Print Inspection: 50WW

The findings of the re-licensure survey, conducted 9/13/21 through 9/15/21, 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 Home and Community Based Services Regulations OARs 411 Division 004.

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 revisit to the re-licensure survey of 09/15/21, conducted 01/31/22 through 02/01/22 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. Findings include, but are not limited to:

During the relicensure survey, conducted 9/13/21 through 9/15/21, oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number of citations.

Refer to deficiencies in report.

1.POC addresses every citation. See Plan of Correction details for citations below.

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

During a tour of the environment on 9/14/21, a propane gas fire pit measuring 29 inches square by 29 inches high was observed in the common outdoor area adjacent to the dining room. It was not in use at the time of the observation. On 9/15/21 at 10:30 am, the finding was reviewed with Staff 1 (Executive Director) who turned the fire pit on by an unsecured knob and ignition switch on the outside of the structure. There was no barrier that prevented access to the flame which posed a significant safety risk to the residents.

At 12:30 PM on 9/15/21, Staff 1 reported the knob which turned on the gas had been removed. At 1:50 PM, Staff 18 (Director of Operations) reported the gas shut-off valve to the fire pit would be capped the following day.

The need to ensure the facility exercised reasonable precautions against any condition that could threaten the health, safety or welfare of residents was discussed with Staff 1, Staff 2 (Health Services Administrator), Staff 6 (Resident Services Coordinator) and Staff 7 (Resident Services Coordinator) on 9/15/21. They acknowledged the findings.

1. We removed the on/off knob, and turned off the gas at the source.  

2. Provider to consult with the policy analyst on next steps per recommendation of the state surveyor.

3. Upon consult with policy analyst:

- Fireplace knob will be kept by staff. Staff will be in charge to turn the fire place on/off during designated events and will monitor safety during event.

Based on interview and record review, it was determined the facility failed to ensure 1 of 6 sampled residents (#2) was treated with dignity and respect.  Findings include, but are not limited to:

During the acuity interview on 9/13/21, it was reported that Resident 2 had been temporarily relocated to another apartment secondary to the need to complete maintenance in his/her permanent residence.

In an interview on 9/14/21 with Staff 9 (CG), she reported that Resident 2 used his/her call light on 9/13/21 to request to use the bedside commode for a bowel movement. Staff 9 reported she told the resident the bedside commode was unavailable and instructed him/her have his/her bowel movement in their incontinent garment. This constituted a failure to treat the resident with dignity and respect.

The failure of the facility to ensure residents were treated with dignity and respect was discussed with Staff 2 (Health Services Administrator), Staff 6 (Resident Services Coordinator) and Staff 7 (Resident Services Coordinator) on 9/15/21. They acknowledged the findings.  

1.  Resident Rights training was conducted with specific staff member and at an all-staff meeting. Resident was educated on the complaint process if they were ever feeling like their rights were being violated.

2.  Resident Rights will be reviewed with staff routinely with the use of specific examples and prompts for staff to identify and correct.  

3.  Quarterly during all-staff meetings.

4.  Administrator

Based on interview and record review, it was determined the facility failed to ensure resident incidents were thoroughly investigated in a timely manner and/or reported to the local Seniors and People with Disability (SPD) office for 2 of 3 sampled residents (#s 2 and 5) who were reviewed with injuries. Findings include, but are not limited to:

1. Resident 5 admitted to the facility in August of 2017 with diagnoses to include neuralgia (nerve pain) and curvature of the cervical spine.

The service plan and Staff interviews revealed Resident 5 required two persons with bed mobility and transfers, using a mechanical lift device since admit to the facility.

Review of Resident 5's record revealed s/he was sent to the hospital for uncontrolled pain on 5/15/21.

During an interview on 9/14/21 at 9:15 am, Resident 5 reported the cause of the increased back pain was related to two staff that moved him/her up in bed by pulling up under both of his/her arms. The resident reported feeling severe back pain during the bed mobility assistance provided.

On 9/14/21 Staff 6 (Resident Services Coordinator) reported he was unaware of an incident causing Resident 5's back pain. Staff 6 then completed an interview with the resident and confirmed the resident's report.

The surveyor asked Staff 2 (Health Services Administrator) to report the incident to the local SPD office. Confirmation of the self report to the local SPD office was received on 9/14/21.

The need to ensure resident incidents were thoroughly investigated and reported to the local SPD office was discussed with Staff 1 (Executive Director), Staff 2, Staff 6 (Resident Services Coordinator) and  Staff 7 (Resident Services Coordinator) on 9/15/21. They acknowledged the findings.

2. Resident 2 was admitted to the facility in February 2018.

Resident 2's 6/13/21 through 9/13/21 facility record was reviewed.

* On 8/3/21, a hospice bath aide note stated, "Looks as if (s/he) has a scratch on right hip."

* On 8/23/21, a hospice bath aide note stated, "Looks like (s/he) has a skinned left knee."

There was no documented evidence the facility was aware of the injuries, had investigated the injuries to rule out abuse or reported them as injuries of unknown cause to the local SPD office.

The facility was directed to report the injuries of unknown cause on 9/14/21. A fax confirmation of the report was provided prior to exit that day.

The need to ensure injuries of unknown cause were investigated to rule out abuse and reported to the local SPD office unless an immediate facility investigation reasonably concluded and documented that the physical injury was not the result of abuse was discussed with Staff 2 (Health Services Administrator), Staff 6 (Resident Services Coordinator) and Staff 7 (Resident Services Coordinator) on 9/15/21. They acknowledged the findings.  

1. Both incidents were reported to local SPD when abuse could not sufficiently be ruled out. Additionally, training has been completed on the following topics: when to initiate an incident report, steps to investigate an incident report, when to report to SPD, & individualizing service plans.

2. MTs and RSCs to launch incident report upon any report or observation of an incident. Administrator or RSC to begin investigation and rule out abuse within 24 hours. Administrator to report to the local SPD if abuse cannot be ruled out within 24 hours.

3. Administrator to review electronic dashboard daily for new incident reports that need investigated. In the absence of the Administrator, the RSC will review dashboard for incident reports and initiate investigation.  Additionally, incident reports, will be evaluated weekly during weekly chart review.

