Print Inspection: H8AB

The findings of the re-licensure survey, conducted 03/06/23 through 03/08/23, 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 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

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 which were rendered in the facility. Findings include, but are not limited to:

During the re-licensure survey, conducted 03/06/23 through 03/08/23, 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.

OAR 411-054-0025 (1) Facility Administration: Operation

Please refer to all citations in this report

2. Resident 3 was admitted to the facility's Douglas House in 2019 with diagnoses including dementia.

The resident's progress notes, dated 12/09/22 through 03/06/23, service plan dated 01/10/23, temporary service plans (TSPs), and facility incident reports were reviewed. The following was identified:

* On 12/23/22, staff documented on an incident report that "resident tried to go in to another resident's room and I tried to bring [him/her] to [his/her] room and [s/he] was resisting and fighting me so [s/he] fell on [his/her] own and fought me to get up...."

There was no documented evidence the altercation which resulted in Resident 3's fall had been investigated to rule out abuse or reported to the local SPD or AAA office if abuse and/or neglect could not be ruled out.

The need to ensure altercations with staff which resulted in a resident fall were immediately investigated, contained all required areas of documentation, including any latent injuries, and, if abuse could be ruled out, were reported to the local SPD office was discussed with Staff 1 (Administrator), Staff 2 (Regional Director of Operations), Staff 3 ( House Manager - Ramp), Staff 4 (RN), and Staff 5 (Regional Compliance Specialist) on 03/08/23. They acknowledged the findings.

The surveyor requested Staff 1 report the incident to the local SPD office on 03/08/23 and verification of reporting was received.

3. Resident 4 was admitted to the facility's Douglas House in 2020 with diagnoses including encephalopathy and dementia.

The resident's progress notes, dated 12/09/22 through 03/06/23, service plan dated 09/30/22, temporary service plans, and facility incident reports were reviewed. The following was identified:

* A progress note dated 01/31/23 indicated Resident 4 was observed to have scattered bruising and discoloration to both forearms, a bruise on the right hand, and a fading skin discoloration to the right leg.

The accident/incident/occurrence report completed 02/03/23 indicated the resident, when asked how he/she had gotten the bruises, stated, "I don't know."

There was no documented evidence the injuries of unknown cause had been immediately investigated to rule out abuse or neglect or was reported to local SPD or AAA office, if abuse and/or neglect could not be ruled out.

The intervention on the incident report to eliminate this type of incident and keep the resident safe was to instruct staff in safe handling and transfer technique and to encourage the resident to move self as much as able.

The need to ensure injuries of unknown cause were immediately investigated, contained all required areas of documentation, and, if abuse could not be immediately ruled out, were reported to the local SPD office was discussed with Staff 1 (Administrator), Staff 2 (Regional Director of Operations), Staff 3 (House Manager - Ramp), Staff 4 (RN), and Staff 5 (Regional Compliance Specialist) on 03/08/23. They acknowledged the findings.

The surveyor requested Staff 1 report the incident to the local SPD office on 03/08/23, and verification of reporting was received.

Based on interview and record review, it was determined the facility failed to ensure injuries of unknown cause and falls were promptly investigated, reviewed by the Administrator, and reported to the local SPD office or the local AAA office when abuse and/or neglect could not reasonably be ruled out, for 3 of 4 sampled residents (#s 1, 3 and 4) with incidents that were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 03/2017 with diagnoses including dementia, vertigo and hallucinations.

The resident's record, including progress notes, incident reports and investigations, and temporary service plans (TSPs) were reviewed, and staff were interviewed. The following was identified:

* 01/09/23, 9:15 am - Unwitnessed fall with two abrasions on the right knee;

* 02/15/23, 10:09 pm - Unwitnessed fall with a skin tear on the left elbow and pain in left arm and side; and

* 03/03/23, 1:35 am - Unwitnessed fall with a scrape on the upper left side of forehead.

The 01/09/23 fall was investigated over three weeks after the incident. There was no documented evidence the 02/15/23 and 03/03/23 falls were investigated.

The facility was instructed to report the injuries of unknown cause to the local SPD office on 03/08/23. Confirmation of the report was received prior to survey exit.

The need for prompt investigations of incidents to immediately rule out abuse and/or neglect, and to self-report incidents to the local SPD office if abuse and/or neglect cannot reasonably be ruled out, was discussed with Staff 1 (Administrator), Staff 2 (Regional Director of Operations), Staff 3 (House Manager - Ramp), Staff 4 (RN), and Staff 5 (Regional Compliance Specialist) on 03/08/23. They acknowledged the findings.

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action    C231

1. All incident reports will be reported in a written format using the accident and incident reporting template.  Interventions for #1 were put in place including increased frequent safety checks around the clock. Staff encouraged use of the walker and staff re training on approach.  Interventions for resident #3 included training with staff on re-approach to assist with transfers and ADLs.  For resident #4, staff were educated on proper transfer techniques to ensure no bruising would occur.

2. All staff will be provided with training on accident and incident reporting and complete the Oregon Care Partners Abuse and Neglect training.                         .

All incidents will be comprehensively investigated in a timely manor.

When abuse and neglect cannot be ruled out, or for injuries of unknow origin, DHS abuse Neglect Reporting requirements will be followed.

3.All incidents will be reviewed daily during standup and clinical meetings. During the daily drill-down review, All incidents will be verified to confirm: a) Investigation is comprehensive, b)Notifications are made, c) Self-reporting ruled out or self-report is completed, d) Interventions or remedies are implemented to reduce reoccurrence or severity of injury.

The Administrator or designee will review and finalize the completed incident report.  The Administrator on record will review and confirm all components of the investigatory process have occurred and the investigation was documented timely.

4.The Administrator and/or designee will be responsible to ensure the corrections are completed/monitored.

