Print Inspection: 6KVY

The findings of the re-licensure survey conducted 07/17/23 through 07/21/23 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first re-visit to the re-licensure survey of 07/21/23, conducted 02/20/24 through 02/21/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:  activities of daily living

bid: twice a day

CBG: capillary blood glucose or blood sugar

CG: caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH: Home Health

LPN:Licensed Practical Nurse

MA:Medication Aide

MAR: Medication Administration Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:quality improvement

RCC:Resident Care Coordinator

RN:Registered Nurse

TAR:Treatment Administration Record

tid:three times a day

The findings of the second revisit to the re-licensure survey of 07/21/23, conducted on 04/18/24, 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 interview and record review, it was determined the facility failed to ensure resident move-in evaluations addressed all required components for 1 of 1 sampled resident (#4) whose new move-in evaluation was reviewed. Findings include, but are not limited to:

Resident 4 moved into the facility in 04/2023.

A record review of the new move-in evaluation failed to address the following areas:

* Customary routines, including bathing;

* Cognition, including memory and confusion;

* History of treatment of mental health issues;

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

* Ability to understand and be understood; and

* Non-pharmaceutical interventions for pain.

The need to ensure move-in evaluations included all required elements was discussed with Staff 1 (ED) and Staff 2 (RN) on 07/21/22. They acknowledged the findings.

1. Evaluation and service plan for resident #4 has been updated to include all required elements.

2. To prevent reccurence, facility will complete preadmission evaluations per regulation and company policy on all new residents. Facility to utilize admisision checklist to ensure that all required elements are addressed. Evaluation will then be reviewed again upon admission to verify that all elements have been addressed.  Evaluations will then be completed within 30 days, quarterly and with significant change of condition.

3. This system to be audited by RCC utilizing the clinical admission checklist which includes elements to be audited prior to admission, upon admission, 72 hours from admission and at 30 days. This system will be evaluated monthly as part of our CQI (Continuous Quality Improvement) program.

4. The Executive Director is responsible for maintaining this system.

2. Resident 4 was admitted to the facility in 04/2023 with diagnoses including chronic venous hypertension with ulcers of bilateral lower extremities and lymphedema.

Resident 4's current service plan, dated 06/15/23, was reviewed, observations were made, and interviews were conducted between 07/17/23 and 07/21/23. Resident 4's service plan was not reflective and did not provide clear instruction to staff in the following areas:

* Cat description and care, including strategies to keep the cat in the apartment;

* Outside provider information, including contact information and frequency of visits;

* Front-wheeled walker vs four-wheeled walker;

* Communication needs;

* Preferences regarding bathroom privacy;

* Falls and fall interventions;

* Pain; and

* Wound care, including management of soiled bandages between home health visits.

The need to ensure service plans were reflective of the identified needs of the resident and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 2 (RN) on 07/21/22. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of resident care needs or provided clear direction to staff regarding the delivery of services for 2 of 5 sampled residents (#s 4 and 5) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 5 was admitted to the facility in 04/2021 with diagnoses including bipolar disorder, hearing loss, and obesity.

Observations of the resident apartment, interviews with the resident and staff from 07/17/23 to 07/20/23, and review of the service plan, dated 07/10/23, indicated the service plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas:

* Transfers;

* Toileting;

* Side rails; and

* Communication interventions for verbal behaviors.

The need for service plans to be reflective of the resident's current care needs and provide clear instruction to staff was discussed with Staff 1 (ED), and Staff 2 (RN) on 07/21/23. They acknowledged the findings.

1. Service plans for resident #4 and resident #5 have been updated to be reflective of current needs and interventions, including clear instructions to staff and have been printed for staff to review.

2. To prevent recurrance, all current resident service plans will be audited for accuracy. Direct care staff will be reeducated regarding the importance of reporting any questions or concerns related to resident service plans as well as reviewing all ISPs as part of shift change. A form was implemented for care staff to document any discrepancies between resident service plans and actual care needs. Form is to be turned into Executive Director so that service plans can be updated and reflective.

3. Interim Service Plans (ISPs) will be reviewed at standup as part of the 24hr/72hr summary review (includes all progress notes written in past 24/72 hours), and service plans will be updated as needed. Service plans will be evaluated and reviewed by all departments upon admission, at 30 days, quarterly and with significant change of condition.

