Print Inspection: FBLK

The findings of the re-licensure survey, conducted 06/10/24 through 06/13/24, 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 for 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 revisit to the re-licensure survey of 06/13/24, conducted 10/07/24 through 10/10/24, are documented in this report. The survey was conducted to determine 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.

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 re-visit to the re-licensure survey of 06/13/24, conducted on 12/12/24, 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 and OARs 411 Division 004 Home and Community Based Services Regulations.

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

A review of Resident Council Meeting notes dated 07/19/24, 08/16/24, and 09/20/24 identified the following resident concerns:

* "Residents concerned about potential stranger coming into the facility early in the morning and are hoping for more reassurance that everyone is safe";

* "One resident was told to deal with a problem herself/himself" by management team;

* "Mail is shoved in their boxes";

* "Food needs to be hot before it gets to the table";

* "Food is cold when it gets to rooms";

* "Portions seem smaller than before";

* "Menus on the table are not kept up to date";

* "Residents concerned that things run out lately";

* "Residents feel that the food has been substandard, and the meat quality has not been good";

* "Food the last couple days was terrible, quality of food is not good"; and

* "Hot evening meals, no sandwiches".

There was no documented evidence the above concerns identified during the Resident Council meetings had been addressed, responded to or resolved.

During the survey from 10/07/24 through 10/10/24, individual interviews with residents and staff were conducted. The following complaints or concerns were brought up:

Residents reported they were unhappy and overall felt unheard. Multiple residents reported it was hard having so many agency staff that did not know them and them not knowing the residents. Residents reported concerns and complaints brought to management were not taken seriously or addressed. Multiple residents complained about the food; and reported the food quality was low, and meals were often served cold; including meals delivered to resident rooms.

Documentation of the facility's method of responding to and resolving resident complaints was requested on 10/09/24. Staff 10 (Senior Executive Director) reported there was no documented evidence resident complaints had been responded to or resolved.

The need to implement effective methods of responding to and resolving resident complaints was discussed with Staff 2 (Wellness Director), Staff 5 (Business Office Manager), Staff 7 (Plant Operations Director), and Staff 10 on 10/10/24. They acknowledged the findings.

1. Town Hall meeting with residents done with Senior Executive Director on 10/28/2024. This identified all of the Residents concerns and issues. Will have a follow up meeting with them in November to review the progress made. Explained the Grievance process and Policy to the residents in this meeting.

2. Leadership team will be trained on the Grievance and Complaint process. Resident Council Meeting notes will be reviewed by the Leadership team. Issues and concerns will be addressed at the Town Hall meeting. Grievance box has been set up so that Residents can write down issues if they would like. ED will respond to the written issues and will attend with Dietary Services Director the Chefs Corner meetings to discuss food concerns.

3. As needed with each resident complaint or concern. Will continue to address in monthly Town Hall meeting and Chefs Corner meeting.

4. ED, WD, RSC, POD, BOM, LED, DSD and SED.  

Based on interview and record review, it was determined the facility failed to immediately report and failed to conduct an immediate investigation for an allegation of abuse to the local Seniors and People with Disabilities (SPD) office, for 1 of 1 sampled resident (# 2). Findings include, but are not limited to:

Resident 2 was admitted to the facility in 09/2019 with diagnoses including dementia.

During an interview with Resident 2 on 06/10/24 at 11:13 am, the resident reported that Staff 14 (CG) handled him/her roughly during and after a shower "a week or so ago". Resident 2 reported Staff 14 had hit him/her in the head with the hair brush while combing his/her hair.

The resident stated the shower incident was reported to Staff 7 (Plant Operations Director).  During an interview on 06/10/24 at 12:25 pm with Staff 7, he stated he had reported the allegation to Staff 4 (Wellness Director). During an interview with  Staff 4 on 06/10/24 at 12:30 pm, she reported that she had interviewed the resident, and acknowledged the allegation of rough handling during shower and cares. She stated she did not report the allegation to the local SPD.