Based on observation and interview, it was determined the facility failed to ensure the kitchens in the facility's Douglas and Ramp Houses were maintained in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to:

1. On 03/06/23 at 02:00 pm, the kitchen in Douglas House was observed to need cleaning in the following areas:

a. Food spills, splatters, debris, dirt, and/or dust was observed on/in or underneath the following:

* Cabinets and drawers;

* Kitchen counters and back splashes;

* Stove top and oven;

* Inside the microwave;

* Spice rack next to stove;

* Wooden cutting board;

* Top of the two refrigerators;

* Coffee pot on the counter;

* Red food splatters on the inside of the garbage can lid;

* Kitchen floor;

* Wall above the back counter, between the two refrigerators; and

* Dry storage room carpet and shelves.

b. Concerns were identified related to food storage, safety and service:

* The dry storage room had three boxes of cereal, a box of white rice, and a package of cookies left unsealed and open to air;

* A chest freezer with food inside was observed to be located in the laundry room directly next to the hopper sink;

* Staff were observed using soapy water and not alcohol wipes to sanitize the probe thermometer after use;

* Multiple food and drink containers observed in both refrigerators were unlabeled or dated; and

* There were no snacks observed to be offered to the residents during the three days of survey observation, unless requested.

The areas of concern were observed and discussed with Staff 1 (Administrator) on 03/07/23. The findings were acknowledged.

2. On 03/07/23 at 9:50 am and 03/08/23 at 11:34 am observations were made in the kitchen in Ramp House.

a. The following had food spills and splatters, debris, dirt, and/or dust on, underneath, or inside of and/or were in need of repair:

* Stove top and oven;

* Microwave;

* Kitchen floor;

* Kitchen sink;

* Cabinets and drawers;

* Counters and back splashes;

* Heating element in oven did not work;

* Vent cover on bottom of left refrigerator was lying on the floor;

* Drawer under oven did not fit properly;

* Several cabinet doors did not hang straight or close properly;

* Laminate was peeling off edge of shelf in lower cabinet next to left refrigerator;

* Varnish around cabinet knobs and drawer pulls was wearing off;

* Drawer front missing from bottom drawer next to the dishwasher;

* Dust pan next to right refrigerator had build-up of brown matter;

* Shelf in dry storage area had chipped paint; and

* Paint on half doors into kitchen was chipped or scraped.

b. Concerns were identified related to food safety and service:

* Temperature of both refrigerators was over 41 degrees Fahrenheit;

* Multiple open containers of food and beverage in both refrigerators were not dated;

* Staff were observed wiping off probe thermometer with a paper towel and not alcohol wipes after use;

* Not all staff washed their hands upon entering the kitchen and prior to food preparation or serving;

* Staff did not temp food prior to serving it to residents;

* A tray of dinner rolls was left on the stove top uncovered;

* Leftover pizza was uncovered on a plate on the counter;

* An open container of cookies was left on the counter;

* A pitcher of juice was left on the counter; and

* No snacks were observed to be offered to the residents during the three days of survey, unless requested.

c. Additional concerns identified included:

* Chemicals were left on the counter next to the sink and stored in an unlocked cabinet under the sink;

* Area between right refrigerator and cabinet to the left was filled with miscellaneous items unrelated to food or food service;

* Personal items belonging to staff were on kitchen counters;

* A pile of empty boxes and plastic bags sat on the floor next to the garbage can;

* Dust pan next to the right refrigerator had a build-up of brown matter; and

* A pile of empty plastic bags was on the floor of the dry storage area.

The areas of concern were observed and discussed with Staff 1 (Administrator) on 03/07/23 and discussed with Staff 1, Staff 2 (Regional Director of Operations), Staff 3 (House Manager - Ramp), Staff 4 (RN), and Staff 5 (Regional Compliance Specialist) on 03/08/23. They acknowledged the findings.

OAR 411-054-0030 (1) (a)

1. A deep clean of both Douglas and Ramp kitchens will be completed to include cabinets and drawers, kitchen counters and back splashes, stove top and oven, inside of microwave. Spice racks,wooden cutting board, top of all refrigerators, all coffee pots.  Any splatters on inside of trash can lids. Kitchen floors, wall above the back counter, between both the two refrigerators. Dry storage room carpet and shelve.

New trash cans to be purchased.

2. Dry storage room to be cleaned and all food to be properly stored, sealed and labeled. The freezer chest located in the laundry room directly next to the hopper sink was moved to the garage on 03/07/2023. Alcohol wipes to be used to sanitize the probe termometers after use. All food and drink containers to be labeled and dated and properly stored.

3. 3 Meals per day with snacks, that include fresh vetables and fresh fruit will be offered by staff to residents per regulations, daily.  

2.Cleaning schedule check lists will be reviewed and updated to reflect daily, weekly and monthly cleaning and sanitizing. All staff will be provided training on updated cleaning and sanitizing schedules.

3. The cleaning schedule check lists will be reviewed daily, then weekly to identify any challenges or concerns and completion of duties

4.  The following repairs will be completed:

A. Cabinets and drawers.

B. Counters and back splashes

C. Heating element in oven in Ramp was replaced 3/8

D. Vent cover on left refrigerator repositioned 3/8

E. Drawer under oven, to fit properly

F. Several cabinet doors need adjustment to fit properly.

G. Laminate repair for peeling off.

H. Varnish around cabinets knobs and drawers.

I.   Replace front drawer missing from bottom of drawer.

J. Replace dust pans in both houses.

K. Touch up paint in dry storage area.

L. Repaint half doors in kitchens.

5. Temps in both refrigerators to be monitored and adjusted to temps per state regulations.

6.All food to be stored per regulations a

as noted above.

7.Staff to wash hands per policies and procedures.

8.Chemicals to be stored per policy.

Area between refridgerators cabinet to be cleared.

9.Personal items of staff to be stored in appropriate areas.

10. Empty boxes and plastic bags to be disposed of.

The Administrator or designee to be responsible to ensure the corrections are completed/monitored. Daily monitoring for cleaning logs, temp logs, food storage, distribution of meals and snacks. Overall cleanliness.

Repairs/replacements to be coordinated by Ashley Manor's Maintenance Team and the RDO.

Based on observation and interview, it was determined the facility failed to ensure a daily program of social and recreational activities that were based upon individual and group interests and physical, mental, and psychosocial needs was provided for residents. Findings include, but are not limited to:

During the survey, conducted 03/06/23 through 03/08/23, there were no observations of individual or group activities being provided for residents in the facility's Douglas or Ramp Houses.

During an interview with Staff 1 (Administrator) on 03/07/23, she stated the universal workers were in charge of providing activities for the residents.

Multiple care staff interviewed during survey reported there was usually not enough time to organize and run activities for the residents.

Throughout the survey residents were observed sitting on couches or in chairs,  watching TV for short periods of time, staring forward, or sleeping. Some residents were wandering around the houses, and many returned to their rooms after each meal and were observed in bed.