4. The Executive Director will be responsible for maintaining this system.

Based on interview and record review, it was determined the facility failed to ensure resident specific instructions or interventions were developed for short-term changes of condition, the interventions were communicated to the staff and the condition was monitored, at least weekly, through resolution for 1 of 3 sampled residents (#4) who experienced changes of condition. Findings include, but are not limited to:

Resident 4 was admitted to the facility in 04/2023 with diagnoses including lymphedema and chronic venous hypertension with ulcers of bilateral lower extremities.

The resident's current service plan dated 06/15/23, progress notes dated 04/25/23 through 07/16/23, and corresponding incident reports were reviewed.

The resident had multiple documented short-term changes of condition between 04/28/23 and 07/16/23.

a. The following changes of condition lacked documented evidence determined actions or interventions were communicated to staff on all shifts:

* 04/28/23 - New admission to the facility;

* 05/06/23 - New antibiotic for leg infection;

* 05/11/23 - New medication (miconazole);

* 05/15/23 - Fall;

* 05/31/23 - Gabapentin dosing change;

* 06/06/23 - Fall with hip bruising;

* 07/12/23 - Fall;

* 07/12/23 - ED visit; and

* 07/13/23 - Fall with bruising.

On 07/21/23 at approximately 9:15 am, Staff 1 (ED) confirmed the facility used interim service plans (ISPs) which were retained in the facility's computer documentation system; however, caregiving staff were unable to access the computer system. The facility printed ISPs for the caregiving staff on all shifts to read and sign; but the facility shredded the ISPs after two or three weeks and retained no copy to demonstrate the communication of interventions to all staff.

b. The following changes of condition lacked documented evidence they were monitored, at least weekly, through resolution:

* 04/28/23 - New admission to the facility;

* 04/28/23 - Chronic bilateral leg wounds;

* 05/03/23 - Two bruises on right arm;

* 05/06/23 - New antibiotic for leg infection;

* 05/11/23 - New medication (miconazole);

* 05/31/23 - Gabapentin dosing change;

* 06/02/23 - Fall;

* 06/06/23 - Behaviors; and

* 06/06/23 - Fall with hip bruising.

The need to ensure actions or interventions for short-term changes of condition were communicated to staff on each shift and the change of condition was monitored through resolution was discussed with Staff 1 and Staff 2 (RN) on 07/21/23. They acknowledged the findings.

1. Resident #4 has been assessed by RN and service plan has been updated to include all necessary information and interventions have been added which include clear direction to direct care staff.

2. To prevent recurrence, staff will be reeducated on our alert charting guidelines and when to notify the LN. When a change of condition is identified, the resident will be placed on alert charting, which will trigger a LN assessment that will identify any changes that need to be made to the plan of care. All residents placed on alert charting will be monitored until resolution is documented by the LN. When a change of condition is determined to be a significant change, a comprehensive nursing assessment will be completed by the RN and the RN will monitor until the resident is stable. The 24 hour summary will be reviewed five days a week as part, of daily standup meeting to audit for any progress notes that may indicate the need for alert charting and verify that the resident is on alert. On Mondays, the 72-hour summary will be reviewed to include review of all documentation from the weekend.

3. This system will be evaluated five days a week as part of daily stand up meeting. This system will further be evaluated monthly as part of the facility CQI process which includes a review of all residents who require significant change of condition monitoring.

4. The Executive Director and RN are responsible for maintaining this system.

Based on observation, interview, and record review, it was determined the facility failed to carry out medication orders as prescribed for 1 of 4 sampled residents (#4) whose orders were reviewed. Resident 4 was not administered antidepressants as prescribed which put the resident at risk of potential harm. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 04/2023 with diagnoses including generalized anxiety disorder and lymphedema.

Resident 4's signed physician orders, MAR/TAR dated 07/01/23 through 07/16/23, and progress notes dated 04/25/23 through 07/16/23  were reviewed during the survey and revealed the following:

a. Resident 4 admitted to the facility with a signed physician order, dated 04/24/23, to administer sertraline 50 mg - two tablets twice daily for depression and anxiety. The resident was to receive 100 mg twice daily for a total of 200 mg per day.

On 07/06/23, the facility received an order from Resident 4's primary care provider to change the resident's sertraline administration time. The resident was to receive sertraline 100 mg - two tablets by mouth daily. This totaled 200 mg once daily.