4. Administrator.

2. Resident 5 was re-admitted to the facility in July 2021. The following required elements were not addressed or included on the move-in evaluation form:

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

* Complex medication regimen;

* Recent losses;

* Unsuccessful prior placements; and

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

On 9/15/21, the need to ensure the move-in evaluation contained all required elements was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Administrator), Staff 6 (Resident Services Coordinator) and Staff 7 (Resident Services Coordinator). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure the new move in evaluation contained all required elements for 2 of 3 sampled residents (#s 3 and 5) whose new move-in evaluations were reviewed.  Findings include, but are not limited to:

Review of Resident 3's new move-in evaluation, dated 6/23/21, lacked the following elements:

* History of mental health treatment;

* Effective non-drug interventions;

* Personality and how the person copes with change and challenging situations; and

* List of treatments.

The need to ensure all required components were included in the new move-in evaluation was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Administrator), Staff 5 (Resident Services Coordinator) and Staff 7 (Resident Services Coordinator) on 9/15/21. They acknowledged the findings.

1. Both Evaluations have been reviewed for accuracy of information that was missed and required information has been added. Training has been completed with RSCs to review required components of move-in and quarterly evaluations and how to capture those components in our evaluation tool.

2.  RSC's will utilize Evaluation checklist to ensure all components are covered during evaluation.

RSC's will review Move-In Evaluations the week after move-in during weekly chart review and again at 30-day care conference to ensure all components are captured.

3. At move-in and weekly by the RSC's with RN oversight if needed.

4. RSC's

5. Observations, interviews and review of Resident 5's service plan dated 6/22/21 revealed it was not reflective of the resident's current status and lacked clear instruction to staff in the following areas:

* Activity assistance;

* Non-drug interventions for back pain;

* Meal set-up in bed, including specific positioning of food;

* Clothing protector for meals;

* Straw in all drinks;

* Two person full assist for bed baths;

* Two person assist for dressing;

* Grooming assistance instruction;

* Hygiene assistance instruction;

* Back brace prior to transfers out of bed, including clear instructions (7/21/21);

* Clear instructions for two person bed mobility assist to minimize discomfort;

* Air mattress on bed;

* Dependent on mobility in wheel chair;

* Evacuation assist;

* Home Health PT and OT;

* Continence of bowel and bladder with instructions;

* Limited range of motion to upper extremities;

* Bed bound;

* Range of motion to lower extremities instructions;

* Bilateral half side rails on bed; and

* Ability to make needs known and direct cares.

The need to ensure all resident service plans were reflective and provided instructions to staff was discussed on 9/15/21 with Staff 1 (Executive Director), Staff 2 (Health Services Administrator), Staff 6 (Resident Services Coordinator) and Staff 7 (Resident Services Coordinator). The staff acknowledged the findings.

3. Review of Resident 2's 6/21/21 service plan, interviews with staff and observations of the resident revealed the service plan was not reflective of the resident's care needs and did not provide clear direction to staff in the following areas:

* Hospice;

* Hospice bath aide provision of bathing services;

* When to call hospice;

* Pre-medication for pain prior to providing assistance with ADLs and transfers;

* Two-person assistance with dressing, toileting/brief change and bed mobility;

* Right hip pain with bed mobility, lower extremity dressing and brief changes;

* Continence;

* Limited upper extremity range of motion;

* Assistance for grooming;

* Presence of dentures;

* Hospital bed;

* Bedside commode; and

* Evacuation assistance.

The need to ensure the service plan was reflective of the resident's care needs and provided clear direction to staff was discussed with Staff 2 (Health Services Administrator), Staff 6 (Resident Services Coordinator) and Staff 7 (Resident Services Coordinator) on 9/15/21. They acknowledged the findings.

4. Resident 3 was admitted to the facility in 7/2021 with a diagnosis of Parkinson's disease.

During an interview on 9/13/21 Staff 7 (Resident Services Coordinator) identified Resident 3 to be independent for all ADL care. She also confirmed Resident 3's service plan was not updated within 30 days of his/her move-in date.

Observations of Resident 3 on 9/14/21 at 9:30 am revealed s/he asked for assistance to get out of his chair.

Review of Resident 3's progress notes dated 7/16/21 through 9/12/21 revealed s/he used a CPAP machine. An interview with Staff 13 (MT) at 12:25 pm on 9/14/21 revealed Resident 3's service plan did not reflect his/her current care needs in the following areas:

* Transfer assistance;

* Use of CPAP;

* Ability to eat using utensils;

* Ability to understand and be understood;

* Use of wheel chair;

* Alert and oriented to time and place; and

* Housekeeping services.

Interview with Staff #7 (Resident Services Coordinator) on 9/13/21 confirmed Resident 3's service plan was not updated within 30 days of move in.

The need to ensure service plans were reflective of care needs, provided clear direction to staff, and were updated within 30 days was reviewed with Staff 1 (Executive Director), Staff 2 (Health Services Administrator), Staff 6 (Resident Services Coordinator) and Staff 7 on 9/15/21. They 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 status, provided clear direction to staff, were updated within 30 days of admission and quarterly and were followed for 5 of 6 sampled residents (#s 1, 2, 3, 4 and 5) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in September 2020 with diagnoses including Dementia.

During the acuity interview on 9/13/21, Resident 1 was identified to have edema, weight loss and was in a relationship with another resident.

Observations, interviews, and review of the current service plan dated 9/7/21, revealed the service plan was not reflective of the resident's current status or provided clear instructions to staff, in the following areas:

* Edema and significant weight changes; and

* Relationship status with another resident.

The need to ensure Resident 1's service plan was reflective of the resident's current status and provided clear instructions to staff was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Administrator), Staff 6 (Resident Services Coordinator) and Staff 7 (Resident Services Coordinator) on 9/15/21. They acknowledged the findings.

2. Resident 4 was admitted to the facility in October 2020 with diagnoses including Type 1 Diabetes.

Observations of the resident, interviews with staff, and a review of the resident's 5/6/21 service plan indicated the service plan failed to reflect the resident's current care needs and lacked clear directions to staff in the following areas:

* Skin wound and treatment plan; and

* Home health wound care services and recommendations.

