Print Inspection: O08P

The findings of the re-licensure survey conducted 09/13/22 through 09/16/22, 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 OARs 411 Division 004 Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first revisit to the re-licensure survey of 09/16/22, conducted 02/15/23 through 02/16/23, 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.

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

MCCMemory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the second re-visit to the re-licensure survey of 09/16/22, conducted on 07/12/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.

Based on observation, interview and record review, it was determined the facility failed to maintain the kitchen in accordance with Food Sanitation Rules, OAR 333-150-000. The kitchen was observed in a condition which had the potential to threaten the health, safety, or welfare of residents. Findings include, but are not limited to:

Observations of the kitchen on 09/13/22 at 10:50 am identified the following deficiencies:

1. Main kitchen area required cleaning and repair in the following areas:

* Walls throughout the kitchen and backsplash behind the two-compartment sink had multiple spills, smears, and food splatters;

* Rolling carts in the kitchen and dining room had loose food debris, dried liquid spills, and stuck on food matter;

* Black and brown matter, dirt and food debris on shelving units and inside cabinets where clean dishes and utensils were stored;

* Kitchen janitor closet walls and flooring had a build up of black and brown matter;

* Black free-standing oscillating fan had a build up of dust debris;

* Exterior of oven was covered in grease and food spills;

* Interior and exterior of oven had a buildup of burnt food debris, grease, and spills;

* Oven hoods had a buildup of grease and dust covering the air intake vent;

* Interior top of the microwave had a buildup of food debris and splatter;

* Interior and exterior of multiple upright refrigerators and freezers, including shelving, had a buildup of food debris, spills, splatters, cobwebs, chipped paint, and areas of rust;

* Garbage cans throughout the kitchen and dining room area were uncovered when not in use, food debris and spills were stuck to the outside of the containers;

* Multiple cutting boards were scored and chipped;

* Doors, door frames, had gouges and exposed wood that was not a smooth and cleanable surface (janitor's closet, dry food storage and main entrance door);

* Upper cabinet wood above the food prep counter was separated from the cabinet and falling down toward the countertop;

* Janitor's closet door handle was missing hardware and was loose;

* A window and screen covering were removed which allowed for the entry of pests and insects;

* Multiple interior and exterior particle board cupboards had exposed wood, making it an uncleanable surface, and multiple cupboard doors were coming off the hinges;

* Wall panel between the two-compartment sink and the dishwasher was removed and had exposed wires and insulation from the exterior of the dishwasher;

* Floor underneath and in front of the dishwasher lacked floor tile which exposed a wood sub-floor, rendering the surface uncleanable;

* Four-foot length of floor tile underneath the two-compartment sink had separated from adjoining tile which created a gap in the floor tile; and

* Multiple countertops throughout the entire kitchen were worn and had multiple areas of chipped veneer which rendered the surface uncleanable.

2. Food storage area:

* Dry food storage had a build-up of black and brown matter spilled on top of food storage bins, built up food debris and dead insects; and

* Refrigerators, freezers, wooden cabinets for dry storage were stored on an outdoor deck and not maintained in a manner that prevented the entry of rodents and pests.

3. Food preparation:

* Food temperature logs documented cooking temperatures for ground beef were under the required 160 degrees F.;

* No process for proper cooling methods; and

* Pasteurized eggs were unavailable.

4. Food Service:

* A probe thermometer to take the temperature of the food prior to serving to the residents' was not used and there were no alcohol wipes to sanitize the probe thermometer; and

* Food trays were uncovered and lacked protection from contamination during transport to individual resident rooms.

5. Sanitation and infection control:

* The facility lacked a system for sanitation when washing dishes in the two-compartment sink which included the use of test strips to check sanitizer levels and staff knowledge on how to use sanitizer test strips; and

* Kitchen staff were not using aprons during food preparation.

On 09/13/22 at 4:30 pm, the survey team discussed a Needs Immediate Correction (NIC) plan of correction with Staff 1 (Administrator). The following areas required immediate correction:

* Proper window covering in the main kitchen;

* Pest control system; and

* Outside food storage.

The NIC plan was received by Staff 1 on Wednesday 09/14/22 at 10:20 am. The survey team approved the NIC plan. Observations of the corrections were confirmed on 09/16/22 prior to survey exit.