This represented an allegation suspected of abuse. There was no documented evidence the facility immediately investigated the allegation. The facility did not report the allegation to the local protective services office as suspected abuse.

The need to ensure allegations of suspected abuse were immediately reported to the local SPD office, or the local AAA, and ensure abuse and suspected abuse were promptly investigated, with measures taken necessary to protect residents and prevent the reoccurrence of abuse was discussed with Staff 1 (ED) on 06/10/24 at 02:00 pm. She acknowledged the findings and stated the staff were preparing the paperwork today to self-report the incident. Verification the facility had reported the incident to the local SPD office was received on 06/11/24.

1. A second investigation was done by wellness director(WD) on 6/10/24 a which revealed that the allegations remained unsubstantiated. On 6/11/24 an APS self report was sent to DHS. APS responded the following day and at this time there has been no final report from APS's investigation

2.Training for all staff on identifying abuse and neglect will be completed by complaince date. Reports to be sent to APS within 24 hours when abuse or neglect is supected.

3. Annual and new hire training for abuse and neglect reporting to be audited monthly. Incident reports to be reviewed daily during clinical meeting.

4. Executive Director, Wellness Director, Resident Services Director and or designee

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, and provided resident-specific direction for staff for 3 of 4 sampled residents' (#s 1, 2 and 4) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 09/2019 with diagnoses including dementia.

Observations of the resident, interviews with the resident and staff, and review of the resident's 05/22/24 service plan, 03/09/24 through 06/10/24 temporary service plans, progress notes, and incident investigations were completed.

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

* Open wound left buttock and right hip;

* Back pain, right hip pain to include non-drug interventions;

* Assistance to stand from bed, toilet, couch, chair;

* Shower assistance;

* Laundry services provided by facility;

* Meals in room preference; and

* Meaningful activities, life enrichment.

The need to ensure resident service plans were reflective of current care needs, and provided clear direction to staff was discussed with Staff 1 (ED), Staff 4 (Wellness Director), and Staff 3 (Regional Wellness Director) on 06/12/24. The staff acknowledged the findings.

2. Resident 1 moved into the facility in 3/2024 with diagnoses including Parkinson's disease, chronic obstructive pulmonary disease and peripheral vascular disease

The resident's 03/22/24 service plan was reviewed, observations were made of the resident, and interviews with staff occurred throughout the survey. The service plan failed to provide clear direction to staff in the following areas:

* Recent visits to the emergency room and diagnoses;

* Frequency of toileting assistance needed;

* Current skin condition and treatment: and

* Clothing protector usage during meals.

On 6/13/24, the need to ensure service plans included clear direction to staff was discussed with Staff 1 (ED) and Staff 7 (Plant Operations Director). They acknowledged the findings

3. Resident 4 moved into the facility in 04/2024 with diagnoses including ischemic cardiomyopathy and chronic kidney disease.

The resident's 05/06/24 service plan was reviewed, observations were made of the resident, and interviews with staff occurred throughout the survey. The service plan failed to provide clear direction to staff in the following areas:

* Hospital bed with side rails; and

* Hospice services and schedule.

On 6/13/24, the need to ensure service plans included clear direction to staff was discussed with Staff 1 (ED) and Staff 7 (Plant Operations Director). They acknowledged the findings

1. Resident 1, 2, and 4 from Survey have been reviewed for their new concerns and increased ADL needs and the service plans have been updated. All other residents service plans will be reviewed for accuracy in ADL assistance, bathing, mobilty, transfers, activity preference and dining/meal  preferences.

2. Education of care staff on reporting changes in residents condition and ADL needs along with Service Plan Training.  New tool has been put in place to gather resident specific information from all departments with each service plan update and CoC.