The need to ensure resident service plans were reflective of the resident's current status and provided clear directions to staff was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Administrator), Staff 6 (Resident Services Coordinator) and Staff 7 (Resident Services Coordinator) on 9/15/21. They acknowledged the findings.

1. Careplans are updated to be reflective of the sampled residents current status and care need with clear direction to staff.

Training has been completed for Caregivers and MTs on Changes Associated with Aging and how to report these changes. Training has been completed with RSCs on Individualizing Service Plans.

2. CGs & MTs to complete 24 hour report at shift changes to communicate any changes with residents. Temporary Services Plans (TSP) to be launched immidately by MT to communicate any changes with a resident and clear direction to staff of support needed.

Outside Provider Notes to be reviewed by MT then RSC with a  final check by RN. TSP, incident report, alert charting or skin log monitoring to be launched for any changes to resident status or care.

Careplans to be reviewed at weekly chart review for accuracy of resident care needs and direction to staff.

RSCs to complete Service Plan update within 30 days of move-in by checking dashboard daily to identify Service Plans coming due.

3.  24 hour report to be completed and reviewed daily.

Outside Provider Notes to be reviewed daily by MT and checked by RSC.

Alert charting to be reviewed and updated daily by MT.

Skin log to be monitored weekly by RN with weekly charting notes until resolved.

Dashboard to reviewed daily by RSCs to identify Service Plans coming due for updates.

Service Plan to be reviewed for accuracy weekly by RSC's and RN as needed.  Administrator to evaluate.

4. Administrator

4. Resident 4 was admitted to the facility in October 2020 with diagnoses including Type 1 Diabetes.

Review of the resident's 6/23/21 through 8/18/21 outside provider notes identified changes of condition related to a leg wound.

There was no documented evidence the facility RN monitored the status of the leg wound or coordinated with the outside agency providing wound care to ensure their monitoring instructions and interventions were implemented and documented in the resident's record.

Interviews with staff during the survey from 9/13/21 through 9/15/21 confirmed the facility failed to monitor and document on the status of the wound.  

The need to ensure the facility monitored the resident and documented on the progress of the wound at least weekly following a change of condition was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Administrator), Staff 6 ( Resident Services Coordinator) and Staff 7 (Resident Services Coordinator) on 9/15/21. They acknowledged the findings.

2. Resident 6 was admitted to the facility in November 2017 with diagnoses including chronic obstructive pulmonary disease.

Resident 2's progress notes dated 6/25/21 through 9/13/21 were reviewed and revealed the resident experienced the following changes of condition:

* On 6/25/21, progress notes revealed a fall with a head wound; and

* On 8/15/21, progress notes revealed a fall with multiple rib fractures.

There was no documented evidence the head wound had been monitored weekly to resolution.

The facility failed to implement the determined intervention to lower Resident 6's bed related to the fall on 6/25/21.

There was no documented evidence Resident 6's fall interventions were evaluated with each instance and monitored for effectiveness.

The need to ensure the facility had a system for evaluating changes of condition and monitoring until resolved was reviewed with Staff 1 (Executive Director), Staff 2 (Health Services Administrator), Staff 6 (Resident Services Coordinator) and Staff 7 (Resident Services Coordinator) on 9/15/21. They acknowledged the findings.

3. Resident 5 admitted to the facility in August of 2017 with diagnoses to include neuralgia, neuritis and kyphosis of the cervical region.

Review of Resident 5's record revealed s/he was sent to the hospital for uncontrolled pain on 5/15/21.

During an interview on 9/14/21 at 9:15 am, Resident 5 reported the cause of the increased back pain was related to two staff moving him/her up in bed by pulling under both of his/her arms. The resident reported feeling severe back pain as a result from the assistance provided.

The resident experienced a change of condition related to increased pain resulting in transfer to the hospital. There was no evaluation completed to determine potential cause, determine actions/interventions indicated.

The need to ensure the facility had a system for evaluating changes of condition was reviewed with Staff 1 (Executive Director), Staff 2 (Health Services Administrator), Staff 6 (Resident Services Coordinator) and Staff 7 (Resident Services Coordinator) on 9/15/21. They acknowledged the findings.

5. Resident 2 was admitted to the facility in February 2018 with diagnoses including failure to thrive.

a. Review of Resident 2's 3/20/21 through 9/14/21 weight records revealed the resident experienced the following significant weight changes:

* Resident 2's documented weight went from 122.8 pounds on 4/5/21 to 105 pounds on 6/26/21, which was a 17.8 pound or 14.49% weight loss in two months which constituted a severe weight loss and significant change of condition.

There was no documented evidence the facility evaluated the resident, referred to the facility RN and updated the service plan.

* Resident 2's documented weight went from 105 pounds on 8/24/21 to 120 pounds on 9/9/21, which was a 15 pound or 14.28% weight gain and constituted a severe weight gain and significant change of condition.

There was no documented evidence the facility evaluated the resident, referred the resident to the facility nurse or updated the service plan .

The facility was requested to reweigh the resident during survey. Resident 2's weight on 9/14/21 was 120 pounds.

b. Review of Resident 2's 6/13/21 through 9/13/21 facility record revealed the resident experienced multiple short-term changes of condition related to the following for which the facility failed to determine what actions and interventions were needed for the resident, communicate them to staff on all shifts, update the service plan and monitor the changes until resolution:

* TIA;

* UTI;

* Medication changes;

* Stage 1 pressure area on right hip;

* "Skinned" left knee; and

* Scratch on right hip.

The failure of the facility to evaluate the resident, refer to the facility RN and update the service plan when the resident experienced significant changes related to weight and failure to determine what actions and interventions were needed for the resident when they experienced short term changes of condition, communicate them to staff on all shifts, update the service plan and monitor the changes through resolution was discussed with Staff 2 (Health Services Administrator), Staff 6 (Resident Services Coordinator) and Staff 7 (Resident Services Coordinator) on 9/15/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to evaluate and monitor changes of conditions, refer any significant changes of condition to the RN, determine and document actions or interventions and communicate those to staff for 5 of 6 sampled residents (#s 2, 3, 4, 5, and 6) who had changes of condition. Findings include, but are not limited to:

1. Review of Resident 3's progress notes and nursing notes dated 7/16/21 through 9/12/21 revealed s/he was not monitored after being admitted to the facility in 7/2021.