Resident 4's MAR indicated s/he received sertraline 50 mg - four tablets by mouth two times a day for major depressive episodes. This totaled 200 mg twice daily for a total of 400 mg per day, or two times the amount prescribed by the resident's physician. The facility documented the resident received a total of 400 mg of sertraline daily for nine consecutive days between 07/08/23 and 07/16/23.

On 07/18/23 at 9:42 am, Staff 1 (ED) was alerted to the medication error, acknowledged the finding, created an incident report and then self-reported the incident to the local Seniors and People with Disabilities (SPD) office. Confirmation of this reporting was received at 11:54 am on 07/18/23.

During an interview with Resident 4 on 07/18/23 at 12:38 pm, s/he reported the facility had brought him/her four tablets of sertraline recently. The resident questioned the number of pills provided because s/he previously took two tablets of sertraline at a time. The resident was assured the medication change was accurate and directed by the physician. With the increased dosing, the resident complained of stomach upset and increased sleepiness with a recent incident where s/he fell asleep in the restroom. Resident 4 was observed to be sleeping during the day on three separate occasions during the relicensure survey.

The resident's statement was corroborated through a progress note dated 07/07/23 at 10:45 pm which stated the following:

"[Resident 4] was asking why there are 4 pills of Sertraline. HCC (Health Care Coordinator) told that it was [his/her] [doctor] who prescribed the increase. [Resident 4] said yes I saw my [doctor] and he didn't tell me about increase [sic] doses. [Resident 4] said I am worried that it would make me more sleeping [sic] before I ask for Xanax later. So [s/he] took two out and gave it to HCC."

The failure to follow physician orders as prescribed for the resident's sertraline put Resident 4 at serious risk of potential harm.

b. Resident 4 had an order to receive Lasix 40 mg (for swelling) one tablet by mouth two times a day. The medication was not administered as prescribed on nine occasions because the facility was awaiting delivery by the pharmacy, or the MAR was blank.

On 07/20/23 at 11:13 am, the surveyor and Staff 12 (MT) observed and checked the MAR and medication supply. Staff 12 confirmed the medication had not been administered as prescribed.

The need to ensure orders were carried out as prescribed was discussed with Staff 1 (ED) and Staff 2 (RN) on 07/21/22. They acknowledged the findings, and no additional information was provided.

1. Physician orders for residents #4 have been reconciled to original orders to ensure accuracy and have been sent to provider for review and signature. A Medication Aide meeting was held to review the process for documenting medication administration accurately, following up on medications out of stock and reporting any resident concerns about their medcations to the LN.

2. To prevent recurrance, all new orders will go through a triple check process, which includes LN review for accuracy of order transcription. EMAR administration progress notes will be reviewed as part of the 24 hour daily audit (72 hour audit on Mondays) to audit for medications out of stock and the RCC or LN will follow up for timely delivery. Weekly MAR audits will also be completed to audit for missing or incorrect documentation and ongoing education will be provided to medication aides as needed based on findings of audits.

3. This will be reviewed daily as part of stand up meeting and 24/72 hour report audit. Additionally, RCC audits will be completed weekly. All medication and treatment orders will be reconciled quarterly and sent to provider for review and signature.

4. Executive Director, RCC and LN will be responsible for maintaining this system.

2. Resident 8 was admitted to the facility in 08/2018 with diagnoses including atrial fibrillation and sleep apnea.

Review of the resident's most recent 90-day physician order summary, signed by the prescriber on 12/02/23, included an order to "Put on in the morning then take off Compression Stocking at night and wash by hand with a bit of soap then hang up until dry for the next day DAILY." The order summary was stamped and initialed as reviewed by two MTs and a facility nurse using the facility's three-check system.

In an interview on 02/21/24, Staff 25 (Regional Nurse Consultant) confirmed the order had not been added to the resident's MAR or TAR until that day.

In interviews on 02/21/24, Staff 22 (MT) and Staff 24 (CG) both stated they were not putting compression stockings on the resident. In an interview also on 02/21/24, Resident 8 confirmed the facility was not putting compression stockings on him/her.

The need to ensure orders are reviewed and carried out as prescribed was discussed with Staff 1 (ED), Staff 3 (LPN) and Staff 25 on 02/21/24. They acknowledged the order for the compression stockings had not been carried out as prescribed.

Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 2 of 3 sampled residents (#s 7 and 8) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 7 was admitted to the facility in 12/2012 with diagnoses including Type II diabetes with diabetic retinopathy and superficial keratitis of both eyes (inflammation of the cornea).

The resident's MAR and TAR dated 02/01/24 through 02/19/24, current physician orders dated 12/06/23, and updated physician orders following medical appointments on 02/06/24 and 02/16/24 were reviewed. The following was revealed:

* Resident 7 had a physician order, dated 12/06/23, to receive one drop of artificial tears in each eye four times daily for eye health. Following an appointment on 02/06/24, the resident's dosing was increased to every two hours while awake. The dosage was changed back to four times daily on 02/16/24. Both updated physician orders were stamped and initialed as reviewed by two medication technicians using the facility's three-check system.

The resident's TAR indicated artificial tears were administered four times daily from 02/01/24 through 02/19/24. There was no documented evidence the eye drops were administered every two hours between 02/06/24 and 02/16/24 as prescribed.

* The resident also had an order, dated 02/06/24, to receive one drop of Refresh Celluvisc in each eye four times daily for corneal epitheliopathy (staining of the corneal epithelial layer). At the resident's follow-up appointment on 02/16/24, the physician ordered the medication to continue to be administered four times daily. Both physician orders were stamped and initialed as reviewed by two medication technicians using the facility's three-check system.

The resident's TAR indicated the Refresh Celluvisc was not administered as ordered between 02/06/24 and 02/19/24.

On 02/21/24 at 11:46 am, this surveyor and Staff 3 (LPN) reviewed the resident's TAR and physician orders. Staff 3 and Staff 25 (Regional Nurse Consultant) confirmed the resident was not administered the accurate dosing of the artificial tears or the Refresh Celluvisc.  

The need to ensure physician orders were carried out as prescribed was discussed with Staff 1 (ED) on 02/21/24. She acknowledged the findings.

1. Physician orders for residents #7 and #8 have been reconciled to original orders to ensure accuracy and have been sent to provider for review and signature. A Medication Aide meeting was held to review the triple check process and the need to actually log in to PCC and verify that the order was transcribed accurately and is being followed as written before signing off on the stamp. Additionally before signing off on the stamp, Med Aides should verify that an ISP was written to notify everyone of the change, and to trigger the service plan to be updated if needed.

2. To prevent recurrence, we will continue to use our triple check process, which includes LN review for accuracy of order transcription, however the noted deficiencies in the process will be corrected. For example, additional nursing hours have been added to ensure the orders being processed through the triple checks are verified by a LN timely, with a goal of within 72 hours. Additionally, LNs have been reminded that they need to also verify that an ISP was written to notify everybody of the change and to trigger the service plan to be updated.

3. All medication and treatment orders will be reconciled quarterly and sent to provider for review and signature.

4. Executive Director and LN will be responsible for maintaining this system.

3. Resident 5 was admitted to the facility in 04/2021 with diagnoses including bipolar disorder and obesity.

Resident 5's 07/01/23 through 07/17/23 MAR was reviewed and identified the following:

a. Resident 5 was prescribed PRN Dulcolax (for constipation) and PRN Miralax (for constipation). The MAR lacked parameters instructing staff on which medication to use first.

b. Resident 5 was prescribed PRN Nystatin (for rash). The MAR lacked medication specific instructions including where and when to administer.

The need to ensure MARs included resident specific parameters and instructions was reviewed with Staff 1 (Executive Director) and Staff 2 (RN) on 07/21/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate, had resident-specific parameters for PRN medications and clear instructions to staff for 3 of 5 sampled residents (#s 3, 4 and 5) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 11/2011 with diagnoses including diabetes.

Resident 3's 07/01/23 through 07/17/23 MAR was reviewed and identified the following:

a. Resident 3 was out of the facility 06/22/23 through 07/14/23. During that time the following medications were documented as given:

*Atorvastatin - 07/03/23 and 07/07/23;

*Gabapentin - 07/03/23 and 07/07/23;

*Risperidone - 07/03/23 and 07/07/23;

*Solifenacin - 07/03/23 and 07/07/23;

*Nystatin Powder - 07/03/23; and

*Zinc paste - 07/03/23.

b. Resident 3 was prescribed PRN Milk of Magnesia (for constipation) and PRN Miralax (for constipation). The MAR lacked parameters instructing staff on which medication to use first.

