Print Inspection: RSO5

The findings of the change in ownership survey, conducted 03/02/22 through 03/04/22, 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 for Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:  activities of daily living

bid: twice a day

CBG: capillary blood glucose or blood sugar

CG: caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH: Home Health

LPN:Licensed Practical Nurse

MA:Medication Aide

MAR: Medication Administration Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:quality improvement

RCC:Resident Care Coordinator

RN:Registered Nurse

TAR:Treatment Administration Record

tid:three times a day

The findings of the first re-visit to the re-licensure survey of 03/04/22, conducted on 05/19/22, 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.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the second re-visit to the re-licensure survey of 03/04/22, conducted 03/31/23,  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.

2. Resident 2 was admitted to the facility in 09/2019 with diagnoses including a history of protein calorie malnutrition.

Resident 2's weight records were reviewed from October 2021 through the time of the survey and noted a significant weight loss.

Resident 2's quarterly evaluation, dated 12/30/21, was not reflective of the resident's current status related to weight loss.

On 03/03/22, the need to ensure evaluations were reflective of the resident's current status and included documented changes of condition was discussed with Staff 1 (Executive Director), Staff 2 (RN), and Staff 3 (LPN). They acknowledged the findings.

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 (#1) and the facility failed to gather data that was relevant to the needs and current condition for 1 of 1 sampled resident (#2 ), whose records were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 12/2021.

Resident 1's move-in evaluation failed to address the following:

* Visits to health practitioners, ER, hospital or nursing facility in the past year;

* Mental health issues including behavior or mood problems, history of treatment and effective non-drug interventions;

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

* Pain: pharmaceutical and non-pharmaceutical interventions including how a person expresses pain or discomfort;

* List of treatments including type, frequency and level of assistance needed;

* Environmental factors that impact the residents behavior; and

* Complex medication regimen.

The need to ensure the facility completed all required elements on Resident 1's new move -in evaluation was discussed with Staff 1 (Executive Director), Staff 2 (RN) and Staff 7 (Regional RN Consultant) on 03/04/22. They acknowledged the findings.  

(1)

1. The initial evaluation was updated to include the elements sufficient to develop an initial service plan.   

2. The system will be corrected after the initial audit and will be updated with each new admission to the community.

3. The area needing correction will go through an initial audit and will not require future audits after the necessary areas have been addressed.  With each new admission, the system will be updated.  

4. The Health Services Director is responsible for the completion and future monitoring of current and future evaluations.

(2)

1. The RN performed a significant change assessment for resident 2.  Health Services Director updated the service plan to appropriately reflect the current weight of Resident 2 and express past instances where weight loss occurred.  

2. Health Services Director will communicate to the ED and to the RN when there is a change in any resident's weight of 3lbs more or less so that an assessment can be completed.

3. Weights will be collected monthly per facility policy and per physician's order if there is a weight change of 3lbs more or less.  

4. The Health Services Director is responsible for this correction and its future monitoring.  

Based on interview and record review, it was determined the facility failed to determine and document what action or intervention was needed for a resident following a short-term change of condition, document on the progress of the condition at least weekly until resolution and ensure documentation of interventions was made part of the resident record, for 2 of 2 sampled residents (#s 1 and 2) with changes of condition or who required monitoring. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 09/2019 with diagnoses including a history of protein calorie malnutrition.
 

The resident's record indicated that the resident experienced a 11 pound weight loss from 10/2021 to 01/2022 which constituted a severe 9.40% loss in three months.

There was no documented evidence of ongoing monitoring of the resident's weight, no documentation the weight loss was reported to the RN and there were no interventions implemented.

Resident weight from 02/2022 was noted as a 4% increase in weight.

On 03/05/22, the surveyor requested a current weight for Resident 2. The weight was noted as an increase of 3.4 pounds since the last weight in 02/2022.
 