The need to ensure a daily activity program was provided for residents was reviewed with Staff 1, Staff 2 (Regional Director of Operations), Staff 3 (House Manger - Ramp), Staff 4 (RN), and Staff 5 (Regional Compliance Specialist) on 03/08/23. They acknowledged the findings.

OAR 411-054-0030 (1) (C-D) Resident Services

Activities.

1. The Facility will schedule one full time employee to be assigned to activities 8 hours per day between Ramp and Douglas, the facility is currently recruiting for this role.

The facility will ensure a daily program of social and recreational activities that are based upon individual and group interests and physical, mental and psychosocial needs are provided for residents. Until a full time Activiy Director in place, staff will do their best to engage residents in activities.

2.The Activities Director will assist the Administrator with updating individual and group interests through resident, and/or family interviews. This information will be used to update each residents service plan with residents history and current preference. The Activity Director will also incorporate the use of the activity program sent monthly by the Home Office.

3.The activity program will be reviewed daily at each community on-going.

4. The Administrator or designee will be responsible to ensure the system has been corrected/monitored.

2. In the facility's Douglas House, Resident 4's clinical record was reviewed and contained an evaluation dated 09/30/22. The next quarterly evaluation would have been due on 12/30/22. There was no documented evidence an evaluation had been completed after 09/30/22.

On 03/08/23, the need to ensure the facility performed evaluations at least quarterly, to correspond with the quarterly service plan updates, was discussed with Staff 1 (Administrator), Staff 2 (Regional Director of Operations), and Staff 3 (House Manager - Ramp), Staff 4 (RN), and Staff 5 (Regional Compliance Specialist). No additional information was provided.

Based on interview and record review, it was determined the facility failed to ensure all required elements were addressed in move-in evaluations and to ensure quarterly evaluations were completed on time for 2 of 4 sampled residents (#s 2 and 4) whose evaluations were reviewed.  Findings include, but are not limited to:

1. Resident 2 was admitted to the facility's Ramp House in 02/2023 with diagnoses including chronic obstructive pulmonary disease and Parkinson's disease.

The resident's pre-admission evaluation and nursing assessment, both dated 02/17/23, were reviewed. The following required elements were not included on the move-in evaluation form or there was no documented evidence they were addressed prior to admit:

* Spiritual, cultural preferences and traditions;

* Visits to health practitioner(s), ER, hospital, or nursing facilities in the past year;

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

* Pain: pharmaceutical and non-pharmaceutical interventions;

* Fall risk or history;

* Complex medication regimen;

* History of dehydration or unexplained weight loss or gain; and

* Recent losses.

The need to address all required elements prior to a resident moving into the facility was discussed with Staff 1 (Administrator), Staff 2 (Regional Director of Operations), Staff 3 (House Manager - Ramp), Staff 4 (RN), and Staff 5 (Regional Compliance Specialist) on 03/08/23. They acknowledged the findings.

OAR 411-054-0034  resident move in and eval

1.(a)Resident #2 was admitted to Hospice on 3/09/23, and has passed away.

1.(b) Resident #4's evaluation will be updated by 4/10/23.

2. The Administrator and House Manager will be provided training on the resident evaluation and all required components. All resident evaluations will be reviewed and updated  to ensure all required componets are reflective of his / her needs.

3. Upon admission of new resident, quarterly and / or with a signifcant change of condition.

4. The Administrator or designee will be responsible to ensure the system has been corrected and monitored, with oversight by RDO.

3. Resident 1 was admitted to the facility's Ramp House in 03/2017 with diagnoses including dementia, vertigo and hallucinations.

A review of the resident's current service plan, dated 01/09/23, observations, and interviews with staff revealed the service plan was not reflective and/or did not provide instruction to staff in the following areas:

* Admit to hospice;

* Increased ADL assistance required;

* Decreased abilities in all areas;

* Decreased appetite;

* Significant weight loss in 12/2022;

* Side rails; and

* Recent falls.

The need for service plans to reflect residents' current status and care needs and to provide clear direction to staff regarding the delivery of services was discussed with Staff 1 (Administrator), Staff 2 (Regional Director of Operations), Staff 3 (House Manager - Ramp), Staff 4 (RN), and Staff 5 (Regional Compliance Specialist) on 03/08/23. 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' needs, provided clear direction to staff, were updated, and/or interventions implemented for 3 of 4 sampled residents (#s 1, 3 and 4) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility's Douglas House in 2019 with diagnoses including dementia.

Observations of Resident 3 during the survey, interviews with staff, and review of the clinical record, including the service plan, dated 01/10/23, revealed the service plan was not reflective of the resident's needs, lacked clear direction regarding the delivery of services, and/or was not implemented in the following areas:

* Transfer assistance;

* Ambulation;

* Whole milk at every meal;

* High calorie snacks at 10:00 am, 2:00 pm, 6:00 pm, and 8:00 pm;

* Motion alarm in room;

* History of pressure ulcers; and

* Wandering behavior, with instructions to staff.

The need to ensure the service plan was reflective and updated of Resident 3's current care needs, provided clear direction to staff, and/or interventions were implemented was discussed with Staff 1 (Administrator), Staff 2 (Director of Operations), Staff 3 (House Manager - Ramp), Staff 4 (RN), and Staff 5 (Regional Compliance Specialist) on 03/08/23. They acknowledged the findings, and no further documentation was provided.

2. Resident 4 was admitted to the facility's Douglas House in 2020 with diagnoses including encephalopathy and anxiety.

Observations of Resident 4 during the survey, interviews with staff, and review of the clinical record, including the service plan dated 09/30/22, revealed the service plan was not reflective of the resident's needs, lacked clear direction regarding the delivery of services, and/or was not implemented in the following areas:

* Use of weighted, large handled utensils to eat;

* Use of a straw for all liquids;

* Instructions to sit up for 30 to 60 minutes after meals;

* Hobbies, interests, social, leisure activities; and

* Wandering into other residents' rooms.

The need to ensure the service plan was reflective and updated of Resident 4's current care needs, provided clear direction to staff, and/or interventions were implemented was discussed with Staff 1 (Administrator), Staff 2 (Director of Operations), Staff 3 (House Manager - Ramp), Staff 4 (RN), and Staff 5 (Regional Compliance Specialist) on 03/08/23. They acknowledged the findings, and no further documentation was provided.