The need to ensure MARs were accurate and had clear parameters and instructions for staff when more than one PRN medication was prescribed for the same condition, was reviewed with Staff 1 (Executive Director) on 07/20/23. She acknowledged the findings.

2. Resident 4 was admitted to the facility in 04/2023 with diagnoses including generalized anxiety disorder and lymphedema.

Resident 4's signed physician orders and 07/01/23 through 07/16/23 MAR/TAR were reviewed during the survey and revealed the following:

a. The following medications lacked medication specific instructions for administration, dose to administer, or resident specific parameters for PRN dosing:

* Fosamax 70 mg;

* Imitrex 50 mg;

* Voltaren;

* Acetaminophen 325 mg; and

* Acetaminophen-Codeine 300-60 mg.

In an interview with Staff 12 (MT) on 07/20/23 at 10:29, he confirmed the identified required information was not available in the electronic MAR.

b. Resident 4 had an order for Xanax 0.5 mg - two tablets by mouth every 12 hours as needed for anxiety. According to the resident's narcotic log and bubble pack, s/he received the medication on 07/11/23 and 07/13/23; however, the MAR was blank for those dates.

Staff 12 (MT) reported on 07/20/23 at approximately 11:30 am that he and a MT he was training administered the doses and forgot to sign the MAR.

The need to ensure the facility maintained an accurate MAR was discussed with Staff 1 (ED) and Staff 2 (RN) on 07/21/22. They acknowledged the findings.

1. A complete MAR audit for all residents was done to ensure all orders have clear and specific instructions for staff. If there is more than one medication ordered for the same purpose, instructions include the order in which medications should be administered, or specific parameters. A Medication Aide meeting was held to review the process for documenting medication administration accurately and notifying the LN of any unclear orders or PRNs without appropriate parameters for use.

2. To prevent recurrence, MAR audits will be completed weekly to check for missing or incorrect documentaion. Controlled Substance audits will also be completed weekly to ensure that all narcotics signed out are also documented on the MAR as given and any discrepancies will be investigated. CQI audits will be completed monthly to ensure all PRN orders have specific instructions for staff including the order in which medications should be administered. Ongoing education will be provided to Medication Aides as needed based on findings of audits. Physician orders will also be reviewed quarterly by LN and sent to provider for signature to provide coordination of care.

3. This system will be evaluated monthly as part of the facility CQI process and will include a review of all above mentioned audits

4. The Executive Director, RCC and LN will be responsible for maintaining this system.

Based on interview and record review, it was determined the facility failed to ensure non-pharmacological interventions were attempted and documented to be ineffective prior to the administration of psychotropic medications for 1 of 1 sampled resident (#4) who was prescribed psychotropic medications. Findings include, but are not limited to:

Resident 4 was admitted to the facility in 04/2023 with diagnoses including general anxiety disorder.

Review of Resident 4's MAR, dated 07/01/23 through 07/16/23, and physician orders revealed the following:

Resident 4 was prescribed PRN Xanax for anxiety or insomnia, and it was documented as administered to the resident on 15 occasions between 07/02/23 and 07/15/23.

The facility lacked documented evidence non-pharmacological interventions were attempted and were ineffective prior to administration of the medications, and the MAR lacked information on non-pharmacological interventions to attempt.

In an interview on 07/20/23, Staff 12 (MT) confirmed the MAR system did not have non-pharmacological interventions listed for staff to attempt prior to administering the PRN medication.

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        On 07/21/23, the need to ensure non-pharmacological interventions were attempted and documented to be ineffective prior to the administration of PRN psychotropic medications was discussed with Staff 1 (ED) and Staff 2 (RN) on 07/21/22. They acknowledged the findings.

1. Resident #4's MAR has been updated to include non-pharmacological interventions to be attempted prior to use of the PRN medication. A Medication Aide meeting was held and included a review of this regulation and how to enter non-pharmacological interventions and how to document the attempts prior to use of the medication.