The need to ensure the kitchen was maintained clean and in good repair and in accordance with the Food Sanitation Rules, OAR 333-150-000, was discussed with Staff 1 on 09/13/22. She acknowledged the findings.

1. Kitchen walls and backsplashes throughout kitchen were deep cleaned during the survey.  The rolling cart was replaced with a new cart that arrived on 9/19/22.  The facility  was already in the process of new cabinets and counters for kitchen; existing cabinets were deep cleaned during the survey.  The kitchen janitorial closet was deep cleaned during survey; the free-standing fan was removed and cleaned during survey.  The interior and exterior of oven was deep cleaned; the hoods/vent were also deep cleaned.  The microwave interior was also wiped down during survey 9/13/22.  The facility had received a new freezer and refrigerator; the rusted freezer was not going to be used anymore and was removed; all the fridges/freezers were deep cleaned at time of transitioning pantry/food items from back deck.  New garbage cans for the dining and kitchen areas with attached lids were ordered and arrived on 9/26/22.  Old cutting boards were thrown out during survey and new ones ordered; they arrived on 9/14/22 and 9/17/22.  All the wood trim throughout facility is in process of refinishing and replacing as needed; all kitchen cabinets in process of replacement.  The janitor closet door handle is in process of replacement.  New plexiglass was installed 9/13/22 in kitchen window by ac unit, covering opening.  The new cabinets/counters will eliminate opening between sink and dishwasher; facility in process of planning for new kitchen vinyl flooring. The pantry was deep cleaned 9/13/22; all appliances and cabinets were emptied of food items during survey; the appliances were moved inside off the deck.  Ice wands for cooling foods were purchased and arrived 9/15/22; cartons of pasteurized eggs purchased during survey.  New thermometers were purchased during survey and arrived 9/14/22.  Staff are using foil to cover any trays that needed to go to resident rooms. Sanitation strips were purchased to use for checking sanitizer levels for dishwashing/cleaning.  New aprons purchased for staff.

The Administrator will conduct inservices with staff on kitchen protocols during October 2022, including proper cooling methods, taking temperatures, sanitation  technique/strips, covering trays when transporting them.  The Administrator is developing a cleaning schedule of tasks to be done by kitchen staff and maintenance staff.  The Administrator and maintenance will do weekly walk throughs to observe for areas that need repair and/or replacement, including cutting boards and other kitchen supplies.  The Administrator will do weekly walk throughs to ensure all cleaning scheduled tasks have been completed; also including having pasteuriezed eggs on hand.  All cabinets and countertops in kitchen are in process of replacement; vinyl flooring in process of replacement; wood trim in process of refinishing and replacement as needed.

During time of survey, new plexiglass was installed and a pest control company was contacted to conduct monthly inspections for any needed pest control.  All food storage outside was moved inside; the fridges and freezer were moved in to back living room at facility.

Based on observation, interview and record review, it was determined the facility failed to maintain the kitchen in accordance with Food Sanitation Rules, OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to:

Observations of the kitchen on 02/15/23 and 02/16/23 identified the following:

1. Main kitchen area and West Wing required cleaning and repair in the following areas:

* Interior and exterior of multiple upright refrigerators and freezers, including shelving and vents, had a buildup of dust, food debris, spills and splatters;

* Lower corner cabinet to the right of the dishwasher was missing half the door;

* Multiple interior particle board cupboards had exposed wood, rendering the surface uncleanable;

* Plastic dry storage bins in the upper cupboard above the handwashing sink had food grime on the exteriors;

* Floor tiles underneath and in front of the dishwasher were chipped and/or had a gap at the seams, rendering the surface uncleanable;

* Hand washing sink faucet and taps were covered in black grime and the sink basin had food splatters;

* Laminate countertop in front of and behind the hand washing sink had an exposed seam rendering the surface uncleanable.

3. Food preparation:

* Food temperature logs documented cooking temperatures for ground beef were consistently under the required 160 degrees F.; and

* Two refrigerators had temperatures above the required 41 degrees F. Staff 1 (Administrator) instructed the cook to discard the food in the main kitchen refrigerator due to the temperature being held above 41 degrees F. for an undetermined length of time.