Physician orders dated 8/27/21 revealed Resident 3 had multiple medication changes and s/he was not monitored for effectiveness or adverse side effects for the following medication changes:

* Solifenacin succinate;

* Trazadone;

* Pramipexole;

* Triamcinolone cream;

* Trihexyphenidyl 1 mg; and

* Trihexyphnidyl 2 mg.

Interviews with Staff 7 (Resident Services Coordinator) and Staff 1 (Executive Director) on 9/14/21 confirmed staff had not monitored Resident 3 after s/he moved into the facility or when medications were changed.

The need to ensure the facility evaluate and monitor changes of conditions, refer any significant changes of condition to the RN, determine and document actions or interventions and communicate those to staff was discussed with Staff 1, Staff 2 (Health Services Administrator), Staff 6 (Resident Services Coordinator) and Staff 7 on 9/15/21. They acknowledged the findings.

1. Short term changes of condition evaluated for all residents with no intervention needed.  Significant changes of conditions assessed by RN and completed for said residents.  

2. Med-techs are to put out TSPs and initiate alert charting for any short term changes of condition. Nurse will review the alert charting and 24 hour report

daily. Nurse will follow-up to determine if short-term or significant change of condition is present and will monitor, chart and assess accordingly.

Additionally, the RSCs, RN & Administrator will review all residents to evaluate these changes at their

weekly chart review meeting. Skin log, bowel log, eMAR Reports, alert charting, care plan updates and vitals are all reviewed. A tracking form is used with specific prompts to question whether there has been a recent change of condition, and whether it is significant or short term change of condition.

3) Alert charting, 24 hour reports, skin log, and eMAR reports are reviewed daily and at weekly chart review meeting. Care plan updates and vitals are reviewed weekly.

3.  Weekly and evaluated by RSC's, RN and Administrator.

4.  RN  

Based on interview and record review, it was determined the facility failed to ensure an RN assessment was completed for significant changes of condition, including findings, resident status and interventions made as a result of the assessment, for 2 of 4 sampled residents (#s 2 and 6) who experienced significant changes of condition related to significant weight changes and a fall with fractures. Findings include, but are not limited to:

1. Resident 6 was admitted to the facility in 2017 with diagnoses including chronic obstructive pulmonary disease.

During the acuity interview on 9/13/21 it was revealed that Resident 6 had fallen and sustained multiple rib fractures.

Resident 6 experienced a significant change of condition related to the fall with multiple rib fractures. There was no documented evidence an RN assessment was completed for the significant change of condition.

The need to complete an RN assessment for significant changes of condition, to include findings, resident status and interventions, was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Administrator) Staff 6 (Resident Services Coordinator) and Staff 7 (Resident Services Coordinator). They acknowledged the findings.

2. Resident 2 was admitted to the facility in February 2018 with diagnoses including failure to thrive.

Review of Resident 2's 3/20/21 through 9/14/21 weight records revealed the resident experienced the following significant weight changes:

a. Resident 2's documented weight went from 122.8 pounds on 4/5/21 to 105 pounds on 6/26/21, which was a 17.8 pound or 14.49% weight loss in two months which constituted a severe weight loss and significant change of condition.

There was no documented evidence the facility RN completed an assessment following the resident's significant weight loss.

b. Resident 2's documented weight went from 105 pounds on 8/24/21 to 120 pounds on 9/9/21, which was a 15 pound or 14.28% weight gain in one month and constituted a severe weight gain and significant change of condition.

There was no documented evidence the facility RN completed an assessment following the resident's significant weight gain.

The need to ensure the facility RN completed an assessment when resident's experienced significant changes of conation was discussed with Staff 2 (Health Services Director), Staff 6 (Resident Services Coordinator) and Staff 7 (Resident Services Coordinator) on 9/15/21. They acknowledged the findings.

1. Significant changes of condition assesments completed by RN for residents 2 and 6  

2. Med-techs are to put out TSPs and initiate alert charting for any change in condition. Nurse will review the alert charting and 24 hour report

daily. Nurse will follow-up to determine if short-term or significant change of condition is present and will monitor, chart and assess accordingly.

Residents to be monitored for Significant changes of condition by RN and RSC's.  This monitoring will take place during daily dashboard reviews of EHR (includes alert charting, 24 hour reports, vital monitoring, eMAR reports, skin monitoring) and weekly chart reviews.

3. Systems to be reviewed weekly by RN, RSC's and Administrator.

4.  RN

Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules, for 1 of 1 sampled resident (# 7) who received insulin injections by unlicensed facility staff.  Findings include, but are not limited to:

During the acuity interview on 9/13/21, Resident 7 was identified to be administered insulin injections by non-licensed staff.

Review of Resident 7's delegation documentation during the survey revealed the following:

Staff 14 (MA) was initially delegated to perform insulin injections on Resident 7 on 7/7/21. Re-evaluation of Staff 14's delegation duties was not completed within 60 days of initial delegation.

The need to ensure delegation and supervision of special tasks of nursing care was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Administrator), Staff 6 (Resident Services Coordinator) and Staff 7 (Resident Services Coordinator) on 9/15/21. They acknowledged the findings.

1.  Delegation duties reviewed in detail for all delegated Med-Techs.

2.  Monthly reviews to ensure accuracy by RN.

Additionally, a delegation tracker is kept to record dates of delegation and track when coming due. In addition to the RN reviewing delegation dates, MTs should check the tracker weekly and communicate with the RN if they are nearing their due date.

3.  Monthly reviews to ensure accuracy by RN.

4. RN

2. Resident 5's records were reviewed and identified he/she was receiving home health physical and occupational therapy services.

The facility failed to ensure the following home health recommendations made between 7/16/21 and 8/30/21 were added to the service plan and communicated to staff:

* "Check heels, elbows, bottom frequently";

* "Donn back brace in bed by rolling prior to hoyer transfer";

* "Once in tilt in space wheel chair, tilt pt (patient) all the way back";

* "Please have staff assist pt into wheelchair one time per day each day";

* "Bed to wheelchair hoyer lift, please get pt into wheelchair one time per day two person assist for rolling and mobility"; and

* "Please get pt up in wheelchair that she has in room currently. Pt tolerates being in wheelchair for 30-60 minutes at a time".

