Print Inspection: K16P

The findings of the re-licensure survey, conducted 8/30/21 through 9/1/21, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first revisit to the re-licensure survey of 09/01/21, conducted 01/26/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the second revisit to the re-licensure survey of 09/01/21, conducted 04/06/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the third revisit to the re-licensure survey of 09/01/21, conducted on 06/15/22, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and maintained in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:

The facility kitchen was toured on 8/30/21 at 10:25 am.

The facility kitchen was observed to need cleaning and repair in the following areas:

a. Food spills, splatters, debris, dirt and black and gray matter were observed on or underneath the following:

* Floors, doors and walls throughout the kitchen and dry storage;

* Drains;

* Pipes under dishwasher and behind ice machine;

* Ceiling vents;

* Light switches;

* Thermostat;

* Fire alarm;

* Vent on wall next to food prep area;

* Shelves throughout the kitchen and in dining room coffee area; and

* Food carts.

b. The following areas were in need of repair:

* Counters and shelves throughout the kitchen had multiple areas with chipped laminate;

* Walls throughout the kitchen had chipped paint, patched holes or holes with exposed drywall;

* Laminate wall covering was pulling away from the wall in multiple places;

* Caulk behind the dishwasher was black;

* Juice machine had a metal shelf with chipped paint and rust had developed on the the metal area where the shelf attached to the machine;

* Stand mixer had an area where paint was chipped and rust had developed; and

* Metal shelves in Refrigerators 1 and 2 had chipped vinyl.

The kitchen was toured on 8/30/21 at 1:05 pm with Staff 1 (Administrator) and Staff 4 (Dining Services Manager). They acknowledged the findings.

On 9/10 the kitchen floor was professionally scrubbed/cleaned. Monthly professional cleaning service has been obtained to begin 10/21.

On 9/3/21 broken kitchen carts were disposed of.

By 10/31/21 all floors, doors, walls, pipes, vents, shelves, mixer stands, food carts and wall accessories throughout kitchen will have been cleaned/replaced if needed and maintained as such.

Cleaning checklist to be updated by 9/30/21.

Dining Manager to review checklist weekly.

Administrator will audit cleaning checklists and kitchen cleanliness monthly.

Formal construction plans have been in place with G. Christianson Construction for kitchen remodel, including  removing wood cabinetry and island, repouring floor with coving, replacing RFP on walls, replacing island and cabinets with rolling stainless steel units, removing current HVAC system and installing a ductless mini-split heat pump. Project has been delayed due to Covid and constraints with meal prep. Permission obtained 9/9 from CBC Survey Manager Jeanne Bristol and ODHS Policy Analyst Debbie Concidine to use facility activity kitchen for meal prep during construction. On 9/9, Project Manager/Construction Company G. Christianson Construction contacted regarding timing to begin kitchen remodel project. On 9/17 Owner Carl Christianson confirmed that construction will be able to start in January or February of 2022, timing to be determined by availability of workers and subcontractors. Project could take up to 12 weeks, based on subcontractor schedules, moving compliance date to possibly late May 2022, though CCP will make every effort to engage G. Christianson Construction to begin project as soon as possible.   

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and maintained in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:

During the revisit survey, conducted 1/26/22, the facility was in process of repairing and remodeling the kitchen.  The allegation of compliance had been extended and the repairs will be reviewed after 5/31/22.  The facility continues to be out of compliance.

Formal construction plans have been in place with G. Christianson Construction for kitchen remodel, including removing wood cabinetry and island, repouring floor with coving, replacing RFP on walls, replacing island and cabinets with rolling stainless steel units, removing current HVAC system and installing a ductless mini-split heat pump. Project has been delayed due to Covid and constraints with meal prep. Permission obtained 9/9/2021 from CBC Survey Manager Jeanne Bristol and ODHS Policy Analyst Debbie Concidine to use facility activity kitchen for meal prep during construction. On 9/9, Project Manager/Construction Company G. Christianson Construction contacted regarding timing to begin kitchen remodel project. On 9/17 Owner Carl Christianson confirmed that construction will be able to start in January or February of 2022, timing to be determined by availability of workers and subcontractors.

As of 2/1/22, Project is set to begin on 2/21/2022 and take approximately 8 weeks.     

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and maintained in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:

During the second revisit survey, conducted 04/06/22, the facility was in process of repairing and remodeling the kitchen.  The allegation of compliance had been extended and the repairs will be reviewed after 5/31/22.  The facility continues to be out of compliance.