On 03/03/2022, the need to respond to significant/severe weight loss with ongoing monitoring, implementation of interventions and evaluation for effectiveness of those interventions was discussed Staff 1 (Executive Director), Staff 2 (RN), and Staff 3 (LPN). They acknowledged the findings.

2. Resident 1 was admitted to the facility in 12/2021 with diagnoses including cardiopulmonary disease.

A review of the service plan dated 01/20/22, temporary care plans (TSP's), progress notes dated 12/20/21 through 03/01/22 and 02/2022 MAR/TAR reviewed during the survey indicated the following short term changes of condition:

a. From 02/06/22-02/09/22, the MAR indicated Resident 1 missed 11 doses of scheduled Lidocaine Patch (for pain) and from 02/03/22-02/15/22 missed six doses of scheduled morphine (for pain).

The service plan indicated non pharmaceutical interventions for pain were rest, talk to LHH (Laurelhurst House) staff, take a brisk walk to relieve pain and the MAR indicated the resident was also prescribed PRN Tylenol for pain.

There was no documented evidence the facility attempted the PRN Tylenol, implemented the non pharmaceutical interventions for pain, evaluated the interventions for effectiveness, communicated the missed pain medications to staff or monitored the residents' condition with weekly progress noted until resolved.

b. From 02/01/22-02/05/22, the MAR indicated Resident 1 missed five doses of scheduled omeprazole (for gastric reflux).

There was no documented the facility determined action or interventions for the resident, communicated to staff or monitored the residents' condition with weekly progress noted until resolved.

The need to ensure the facility determined and documented interventions, communicated the interventions to staff, documented weekly monitoring when residents experienced changes in condition was discussed on 03/03/22 with Staff 1 (Executive Director), Staff 2 (RN), and Staff 3 (LPN). They acknowledged the findings.

(1)

Updated the documentation in Resident 2's service plan to include more detail on diagnosis of protein deficiency and hx of protein calorie malnutrition.  RN completed weight loss assessment on 3/4/22.  

1. The RN performed a significant change assessment for Resident 2.  Health Services Director updated the service plan to appropriately reflect the current weight of Resident 2 and express past instances where weight loss occurred.  

2. Health Services Director will communicate to the ED and to the RN when there is a change in any resident's weight change of 3lbs more or less so that an assessment can be completed.  Health Services department was in-serviced on the weight policy and procedure and what to do when there is a weight variance.  

3. Weights will be collected monthly per facility policy and per physician's order if there is a weight change of 3lbs more or less, the system will be audited by the Health Services Director for any changes in resident weight that might trigger the need for RN oversight.

4. The Health Services Director is responsible for monitoring and notifying the RN for this correction and its future monitoring.

(2 a and b)

1. The medications for Resident 1(a and b) were received and medication has been administered per physician's orders daily.    

2. Med staff were in serviced on the how to report meds not available or pharmacy delays to the Health Services Director and on the 24-hour report.  Med tech or designee will audit the MAR/TAR/DAR on a weekly basis and document holes.  Any holes in the MAR/TAR/DAR will be reported to the Health Services Director and they will address any concerns as they arise.     

3. MAR/TAR/DAR will be audited weekly by the Med Tech or designee and any concerns will be addressed immediately by the Health Services Director.

4. The Health Services Director is responsible for the correction and monitoring of this system.

Based on interview and record review, it was determined the facility failed to ensure a significant change of condition was thoroughly assessed by an RN, with resident status documented and interventions developed as a result of the assessment, for 2 of 2 sampled residents (#s 2 and 4) who were reviewed with significant changes of condition related to weight loss and skin issues. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 09/2019 with diagnoses including a history of protein calorie malnutrition.

A review of the residents weight record from 10/2021 through 01/2022 was reviewed during the survey. The residents weights were documented as follows:

*10/2021 - 11/2021 115 lbs.;

*11/2021 - 12/2021  114.4 lbs; and

*12/2021 - 1/2022 106 lbs;

Between 10/2021 and 01/2022 Resident 2 lost 9 pounds which constituted a severe weight loss of 9.4% of total body weight in three months and required an RN assessment.