4. Food Service:

* Beverage cups were uncovered and lacked protection from contamination during transport to individual resident rooms.

5. Sanitation and infection control:

* Staff were observed to use the dedicated hand washing sink for dirty dishes and frozen meat;

* Staff were observed touching personal clothing and dirty dishes, then touching clean trays and other kitchen surfaces without performing hand hygiene in between.

The need to ensure the kitchen was maintained clean and in good repair and in accordance with the Food Sanitation Rules, OAR 333-150-000, was discussed with Staff 1 and Staff 2 (Administrator) on 02/16/23. They acknowledged the findings.

Kitchen cabinets are continuing to be replaced and re-stained as needed by maintenance.  All fridges and freezers were deep cleaned; including lower fridge vent in west wing.  The missing cabinet door was in process of being wood glued during survey and was put back on by maintenance.  Kitchen bins were cleaned and will be replaced as needed.   

In process of getting bids to replace all vinyl flooring in kitchen; the piece that broke when dishwasher was repaired was fixed by maintenance.  The handwashing sink and taps was cleaned by staff; the countertop seam was repaired by maintenance.  Two refrigerators broke during survey; they had temped appropriately prior and then noted to be warm.  The refrigerators were replaced during survey.  A sign was posted in the kitchen to keep wrap or cover on any cup being transported by staff out of the dining room; cups with lids and straws were purchased by the Administrator to use for this purpose instead of foil/syran wrap.  A sign was posted by the hand wash sink to remind staff not to use that sink to thaw meats or for dishes.  The sign also reminds staff to wash between touching clean surfaces each time.

Due to ongoing remodeling and maintenance; a daily walk through and checklist will be done by the Administrator, kitchen staff, or admin designee, to look for things that need to be repaired or replaced, cleaned through this process of completion and ongoing.   Refrigerator temps will be taken once per shift rather than once daily by kitchen staff to observe for proper cooling temps being maintained.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (#3) whose evaluation was reviewed. Findings include, but are not limited to:

Resident 3 was admitted to the facility in June 2022. The move-in evaluation was reviewed and lacked the following required elements:

* Personality and how a person copes with change or challenging situations; and

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

On 09/15/22 the need to address all required elements on the move-in evaluation was discussed with Staff 1 (Administrator). She acknowledged the findings.

The Administrator is adding the following sections to resident #3 eval:

1. Personality and how a person copes with change or challening situations;

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

The Administrator will add these sections on to facility master evaluation form and also add it to all current resident evaluations so moving forward these sections are on both new and exisiting evaluations.

Based on interview and record review, it was determined the facility failed to ensure resident evaluations contained sufficient and/or accurate information, with updates dated and initialed and were used as the basis for the resident's quarterly service plan for 1 of 2 sampled residents (#5) whose evaluation was reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 5 was admitted to the facility in 03/2022 with diagnoses including bipolar mood disorder and anxiety.

Resident 5's quarterly evaluation, dated 01/23/23, contained inaccurate or incomplete information in the following areas:

* Cannabis use;

* Self administering insulin;

* Unsuccessful prior placements;

* Smoking status;

* Emergency evacuation status and ability; and

* Elopement risk.

The need to ensure quarterly evaluations contained sufficient and/or accurate information, were dated and initialed when updated and used as the basis of the quarterly service plan was discussed with Staff 1 (Administrator) and Staff 2 (Administrator) on 02/16/23. They acknowledged the findings.

All resident evaluations are currently being reviewed by the Administrator to add detail and information as needed to all categories. An audit form will be utilized by the Administrator to use during service planning and resident evals to ensure relevant information is on both.

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

1. Resident 2 was admitted to the facility in May 2021.

The resident's 08/2022 service plan was reviewed and was not reflective of the resident's current needs and lacked clear direction to staff in the following areas:

* Fluid restrictions;

* Medication management;

* Smoking;

* Ambulation;

* Transfers;

* Toileting; and

* Dressing.

The need to ensure service plans were reflective of residents current needs and provided clear direction to staff was discussed with Staff 1 (Administrator) and Staff 3 (RN) on 09/16/22. The staff acknowledged the findings.