3. Assessments to be done on admission, 30 days after admission, and then every 90 days and/or change of condition.   

4. Executive Director, Wellness Director, Resident Services Director and or designee.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' preferences and needs for 3 of 3 sampled residents (#s 5, 6, and 7) whose service plans were reviewed. This is a repeat citation.  Findings include, but are not limited to:

1. Resident 5 moved into the facility in 06/2021 with diagnoses including congestive heart failure and dysphasia.

The resident's current service plan dated 08/06/24 was reviewed, observations were made, and interviews with the resident, staff and the resident's family were conducted. The service plan was not reflective of the resident's needs and preferences in the following areas:

* Current skin condition and treatment; and

* Female caregivers to assist with bed baths.

The need to ensure service plans reflected the resident's preferences and needs was discussed with Staff 2 (Wellness Director) and Staff 10 (Senior Executive Director) on 10/10/24. They acknowledged the findings.

2. Resident 6 moved into the facility in 08/2024 with a diagnoses including a nontraumatic intracranial hemorrhage.

The resident's current service plan dated 08/24/24 was reviewed, observations were made and interviews with the resident and staff were conducted. The service plan was not reflective of the resident's needs and preferences in the following areas:

* Vegetarian diet including food likes and dislikes; and

* Fluid preferences.

The need to ensure service plans reflected the resident's needs and preferences was discussed with Staff 2 (Wellness Director) on 10/09/24. She acknowledged the findings.

3. Resident 7 moved into the facility in 04/2024 with a diagnoses including chronic kidney disease stage 4 and congestive heart failure.  

The resident's current service plan dated 09/26/24 was reviewed, observations were made and interviews with the resident and staff were conducted. The service plan was not reflective of the resident's needs and preferences in the following areas:

* Use of wheelchair for mobility;

* Female caregivers to assist with toileting;

* Recent diagnosis of a heart attack; and

* Recent fall with injury including interventions to minimize falls.

The need to ensure service plans reflected the resident's preferences and needs was discussed with Staff 2 (Wellness Director) and Staff 10 (Senior Executive Director) on 10/10/24. They acknowledged the findings.

1. Resident 5, 6 and 7's Service plans updated to reflect assistance needed with ADL's, Male or Female Care preference and Food/Drink Preferences. All other Residents Service Plans will be reviewed and updated by the RSC, ED and WD. ABST will then be updated to refelct any changes by the ED.

2. Service Plan Training will be provided for the ED, WD and RSC by Heather Golden Senior ED. When a Service plan is completed it will be reviewd by another person for accuracy. For Example if WD does Service plan she will have the RSC review it. Service Plan Review Forms will be utilized when doing every Service Plan to gather information from all departments.

3. ED, RSC and WD will meet weekly about upcoming service plans

4. WD, ED and RSC and RN with Significant Changes.

3. Resident 2 was admitted to the facility in 09/2019 with diagnoses including dementia.

The resident's current service plan dated 05/22/24, progress notes, temporary service plans, and incident reports dated 03/09/24 through 06/10/24 were reviewed.  

The following short term changes of condition lacked an evaluation and/or monitoring of progress noted weekly through resolution:

* 04/23/24 - A recent loss of a friend;

* 04/25/24 - Fall with back pain;

* 05/03/24 - Emergency room visit for severe tail-bone pain, resulting in new narcotic pain medication;

* 05/08/24 - Narcotic discontinued, new orders for acetaminophen for pain; and

* 05/31/24 - Increased difficulty swallowing, lacked both evaluation and monitoring.

The need to ensure changes of condition were evaluated and monitored through resolution was discussed with Staff 1 (ED), Staff 4 (Wellness Director) and Staff 3 (Regional Wellness Director) on 06/12/24. They acknowledged the findings.

4. Resident 3 was admitted to the facility in 01/2024 with diagnoses including diabetes and congestive heart failure.

The resident's current service plan dated 05/17/24, progress notes, temporary service plans, and incident reports dated 03/09/24 through 06/10/24 were reviewed.  

The following short term changes of condition lacked monitoring of progress noted weekly through resolution:

* 04/05/24 - Change in Coumadin dosage;

* 04/19/24 - Fall with head strike, emergency department transport;

* 04/25/24 - Debridement of diabetic foot ulcer; and

* 04/29/24- Compression gloves with instructions.