Formal construction plans have been in place with G. Christianson Construction for kitchen remodel, including removing wood cabinetry and island, repouring floor with coving, replacing RFP on walls, replacing island and cabinets with rolling stainless steel units, removing current HVAC system and installing two ductless mini-split heat pumps. Project had been delayed due to Covid and constraints with meal prep. Permission obtained 9/9/2021 from CBC Survey Manager Jeanne Bristol and former ODHS Policy Analyst Debbie Concidine to use facility activity kitchen for meal prep during construction. Project began 2/21/22 with estimated 8 - 10 week timeline. As of 4/18/22, project is on track to be complete by early May. Facility will then move back into completed kitchen and be fully functional by 5/31/22.

Based on interview and record review, it was determined the facility failed to ensure residents who had short term changes of condition had resident-specific instructions and/or interventions developed, implemented and interventions reviewed for effectiveness and that the condition was monitored to resolution at least weekly for 3 of 4 sampled residents (#s 1, 4 and 5) who experienced changes of condition.  Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in October 2015 with diagnoses including Parkinson's disease.

The resident's July 2021 service plan, 6/3/21 through 8/30/21 progress notes, temporary service plans and physician communications were reviewed. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness and/or lacked resident specific directions to staff in the following areas:

* Abrasions and bruises;

* Medication changes;

* Lethargy and weakness;

* Multiple non injury falls within the facility; and

* Multiple falls with injury at the facility and off the facility property.

The need to ensure short term changes of condition had documentation to reflect monitoring to resolution at least weekly and interventions were reviewed for effectiveness was discussed with Staff 1 (Administrator) on 8/31/21. She acknowledged the findings.

2. Resident 5 was admitted to the facility in March 2006 with diagnoses including paralysis and anxiety.

The resident's June 2021 service plan, 6/3/21 through 8/30/21 progress notes, temporary service plans and physician communications were reviewed. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness and/or lacked resident specific directions to staff in the following areas:

* Skin tears to the thigh and forearm;

* Weight changes;

* Lower leg hematoma; and

* Medication changes.

The need to ensure short term changes of condition had documentation to reflect monitoring to resolution at least weekly and interventions were reviewed for effectiveness was discussed with Staff 1 (Administrator) on 8/31/21. She acknowledged the findings.

3.  Resident 1 was admitted to the facility in August 2018 with diagnoses including history of colon cancer.

The resident's June 2021 service plan, 6/3/21 through 8/30/21 progress notes and temporary service plans were reviewed. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness and/or lacked resident specific directions to staff in the following areas:

* Multiple non-injury falls within the facility and in the community;

* Rectal bleeding; and

* New medications.

The need to ensure short-term changes of condition had documentation to reflect monitoring to resolution at least weekly and interventions were reviewed for effectiveness was discussed with Staff 1 (Administrator), Staff 2 (RN) and Staff 3 (RCC) on 8/30/21. They acknowledged the findings.

Health Services Director (HSD) reviewed Change of Condition on 9/16/21 with RN Consultant Kathleen Elias, including protocols and signs that may indicate a short term or significant change of condition, and unplanned weight change. Reviewed need for documentation to reflect monitoring to resolution and providing resident-specific directions and suggestions to staff via Interim Service Plans (ISPs).

For resident 4 - Safety Assessment and Plan for fall prevention measures will be in resident's record and available to direct care staff by 9/30/21.

For resident 5 - Change of Condition assessment completed and service plan updated by 9/10/21. HSD performed quarterly skin assessment on 9/3/21. PCP notified of weight changes.

For resident 1 - Change of Condition assessment completed and service plan updated by 9/10/21.

On 9/3/21, Med Tech staff educated on specifying purpose of alert charting and specifying start and end of alert charting for each individual event. HSD to provide ongoing education to Med Techs at monthly meetings.

HSD to enter weekly chart note summarizing status and monitoring of Change of Condition to resolution.

Caregivers and Medication Technicians to be trained on weight variances and reweighing protocol, and identifying and reporting change of condition, including skin tears, bruising, weakness, bleeding, to HSD, by 10/31/21.

HSD will be informed of changes in resident care needs at Stand Up interdisciplinary team meeting Monday through Friday and as needed other times.

RN Consultant will be consulted as needed regarding appropriate interventions and strategies of care.

The Administrator is responsible to ensure that change of condition documentation, evaluation, service planning and monitoring are occuring in a timely manner and at appropriate intervals for short-term and long-term changes of condition.  