During interview with Staff 2 (Health Services Administrator), he reported that the resident refuses to get up to the wheelchair.

There was no evidence the facility had communicated the residents refusal to get up from bed with staff to the outside provider, nor was the service plan updated and recommendations communicated to staff.

The need to ensure outside provider care was coordinated and implemented was reviewed with Staff 1 (Executive Director), Staff  2 ( Health Services Administrator), Staff 6 (Resident Services Coordinator) and Staff 7 (Resident Services Coordinator). They acknowledged Resident 5's service plan had not been updated to include the home health recommendations.

Based on interview and record review, it was determined the facility failed to coordinate care with outside providers, ensure that clinical information was reviewed and recommendations added to the service plan for 3 of 4 sampled residents (#s 2, 4 and 5) who were receiving services from outside providers. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in February 2018 with diagnoses including failure to thrive.

During the acuity interview on 9/13/21, the resident was reported to receive hospice services from an outside service provider.

Review of Resident 2's 6/13/21 through 9/13/21 facility record revealed the following hospice communications and clinical information were not reviewed for follow up and were not added to the service plan:

* 6/25/21: RN: "Call hospice prior to administering ...lorazepam";

* 6/28/21 RN: "Fluids bedside";

* 7/5/21 RN: "Calendar to monitor BM";

* 8/3/21 Bath aide: "Looks as if (s/he) has a scratch on R hip";

* 8/3/21 RN: "Premedicate with morphine prior to cares";

* 8/9/21 RN: "1. Monitor for signs and symptoms of UTI 2. Track BMs ...5. Continue to medicate patient prior to cares/transfers with morphine."

* 8/23/21 Bath aide: "Looks like (s/he) has a skinned left knee."

* 9/1/21 RN: "Please, please, please have staff utilize BM tracking calendar in (his/her) bathroom. There was only one BM tracked for August and I'm guessing that's not accurate in regards to frequency. I need the information for documentation and to be sure (s/he) is comfortable."

The failure of the facility to coordinate care with outside providers, ensure that clinical information was reviewed and recommendations added to the service plan was discussed with Staff 2 (Health Services Administrator), Staff 6 (Resident Services Coordinator) and Staff 7 (Resident Services Coordinator) on 9/15/21. They acknowledged the findings.

3. Resident 4 was admitted to the facility in October 2020 with diagnoses including Type 1 Diabetes.

During the acuity interview on 9/13/21, Resident 4 was identified as receiving outside provider services related to wound care.

Outside provider notes for the previous 90 days were requested. Three HH notes were provided and reviewed:

* HH note dated 6/23/21 identified the wound was worsening and instructed staff to monitor the wound for saturation daily and change as needed;

* HH note dated 7/23/21 indicated the resident received wound care from HH once a week; and

* HH note dated 8/18/21 instructed staff to encourage the resident to elevate their lower extremity and for staff to monitor signs and symptoms of an infection and to report concerns to HH 24/7.

Interviews on 9/14/21 and 9/15/21 revealed staff were unclear on how often HH provided wound care or if the resident was going out to a wound clinic.

There was no documented evidence the facility consistently collected written information from the outside provider visits or implemented the above instructions and monitoring into the resident's record.

The need to ensure ongoing coordination of care was maintained, documented, and implemented was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Administrator), Staff 6 (Resident Services Coordinator), and Staff 7 (Resident Services Coordinator) on 9/15/21. They acknowledged the findings.

1. Outside provider notes for each resident were reviewed and care planned accordingly.

2. Outside provider notes to be reviewed daily by Med-Tech and TSPs, alert charting or incident reports launched for any changes identified. RSCs to do a second check for review of details and if accurate documentation and communication has been started. Final review to be done by RN.

Additionally, all Outside provider notes to be reviewed weekly during each resident chart review.

3.  System to be reviewed weekly during chart review by RSC, RN and Administrator.

4. Administrator

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

During the relicensure survey, conducted 9/13/21 through 9/15/21, 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 282: Systems:  RN Delegation and Teaching;

* C 302: Systems: Tracking Controlled Substances;

* C 303: Systems: Medication and Treatment Orders;

* C 305:  Systems: Residents Right to Refuse;

* C 310: Systems: Medication Administration;

* C 325: Systems:  Self Administration of Medication; and

* C 330: Systems:  Psychotropic Medications.

Failure to ensure a safe medication system and to ensure adequate professional oversight based on deficiencies related to medication administration was discussed during the exit meeting on 9/15/21.

See POC for C282, C302, C303, C305, C310, C325, C330

Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 1 of 3 sampled resident (# 2) whose MARs and Controlled Substance Disposition logs were reviewed for accuracy. Findings include, but are not limited to:

Resident 2 was admitted to the facility in February 2018 with diagnoses including a history of a lumbar compression fracture.

Resident 2's 6/23/21 signed physician orders included .25 ml morphine sulfate oral solution  prn every 2 hours for severe pain or shortness of breath.

Review of the 8/1/21 through 9/13/21 MAR and Controlled Substance Disposition logs revealed one dose of morphine sulfate was signed out on the disposition log on 8/14/21 and another on 9/4/21. Neither were initialed as administered on the MAR.

The need to ensure an accurate narcotic disposition log was maintained for all controlled substances was discussed with Staff 2 (Health Services Administrator), Staff 6 (Resident Services Coordinator) and Staff 7 (Resident Services Coordinator) on 9/15/21. They acknowledged the findings.   

1.  This residents MAR and disposition log reviewed for accuracy and discrepencies.

2.  Med-Techs to utilize charting feature in eMAR to document number of narcotics on the MAR to log in the Narcotic log.

Narcotic log to be reviewed weekly by NOC shift MT.

Monthly review of narcotic disposition logs and MAR's by RN.