2. Resident 4 was admitted to the facility August 2016.

The resident's 08/2022 service plan was reviewed and was not reflective of the resident's current needs, and lacked clear direction to staff in the following areas:

* Denture care;

* Dressing;

* Toileting;

* Monthly medication injection; and

* Ability to request PRN pain medication.

The need to ensure service plans were reflective of residents current needs and provided clear direction to staff was discussed with Staff 1 (Administrator) and Staff 3 (RN) on 09/16/22. The staff acknowledged the findings.

3. Resident 1 was admitted to the facility in December 2019.

The resident's 06/2022 service plan was reviewed and was not reflective of the resident's current needs and lacked clear direction to staff in the following areas:

* Evacuation instructions;

* Ability to safely self administer medications;

* Monthly IM (intramuscular) injections;

* Personality and coping with change; and

* Environmental factors that impact mood and behaviors.

The need to ensure service plans were reflective of residents current needs and provided clear direction to staff was discussed with Staff 1 (Administrator) on 09/15/22. She acknowledged the findings.

The service plan format has current updates listed below historical information.  Resident 2's service plan stated that her fluid restrictions were discontinued on 6/18/21 and she has no current restrictions.  It states she is not a current smoker but still enjoys going out and sitting with others while they smoke. The Administrator will move historical information to the bottom of each section so current needs are listed first at the top of each section.  The Administrator will add detail to the top of the toileting/dressing/transfer sections. Resident 4's service plan says full assist with dressing and toileting; current info is currently listed below historical info.  Resident 4's monthly injection was dc'd by prescriber in Jan. 2021 and this is listed on service plan below historical info; Resident 4 is in process of acquiring new dentures and the Administrator will add detail to denture care sections as well as her ability to request PRN medications.  On Resident 1's service plan, the Administrator will add that she evacuates independently with staff cues.  The Administrator will add the DC date for Resident 1's IM injection to the service plan.  The service plan says she was observed by the nurse to be able to demonstrate how to safely check her own CBG and administer her insulin when converted to taught task. Resident 1's orders for insulin and CBG checks were dc'd by PCP and this will be added to the service plan by the Administrator.  Specific info on how Resident 1 copes with change and how it affects her personality, as well as environmental factors that impact her mood and behaviors will be added as specific sections to her service plan by the Administrator.

The Administrator will move current information to the top of service plan sections so historical information is at the bottom to make it clearer to the reader/staff what the current needs are for each resident.  The Administrator will modify all resident service plans during the month of October 2022 so current information is at the top and will continue to keep current information at the top of each section and move historical info to the bottom to ensure clarity for staff during regular updates ongoing.

The Administrator and RN will review service plans monthly during regular update/reviews to ensure current information is clear and visible to staff.

Based on interview and record review, it was determined the facility failed to ensure service plans were accessible to staff, reflective of residents' current status and provided clear direction to staff for 1 of 2 sampled residents (#5) whose service plan was reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 5 was admitted to the facility in 03/2022 with diagnoses of bipolar mood disorder and anxiety.

The resident's quarterly service plan, dated 01/23/23 was not accessible to staff, reflective of the resident's current needs and lacked clear direction to staff in the following areas:

* Behavior interventions; and

* Cannabis use and interventions.

The need to ensure resident's quarterly service plans were reflective of the resident's current status and care needs and provided clear instructions for staff was discussed with Staff 1 (Administrator) and Staff 2 (Administrator) on 02/16/23. They acknowledged the findings.

A new binder was created during the survey with tabs for each resident; this binder will have a copy of current service and behavior plan in it for each resident.  Copies of the plans will continue to be accessible in the resident's charts as well.

The Administrator is currently reviewing all resident service and behavior plans and adding information and detail as needed.  An audit form will be utilized by the Administrator to use during service planning and resident evals to ensure relevant information is on both.

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

Resident 1 was admitted to the facility in December 2019 with diagnosis including Type 2 diabetes.

A review of signed physician orders dated 08/23/22, DAR (diabetic administration record) dated 08/18/22 through 09/14/22 and interviews with staff identified the following:

* Resident 1 was prescribed Lantus 25 units, daily and Humalog 4-14 units based on the recorded CBG value prior to administering the sliding scale dose;

* On three occasions, Staff 5 (MT/Universal worker) recorded CBG's and administered insulin to Resident 1. The records lacked documented evidence of Staff 5 being delegated to administer insulin to Resident 1; and

* Attempts were made three times per day by various other unlicensed staff to administer the insulin to the resident.