2. To prevent recurrence, audits will be completed monthly to ensure all PRN psychoactive medications have non-pharmacological interventions, unless otherwise stated in the order. 24-hour daily audit will also include e-MAR progress notes and will be reviewed to ensure documentation of non-pharmacological interventions is happening prior to administration of medication. Ongoing education will be provided to Medication Aides as needed based on findings of these audits. Physician orders will also be reviewed quarterly by LN and sent to provider for signature to provide coordination of care.

3. This system will be evaluated monthly as part of the facility continuous quality improvement process and will include a review of all MAR audits, and PRN Psychoactive medication audits.

4. The Executive Director and LN will be responsible for maintaining this system.

Based on observation, interview, and record review, it was determined the facility failed to ensure an assessment by a PT, OT or RN was completed at least quarterly for assistive devices with potentially restraining qualities for 1 of 3 sampled residents (#5) reviewed who had a supportive device. Findings include, but are not limited to:

Resident 5 was admitted to the facility in 04/2021 with diagnoses including bipolar disorder and obesity.

During the entrance conference, 07/17/23, Resident 5 was identified as having side rails on his/her hospital bed. Observations of the resident and the resident's room showed the left side rail was in the up position on 07/19/23 and the left and right side rails were in the up position on 07/20/23. During an interview with Resident 5 on 07/20/23, s/he reported that s/he used the left side rail to assist with repositioning and transferring, and that s/he preferred the right side rail down.

There was no quarterly assessment for the bilateral side rails completed by the RN, PT or OT for use of the assistive devices with potentially restraining qualities. There were no instructions to staff in the resident's service plan regarding the use or safety precautions of the side rails.

The need to complete assessments of supportive devices with restraining qualities at least quarterly was discussed with Staff 1 (ED) and Staff 2 (RN) on 07/21/23. They acknowledged the findings.

1.Resident #5 has been assessed by the facility RN for the use of a supportive device with restraining qualities and service plan has been updated with instructions to staff regarding the use of the side rails and safety precautions. An audit was done of all existing residents who use any type of supportive device with restraining qualities to ensure we have updated assessments and physician orders for use.

2. To prevent recurrence, all resident evaluations prior to admission, upon admission, at 30 days, quarterly and with significant change of condition will include evaluation of whether or not the resident utilizes a supportive device with restraining qualities and will automatically trigger a RN supportive device. Each quarter or with significant change of condition the assessment will be updated to ensure it is still appropriate and meets the safety guidelines.

3. This system will be evaluated as part of the CQI program, which inludes auditing supportive devices in the community twice a year.

4. The Executive Director and RN are responsible for maintaining this system.  

Based on interview and record review, it was determined the facility failed to ensure resident entries were reflective of resident care needs and were updated quarterly for 3 of 5 sampled resident (#s 3, 4 and 5) whose ABST were reviewed.  Findings include, but are not limited to:

Review of three sampled residents' records, interviews with staff, and observations of the residents noted ABST entries were not reflective of the current care needs and/or updated quarterly. The ABST data showed multiple areas which reflected zero minutes when the resident required more than zero minutes of assistance in several of the marked areas.

Inaccuracies on resident entries for the ABST tool was discussed with Staff 1 (ED) on 07/20/23. She acknowledged the findings.

1. ABST has been updated to include all required components for resident #4 and #5. ABST will be fully audited to ensure it is up to date with all current resident services.

2. To prevent reccurence, facility will update the ABST prior to admission of a new resident, when a resident discharges, and any time the level of care evaluation and service plan is updated for existing residents. This will include admission if there are changes from the pre-admission, 30-days, quarterly and with significant change of condition.

3. This system will be evaluated each time updates are made to the ABST to ensure that our posted staffing numbers meet the acuity needs of the residents. This system will also be evaluated monthly as part of our CQI program.

4. The Executive Director is responsible for maintaining this system.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted according to the Oregon Fire Code (OFC). Findings include, but are not limited to:

On 07/18/23, review of facility fire drill and fire and life safety instruction records, from 02/2023 through 07/2023, and interviews with staff revealed the following was not documented on fire drills;

* The escape route used;

* Problems encountered and comments related to residents who resisted or failed to participate in the drills was not documented;

* Evacuation time needed: and

* Number of occupants evacuated.

On 07/18/23, the need to ensure fire drills had all required elements was discussed with Staff 1 (Executive Director) and Staff 8 (Maintenance Director). They acknowledged the findings.