Based on interview and record review, it was determined the facility failed to ensure residents with changes of condition were evaluated and resident-specific instructions or interventions were determined, documented and monitored for effectiveness at least weekly through condition resolution for 1 of 4 sampled residents (# 9) who experienced changes of condition.  Findings include, but are not limited to:

Resident 9 was admitted to the facility in 2017 with a diagnosis of multiple sclerosis.

The resident's records including progress notes dated 11/01/21 through 01/26/22, service plans and interim service plans were reviewed during survey and indicated the following:

The resident's service plan dated 11/15/21 indicated the resident had a history of falls and was considered a high fall risk, displayed confusion and difficulty focusing but was able to make decisions and was independent with most ADLs. The resident would call for staff assistance if s/he felt unsteady. The service plan instructed staff to encourage clean pathways as the resident's room was frequently cluttered which created a fall hazard.

The resident experienced numerous falls, both injury and non-injury, between 11/01/21 and 01/26/22.

a. There was no evidence an interim service plan or other documentation was recorded to show the facility had determined resident specific interventions, evaluated current interventions for effectiveness and determined the need to implement additional interventions when the resident experienced the following falls:

*11/15/21 The resident called the facility phone to let staff know s/he had fallen out of bed, when staff assisted the resident up, they noted blood coming from his/her upper and lower eyelid. The resident refused further evaluation.

*12/13/21 Staff noted the resident fell into his/her closet when s/he lost balance transferring from his/her electric scooter. No injury was noted.

*12/18/21 Staff responded to the resident's call light and found the resident on the floor next to the commode. Staff noted a small bump on the back of the resident's head. The resident refused to be sent out for further evaluation.

*12/22/21 Staff responded to the resident's call light and found the resident on the floor next to the commode. No injury was noted.

On 01/26/22 Staff 2 (RN) and Staff 3 (RCC) stated it appeared interim service plans had not been implemented for the above falls and staff involved had been provided with education.

b. Interim service plans related to multiple falls were not resident specific and provided identical interventions and instructions for staff. There was no indication a need for new interventions was evaluated for each of the following falls:

* 11/18/21 Staff responded to the resident's call button and found the resident on the floor of his/her kitchen area. Staff noted the resident sustained an abrasion to the right knee.

*12/02/21, twice on 12/27/21, 01/11/22, 01/12/22, 01/20/22, 01/25/22 the resident experienced non-injury falls in his/her apartment.

*01/17/22 Staff responded to the resident's call light and found the resident on the floor in his/her kitchen. The resident stated s/he hit his/her head but refused to be evaluated by emergency medical services.

The need to ensure residents with changes of condition were evaluated and resident-specific instructions or interventions were determined, documented and monitored for effectiveness at least weekly through condition resolution was discussed with Staff 1 (Administrator), Staff 2 and Staff 3 on 01/26/22. They acknowledged the findings.

Health Services Director (HSD) will review Change of Condition on 2/8/22 with RN Consultant Kathleen Elias, including protocols and signs that may indicate a short term or significant change of condition, and resident-specific interventions.

For resident 9 - Safety Assessment and Plan for fall prevention measures will be in resident's record and available to direct care staff by 2/4/22. Plan to be reviewed after each fall and updated at least quarterly and as needed. Risk Agreement to be created with resident by 2/18/22.

Interim Service Plan (ISP) process for falls was updated on 2/1/22 to ensure that personalized interventions are created for each fall, including requesting orders for therapies, and that, if applicable, safety assessment and plan is in place and being followed.

On 2/4/22, Med Tech staff educated on resident-specific interventions for falls and updated ISP process. HSD to provide ongoing education to Med Techs at monthly meetings.

HSD to enter weekly chart note summarizing status and monitoring of Change of Condition to resolution.

HSD will be informed of changes in resident care needs at Stand Up interdisciplinary team meeting Monday through Friday and as needed other times.

RN Consultant will be consulted as needed regarding appropriate interventions and strategies of care.

The Administrator is responsible to ensure that change of condition documentation, evaluation, service planning and monitoring are occuring in a timely manner and at appropriate intervals for short-term and long-term changes of condition.  

Based on observation, interview and record review, it was determined the facility failed to ensure the RN performed an assessment, developed interventions based on the condition of the resident, and updated the service plan for 2 of 3 sampled residents (#s 1 and 5) who experienced significant weight changes. Findings include, but are not limited to:

1. Resident 5 was admitted to the facility in March 2006 with diagnoses including paralysis and anxiety.   

Weight records dated 3/1/21 to 8/10/21, progress notes and RN notes dated 6/3/21 through 8/30/21, indicated the resident experienced the following:

A 10.8 pound weight loss from 4/26/21 to 5/24/21. This constituted a 7.34% severe weight loss in one month.