The need to ensure changes of condition were monitored weekly through resolution was discussed with Staff 1 (ED), Staff 4 (Wellness Director) and Staff 3 (Regional Wellness Director) on 06/12/24. They acknowledged the findings.

Based on interview, and record review, it was determined the facility failed to ensure changes of condition were evaluated and monitored with weekly progress noted to resolution for 4 of 4 sampled residents (#s 1, 2, 3 and 4) reviewed for changes of condition. Findings include, but are not limited to:

1. Resident 1 moved into the facility in 03/2024 with diagnoses including Parkinson's disease, chronic obstructive pulmonary disease, and peripheral vascular disease.

The resident's current service plan dated 03/22/24, progress notes and temporary service plans dated 03/29/24 through 06/04/24 were reviewed.  

The following short-term changes of condition lacked monitoring of progress noted weekly through resolution:

* 03/29/24 - Resident moved into the facility;

* 04/04/24 - Resident self-administered medications at the wrong time;

* 04/06/24 - Discontinued warfarin and started new medication, Pradaxa (blood thinner);

* 04/22/24 - Non-injury fall;  

* 05/01/24 - New treatment order for clotrimazole and mupirocin for skin infection;

* 05/08/24 - Discontinued clotrimazole and mupirocin and started nystatin (antifungal medication);

* 05/12/24 -  Resident went to the emergency room, for increased pitting edema, increased difficulty with ambulation, and shortness of breath;

* 05/15/24 - Returned from hospital;

* 05/15/24 - New medication order for furosemide (diuretic) and start of supplemental oxygen; and

* 06/03/24 - Red/pink colored urine.

On 06/13/24, the need to ensure short term changes of condition were monitored weekly through resolution was discussed with Staff 2 ( Wellness Director) and Staff 3 ( Regional Wellness Director). They acknowledged the findings.  

2. Resident 4 moved into the facility in 04/2024 with diagnoses including ischemic cardiomyopathy and chronic kidney disease.

The resident's current service plan dated 05/06/24, progress notes and temporary service plans dated 04/05/24 through 06/09/24 were reviewed.

The following short-term changes of condition lacked monitoring of progress noted weekly through resolution:

* 04/05/24 - Resident moved into the facility;

* 04/16/24 - New medication order for guaifenesin (treats coughs and congestion);  

* 05/14/24 - New medication order for mehadone for pain; and  

* 06/07/24 - Discontinued tramadol and started new medication, oxycodone for pain.

On 06/13/24, the need to ensure short term changes of condition were monitored weekly through resolution was discussed with Staff 2 ( Wellness Director) and Staff 3 ( Regional Wellness Director). They acknowledged the findings.  

1. Community WD and RN oversight reviewed and updated residents #1, 2, 3, and 4 from survey for Change of Condition and Service plans, as well as current residents with short term change of conditions. Nurse to document on residents change of condition at onset, at resolution or new baseline. Education was provided on the process by Regional Wellness Director during the survey process.

2.WD has a tracking process in place to monitor residents who have a change of condition so that they can be monitored from onset, weekly and until resolution. WD to coordinate with RNOS to ensure that residents with a significant change of condition are also monitored in this fashion. Training done with all staff on Change of Condition, how to identify and report.

3.Weekly

4. Executive Director, Wellness Director, or designee

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

1. Resident 3 moved into the facility in 01/2024 with diagnoses including congestive heart failure and type 2 diabetes.

The resident's signed physician orders and 09/01/24 through 10/07/24 MARs were reviewed.

Resident 3 was prescribed warfarin (a blood thinner) on 10/04/24. The physician's order stated that a 5 mg tablet of warfarin was to be taken by mouth, on Monday. The resident's MAR showed the facility administered a 5 mg and a 2.5 mg tablets on Monday, 10/07/24.

On 10/10/24, Staff 12 (RN) confirmed that  the resident was administered an additional 2.5 mg tablet of warfarin on 10/07/24.