During an interview with Staff 3 (RN) reported the facility doesn't have any delegation records for any of the unlicensed staff.

The requirements for delegation of unlicensed staff who administered insulin and the need to ensure accurate documentation was reviewed with Staff 1 (Administrator) and Staff 3 during the survey. They acknowledged the findings.

Med trained staff were not delegated for Resident 1 insulin and CBGs as they were being done as taught nursing tasks.  Resident 1 preferred to do her own insulin injection and do her own CBG with med staff supervision.  Med staff taught tasks included resident CBGs and the drawing up of insulin.

If residents are not able to do all steps themselves start to finish, staff will be delegated for all tasks and steps by facility RN.  Resident 1's PCP discontinued her insulin and CBG orders on 9/22/22 due to multiple refusals.  

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate, provided resident-specific parameters and staff instruction for 1 of 3 sampled residents (#1) whose MAR and DAR (diabetic administration record) was reviewed. Findings include, but are not limited to:

Resident 1 was admitted to the facility in December 2019 with diagnoses including Type 2 Diabetes and Schizoaffective disorder.

a. Resident 1's 08/18/22 through 09/14/22 MAR identified the following medications lacked clear instructions including a description of what anxiety and agitation looks like for Resident 1, non-drug interventions to attempt with ineffective results prior to administering the PRN psychotropic's and instructions on who to report to:

PRN Clonazepam for anxiety;

PRN calcium and magnesium for anxiety; and

PRN Natural Vitality Calm gummies for anxiety.

Resident 1 was not administered any of the PRN anxiety medications during the time period reviewed during the survey.

b. Resident 1's 08/18/22 through 09/14/22 DAR identified the following inaccuracies:

There were blanks on the DAR for sliding scale insulin at 8:00 am and 12:00 pm on 08/26/22 and 08/29/22, 8:00 am on 08/30/22, 08/31/22 and 09/09/22. There was no documented evidence of why the medication wasn't administered.

The need to ensure the facility had a system in place to ensure accurate MAR/DAR's were kept was discussed with Staff 1 (Administrator) and Staff 3( RN) on 09/15/22. They acknowledged the findings.

Facility RN added that Resident 3 is able to self request her PRNs without interventions to the MAR per the prescriber; what anxiety/agitation looks like was also added to her MAR for her PRNs.  The facility RN went through all MARs to add interventions or signs of to any entry that required it.

The facility RN and Administrator will go through all MARs each month to add interventions where necessary for PRN psychotropic medications; they will also add "as evidenced by" signs and symptoms for what the PRN is being ordered to assist with.

Med aides will be inserviced by the Administrator to double check for holes prior to leaving their shift for the day.  Facility RN and Administrator will check MAR frequently to observe for any missing initials.

Based on interview and record review, it was determined the facility failed to obtain a physician's order to self-administer a specific medication for 1 of 1 sampled resident (#1) who partially self-administered insulin. Findings include, but are not limited to:

Resident 1 was admitted to the facility in December 2019 with diagnosis of Type 2 diabetes.

A review of signed physician orders dated 08/23/22 and DAR (diabetic administration record) dated 08/18/22 through 09/14/22 identified the following:

Resident 1 was prescribed Lantus 25 units, daily and Humalog 4-14 units based on the recorded CBG value prior to administering the sliding scale dose.

During an interview with Staff 3 (RN) on 09/14/22, she reported Resident 1 only self-administered his/her insulin with supervision and assistance from staff. The resident would take there own CBG's and show the unlicensed staff what the CBG value was. Unlicensed staff would draw up the insulin base units, advise the resident on additional sliding scale dose and draw up the additional units for the resident and then the resident would administer the insulin him/herself.

There was no documented evidence the physician signed an order for the resident to self-administer prescribed insulin orders.

The need to obtain signed physician orders for resident's that chose to self-administer their own medications or treatments was discussed with Staff 1 (Administrator) and Staff 3 during the survey. They acknowledged the findings.