The resident's weights were monitored weekly through mid August 2021 when orders were changed to monthly weights. The resident's weight stabilized between 142 pounds and 144 pounds from June 2021 to August 2021.

The resident's meal intake remained stable with good intake at all three meals. The resident was able to feed herself/himself without issue and made their own dietary selections throughout the day.

Observations of the resident on 8/30/21 and 8/31/21 showed the resident transported herself/himself to the dining room for meals, selected from available options and ate the meal without assistance after delivery. The resident was observed to eat 100% at breakfast and two lunch meals.

The resident indicated during an interview on 8/31/21 that s/he received plenty to eat and had a few snacks in her/his apartment. The resident further stated s/he went out three times a week to the gym to complete work outs and work on strengthening, as well as spend time with friends. The resident stated during parts of COVID s/he was unable to go out or go to the gym which affected her/his activity level "significantly."

The facility failed to ensure an RN assessment was completed for the severe weight loss with documented findings, resident status and interventions made as a result of the assessment.

The need to ensure an RN assessment was completed related to significant changes in condition which documented findings, resident status and interventions made as a result of the assessment was discussed with Staff 1 (Administrator) and Staff 3 (RCC) on 8/31/21 and Staff 2 (RN) on 9/1/21. The staff acknowledged the findings.

2. Resident 1 was admitted to the facility in August 2018 with diagnoses including a history of colon cancer.

Review of the resident's 6/5/21 service plan, temporary service plans, RN assessments and March 2021 through August 2021 weight records revealed the following:

a. Weight records indicated that Resident 1 weighed 141.2 pounds on June 6, 2021 and 151.2 pounds on July 7, 2021, which constituted a 10 pound or 7.08% severe weight gain in one month.

b. The resident's weight on August 4, 2021 was 147.6 which represented a weight loss of 3.6 pounds or 2.38% since July 7, 2021. Subsequent weekly weights in August were within two pounds of the August 4th weight and were stable.

There was no documented evidence the significant weight gain had been assessed by the RN to include findings, resident status, and interventions made as a result of the assessment.

In an interview with Staff 9 (CG), she reported the resident was eating "more lately" and usually eats 75-100% of his meals.

Observation of the resident during the 8/30/21 lunch meal showed s/he ate 100% of the meal.

The need to ensure residents who experienced significant weight changes were assessed by the RN was discussed with Staff 1 (Administrator), Staff 2 (RN) and Staff 3 (RCC) on 8/31/21. They acknowledged the findings.

Weights are obtained at least monthly for every resident and entered into EHR. On or about the 15th of each month HSD to run weight report within EHR to review for weight increases or losses and perform assessment on residents nearing or experiencing significant weight change, planned or unplanned, and perform RN assessment, document accordingly, implement interventions, and notify PCPs.

EHR has active notification setting to inform HSD, RCC, and Administrator of 3 lb increase or decrease in weight between resident weight entries. Beginning 9/20/21, flagged changes to be discussed at weekday Stand Up interdisciplinary team meeting and reviewed by HSD.

On 9/16/21, HSD reviewed weight monitoring process with RN Consultant Kathleen Elias and performed review of all weights for past 30, 90, and 180 days.  

For resident 5, resident is weighed weekly and weights entered into EHR. Resident experienced a planned weight loss that HSD had verbally discussed with resident. On 9/20/21, HSD faxed weight history to PCP with update on resident's current weight.  

Caregivers and Medication Technicians to be trained on weight variances and reweighing protocol, and identifying and reporting change of condition to HSD, by 10/31/21.

HSD will be informed of changes in resident care needs at Stand Up interdisciplinary team meeting Monday through Friday and as needed other times.

RN Consultant will be consulted as needed regarding appropriate interventions and strategies of care.

The Administrator is responsible to ensure that systems are in place to respond to the 24-hour care needs of residents.

Based on interview and record review, it was determined the facility failed to ensure signed physician orders for all medications the facility was responsible to administer were located in the resident's facility record and that medication orders were carried out as prescribed for 1 of 4 sampled resident (#1) whose facility records were reviewed. Findings include, but are not limited to:

Resident 1 was admitted to the facility in August 2018 and had a diagnosis of Parkinson's Disease.