The need to ensure medication and treatment orders were carried out as prescribed was discussed with Staff 2 (Wellness Director) and Staff 10 (Senior Executive Director) on 10/10/24. They acknowledged the findings.

2. Resident 7 moved into the facility in 04/2024 with a diagnoses including chronic kidney disease stage 4 and congestive heart failure.  

The resident's signed physician orders and 09/01/24 through 10/07/24 MARs were reviewed, and the following was identified:

The resident had a current signed physician order dated 10/04/24 for Torsemide 20 mg, four tablets (80 mg total) by mouth twice daily for edema.

The MAR showed that on 10/05/24, 10/06/24, and 10/07/24 the resident was administered 60 mg, not 80 mg as prescribed.  

On 10/10/24, Staff 12 (RN) confirmed the resident was administered the incorrect dosage on the above dates.

The need to ensure  medication and treatment orders were carried out as prescribed was discussed with Staff 2 (Wellness Director) and Staff 10 (Senior Executive Director) on 10/10/24. They acknowledged the findings.

1. Sample Resident 3 and 7's Mars, Physican orders and chart reviewed for Accuracy. All other residents Physician Orders, Mars and charts will be reviewed.

2. Wellness Director and RN oversite will complete Medication Modules on Nurse Learn. Once completed they will hold a training with all med techs to review the information. New Orders will be checked by the Wellness Director daily during her work hours. Training on Triple check process will occur with all Med techs.

3. Orders will be processed daily.

4. Wellness Director, RN Oversite, Resident Services Coordinator, Executive Director  

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

Resident 2's 05/01/24 through 06/10/24 MAR were reviewed and revealed the following:

* Resident 2's MAR included application of Clobetasol 0/05% cream, a pea size amount every other day externally for sclerosis, which lacked the area to apply the medication; and

* The MAR included multiple prn pain medications which lacked parameters and clear instruction to staff for administration, to include two different orders, doses and time frames for administration of acetaminophen and acetaminophen with codeine, one to two tablets twice daily for pain.

The need to ensure medications had resident-specific parameters for PRN medications and clear instructions to staff was reviewed with Staff 1 (ED), Staff 3 (Regional Wellness Director) and Staff 4 (Wellness Director) on 06/12/24. They acknowledged the findings.

1. Resident 2 had the PRN parameters and notifications clarified by the time of the survey exit. MAR Audit to be done to reivew all PRN medications to ensure that residents have parameters in place and when to notify WD and/or PCP.

2. All orders to be reviewed by nursing to ensure that orders have clear parameters and instrucitons for non-licensed staff to follow.  Nursing to review all 90 day orders to ensure orders have clear instructions and there are no duplication of orders. Clinical meetings to be held for review of orders at least three days a week to review new orders.

3. Clinical meetings to be held at least three times per week.

4. Executive Director, Wellness Director, Resident Services Director and or designee

Based on interview and record review, it was determined the facility failed to evaluate a resident's ability to safely self-administer medications and have a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications for 1 of 1 sampled resident (# 1) who chose to self-administer their medications. Findings include, but are not limited to:

Resident 1 moved into the facility in 03/2024 with diagnoses including Parkinson's disease, chronic obstructive pulmonary disease, and peripheral vascular disease

During the acuity interview on 06/10/24, Resident 1 was identified as administering their own medications with the assistance of a family member, who set up and filled the resident's weekly pill organizer. The facility provided a copy of an assessment, "Family Assistance with Medication," dated  05/09/24, which showed the family member set up prescriptions and over-the-counter drugs. There was no documented evidence an evaluation of Resident 1's ability to self administer their medications had been completed.

A physician order dated 03/20/24, indicated Resident 1 may not administer their own medications.

In an interview on 06/13/24, Staff 11 (MT) indicated Resident 1 was forgetful and had observed on multiple occasions that the resident had forgotten to take medications from their pill organizer.  

The above information was shared and discussed with Staff 3 (Regional Wellness Director) who stated Resident 1 needed to be revaluated on his/her ability to self-administer.