Resident 1 preferred to inject her own insulin and take her own CBG reading in the presence and supervision of med staff; Resident 1 was observed by the RN to be able to perform these tasks and med staff had been taught by the RN to perform CBG checks and draw up insulin (taught tasks).  Resident was partially able to self-administer her insulin; her PCP DC'd all insulin and CBG orders due to multiple refusals.

In the future, if any resident is able to complete a med task or treatment 100% of the steps on their own, an order to approve the self-administration of medicaion will be pursued from the resident's PCP by the facility RN.  If a resident is not able to fully self-administer, staff will complete all tasks.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 newly hired direct care staff (#s 8 and 9) demonstrated competency of skills in all assigned job duties within 30 days of hire. Findings include, but are not limited to:

Training records were reviewed on 09/14/22 and identified the following:

Staff 8 (Universal Worker) hired on 04/07/22 and Staff 9 (Universal worker/MT) hired on 05/08/22, lacked documentation of demonstrated competency in First Aid and abdominal thrust.

The need to ensure staff demonstrated competency in all assigned job duties within 30 days of hire was discussed with Staff 1 (Administrator) and Staff 3 (RN) on 09/16/22. They acknowledged the findings.

Newly hired staff will be signed up for a Healthcare First Aid/Abdominal Thrust course if they are not able to present a copy of their current card to the Administrator on the first day of employment.

The Administrator will add new hires to a tracking sheet and on the calendar to ensure all new hires have First Aid Abdominal Thrust training within their first 30 days of employment.

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

Refer to C240, C252, C260, C610 and C613.

Additional daily checklists will be utilized for monitor for any repairs, cleaning, or item replacement for the kitchen, interior, and exterior of facility and grounds.

The Administrator, maintenance, and staff designated by the Admininstrator will assist with using these checklists and reporting things to be repaired.  An audit form will be utilized by the Administrator to use during service planning and resident evals to ensure relevant information is on both.

Based on observation and interview, it was determined the facility failed to ensure the grounds were kept orderly and free of litter, refuse, garbage and pathways were smooth and maintained. The facility's environment was found to be unsafe and required immediate correction. Findings include, but are not limited to:

The exterior of the facility was toured on 09/13/22 at 11:00 am. The following issues were identified:

* There were broken bed frames, mattresses, multiple washing machines, a refrigerator, old paint cans, broken pieces of wood and a motor parts;

* There were maintenance supplies including a pressure washer;

* The furniture in the smoking area had fabric that was ripped and torn;

* The garden hose was across the yard presenting a tripping hazard;

* The fencing around the garbage dumpster's was broken in multiple places;

* The entrance stairway had dry rot and was missing varnish/paint;

* The walkways in the front and on the side of the building were overgrown with weeds;

* The pathway leading to the back yard was an uneven surface and had drop-offs presenting a tripping hazards;

* The back deck had a recycle bin overflowing with cans;

* There were multiple pieces of broken and used furniture stored on the back deck;

* The front porch was being used to store multiple boxes and a walker;

* There was a "lip" at the bottom of the wheelchair ramp that represented an unsafe situation; and

* An over-grown tree was infringing on the East side fire escape porch.

The building's exterior was toured with Staff 1 (Administrator) and Staff 2 (Administrator) on 09/13/22 at 4:00 pm.

On 09/13/22 at 4:30 pm, the survey team discussed a Needs Immediate Correction (NIC) plan of correction with Staff 1 (Administrator).

The following areas required immediate correction:

* Broken bed frames, mattresses, multiple washing machines, a refrigerator, old paint cans, broken pieces of wood and a motor part all which represented an unsafe situation.

The NIC plan was received by Staff 1 on Wednesday 09/14/22 at 10:20 am. The survey team approved the NIC plan and observations of the corrections were confirmed on 09/16/22 prior to survey exit.

The need to ensure the facility grounds were kept orderly, free of litter, refuse and the exterior pathways were in good repair was reviewed with Staff 1 and Staff 2. They acknowledged the shared findings.