Review of Resident 1's 4/30/21 signed physician orders and 8/1/21 through 8/30/21 revealed the following:

1. The facility lacked signed physician orders for the following medications entered on the August 2021 MAR:  

*Carbidopa Levadopa (For Parkinson's);

*Lidocaine patch (pain); and

*Omeprazole (Stomach upset).

2. The following medications were reported by Staff 2 (RN) to have been discontinued without evidence of a discontinue order in the resident's facility record:

*Diphenhydamine (itching); and

*Aquaphor ointment (skin irritation).

3. The 4/30/21 physician order for Albuterol was not carried out as prescribed.

The need to ensure there was a signed physician order for all medications the facility was responsible to administer located in the residents facility record and that physician orders were carried out as prescribed was discussed with Staff 1 (Administrator), Staff 2 (RN) and Staff 3 (RCC) on 8/30/21. They acknowledged the findings.

On 9/2/21, signed discontinue order for resident 1 Albuterol nebulizer received and new signed order received for as needed Albuterol inhaler.

All physician orders to be faxed to PCPs quarterly with follow-up faxes sent to PCPs weekly until signed orders are received. HSD to follow up by phone to PCP if orders not received within 30 days.

As of 9/1/21, Physician Orders report from EHR includes "authorize the LN to discontinue any PRN medications or treatments not used within 60 days."

On 9/3/21, HSD and RCC faxed all PCPs for updated Physician Orders.  

On 9/3/21 Med Tech staff educated to fax PCP for order or to fax pharmacy for prescription if order change included in after visit summary and not sent as a signed order or prescription.

By 9/3/21, all resident charts include section for orders.  

HSD and RCC review all after visit summaries and will ensure fax sent for appropriate order or prescription.

HSD to ensure there is a signed physician order for all medications facility administers, that orders are carried out as prescribed, and that orders are in resident charts.

HSD to audit 25% of charts quarterly.

HSD to review monthly with Med Techs the system of obtaining signed orders or prescriptions.    

Based on interview and record review, it was determined the facility failed to ensure the physician was notified when residents refused to consent to a medication or treatment order for 3 of 3 sampled residents (#s 1, 4 and 5) whose records were reviewed: Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in August 2018 with diagnoses including a history of colon cancer.

Review of Resident 1's current signed physician orders, 8/1/21 through 8/30/21 MAR and physician communications revealed that the resident had refused to consent to multiple medication orders in the time frame reviewed:

* Albuterol (asthma) 40 times ;

* Ciclopirox cream (fungus) five times;

* Clotrimazole cream (fungus) five times;

* Lidocaine patch (pain) two times; and

* Ensure (nutritional supplement) one time.

There was no documented evidence the facility had notified the physician when Resident 1 refused to consent to the medication orders.

The need to ensure the physician was notified when a resident refuses to consent to a medication or treatment order was discussed with Staff 1 (Administrator), Staff 2 (RN) and Staff 3 (RCC) on 8/31/21. They acknowledged the findings.

2. Resident 4 was admitted to the facility in October 2015 with diagnoses including Parkinson's disease.

Resident 4's 6/3/21 through 8/30/21 progress notes, physician communications and 8/1/21 through 8/30/21 MAR/TAR were reviewed.

The resident's record showed 11 refusals of her/his NuStep exercise plan in the month of August.  

There was no documented evidence the facility notified the physician each time the resident refused to consent to the orders.  

The need to ensure the facility notified physicians of medication or treatment refusals was discussed with Staff 1 (Administrator) on 8/31/21. She acknowledged the findings.

3. Resident 5 was admitted to the facility in March 2006.

Resident 5's 6/3/21 through 8/30/21 progress notes and physician communications and 8/1/21 through 8/30/21 MAR/TAR were reviewed.

The resident's record showed 22 refusals of her/his polyethylene glycol powder (a bowel medication) in the month of August.  

There was no documented evidence the facility notified the physician each time the resident refused to consent to the orders.  

The need to ensure the facility notified physicians of medication or treatment refusals was discussed with Staff 1 (Administrator) on 8/31/21. She acknowledged the findings.

By 9/3/21 HSD faxed PCPs for resident 1, 4, 5 explaining medication and treatment refusals over last 90 days.

On 9/2 HSD created fax template for notifying PCPs of each medication and/or treatment refusal. Fax includes opportunity for PCP to indicate frequency of notifications if other than with each occurrence.

On 9/2 filing system created for tracking refused med/treament faxes and specified frequency.