Resident 2 was weighed at the time of the survey and had not continued to lose weight.

There was no documented evidence an RN significant change of condition was completed at the time of the weight loss noted in 01/2022.

During an interview on 03/03/2022, Resident 2 reported that s/he ate in his/her room for meals and did not typically eat the facility food that was provided.

On 03/03/22, the need for an RN assessment to be documented related to significant weight loss was discussed with Staff 1 (Executive Director), Staff 2 (RN), and Staff 3 (LPN). They acknowledged the findings.

2. Resident 4 was admitted to the facility in 10/2019. During the acuity interview conducted 03/02/22, the resident was identified with a diabetic ulcer.

An outside provider note indicted the resident had a diabetic ulcer that was identified on 11/22/21.

A progress note by the facility RN dated 02/18/22 indicated Resident 4 had "wound care to lower leg with wound care managing all wound care and dressing, the community will not remove or touch any wounds".

The diabetic ulcer was considered a significant change of condition for the resident for which an assessment by the facility RN was required.

There was no documented evidence the facility RN conducted an immediate assessment which included documentation of findings, resident status and interventions made as a result of this assessment.

During an interview on 03/03/22 with Staff 2 (RN) and Staff 7 (RN Consultant) it was reported the resident went out twice per week for assessment and wound care, therefore the facility RN had not completed an RN assessment and had not monitored the ulcer.

The need to ensure the RN conducted an assessment of Resident 4's diabetic ulcer was reviewed with Staff 1 (Executive Director), Staff 2 and Staff 7 on 03/03/22. They acknowledged the lack of an assessment.

(1)

1. The RN performed a significant change assesment for resident.  Health Services Director updated the service plan to appropriately reflect the current weight of Resident 2 and update past instances where weight loss occurred.  

2. Health Services Director will communicate to the ED and to the RN when there is a change in any residents weight of 3lbs more or less so that an assessment can be completed.

3. Weights will be collected monthly per facility policy and per physician's order if there is a weight change of 3lbs more or less, the system will be audited by the Health Services Director for any changes in resident weight that might trigger the need for RN oversight.    

4. The Health Services Director is responsible for this correction and its future monitoring.

(2)

1. RN will follow up on outside provider assesment and treatment of the diabetic ulcer that Resident 4 is treated for outside of the community.

2. As Resident 4 continues his treatment out of facility for the diabetic ulcer, RN will coordinate wound care/assessment with the wound clinic.  

3. The RN will assess any diabetic ulcers or pressure areas on a weekly basis.

4. The RN will be responsible to see that the corrections are completed and the Executive Director will follow up to ensure compliance.  

Based on interview and record review, it was determined the facility failed to ensure residents' MARs were accurate, provided clear instruction, had parameters for PRN administration and as needed medications had documented effectiveness for 2 of 2 sampled residents (#s 1 and 2) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 09/2019.

a. Review of 02/2022 MAR/TAR, identified the following PRN medications lacked clear parameters:

PRN medications for constipation:

*Bisacodyl 10 mg suppository;

*Milk of Magnesia 400 mg/ml; and

*Senna 8.6 mg.

The MAR failed to include clear parameters and instructions to unlicensed staff for when Senna should be administered.

b. The following medications lacked reasons for use on the MAR:

*Glucerna carton;

*Lantus Solostar 100 u/ml;

*Metoprolol 25mg; and

*PRN Amoxicillin 250 mg.

On 03/03/21, the need to ensure PRN medications included resident specific parameters and instructions for use and that the MAR included reason for use of medications was discussed with Staff 1 (Executive Director), Staff 2 (RN), and Staff 3 (LPN). They acknowledged the findings.