The need to ensure the facility evaluated resident's ability to safely self-administer medications and had a corresponding physician's order was discussed with Staff 1 (ED) and Staff 7 (Plant Operations Director) on 06/13/24. They acknowledged the findings

1. Resident 1 had self medication orders clarified and is no longer self medicating. All residents who currently self administer medications have been checked for assessment accuracy and Physician Orders

2. Residents who are admitted with self medication orders will have self medication assessment done prior to arrival and have clear orders from PCP for self medication. Residents will have self med orders put on MAR so that this can be reviewed by PCP every time their orders are reviewed and signed. Training completed with staff on reporting increase is confusion or other conerns regarding residents who self administer medications.

3. On admission, every 90 days and for any change of condition

4. Executive Director, Wellness Director, and or designee

Based on observation, interview and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities had a thorough assessment completed by an RN, PT or OT prior to use which included documentation of less restrictive alternatives evaluated prior to use, the resident was informed of the risks and benefits of the device, and instruction to caregivers on the correct use and precautions of the device was included on the service plan for 1 of 2 sampled residents (# 4) who had a quarter-length side rail on their bed. Findings include, but are not limited to:

Resident 4 moved into the facility in 04/2024 with diagnoses including ischemic cardiomyopathy and chronic kidney disease.

During an interview and observation on 06/10/24, Resident 4's hospital bed was observed to have a quarter length side rail in the up position.

There was no documented evidence the device with potentially restraining qualities had been assessed by an RN, PT or OT, including documentation of less restrictive alternatives evaluated prior to use, the resident had been informed of the risks and benefits of the device, or the service plan had identified the correct use and precautions related to the device.

On 06/13/24, Staff 2 (Wellness Director) and Staff 3 ( Regional Wellness Director) confirmed there was no documented evidence an assessment of the device with restraining qualities had been completed.

The need to ensure the use of a supportive device with potentially restraining qualities included documentation of all required elements and was included in the resident's service plan was discussed with Staff 1 (ED) and Staff 7 (Plant Operations Director) on 06/13/24. They acknowledged the findings.

1. Resident 1 and 4 Supportive device assessment completed by RN. RN audited the building for supportive devices. Nurse evaluated each one to determine if it is the least restrictive option meet the residents needs. Once need is determined the nurse will do an assessment and obtain consent for devices used.

2. With every quarterly service plan update supportice device review will be completed. Staff will be trained on what to do if a supportive device is brought into the community and what a supportice devices is.

3. Quarterly and as needed by WD or designee.

4. Executive Director, Wellness Director, Resident Services Director, Registered Nurse and or designee

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 13, 14, and 15) demonstrated satisfactory performance in assigned duties within 30 days of hire or prior to providing care for residents. Findings include, but are not limited to:

Staff training records were reviewed on 06/11/24, and interviews were completed with Staff 5 (Business Office Manager) and Staff 1 (Executive Director).  

a. There was no documented evidence Staff 14 (CG) hired 01/18/24 and Staff 15 (MT) hired on 03/12/24 demonstrated satisfactory performance in the following required areas:

* Role of service plans in providing individualized care.

b. There was no documented evidence Staff 15 (MT) demonstrated satisfactory performance in the following required areas:

* Providing assistance with ADLs.

c. There was no documented evidence Staff 13 (CG) hired on 01/09/24, Staff 14 (CG), and Staff 15 (MT) demonstrated competence in the following required areas:

* Changes associated with normal aging;

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

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

* General food safety, serving, and sanitation.

The need for direct care staff to demonstrate competence in assigned job duties prior to providing care for residents was discussed with Staff 1, Staff 3 (Regional Wellness Director), Staff 4 (Wellness Director), and Staff 5 on 06/13/24. They acknowledged the findings.

1. New hires surveyed #13, 14, and 15 reviewed, trainings completed or removed from providing care for residents till completed. All other staff have been reviewed and assigned all required trainings. New training spreadsheet has been created for required trainings before staff are assisgned to care for residents. Audited of all employee files has been completed. Staff have been assigned missing training to complete prior to our complaince date and if out of compliance re-assigned till training is complete and before caring for the residents.