3.  System to be reviewed by RN on a monthly basis.

4. RN

2. Review of Resident 2's current physician orders and 8/1/21 through 9/12/21 MAR revealed the following:

a. The facility lacked documented evidence of signed provider orders for the following medications that were transcribed onto the MAR:

* Antac + sim (stomach upset);

* Milk of Magnesia (bowel care);

* Sodium Phosphate enema ( bowel care);  

* Triple antibiotic ointment (skin); and

* Sulfa/trim antibiotic (UTI).

b. Signed prescriber order dated 6/25/21 indicated staff were to call hospice RN prior to administering lorazepam for anxiety/agitation/shortness of breath. Resident 2 was administered lorazepam on 8/19/21. There was no documented evidence the facility called the hospice RN prior to the administration of the medication.

The need to ensure signed prescriber orders were documented in the resident's facility record for all medications the facility was responsible to administer and that orders were carried out as prescribed was discussed with Staff 2 (Administrator), Staff 6 (Resident Service Coordinator) and Staff 7 (Resident Service Coordinator) on 9/15/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed for all medications the facility was responsible to administer, for 2 of 6 sampled residents (#s 2 and 3) whose MARs and orders were reviewed. Findings include, but are not limited to:

1. Review of Resident 3's MAR dated 9/1/21 through 9/12/21 and most recent signed physician's orders dated 8/27/21 revealed the following medication which were not on the MAR:

* Atorvastin 20 mg (cholesterol);

* Hydrocortisone acetate1% cream (itch); and

* PRN Trazadone 50 mg (sleep).

The need to ensure medication and treatment orders were carried out as prescribed for all medications the facility was responsible to administer was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Administrator), Staff 6 (Resident Services Coordinator) and Staff 7 (Resident Services Coordinator) on 9/15/21. They acknowledged the findings.

1.  Listed discrepencies have been reconciled with appropriate physician. Med-Techs have been trained on following orders as prescribed

2. Upon receiving any new order, after-visit summary, or med list from a doctor a three-check system will take place. First, Med-Tech will reconcile against eMAR, RSC will double check and RN will triple check. We will fax doctor to clarify if any discrepencies are identified.

Additionally, medication reviews to occur on a quarterly basis for all residents.

Through monthly audits we will initiate pulling random sampling of residents of which will be the responsibility of the RSC, RN and Administrator.

When notification to a provider is required per the orders, Med-Tech to be trained on and utilize charting prompt in MAR to document if notification took place.

3. Upon receipt of any medication order or list. Monthly checks through random audits. Quarterly medication reviews for all residents.

4.  Administrator

2. Resident 2 was admitted to the facility in February 2018 with diagnoses including compression fracture of lumbar vertebrae and constipation.

Review of Resident 2's current signed physician orders and 8/1/21 through 9/13/21 MAR revealed the resident had refused to consent to multiple medication orders in the time frame reviewed:

* Polyethylene Glycol (bowel care) 11 times;

* Acetaminophen (pain) twice;

* Ibuprofen (pain) twice; and

* Senna (bowel care) twice.

During an interview with Staff 7 (Resident Services Coordinator) on 9/15/21, she reported they had not notified the physician of the refusals.

The need to ensure the physician was notified when a resident refuses to consent to a medication or treatment order was discussed with Staff 2 (Health Services Administrator), Staff 6 (Resident Services Coordinator and ) and Staff 7 on 9/15/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused to consent to orders for 2 of 2 sampled residents (#s 1 and 2) who had documented medication refusals. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in September 2020.

Physician orders directed staff to notify the physician if the resident refused medications for three consecutive days.

Resident 1's MAR from 9/1/21 through 9/13/21 was reviewed and revealed the following:

* The resident refused all his/her medications consecutively from 9/1/21 through 9/4/21 and 9/8/21 through 9/12/21.

There was no documented evidence the facility notified the physician when the resident refused medications for three consecutive days.

The need to ensure the facility notified physicians or practitioners of medication refusals was reviewed with Staff 1 (Executive Director), Staff 2 (Health Services Administrator), Staff 6 (Resident Services Coordinator) and Staff 7 (Resident Services Coordinator) on 9/15/21. The staff acknowledged the findings.

1.  Physician has been notified for refusals for both residents. Med-Techs have been trained on notification to PCP of med refusals.

2. MAR to be reviewed for refusals by RN and RSC's during weekly chart reviews.

Section created in Med Room Binder specific for "Medication Refusal" tracking. Med Techs should place faxes sent to doctor notifying doctor of refusal in this section. RN to complete a weekly audit to identify if notifications are taking place.

3. Evaluated weekly during the chart reviews and binder audit to be overseen by RN.

4.  Administrator  

Based on interview and record review, it was determined the facility failed to ensure residents' MARs were accurate, provided clear instruction and parameters for administration of PRN medications, were accurately transcribed, included reason for use, effectiveness of PRN medications administered and listed potential side effects for 6 of 6 sampled residents (#s 1, 2, 3, 4, 5 and 6) whose MARs were reviewed. Findings include, but are not limited to:

1.  Resident 5's 9/1/21 through 9/13/21 MARS were reviewed and revealed the following:

* PRN pain medications (Tylenol, Oxycodone and Tramadol) lacked clear instruction to staff regarding the order of administration;  

* PRN Senna lacked clear instructions for administration in relation to multiple other PRN bowel care medications;

* PRN Tramadol was initialed as administered on 9/1/21 and 9/13/21. There was no evidence the medication had been signed out on the narcotic log or removed from the bottle; and

* The MAR did not include the reason for use for Diazepam.

The need to ensure MARs were accurate, included reason for use and clear parameters and instruction to staff for medication administration  was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Administrator), Staff 6 (Resident Services Coordinator) and Staff 7 (Resident Services Coordinator) on 9/15/21. They acknowledged the findings.

2. Resident 6's 9/1/21 through 9/13/21 MARS were reviewed and revealed the following:

* Multiple PRN bowel care medications (Glycerin Suppository, Milk of Magnesia, Miralax and Senna) lacked instruction to staff regarding the order of administration;  and

* The MAR did not include the reason for use of Spireva Respirmat inhaler and Caltrate+D3.

The need to ensure MARs included reason for use, clear parameters and instruction to staff for medication administration  was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Administrator), Staff 6 (Resident Services Coordinator) and Staff 7 (Resident Services Coordinator) on 9/15/21. They acknowledged the findings.

