The lower portion of resident room 18 had dark black scuffs;

* Resident room 22's entry door frame was damaged;

* Resident room 37's entry door and interior doors were badly damaged and gouged, exposing bare wood and rough surfaces, and the walls throughout the apartment were deeply gouged;

* Resident room 37's entry door handle did not operate correctly;

* The frame of the exit door in Hallway 4 was gouged, exposing bare wood and rough surfaces;

* Several bench seats in Hallway 1 had spots or stains; and

* The flushing rim sink in the facility laundry room had black debris.

The building was toured and areas needing cleaning or repair were discussed with Staff 1 (Executive Director) and Staff 3 (Plant Operations Director) on 07/19/22. They acknowledged the areas needing cleaning and repair.

1.) The following actions will be taken to correct the violation:

a. The carpet in apartments 1,9,17,21,22,30, and 38 will be shampooed and cleaned to remove dark spots or stains.

b. The carpet in apartment 37 will be replaced with laminate flooring.

c. The dark scuffs in apartment 18 will be cleaned and repainted.

d. The door frame in apartment 22 will be repaired and repainted.

e. Apartment 37 receive a new door with a new, working doorknob. The door frame will be repaired and repainted. The walls will be repared and reinforced by wall and corner guards.

f. The frame of the exit door in Hallway 4 will be repaired and repainted.

g. Bench seats on hallway 1 will be shampooed and cleaned.

h. The flushing rim sink in the facility laundry room will be cleaned and removed of all black debris.

2.) The POD will schedule carpet shampooing and cleaning of all apartments through the TELS system. The POD will be responsible for having identified carpets shampooed and cleaned as needed before dark spots or stains set in. Quarterly upholstery cleaning for all community benches and chairs will be scheduled through the TELS system for the Plant Operations department to complete as scheduled and as needed. The flushing sink in the laundry room will be added to housekeeping's weekly tasks and will be cleaned once a week, and on a as needed basis. ED and POD will complete a walk-through inspection of the community once a month to ensure that the building is kept clean and in good repair.

3.) The system to keep the building in clean and good repair will be evaluated once a month during the monthly Management Meetings.

4.) The Executive Director is responsible for ensuring that the above corrections are completed and monitored.

Based on observation and interview, it was determined the facility failed to ensure the environment was kept clean and free from unpleasant odors. This is a repeat citation. Findings include, but are not limited to:

Observations of the facility between 02/13/23 and 02/14/23 revealed the following:

* Unpleasant odors inside and outside of room nine.

The surveyor, Staff 15 (Plant Operations Director) and Staff 17 (Interim Executive Director) toured the environment on 02/13/23. They acknowledged the findings.