2. Resident 1's 02/2022 MAR/TAR identified the following inaccuracies:

a. The following PRN medications lacked clear parameters for the sequence of administration and documented effectiveness:

* Polyethylene Glycol and Milk of Magnesia (for bowel care);

* Tylenol and Morphine (for pain);

b. The following PRN medications lacked documented effectiveness:

* 73 occasions of PRN morphine 30 mg was administered;

* Five occasions of PRN Tylenol 325 mg was administered; and

* Three occasions of PRN Nystatin powder 100,000 u/gm was administered.

The need to ensure MARs had clear parameters for multiple PRN medication used to treat the same condition and the need to ensure effectiveness of PRN administration was recorded on the MAR/TAR was discussed with Staff 1 (Executive Director), Staff 2 (RN) and Staff 7 (RN Consultant) on 03/03/22. They acknowledged the findings.

(1)

1. Health Services Director and ED communicated with the PCP for Resident 1 with Providence Elderplace to get clear parameters for bowel medication.

(b) Health Services Director audited the MARs and TARs to ensure that appropriate diagnosis was listed with each of the medications and treatments.

2. The MAR/TAR/DAR for current residents will be audited by RN to ensure parameters are in place.  With each new admission, within a week of move-in, RN will review MAR/TAR/DAR to ensure orders have clear parameters.  All new PRN medications will be reviewed during chart review to ensure parameters are in place.

3. This will be evaluated initially via an audit completed by the RN and ongoing with each new admission.

4. The RN is responsible for this correction and ED will follow up to ensure compliance.

(2)

1. (a) In-service for Health Services staff to train on documenting PRN result and parameters.

(b) In-service was completed with Health Services staff to review appropriate documentation of efficacy of med/treatment after PRN administration.

2. MAR/TAR/DAR will be audited by Health Services Director for accuracy, during this audit, reports of effectiveness of PRN will be reviewed and flagged for correction if not in place.

3. This will initially be evaluated via an audit performed by the Health Services Director and ongoing on a weekly basis.

4. The Health Services Director is responsible for this correction and ED will follow up to ensure compliance.   

2. Resident 2's 02/2022 TAR was reviewed and identified the following:  

There were blanks on the February TAR on 02/08/22 and 02/16/22 for Latanoprost 0.005% solution eye drops (Glaucoma).

On 03/03/22, the need to ensure residents' TARs were accurate was discussed Staff 1 (Executive Director), Staff 2 (RN), and Staff 3 (LPN). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure an accurate TAR, with clear instructions to staff, accurate documentation and specific treatment orders by a legally-recognized practitioner for 2 of 2 sampled residents (#s 1 and 2) who were reviewed with treatment orders. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 12/2021 with diagnoses including cardiopulmonary disease.

Resident 1 was prescribed continuous oxygen on 02/01/22. The 02/2022 TAR noted the following inaccuracies:

* Lacked date and time oxygen was administered;

* Lacked initials of person ensuring the oxygen was in place and administered; and

* No clear instructions for when to call the prescriber or nurse.

The need to ensure the facility included clear instructions for staff and documented treatments administered on the TAR was discussed with Staff 1 (Executive Director), Staff 2 (RN) and Staff 7 (RN Consultant) on 03/03/22. They acknowledged the findings.

(1)

1. We received clarification orders for Resident 1's oxygen use from their PCP.

2. Health Services Director and ED will audit MAR/TAR/DAR weekly to ensure accuracy.  Additional training will be provided to care staff offering clear instructions for when to contact the prescriber or nurse.

3. We will be evaluating the area needing correction weekly by the Health Services Director and ED.

4. The Health Services Director and ED will be responsible for the weekly audits of the MAR/TAR/DAR.

(2)

1.  In-service was completed with Health Services staff to review signing for meds/treatments that are being administered by staff.  

2. MAR/TAR/DAR will be audited by Health Services Director for accuracy, any holes in the MAR/TAR/DAR will be flagged for correction.