On 9/3 HSD educated Med Techs on reporting to PCP any medication or treatment refusals utilizing standardized faxes and filing system.

Informational Order created in EHR to indicate frequency of faxing PCP regarding refusals if less than with each occurrence.

HSD to audit monthly all refusals, documentation, and communication with PCPs. HSD to review monthly with Med Techs the system of communicating refusals to PCPs.  

Based on interview and record review, it was determined the facility failed to ensure fire and life safety instruction to staff was provided on alternate months and that documentation reflected all required fire drill components. Findings include, but are not limited to:

Fire drill and fire and life safety records were reviewed from February 2021 to August 2021. The following deficiencies were identified:

* There was no documented evidence the facility was providing fire and life safety training on alternating months for staff; and

* The fire drill training records and the August 2021 evacuation/drill forms did not contain information on the escape route used or the number of occupants evacuated.

The requirements regarding fire drills and fire and life safety instruction for staff were reviewed with Staff 1 (Administrator) on 8/31/21. She acknowledged the findings.

Annual calendar to be created for alternating month fire and life safety training topics for staff. Alternating month training to be delivered at staff meetings, either in-person or virtually.

Topics to be reviewed bi-monthly with Leadership Team to evaluate content.

Fire Drill/Evacuation Form will be updated by 9/30/21 to include evacuation route field, alternate evacuation route field, and field for number of occupants evacuated.

Administrator to monitor training calendar annually to ensure relevant content and Fire Drill form on months when fire drills performed to ensure it is completed correctly.  

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

Refer to C 240 and C 270.

Surveyor stated this tag did not need response. Refer to previous citations.

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

Observations of the patio area on 8/30/21 showed the following:

* Uneven surfaces were noted where the concrete had cracked, separated and began to push up; and

* Multiple drop offs of 2-4 inches were noted along pathway edges.

The need to ensure pathways did not have potential tripping hazards was discussed with Staff 1 (Administrator) on 8/30/21. She acknowledged the findings.

On 8/31/21 sidewalks were ground to even levels by facility Maintenance Technician. Walkway cracks in process of being filled or concrete replaced, if needed.

Maintenance Technician to perform checks of exterior grounds monthly to ensure safe walkways with even surfaces and correct issues as needed.

Environmental Rounds program to be created by 9/30/21 with monthly and quarterly assignments for departments to review the exterior of building for areas of concern. Findings will be documented and plans for improvement created and carried out by Maintenance Technician or outside provider, if needed. Leadership Team to review monthly.  Administrator to ensure work is performed in a timely manner.  

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

Observations of the facility on 8/30/21 and 8/31/21 showed the following areas in need of cleaning or repair:

* Carpet in the dining room, the first and second floor hallways and elevator had multiple dark stains of varying sizes. The edges of the carpet near the entry way to the dining room was frayed and pulling apart;

* Rooms 104, 113 and 220 had gouges, scrapes, drips and/or chips to doors and door frames. The wood moulding outside room 220 was pulling away from the wall at the corner;

* Room 107 and 115 had dark black and gray stains to the living room carpets of various sizes and room 107's carpet was significantly frayed/torn;

* Room 108 had large, dark stains to the living room carpet; multiple chips, dings and gouges to walls, doors and door frames; dark accumulation at the edges of the shower stall and the rubber/vinyl seal at the edge of the shower stall was loose and pulling away from the surface.

The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (Administrator) on 8/30/21 and 8/31/21. She acknowledged the findings.

On 9/10/21, all hallway and common area carpets were professionally cleaned.

By 9/7/21, Maintenance Technician cleaned shower stall and replaced shower rubber base in apt 108, repaired walls/moulding, cleaned carpet.

On 9/9/21, Apt 107 and 115 carpets cleaned by Maintenance Technician. Repairs to 107 carpet to be made by 10/31/21.

By 10/31/21, remaining noted apartments to be repaired by Maintenance Technician.

Administrator to ensure professional carpet cleaning completed at least annually.

Housekeeping staff to monitor apartments weekly for stains, spills, damage in apartments/bathrooms, enter into maintenance work order software, and report to Maintenance Technician for repair. Administrator to review work orders monthly for completion.

Environmental Rounds program to be created by 9/30/21 with monthly and quarterly assignments for departments to review the interior of building for areas of concern. Findings will be documented and plans for improvement created and carried out by Maintenance Technician or outside provider, if needed. Leadership Team to review monthly. Administrator to ensure work is performed in a timely manner.