OAR 411-04-0036 Service Plans

1(a). Resident # 3 was admitted to Hospice on 3/22/23 and has passed away.

1(b). Resident # 4's service plan will be updated by 4/12/23. The update will be reflective of the residents current needs and give clear directions for staff regarding the delivery of services. Updates will include the use of weighted, large handled utensils; use of straw for all liquids; instruction to sit upright for 30 to 60 minutes after meals, as well as hobbies, interests, social, leisure, activites, and wandering into other residents' rooms.

1(c). Resident #1 was on Hospice Services and has passed away.

2. The Administrator and House Manager will be provided training on resident service planning and all required components. All resident service plans will be reviewed and updated  to ensure all required componets are reflective of his / her needs.

3. Upon admission of new resident, quarterly and / or with a signifcant change of condition.

4. The Administrator or designee will be responsible to ensure the system has been corrected and monitored, with oversight by RDO

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team which consisted of the resident, the resident's legal representative if applicable, any person of the resident's choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services to the resident, for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose service plans were reviewed. Findings include, but are not limited to:

Resident 1, 2, 3 and 4's most recent service plans lacked documentation a Service Planning Team reviewed and participated in the development of the service plans.

The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (Administrator),  Staff 2 (Regional Director of Operations), Staff 3 (House Manager - Ramp), Staff 4 (RN), and Staff 5 (Regional Compliance Specialist) on 03/08/23. They acknowledged the findings.

OAR 411-054-0036 Service Plan Service Planning Team

1. Resident #4 will be scheduled for a service plan team meeting by 4/15/23.  

2.The Administrator and House Manager will be provided training on the requirements and importantance of a service planning team; including the role of the service planning team, which consists of the resident, residents legal representative, person of the residents choice, Administrator or Designee, Case manager if applicable, Nursing if receiving nursing services, and at least one other staff person who is familiar with or providing services to the resident.  The Administrator/Interim Admin or the Designee will be responsible to schedule the service plan team meetings.

3.  Initially, quarterly, with signifigant change of condition, and with monthly Administrator Quality Assurance Audit.

4. The Administrator/Interim, and/or designess with oversight from RDO.

2. Resident 3 was admitted to the facility's Douglas House in 2019 with diagnoses including dementia.

Interviews with staff, review of the service plan dated 01/10/23, temporary service plans, incident reports, and progress notes dated 12/09/22 through 03/06/23 were completed. The following was identified:

* An incident report dated 01/29/23 indicated Resident 3 "... tried to go in to another resident's room and I tried to bring [the resident] to [his/her] room and [s/he] was resisting and fighting me so [s/he] fell ... and fought me to get up ..."  

There was no documented evidence the incident was evaluated, resident-specific instructions were provided to staff following the incident, service-planned interventions were reviewed for effectiveness, or progress was noted weekly through resolution.

The need to ensure changes of condition were evaluated, interventions were developed and communicated to staff, resident-specific instruction provided to staff, interventions were evaluated for effectiveness and progress was noted weekly through resolution was discussed with Staff 1 (Administrator), Staff 2 (Regional Director of Operations), Staff 3 (House Manager - Ramp), Staff 4 (RN), and Staff 5 (Regional Compliance Specialist) on 03/08/23. They acknowledged the findings.

3. Resident 4 was admitted to the facility's Douglas House in 2020 with diagnoses including dementia and encephalopathy.

Observations of the resident, interviews with staff, review of the service plan dated 09/30/22, temporary service plans, incident reports, and progress notes dated 12/09/22 through 03/06/23 were completed. The resident experienced multiple short-term changes of condition in the following areas:

* 01/30/23 - Bruising to both arms, top of right hand, and resolving bruise to right leg;

* 02/15/23 - A resolved back wound was observed to have "white paste" coming from the area; and

* 02/16/23 - Return from emergency room related to complaint of chest pain and fluctuating blood pressure and pulse.

There was no documented evidence these changes of condition were evaluated, actions or interventions were determined and communicated with staff, resident-specific instructions were provided to staff, and progress was noted weekly through resolution.

The need to ensure there was documentation to reflect short-term changes of condition were evaluated, interventions were developed and communicated with staff, along with resident-specific instructions, and progress was noted at least weekly until resolution was discussed with Staff 1 (Administrator), Staff 2 (Regional Director of Operations), Staff 3 (House Manager - Ramp), Staff 4 (RN), and Staff 5 (Regional Compliance Specialist) on 03/08/23. They acknowledged the findings.

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

1. Resident 1 was admitted to the facility in 03/2017 with diagnoses including dementia, vertigo and hallucinations.

The resident's progress notes, dated 12/06/22 through 02/17/23, temporary service plans (TSPs), RN assessments, and incident reports and investigations were reviewed, and staff were interviewed. The following changes of condition were identified:

* 01/09/23 - Two falls, one with injury;

* 01/17/23 - Returned to the facility after a visit to the ER;

* 01/30/23 - Returned to the facility from a stay in the hospital;

* 02/15/23 - Two falls, one with injury; and

* 03/03/23 - A fall with injury.

There was no documented evidence these changes of condition were evaluated and referred to the RN if needed; actions or interventions were determined and communicated to staff on each shift; staff instructions were resident-specific and made part of the resident record; or monitored through resolution, with weekly progress noted.

In an interview on 03/07/23, Staff 1 (Administrator) reported there was "not much" documentation of monitoring occurring. She indicated she was implementing a part of their software program where staff could document monitoring.

The need to evaluate and develop actions or interventions, communicate interventions to staff, implement resident-specific instructions and make them part of the resident record, and monitor changes and document progress weekly through resolution was discussed with Staff 1, Staff 2 (Regional Director of Operations), Staff 3 (House Manager - Ramp), Staff 4 (RN), and Staff 5 (Regional Compliance Specialist) on 03/08/23. They acknowledged the findings. No additional information was provided.

OAR 411-054-0040 Change of Condition

1. Resident #1 and #3 have passed away while on Hospice Services. Facility Registered Nurse and Administrator/Interim will review short term changes of condition for Resident #4 including bruising to both arms, top of right hand, bruise to right leg, resolved back wound and return from emergency related to complaints of chest pain and fluctuating blood pressure and pulse. If a change is identified, New Resident Monitoring in Emar will be implemented.