1. A training was done with Maintenance Director that included a review of all required components related to the correct procedure for fire drills. All staff will be re-educated at next staff meeting on the fire drill procedure.

2. To prevent recurrance company fire drill form will be utilized and will be filled out completely, including all required components. Computer program used to document fire drills has been updated to include all required components as well as rotating schedule for locations and shifts.

3. Fire drills and fire and life safety trainings will be reviewed monthly as part of our CQI process to ensure compliance.

4. The Executive Director and Maintenance Director will be responsible for maintaining this system.

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

Refer to C303 and C613.

See POC for C303 and C613

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 07/17/23. The following areas needed cleaning or repair:

* Gouges, scrapes, and chunks of missing wood on resident and bathroom doors throughout the facility;

* Gouges and scrapes on handrails throughout the facility;

* Black streaks and chipped paint on metal exit doors throughout facility;

* Dark carpet stains outside multiple resident room doors on the first floor; and

* Black matter and gray build-up in all elevators' sill grooves.

The building was toured and areas needing cleaning or repair were discussed with Staff 1 (Executive Director) and Staff 8 (Maintenance Director) on 07/19/23. They acknowledged the areas needing cleaning and repair.  

1. A complete walkthrough of the community was completed and all areas needing cleaning and/or repair will be completed no later than 9.19.2023.

2. To prevent recurrance, Maintenance Director will conduct a weekly walkthrough of the community and will identify any areas needing cleaning and/or repair. Weekly walkthrough will be reviewed at standup meeting and a plan will be put in place for any identified items.

3. Completion of weekly walkthrough tasks will be reviewed monthly as part of the community's CQI process.

4. Executive Director and Maintenance Director are responsible for maintaining this system

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. This is a repeat citation. Findings include, but are not limited to:

The interior of the facility was toured on 02/20/24. The following areas needed cleaning or repair:

* Wood pillars and baseboard had scrapes and gouges on exposed corners in the lobby, fireplace seating area and at the resident mailboxes;

* The wood entry doors and door jambs in the lobby facing the front desk had gouges and scrapes;

* The baseboard across from the med room had scrapes and gouges;

* The activities room on the first floor had scrapes and chipped paint on the drywall next to the windows;

* There were gouges and scrapes on handrails near room 107 and across from elevator on the 4th floor;

* There were black streaks and chipped paint on metal exit doors and door jambs near room 101;

* There were gouges, scrapes, and chunks of missing wood on resident apartment doors and door jambs including rooms 102, 201, 203, 204, 205, 207, 208, 209, 210, 211, 215, 216, 301, 302, 305, 309, 310, 312, 313, 314, 315, 316, 318, 401, 402, 404, 407, 412, 413 and 415;

* There were gouges, scrapes and chunks of missing wood on doors and door jambs including communication room, bathroom next to activities room, activities room, bathroom across from room 216, staff lounge, second floor laundry room, and the bathroom near room 417;

* Several chairs and loveseats throughout the facility had stains, spots, or dried matter including one chair near room 104, two chairs near the second floor elevator, one chair near the second floor VP room, one tan chair near room 302, one loveseat near room 306, two red chairs near room 404 and one loveseat near fourth floor stairwell and janitor/mechanical room;

* The elevator door jambs on the first, second, third and fourth floors had scrapes and gouges; and

* The elevators' sill grooves on the first, second, third and fourth floors had black matter and gray build-up.

The building was toured and areas needing cleaning or repair were discussed with Staff 1 (ED) and Staff 8 (Maintenance Director) on 02/20/24. They acknowledged the areas needing cleaning and repair.  

1. A complete walkthrough of the community was done, and all areas needing cleaning and/or repair will be completed no later than 04.06.2024. Our vendor for furniture replacement was contacted and is putting together a couple of options for furniture packages. A decision will be made timely and furniture will be ordered. In the meantime, existing furniture will be cleaned as well as can be.

2. To prevent recurrence, Executive Director and Maintenance Director will conduct a weekly walkthrough of the community and will identify any areas needing cleaning and/or repair. Weekly walkthrough will be reviewed at standup meeting and a plan will be put in place for any identified items.

3. Completion of weekly walkthrough tasks will be reviewed monthly as part of the community's CQI process.

4. Executive Director and Maintenance Director are responsible for maintaining this system