3. Review of Resident 2's 8/1/21 through 9/13/21 MAR and current physician orders revealed the following:

* Instructions on the MAR for prn acetaminophen were to administer for mild pain and morphine for moderate to severe pain.  There were no parameters listed for staff to determine what constituted mild/moderate/severe pain.

* Prescriber orders on 8/3/21 instructed staff to call hospice RN prior to administration of Lorazepam. The instructions were not transcribed onto the MAR.

* Reasons for use for scheduled acetaminophen and ibuprofen were incorrectly transcribed onto the MAR from the physician's order.

* Senna was indicated to have been held on 9/3/21 without documentation as to the reason.

* PRN morphine instructions on the MAR indicated the medication was to be administered for moderate to severe pain or shortness of breath. The medication was administered multiple times during the time frame reviewed without documentation as to the reason for administration.

The need to ensure MARs were accurate, included clear parameters and instruction to staff for medication administration  was discussed with Staff 2 (Health Services Administrator), Staff 6 (Resident Services Coordinator) and Staff 7 (Resident Services Coordinator) on 9/15/21. They acknowledged the findings.

4. Review of Resident 3's MAR dated 9/1/21 through 9/12/21 was reviewed and revealed the following medications lacked reasons for use:

* Donepezil;

* Finasteride;

* Florastor;

* Lions mane mushroom tab;

* Reservatrol;

* Liposomal Glutathione liquid;

* Lisinopril;

* Pramipexole;

* Rosuvastin;

* Solifenacin Succinate;

* Trazadone;

* Vitamin B-12;

* Xarelto;

* Pramipoxele;

* Trihexyphenidyl HCL;

* Loperamide;

* Geri-Lanta Susp; and

* Multiple bowel medications (bisacodyl suppository, milk of mag and sodium phosphate enema).

The need to ensure all medications have a reason for use was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Administrator), Staff 5 (Resident Services Coordinator) and Staff 7 (Resident Services Coordinator) on 9/15/21. They acknowledged the findings.

5. Resident 1 was admitted to the facility in September 2020 with diagnoses that included Major Depressive Disorder and Atrial Fibrillation.

Resident 1's 9/1/21 through 9/13/21 MAR was reviewed and identified the following medications were lacking reasons for use:

* Bystolic;

* Sertraline;

* Flecainide; and

* Trimethoprim.

The need to ensure MARs were accurate and included reasons for use was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Administrator), Staff 6 (Resident Services Coordinator) and Staff 7 (Resident Services Coordinator) on 9/15/21. They acknowledged the findings.   

6. Resident 4's 9/1/21 through 9/13/21 MAR was reviewed and identified the following:

* PRN Polyethylene Glycol Powder lacked clear instructions for administration in relation to multiple other PRN bowel care medications.

The need to ensure MARs included clear instructions to staff for medication administration was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Administrator), Staff 6 (Resident Services Coordinator) and Staff 7 (Resident Services Coordinator) on 9/15/21. They acknowledged the findings.   

1. PRN medications for sampled residents now have clear instructions. The medications without reasons for use now have reasons for use. Staff education for when to notify hospice according to the hospice orders and for notifying RN if parameters are missing on a PRN.  For sampled residents, discrepencies between the MAR and narcotic log are resolved.  

2. Upon receiving new order, MT does first check and should chart 'do not give, must notify RN first,' RSC does 2nd review of order and RN does final review of order and place parameters.

Additionally, PRN and indications for use would be captured during the weekly chart review.   

Narcotic log to be reviewed weekly by NOC MedTech's.

3. Weekly by the RN, RSC's and Administrator

4. RN  

Based on interview and record review, it was determined the facility failed to ensure self-administration of medication evaluations were completed quarterly for 1 of 4 sampled resident (#4) who self-administered medications. Findings include, but are not limited to:

Resident 4 was admitted to the facility in October 2020 with diagnoses including Type 1 Diabetes.

During the acuity interview on 9/13/21, Resident 4 was identified as self-administering his/her insulin injections.

A review of the clinical record revealed the self-administration evaluation was last completed on 10/26/20. There was no documented evidence the facility had completed the quarterly self-administration evaluations for Resident 4's insulin injections.

The need to ensure the facility evaluated Resident 4's ability to safely self-administer his/her insulin injections quarterly was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Administrator), Staff 6 (Resident Services Coordinator) and Staff 7 (Resident Services Coordinator) on 9/15/21. They acknowledged the findings.  

1. Self med assessment performed for sampled resident

2. Self med assessments to be reviewed during weekly chart reviews.

EHR to be reviewed daily for notification of assessments coming due.

3.  Weekly chart reviews will evaluate assessments like the self med assessment for completion and timeliness.

4.  RN

Based on interview and record review, it was determined the facility failed to ensure prn medications used to treat a resident's behavior had written, resident-specific parameters and non-drug interventions for staff to attempt prior to administering a PRN psychotropic medication for 1 of 1 sampled resident (#2) whose facility record was reviewed for psychotropic medications. Findings include, but are not limited to:

Resident 2 was admitted to the facility in February 2018.

Review of Resident 2's facility record revealed signed physician orders dated 6/23/21 which included:

Lorazepam, 0.5 mg, to be administered prn every four hours for anxiety/agitation/shortness of breath.  

Review of the the 8/1/21 through 9/14/21 MAR revealed it lacked instruction related to non-pharmalogical interventions for staff to attempt prior to administration of the medication and failed to identify how the resident's anxiety/agitation was displayed.

Resident 2 was administered prn Lorazepam on 8/19/21. There was no documentation which indicated why the medication had been administered or that non-pharmalogical interventions had been attempted prior to administration.

The need to ensure non-pharmalogical interventions were listed on the MAR for staff to attempt prior to administering psychotropic medications for behaviors and that the interventions were attempted with ineffective results prior to administration of the medication was discussed with Staff 2 (Health Services Administrator), Staff 6 (Resident Service Coordinator) and Staff 7 (Resident Service Coordinator) on 9/15/21. They acknowledged the findings.

1. Psychotropic medications have been updated with non-pharmalogical interventions to follow and how anxiety/agitation presents.