2. Staff will receive in-servicing specific to New Resident Monitoring program for changes of condition, inclucing appropriate documentation related to the change, and when to notify the nurse.

Staff will also be provided with re-training for the use of The "24 hour binder" communication system.

The "24 hour binder" will be set up to include

a) Shift to Shift Communication Log

b) Alert charting log

c)Temporary Service Plan

d) Signifcant Change of Condition Log

e) Weekly Skin Monitoring Log

Staff will start Short Term Monitoring / Communication System for any resident identified to have a change of condition including but not limited to, return from hospital, signs or symptoms of urinary tract infection, new or missed medication etc.. Staff will initiate the alert log, including resident name, change identified, start a temporary service plan, and complete proper notifications to ensure the resident is placed on Resident Monitoring on Emar. The staff will be aware of what to report to nurse and/or physician per temporary service plan  which corresponds with the resident change of condition. Resident Monitoring and  Temporary Service Plan will have specific directions for staff including what to look for, interventions to put in place, signs and symptoms to report, who to report to and staff signature lines to sign once they have read and understood the Temporary Service Plan.

Staff will monitor the residents status until the residents condition resolves and they are back to their baseline.

24 Hour Binder process and Resident Monitoring in Emar, will be reviewed daily during Daily clinical meetings as a means to identify potential significant change that needs to be assessed by the Registered Nurse.

3. The system will be reviewed daily to ensure compliance is maintained.

4. The Administrator or designee and Registered Nurse will be respsonsible to ensure the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure controlled substances were logged and administered accurately for 1 of 1 sampled resident (#1) whose PRN narcotic medications were reviewed. Findings include, but are not limited to:

Resident 1 was admitted to the facility's Ramp House in 03/2017 with diagnoses including dementia, vertigo, and hallucinations. During the acuity interview, the resident was identified receiving hospice services.

A review of the resident's 02/01/23 through 03/06/23 MAR, physician orders, medication card and bottle, and the Controlled Substance Log revealed the following:

* The resident had an order for morphine sulfate (a pain reliever), 0.50 ml every hour as needed for pain or shortness of breath.

* A comparison of the Controlled Substance Log and the 02/01/23 through 03/06/23 MARs revealed the following:

- 2/18/23: There was no time documented on the Controlled Substance Log indicating when the medication was removed from the medication cart. The time documented for administration on the MAR was 11:36 am.

- The MAR indicated the resident was administered morphine on 02/21/23 at 6:25 pm and 02/27/23 at 10:17 am, but neither administration was documented on the Controlled Substance Log.

- The MAR indicated the resident was administered morphine on 03/03/23 at 8:11 am and 10:18 am, although neither administration was documented on the Controlled Substance Log.

- The resident was administered morphine on 03/04/23. The time of administration  documented on the MAR was 7:56 pm, although the time documented on the Controlled Substance Log was unclear, as it had been written over and was not legible.

- The quantity of morphine remaining in the bottle was not documented on the Controlled Substance Log on 28 occasions between 02/17/23 and 03/07/23.

On 03/08/23 at 8:48 am the bottle of morphine sulfate was observed to have approximately 4 ml remaining.

In an interview on 03/08/23, Staff 1 (Administrator) and Staff 4 (RN) indicated they were unaware the documentation of morphine administration in the Controlled Substance Log and on the MAR did not match.

The need for controlled substance administration to be documented accurately and for the Controlled Substance Log and the MAR to match was discussed with Staff 1, Staff 2 (Regional Director of Operations), Staff 3 (House Manager - Ramp), Staff 4, and Staff 5 (Regional Compliance Specialist) on 03/08/23. They acknowledged the findings and indicated they would be providing training to MT's about proper documentation of controlled substance administration.

OAR 411-054-0055 (1) e Systems:

Tracking Control Substances.

1. An audit of all controlled substances will by completed by the facility RN and Administrator. All controlled substances will be entered into Alis, the Emar system to ensure that controlled substances are tracked and documented correctly.  

2.Staff will be provided training on medication policies, documenting and tracking controlled substances using the Emar, including disposal of all unused, outdated or discontinued medications as well as who to contact for discrepancies.

3.The system will be audited each shift during shift to shift controlled subance count, as well as daily in clinical meetings, to ensure that all controlled substances were logged and administered accurately.

4.The Administrator or designee and Registered Nurse will be respsonsible to ensure the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed and to have written, signed physician orders in residents' charts for 2 of 4 sampled residents (#s 1 and 2) whose MARs and physician orders were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility's Ramp House in 03/2017 with diagnoses including dementia, vertigo, and hallucinations. During the acuity interview, s/he was identified to be receiving hospice services.

The resident's physician orders and 02/02/23 through 03/06/23 MARs were reviewed. The following was identified:

* The resident had a physician order for Haldol, 0.5 ml every 4 hours as needed for anxiety, restlessness, or nausea. The order stated, "Use if lorazepam or Zofran are ineffective."; and

* Haldol was administered to the resident on 18 occasions between 02/15/23 and 03/06/23 without lorazepam or Zofran being administered first as ordered.

The need to follow physician orders as prescribed was discussed with Staff 1 (Administrator), Staff 2 (Regional Director of Operations), Staff 3 (House Manager - Ramp), Staff 4 (RN), and Staff 5 (Regional Compliance Specialist) on 03/08/23. They acknowledged the findings.

2. Resident 2 was admitted to the facility's Ramp House in 02/2023 with diagnoses including Parkinson's disease and chronic obstructive pulmonary disease. The resident's record, including 02/17/23 through 03/06/23 MARs, progress notes, and incident reports were reviewed, and staff were interviewed. The following was identified:

a. The resident had a signed physician order for carbidopa-levodopa (for Parkinson's disease), 25-100 mg, one tablet five times a day. Both the 02/2023 and 03/01/23 through 03/06/23 MARs indicated the dosage was 10-100 mg tablet five times per day.

Between 02/01/23 and 03/06/23, the resident was administered a 10-100 mg tablet five times a day instead of the prescribed 25-100 mg tablet five times a day.

b. There were no signed physician orders in Resident 2's chart for the following medications and/or treatments:

* Albuterol Sulfate inhaler;

* Atrovent inhaler;

* Oxygen 2 LPM; and

* Prednisone.

The inhalers and prednisone were prescribed when the resident was sent to the emergency room on 03/01/23 because s/he "couldn't breathe" and were discontinued on 03/05/23.