2. All new employees will have a checklist with required trainings that will be completed prior to working with residents.

3. Monitored monthly by BOM

4. Executive Director, Wellness Director, Business Office Manager, and or designee

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 long term, non-direct care staff (#s 8 and 12) completed required annual infectious disease training. Findings include, but are not limited to:

Staff training records were reviewed on 06/11/24, and interviews were conducted with Staff 5 (Business Office Manager).

There was no documented evidence Staff 8 (Life Enrichment Director) hired on 02/24/21, and Staff 12 (MT) hired 01/05/21 completed the required training.

The need to ensure all staff completed the required annual infectious disease training was discussed with Staff 1 (Executive Director), Staff 3 (Regional Wellness Director), Staff 4 (Wellness Director), and Staff 5 on 06/13/24. They acknowledged the findings.

1. Staff training has been audited for infectious disease (ID) training.  Staff that have not completed ID training have been assisgned training and have been notified that it needs to be completed.

2. Spreadsheet for training of tracking that includes all required training components that employees need to complete prior to working with residents. The spreadsheet will be maintained to also ensure required annual trainings including ID training are done.

3. Monthly

4. Executive Director, Business Office Manager, Wellness Director, and or designee

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

Refer to C 260.

1. Resident Service plans will be updated to reflect assistance needed with ADL's, Male or Female Care preference and Food/Drink Preferences. All other Residents Service Plans will be reviewed and updated by the Resident Services Coordinator, Executive Director and Wellness Director. ABST will then be updated to refelct any changes by the ED.

2. Service Plan Training will be provided for the ED, WD and RSC by Senior ED. When a Service plan is completed it will be reviewd by 2nd person for accuracy. Tool implemented to gather resident specific information from all departments and Care/Med Associates with each service plan update and CoC.

3. ED, RSC and WD will meet weekly about upcoming service plans.  Assessments to be done on admission, 30 days after admission, and then every 90 days and/or change of condition.   

4. Executive Director, Wellness Director, Resident Services Coordinator and or designee.

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, and free from unpleasant odors. Findings include, but are not limited to:

During the survey from 06/10/24 through 06/13/24, multiple staff reported concerns regarding Room 411. Staff reported the following:

* Pungent urine odor that does not dissipate after cleaning;

* Flies in the bathroom; and

* Furniture, carpet, floors, and walls were stained.

On 06/12/24 at 9:15 am, the surveyor and Staff 7 (Plant Operations Director) requested permission to enter Room 411. The resident agreed. The following was observed:

* Pervasive urine odor throughout the room;

* The carpet was heavily stained throughout and ripped;

* Dark stains on furniture; and

* The bathroom flooring was stained around the toilet and shower area.

The need to ensure the facility interior was clean, in good repair and free of unpleasant odor was discussed with Staff 1 (ED) on 06/12/24. She acknowledged the findings.

On 06/13/24 at 12:40 pm Staff 1 reported that the resident living in Room 411 would move into another apartment until their flooring and furniture had been replaced and the apartment had undergone a deep cleaning.

1. Resident referred to in 613 of citation temporarily moved to another apartment so that his apartment could have the flooring replaced with vinyl flooring. The apartment was sprayed for bugs and thouroughly cleaned.  Community obtained new furniture and clothing. Resident has had his service plan updated to include new approaches for staff who assist him with showers. Resident and his apartment are now odor free.

2. New interventions put in place for more frequent care assistance. Increased housekeeping days to four times per week instead of three times per week.

3.Weekly monitoring for cleanliness of apartment and odor.

4. Executive Director, Plant Operations Director, Wellness Director, and or designee

Concerns were identified and technical assistance was provided for the following:

H 1510: OAR411-004-0020 (1)(c): Individual Rights Settings: Privacy, Dignity

(1) Residential and non-residential HCB settings must have all of the following qualities: (c) The setting ensures individual rights of privacy, dignity, respect, and freedom from coercion and restraint.