2. During weekly chart reviews, psychotropic medications will be reviewed to ensure they have non-pharmalogical interventions and signs and symptoms related to indicated use.

3. This area will be evaluated at the same time of the weekly chart reviews.

4. RN

Based on observation, interview and record review, it was determined the facility failed to ensure supportive devices with potentially restraining qualities were assessed, included a thorough review by an RN, PT or OT prior to use, documented less restrictive alternatives prior to use, and provided instruction to caregivers on the correct use of and precautions for the device for 1 of 2 sampled residents (#5) who had side rails on their bed. Findings include, but are not limited to:

On 9/14/21 Resident 5's bed was observed to have two quarter length side rails in the up position.

There was no documented evidence the device with restraining qualities had been assessed by an RN, PT or OT including documentation of less restrictive alternatives prior to use, nor was there evidence the service plan had identified the use of and precautions related to the device.

The lack of assessment and instructions provided for use of supportive devices with potentially restraining qualities was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Administrator), Staff 6 (Health Services Coordinator) and Staff 7 (Health Services Coordinator) on 9/15/21. They acknowledged the findings.

1. RN has assessed residents side rails. Training completed by all staff on side rail use, safety and what to communicate to the RN.

2.  All supportive devices with restraining qualities that are recommended will be reviewed during our weekly chart reviews.

Upon entering side raile use for a resident in their Evaluation, an assessment will be prompted for RN to complete.

3.  To be reviewed weekly by RN

4. RN  

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 newly hired direct care staff (#s 11 and 14) had documentation of demonstrated competency in all assigned job duties within 30 days of hire. Findings include, but are not limited to:

Review of training records with Staff 3 (Business Office Manager) on 9/15/21 revealed Staff 11 (CG) and Staff 14 (MT) lacked documented evidence competency was demonstrated in the following required areas:

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

* Providing assistance with ADLs;

The need to ensure staff demonstrated competency in all assigned job duties within 30 days of hire was reviewed with Staff 3 (Business Office Manager), Staff 2 (Health Services Administrator), Staff 6 (Resident Service Coordinator) and Staff 7 (Resident Service Coordinator) on 9/15/21. No further information was provided.

1. By 11/14/21, all employees have completed preservice and 30-day training requirements.

Additionally, new staff members will not start training on the floor until these trainings are completed. A training report can be ran to help audit training records.

2. Business Office Manager and Administrator will audit training records at least every two weeks for trainings that are not complete.

3. This will be evaluated by the Business Office Manager and Administrator at least monthly.

4. Administrator

Based on interview and record review, it was determined the facility failed to document a minimum of 12 hours of annual in-service training related to the provision of care in a community based care was completed for 1 of 3 long term staff (#17) whose training records were reviewed. Findings include, but are not limited to:

Staff training records reviewed on 9/15/21 revealed Staff 17 (CG), hired 9/1/17, had completed six of the required 12 hours of annual in-service training.

The need to ensure all required in-service training hours and requirements were completed annually was reviewed with Staff 3 (Business Office Manager), Staff 2 (Health Services Administrator), Staff 6 (Resident Services Coordinator) and Staff 7 (Resident Services Coordinator) on 9/15/21. No further information was provided.

1.By 11/14/21, employees who are lacking their 12 hours of annual inservice training related to the provision of care will be

assigned additional trainings to meet the hours requirement. A training report can be ran to help audit training records.

2. Business Office Manager and Administrator will audit training records at least every two weeks for trainings that are not complete.

3. This will be evaluated by the Business Office Manager and Administrator at least monthly.

4. Administrator

Based on interview and record review, it was determined the facility failed to provide documentation that fire drills included all required components and fire life safety training was conducted on alternating months. Findings include, but are not limited to:

Fire and life safety records for March 2021- August 2021 were reviewed and lacked the following components:

* Location of simulated fire origin;

* Evacuation time period needed;

* Escape route used;

* Number of occupants evacuated; and

* There was no documented evidence that fire and life safety training was conducted on alternating months of fire drills.

The need to ensure the facility was in compliance with all required fire drill components and fire and life safety instruction was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Administrator), Staff 6 (Resident Services Coordinator) and Staff 7 (Resident Services Coordinator) on 9/15/21. They acknowledged the findings.

1. Fire drill forms have been updated to include the missing components that must be documented.

2. Fire drill form has been updated. Monthly calendar of fire and life safety trainings has been updated and will be followed.

3. To be evaluated on a monthly basis by Director of Plant Operations and Administrator.

4. Director of Plant Operations

Based on observation and interview, it was determined the facility failed to ensure perimeter walkway surfaces were maintained in good repair. Findings include, but are not limited to:

Observations of the concrete walkways along the perimeter of the building on 9/14/21 showed there were multiple drop offs of 2-6 inches along pathway edges which created potential hazards for residents.  

The need to ensure the pathways did not have potential safety hazards was discussed with Staff 1 (Executive Director) and Staff 2 (Health Services Administrator) on 9/15/2121. The staff acknowledged the findings.

1. Drop offs along walking paths have been filled in to eliminate the potential hazards.

2. Plant operations to perform environmental audits of paths weekly to ensure they are free of potential hazards.

3. Administrator and Director of Plant Operations to evaluate this area at least quarterly.

4. Director of Plant Operations, Administrator

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 installed in locations that were subject to incidental contact by individuals. Findings include, but are not limited to:

During a tour of the environment on 9/15/21 with Staff 2 (Health Services Director), the fireplace in the common area across from the mailboxes was turned on for inspection. The temperature of the metal screen covering the fireplace registered 147 degrees F when measured with the surveyor's thermometer. Staff 2 reported he would keep the remote control for the unit in his office until the fireplace screen reached a temperature below 120 degrees.

The need to ensure residents could not come into incidental contact with fireplace elements that exceeded 120 degrees F was discussed with Staff 2 on 9/15/21. He acknowledged the findings.

1. Fireplace no longer in use and remote is in Administrators locked office drawer.

2. Fireplace company to evaluate temperature and to ensure temperature to be below 120 degrees.  

3. Monthly temperature check to be completed by Maintenance.  Adminstrator to ensure process.

4. Administrator