The need to have signed physician orders in the resident's record was discussed with Staff 1 (Administrator), Staff 2 (Regional Director of Operations), Staff 3 (House Manager - Ramp), Staff 4 (RN), and Staff 5 (Regional Compliance Specialist) on 03/08/23. They acknowledged the findings.

OAR 411-054-0055 (1) (f-h)

Systems: Treatment Orders

1.An audit of all physician orders and Emar will be completed. Any orders that are not being carried out as prescribed will be corrected and physician quarterly orders will be sent out to physician/providers.  

2.Staff will be provided with training for; following physician's orders, and ensuring that all orders are carried out as prescribed, as well as when to notify the Administrator and/or Registered Nurse.

3.The area will be reviewed daily at clinical meeting using the the medication exception, medication changes report and the 24 hour binder to ensure all orders have been processed and entered correctly.

4. The Administrator or designee and Registered Nurse will be respsonsible to ensure the corrections are completed and monitored.

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 4 of 4 sampled residents (#s 1, 2, 3 and 4) who had documented medication refusals. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility's Douglas House in 2019 with diagnoses including dementia.

Resident 3's 02/01/23 through 03/06/23 progress notes, physician communications, and 02/01/23 through 03/06/23 MAR/TAR were reviewed. The resident's record showed multiple refusals of the following medications and treatments:

* Amlodipine (for hypertension);

* Docusate Sodium (for bowel care);

* Acetaminophen (for pain);

* High calorie drinks twice daily;

* Mirtazapine (antidepressant);

* Weekly weights; and

* Treatment for a skin rash.

The physician/practitioner had ordered the facility to send notification of refusals monthly. There was no documented evidence the facility had a system for notifying prescribers when the resident refused to consent to orders.

The need to ensure the facility notified the physician/practitioner of medication refusals as ordered was discussed with Staff 1 (Administrator), Staff 2 (Director of Operations), Staff 3 (House Manager - Ramp), Staff 4 (RN), and Staff 5 (Regional Compliance Specialist) on 03/08/23. They acknowledged the findings.

2. Resident 4 was admitted to the facility's Douglas House in 2020 with diagnoses including encephalopathy.

Resident 4's 02/01/23 through 03/06/23 progress notes, physician communications, and 02/01/23 through 03/06/23 MAR/TAR were reviewed. The resident's record showed multiple refusals of the following medications:

* Amlodipine (for hypertension);

* Citalopram Hydrobromide (psychotropic medications);

* Famitodine (for gastric esophageal reflux);

* Metoprolol (for hypertension);

* Miralax (bowel care);

* Prednisone (a steroid); and

* Senna (bowel care).

The physician/practitioner had ordered the facility to send notification of refusals monthly. There was no documented evidence the facility had a system for notifying prescribers when the resident refused to consent to orders.

The need to ensure the facility notified the physician/practitioner of medication refusals as ordered was discussed with Staff 1 (Administrator), Staff 2 (Director of Operations), Staff 3 (House Manager - Ramp), Staff 4 (RN), and Staff 4 (Regional Compliance Specialist) on 03/08/23. They acknowledged the findings.

2. Resident 1 was admitted to the facility in 03/2017 with diagnoses including dementia, vertigo and hallucinations.

A review of the resident's 02/01/23 through 03/06/23 MARs revealed multiple occasions when the resident refused multiple medications. There was no documented evidence the physician was notified of the resident refusing medications.

The need to notify the physician when a resident refused medications and/or treatments was discussed with Staff 1 (Administrator), Staff 2 (Regional Director of Operations), Staff 3 (House Manager - Ramp), and Staff 4 (RN) on 03/08/23. They acknowledged the findings. Staff 1 stated she was unable to finding any documentation the physician was notified of medication refusals.

3. Resident 2 was admitted to the facility in 02/2023 with diagnoses including Parkinson's disease and chronic obstructive pulmonary disease.

A review of the resident's 02/17/23 through 03/06/23 MARs revealed s/he refused multiple medications in 02/2023 on multiple occasions and refused Miralax (for constipation) on one occasion in 03/2023. There was no documented evidence the resident's physician was notified of his/her medication refusals.

The need to notify the physician when a resident refused medications and/or treatments was discussed with Staff 1 (Administrator), Staff 2 (Regional Director of Operations), Staff 3 (House Manager - Ramp), Staff 4 (RN), and Staff 5 (Regional Compliance Specialist) on 03/08/23. They acknowledged the findings. Staff 1 stated she was unable to find any documentation the physician was notified of medication refusals.

OAR 411-054-0055 (1) (j-k) Systems:

Resident Right to Refuse.

1. An audit will be completed to ensure all providers directions for notification are in place accurately. The notifications will be updated with instruction for the medication technician to print out the refusals, create a fax cover and place in administrators box to be faxed to provider. The Administrator will place in the 24 hour binder under "pending faxes" and provide follow up to ensure received.

2. Medication technicians will be provided with training on the process of notifying providers. Training will be provided with each current and new medication technician.

3.The area will be evaluated during daily clinical minutes by reviewing exception reports and review of pending faxes in the 24 hour binder.

4.The Administrator or designee and Registered Nurse will be respsonsible to ensure the corrections are completed and monitored.

Based on observation, interview and record review, it was determined the facility failed to have staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident to compensate for staff duties beyond direct resident care. Findings include, but are not limited to:

During the survey, from 03/06/23 through 03/08/23, a need for increased staffing was identified based on observations and interviews with staff and sampled and unsampled residents. The facility employed "universal workers" whose duties included caregiving, medication administration, laundry, housekeeping, cooking, and providing activities. The staff plan for both Ramp and Douglas houses was two universal staff for both day and swing shifts and one for the overnight shift.

Observations of both houses revealed the following:

* Both Ramp and Douglas houses were found to be in need of a deep cleaning and repair in several areas;

* Dirty laundry was observed accumulating in the laundry room of both Ramp and Douglas houses;

* In Douglas House on both 03/07/23 and 03/08/23 there was a pile of soiled linens on the floor in front of the washing machine of the laundry room; and

* No scheduled or unscheduled activities were offered to residents in either house throughout the survey.