There were several items gathered outside that had been identified to be disposed of at the dump including mattresses, old appliances, paint cans, bed frames.  These items were removed during the survey and disposed of.  The furniture in the smoking area was also disposed of and replaced with new furniture.  A new reel was purchased for the backyard hose; the garbage dumpster enclosure was hit by the garbage company during a pick-up and is in the process of being repaired.  The entrance stairway was in process of discussion on ways of replacing at time of survey (i.e. tear out and redo with concrete, new decking, etc.); stone tiles had already been purchased for the top of stairway sides.  Walkways in the front and on side of building were cleared by maintenance staff by 9/23/22.  The pathway to the backyard is in process of being leveled and paved over to create a smoother walkway.  The soda cans that residents were saving on the back patio were bagged up for return to Bottle Drop.  Staff will be inserviced on keeping the bags bagged up so the lid stays tight on the can by the Administrator.  Used and broken furniture on the back patio was also disposed of during the survey; the front porch had boxes and items that residents decided they didn't want and are in the process of clearing the space and disposing of any items not being used.  The concrete at the bottom of the ramp is in the process of being leveled out to create a more even surface.  The tree on the East side porch was trimmed by maintenance 9/16/22.

The items identified for disposal were taken to the dump during survey by maintenance staff.

The Administrator will conduct inservices with staff on soda cans protocols during October 2022, including when to bag the cans up and where they go.  The Administrator is developing a schedule of tasks to be done regularly by maintenance staff.  The Administrator and maintenance will do weekly walk throughs to observe for areas that need repair and/or replacement, including the backyard, back patio, smoking area.  The Administrator will do weekly walk through to ensure all scheduled maintenance tasks have been completed.  The entrance stairway is in the process of repair, including refinishing or replacement of any siding or wood with dry rot or total replacement; stone tiles to put on top of the wood to keep moisture out.  The cement at the bottom of the ramp is also in the process of being leveled out, as well as the walkway to the backyard, by maintenance.  Outside contractors have already been contacted for bids and to advise.

Based on observation and interview, it was determined the facility failed to ensure the grounds were kept orderly and free of litter, refuse, garbage and pathways were smooth and maintained. This is a repeat citation. Findings include, but are not limited to:

The exterior of the facility was toured on 02/15/23 at 10:38 am. The following issues were identified:

* The pathway leading to the back yard was an uneven surface and had drop-offs presenting a tripping hazard;

* There were missing handrails along the walkway leading to the back yard;

* There was a wood picnic table that had rough areas with splintered wood;

* The wooden garden beds were overgrown and had a pile of metal and plastic debris;

* There were discarded chairs, cabinets, a freezer, broken pieces of wood and metal, and an overflowing trash bin underneath the back deck which was accessible to residents;

* There were maintenance supplies including ladders, shovels, and hand trucks (for moving heavy items) underneath the back deck;

* The pathway around the front walkway and smoking area had drop-offs of up to four inches, which presented a tripping hazard;

* There were missing/broken handrails along the ramp leading to the smoking area;

* The garden hose in the front of the building was not properly stored;

* Two lawn chairs in the front of the building had stained fabric and were rusted;

* The fencing around the garbage dumpsters was broken in multiple places;

* There was litter and refuse scattered throughout the entire facility grounds; and

* The entrance stairway had dry rot and was missing varnish/paint.

The building's exterior was toured with Staff 1 (Administrator) on 02/15/23. She acknowledged the findings.

The concrete path towards back yard and in front were in process during survey.  Handrails are installed at bottom of ramp heading to smoking area to prevent any drop-off; handrails are in process of being installed in back yard area.  Still in process of additional concrete work in backyard area.  The wood picnic table has not been used; it was being determined if it was going to be kept and has now been replaced by the Administrator.  The resident garden beds will be weeded.  A new pile for the dump was gathered during the survey and was taken away by maintenance. All maintenance supplies were moved into locked storage.  New barkdust will be added to areas as needed to be level with walkway. A new hose reel for front yard hose was purchased and installed by maintenance.  The lawn chairs were thrown away during the survey.  The garbage enclosure had been re-built; maintenance had removed some boards in order to remove tree limbs from the area.  The boards were put back on and the tree removed.  The Administrator and maintenance walked the grounds and removed any litter noted.  A plan is still being developed for the front ramp/stairs; bids are being obtained for different routes of replacement.

Additional daily checklists will be utilized for monitor for any repairs, cleaning, or item replacement for the kitchen, interior, and exterior of facility and grounds.

The Administrator, maintenance, and staff designated by the Admininstrator will assist with using these checklists and reporting things to be repaired.  

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

The facility was toured on 09/13/22 at 11:00 am. The following areas were observed to need cleaning and/or repair:

* Carpet was frayed, stained, torn and/or covered with tape throughout building;

* Rooms 1 through 13, the doors to each hallway, the medication room, the kitchen and the office had scraped doors and door frames with gouges and bare wood exposed;

* The light fixture in the men's room was broken;

* Walls outside room 11 had large scrapes and gouges in the drywall;

* Corner wall near suggestion box was gouged and missing paint/dry wall;

* Chairs in the living room had stains and/or torn fabric;

* The second living room in the East wing had miscellaneous extra furniture and medical equipment being stored there; and

* The couch in the second living room had torn fabric.

The surveyor toured the environment with Staff 1 (Administrator)  and Staff 2 (Administrator) on 09/13/22 at 4:00 pm. They acknowledged the above areas needed to be cleaned and repaired.

The facility carpeting was a planned replacement prior to survey; waiting on an install date from contractor to replace carpeting in all common areas, hallways, offices, med room, and any resident rooms that needed replacement.  All floor wood trim being replaced with carpet base when new carpet installed.  All facility wood trim around resident room doors and facility doors is in the process of being refinished and repaired by maintenance.  The light fixture in the mens bathroom was repaired during survey by maintenance staff.  Maintenance staff is in the process of repairing any dry wall with gouges, dents; protective sheets are going to be added to areas with high traffic with electric wheelchairs for added wall protection.  Facility walls in the process of being repainted and touched up by maintenance staff.  A resident had put their old chair in back living room for disposal; it was disposed of by maintenance 9/16/22.  Extra resident furniture, belongings, and medical equipment was either disposed of or moved to resident rooms; other non-wanted items were disposed of 9/16/22 by maintenance staff.  The sofa in the back dining room with tears was disposed of on 9/16/22 by maintenance staff.  The second sofa was approved by survey team to put a cover on at time of survey; a cover was ordered and will be kept on the second sofa.

The Administrator and maintenance will do weekly walk throughs to observe for areas that need repair and/or replacement, including the back living room and common areas.  The Administrator will do weekly walk throughs to ensure all scheduled maintenance tasks have been completed.  The facility carpet is in the process of being replaced in all hallways, common areas, med room, offices, and any other rooms as needed (waiting on install date to be set by contractor).  All facilty interior trim is in the process of being refinished and/or replaced as needed by maintenance staff.  Drywall is being repaired in areas as needed; protective plates being added to areas of high frequency interaction with electric wheelchairs.  Maintenance in process of painting interior walls.

Based on observation and interview, it was determined the facility failed to ensure the environment was kept clean and in good repair. This is a repeat citation. Findings include, but are not limited to:

The facility was toured on 02/15/23 at 10:10 am. The following areas were observed to need cleaning and/or repair:

* Multiple resident unit doors, fire safe doors and door frames were gouged and had bare wood exposed;

* Walls throughout the building had patched areas without paint;

* Corner wall near front entrance had missing paint with exposed dry wall;

* Front entrance door had multiple areas were the paint was scraped off;

* A window in the staff lounge, which opened directly to the resident corridor did not have a window screen; and

* Multiple chairs/couches in the living room had stains and/or torn fabric.

The surveyor toured the environment with Staff 1 (Administrator) on 02/16/23. She acknowledged the findings.

The Administrator purchased kick plates for all facility doors;  door frames and trim are continuing to be replaced as needed by maintenance.  Kick plates will be installed by maintenance.  All drywall being repaired will be re-painted as needed by maintenance.  Facility main doors were in process of being painted by maintenance during survey and will all be re-painted as needed.  The screen in the staff break room was replaced by maintenance.  Furniture is in process of replacement as needed by the Administrator.

Additional daily checklists will be utilized for monitor for any repairs, cleaning, or item replacement for the kitchen, interior, and exterior of facility and grounds.

The Administrator, maintenance, and staff designated by the Admininstrator will assist with using these checklists and reporting things to be repaired.