Interviews with staff indicated:

* With all the caregiving, cooking, and laundry, caregivers "can only do so much housekeeping";

* "Things seem out of order, chaotic" in the facility;

* "There is a high turnover" of staff;

* There was a resident who required at least two people for transfer assistance;

* There were no clean "chux" pads in Douglas House on the morning of 03/07/23; and

* There was "not enough time or the people to do all the showers."

Residents were interviewed and shared the following:

* "It takes forever" to get staff to answer call lights; and

* An unsampled resident reported s/he had not had a shower since they were admitted to the facility approximately two weeks prior.

The facility was using the Department's acuity-based staffing tool, but were not consistently staffing to the plan generated by the tool.

The need for a higher level of staffing was discussed with Staff 1 (Administrator), Staff 2 (Regional Director of Operations), Staff 3 (House Manager - Ramp), Staff 4 (RN), and Staff 5 (Regional Compliance Specialist) on 03/08/23. They acknowledged the findings.

OAR 411-054-0070  Staffing requirements and training

1. Ashley Manor-Roseburg will recruit and hire additional staff per the staffing hours that have been agreed upon in the Letter of Agreement with the Oregon Department of Human Services Aging and People with Disabilities Licensing.  Deadlines for having new staff hired and training will be met. Active recruiting and hiring is taking place.  New hires are presently in training.

2. Ashley Manor will continue to recruit,hire and train new staff to ensure adequate staffing is present and available.

3.The schedule will be reviewed daily, and staffing will be adjusted as needed to ensure staffing hours are following the Letter of Agreement  

4.  The Administrator or designee, and RDO will be responsible to ensure that the corrections are completed and monitered.

Based on interview and record review, it was determined the facility failed to ensure 1 of 3 newly hired (#10) staff completed all elements of pre-service orientation and dementia training prior to providing care to residents. Findings include, but are not limited to:

Staff training records were reviewed on 03/08/23 and revealed the following:

There was no documented evidence Staff 10 (MT) completed the required elements of pre-service orientation prior to beginning their job responsibilities or dementia training prior to providing care to residents.

The need for all newly hired staff to complete all required elements of pre-service orientation and dementia training in the specified time frame was discussed with Staff 1 (Administrator), Staff 2 (Regional Director of Operations), Staff 3 (House Manager - Ramp), Staff 4 (RN), and Staff 5 (Regional Compliance Specialist) on 03/08/23. They acknowledged the findings, and the Administrator indicated she believed the training had been completed but she was unable to find the documentation.

OAR 411-054-0070 (3-4) Staffing Rqmts and Training: Caregiver Rqmts

1) An audit of training records will be conducted, any staff missing preservice dementia training or preservice orientation will be removed from the schedule and required to complete training before being placed back on the schedule.

2. To ensure the system is corrected and staff remain in compliance with all training requirements, at time of hire, the employee will be assigned required trainings in the Bridge and Oregon Care Partners online training program. With each new hire, Admin/Designee will ensure new staff are not scheduled to work until required trainings are completed.

3. Staff training records will be evaluated on a monthly basis via the Ashley Manor monthly administrator audit that is turned in monthly and reviewed/monitored by Regional Director of Operations and Compliance Director .

4. The Administrator or designee will be responsible to see that the corrections are completed and monitored with oversight of the Regional Director.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 newly hired staff demonstrated competency in assigned job duties and completed first aid and abdominal thrust training within 30 days of hire. Findings include, but are not limited to:

Training records were reviewed on 03/08/23 and the following was identified:

There was no documented evidence Staff 10 (MT) and Staff 11 (MT) demonstrated competency in the following areas within 30 days of hire:

* Role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Changes associated with normal aging;

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

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

* General food safety, serving, and sanitation; and

* First aid/abdominal thrust.

The need to ensure direct care staff demonstrate competency in all required areas within 30 days of hire was discussed with Staff 1 (Administrator), Staff 2 (Regional Director of Operations), Staff 3 (House Manager - Ramp), Staff 4 (RN), and Staff 5 (Regional Compliance Specialist) on 03/08/23. They acknowledged the findings.

OAR 411-054-0070 (6)(9) Training within 30 days: Direct Care Staff

1.(a) A audit of staff trainng records will be completed and any staff without the required demonstrated competencies within 30 days of hire including Role of service plans in providing individualized care;providing assistance with ADL's; changes associated with normal aging;identification, documentation and reporting of changes of condition; conditions that require assessment, treatment and observation and reporting, and General food safety, serving and sanitation will be provided the training.  

(b) An audit of staff training records will be completed and any staff without the required First Aid and Abdominal Thrust training will be provided the training.

2. To ensure the system is corrected and staff remain in compliance with all training requirements, at time of hire, the employee will be assigned required trainings in the Bridge and Oregon Care Partners online training program. With each new hire, Admin/Designee will ensure new hire is not scheduled to work until required trainings are completed.

3. Staff training records will  be audited by the Admin/Designee on a monthly basis via the Administrator monthly audit that is turned in monthly and reviewed/monitored by Regional Director and Compliance Director.

4. Administrator/designee will be responsible to see that the corrections are completed and monitored.

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

Fire and life safety records were reviewed on 03/08/23 at 8:38 am.

The facility provided documentation of one fire drill in the last six months, which occurred on 12/01/22. There was no documented evidence fire drills were conducted every other month.

In addition, there was no documented evidence staff were instructed on fire and life safety on alternating months from fire drills.

The need to ensure fire drills were conducted and staff instruction was provided according to the OFC was discussed with Staff 1 (Administrator, Staff 2 (Regional Director of Operations), Staff 3 (House Manager - Ramp), Staff 4 (RN), and Staff 5 (Regional Compliance Specialist). They acknowledged the findings.

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety

1. Fire Drills will be conducted and recorded at a minimum of every other month at different times of the day, evening and night shift. Fire and Life Safety Training will be provided on alternating months.

The fire drill document will include the following components: Date and time of day, location of simulated fire origin, the escape route used, problems encountered and comments relating to residents who resided or failed to participate in the drills, evacuation time period needed, staff members on duty, residents participating, number of occupants evacuated.

2. Fire Drills and Fire and Life Safety Training will be competed with all current staff to ensure awareness and understanding of emergency procedures including,

but not limited to evacuation routes, fire extinguisher use, locating and reading the fire panel, etc. Staff will be provided with a written fire drill protocol for reference. The fire drill documents and fire and life safety instruction documents will be filed in the Fire Drill/Fire and life safety binder in order of month.

3. The system will be evaluated monthly to ensure all requirements have been met and documented.

4. The Administrator /designee will be responsible to ensure the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure residents were instructed on fire and life safety procedures within 24 hours of admission and at least annually thereafter. Findings include, but are not limited to:

Fire and life safety records were reviewed on 03/08/23 and revealed a lack of documented evidence related to the following required elements:

* Instructions to residents on fire and life safety procedures within 24 hours of admission; and

* A written record, including content and residents attending, of annual re-instruction for residents on general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places inside or outside the building in the event of an actual fire.

The need to provide training to residents on fire and life safety as required by the Oregon Fire Code was discussed with Staff 1 (Administrator), Staff 2 (Regional Director of Operations), Staff 3 (House Manager - Ramp), Staff 4 (RN), and Staff 5 (Regional Compliance Specialist) on 03/08/23. They acknowledged the findings.

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents

1.General Fire and Life Safety training will be provided and documented for current residents, and at a minimum annually.

2. General Fire and Life Safety training will be provided for all new residents within 24 hours of admission and at a minimum annually.Training to include the following: alternative exit route used during fire drills. Additionally, documentation of partcipation in fire drills and training to assess ongoing evacuation capabilities of both residents and staff and interventions and resolution related to resident evaucation concerns identified during fire drills.

3. This system will evaluated at a minimun of monthly to ensure all requirements have been met and documented.

4. The Administrator/designee will be responsible to ensure the corrections are completed/monitored.

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

1. The  facility's Douglas House was toured on 03/06/23 and 03/07/23, and multiple areas needing cleaning and/or repair were identified:

* Door frames throughout the Douglas House had scrapes and gouges present, including all entrance doors to resident rooms, bathrooms, laundry room, pantry and half doors leading into the kitchen;

* The screen of the electric fireplace was covered with dust, and the right side of the screen had broken away from the frame;

* A leather couch in the living room was worn, with cracked leather on one cushion and a large area on the back of the couch;

* A red chair in the living room had dark stains and food debris;

* The floor heat vents in the living room and entry areas were covered with dust and dark liquid spatters;

* The half wall separating the living/dining areas from the kitchen had stains and food splatters;

* Baseboards throughout the common areas were covered with dirt, debris, and some areas with food splatters;

* In the laundry room, there was missing linoleum to an area approximately 2 feet square;

* The laundry room floor was observed to be dirty, with dirt, debris, used gloves, and paper garbage products on the floor;

* On 03/07/23 and 03/08/23 there were soiled linens observed on the bare floor in the laundry room in front of the washing machine;

* Room 3's bathroom had two of three light bulbs not functional, and the toilet bowl was stained brown; and

* The lower portion of the wood fencing in the courtyard of Douglas House had multiple sections with rotten wood boards observed.

The need to ensure the environment was kept clean and in good repair was discussed with Staff 1 (Administrator) on 03/07/23 and 03/0823. She acknowledged the findings.

2. The facility's Ramp House was toured on 03/06/23, 03/07/23, and 03/08/23, and the following was identified:

* The inside of the front door was dented in several places;

* The floor vent to the left of the fireplace had a build-up of brown matter;

* The half-wall around the kitchen had food spills and splatters;

* There was debris on the carpeting throughout the building;

* There was debris and dirt on the window sill by the front door;

* Paint was wearing off of the edge of the window sill in the dining room, exposing unfinished wood;

* Doors and door jambs throughout Ramp House had scrapes and gouges, and the finish was wearing off around the door handles, including all entrance doors to resident rooms, bathrooms, laundry room, pantry, and half doors leading into the kitchen;

* There was debris and dirt on the floor in the laundry room;

* A step stool next to the hopper sink had brown splatters;

* The floor vent near the hopper sink had a build-up of brown and rust-colored matter;

* There were pieces of white debris in the hopper sink;

* The carpet sweeper, wet mop, and carpet cleaner stored near the hopper sink had a build-up of brown matter;

* Varnish was wearing off cabinet doors around the door knobs;

* There was a container of laundry detergent on the counter without a lid;

* A cupboard across from the hopper sink contained chemicals and was unlocked;

* There was a small, locked refrigerator on the counter beside the hopper sink; and

* The vinyl flooring in the bathroom in Room 6A was peeling up near the toilet and sink, the floor was soft in that area, and there was a yellow substance around the base of the toilet.

The need to ensure the environment was kept clean and in good repair was discussed with Staff 1 (Administrator) on 03/07/23 and with Staff 1, Staff 2 (Regional Director of Operations), Staff 3 (House Manager - Ramp), Staff 4 (RN), and Staff 5 (Regional Compliance Specialist) on 03/08/23. They acknowledged the findings.

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors

1. Maintenance will fix all stated issues in both Douglas and Ramp including Door frames, flooring, fencing, painting, and cabinetry. Full time housekeeper will be hired for all cleaning needs.

2. Once all of the concerns have been addressed the Admin/Designee  and the RDO (Regional Director of Opporations) will complete an audit of maintenance and cleaning needs.  All staff will be re-trained on proper cleaning techniques by Admin/Designee.  

3. Audit will be completed weekly by Admin/Designee and monthly by RDO to ensure all maintenance and cleaning needs are being addressed.

4. RDO and Admin/Designee will be responsible to ensure maintenance and cleaning are completed and monitored.

Based on observation and interview, it was determined the facility failed to ensure washing machines had a minimum rinse temperature of 140 degrees Fahrenheit or used a chemical disinfectant when washing soiled linens and soiled clothing. Findings include, but are not limited to:

The facility laundry rooms were observed on 03/06/23 and 03/07/23 in both Douglas and Ramp houses. The washing machines were a residential type with no indicator for the water temperature. The detergent the facility used did not include a disinfecting agent.

The need to ensure soiled laundry was properly disinfected was discussed with Staff 1 (Administrator) on 03/08/23. She acknowledged the findings.

OAR 411-054-0200 (7)(b-d) Housekeeping and Laundry

1. Actions taken to correct the rule violation include adding chemical disinfectant to soiled laundry.

2. System will be corrected with staff in-servicing on proper use of disinfectant with soiled laundry.

3. Area needing correction will be evaluated weekly and monthly to ensure disinfectant is being use properly.

4. Administrator/Designee will be responsible for corrections and monitoring.