3. This will initially be evaluated via an audit performed by the Health Services Director and ongoing on a weekly basis.

4. The Health Services Director is responsible for this correction and the ED will follow up to ensure compliance.   

Based on observation, interview and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities was assessed thoroughly by an RN, PT or OT prior to use for 1 of 1 sampled resident (#3) who had two half-length siderails on their bed. Findings include, but are not limited to:

Resident 3 was observed during the survey and noted to have half-length siderails attached to one side of their bed.

Review of the resident's clinical record revealed the following:

* No documented evidence of an assessment completed by an RN, PT or OT for the use of the siderails;

* No documented evidence that other less restrictive alternatives had been attempted prior to use; and

* There was no clear instruction to caregivers on the correct use and precautions related to use of the device.

On 03/03/21, the need to complete an assessment and the required components for the use of devices with potentially restraining qualities was discussed with Staff 1 (Executive Director), Staff 2 (RN), and Staff 3 (LPN). They acknowledged the findings.

1. Resident 3 now has an order from her PCP for the side rails in place.  RN will ensure that all other residents with devices have been assessed.

2. Each resident using devices will be reviewed quarterly by the RN and as needed.  Health Services Director will update service plans to reflect the use of devices for individual residents.

3. Each resident using devices will be reviewed quarterly by the RN and as needed.

4. The RN is responsible for this and the ED will follow up to ensure compliance.

Based on interview and record review, it was determined the facility failed to ensure documentation that 2 of 2 sampled newly-hired employees (#s 9 and 10) completed the required dementia care training prior to assuming their job duties. Findings include, but are not limited to:

Staff training records were reviewed with Staff 1 (Executive Director) on 03/03/22. The following deficiencies were identified:

Staff 9 and Staff 10, both care partners who provided direct care to residents, lacked documented evidence they completed approved pre-service dementia training prior to providing care to residents including:

* Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms;

* Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses;

* Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; and

* Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: identify and address pain, provide food and fluids, prevent wandering and elopement, and use a person-centered approach.

The need to ensure documentation of pre-service training was reviewed with Staff 1 on 03/03/22. She acknowledged the lack of training documentation.

1. The ED, to endure the completion of pre-serice training, will perform an initial audit of all employees records. Secondly, implementing a new system and assigning trainings through Oregon Care Partners and in-service trainings to employees who are lacking CEUs.

2. Initially, it will be corrected with an audit and in an ongoing basis, daily, weekly and monthly depending on new hires, training, and monthly in-services to ensure staff are in compliance with their required yearly training.

3. All employees will be required to turn in one CEU from Oregon Care Partners per month, in addition to on site trainings; therefore, meeting the minimum 12 CEU per year requirement.  

4. This will be evaluated in an ongoing basis, daily, weekly and monthly depending on new hires, training, and monthly inservices.  The ED is responsible for completing and monitoring this.

Based on interview and record review, it was determined the facility failed to ensure that 2 of 2 newly-hired direct care staff (#s 9 and 10) received documented training in required areas. Findings include, but are not limited to:

Staff training records were reviewed on 03/03/22 with Staff 1 (Executive Director).

Staff 9 (Care Partner) was hired 07/02/21, and Staff 10 (CG) was hired 11/22/21 The following deficiencies with the training requirements were identified:

There was no documented evidence Staff 9 and Staff 10 had completed the required training in the areas of:

* Changes associated with normal aging;

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

* Training in the use of the abdominal thrust and First Aid.

The requirement to complete and document staff training was reviewed on 03/03/22 with Staff 1, who acknowledged the findings.

1. 30-day competency form was updated to include changes associated with normal aging, conditions that require assessment, treatment, observation and reporting and training in the use of abdominal thrust and first aid.  

ED will perform an initial audit for all employees first aid and abdominal thrust certifications.

2. Initially, it will be corrected with an audit, and checked monthly and as needed for new hire to ensrue compliance.

3. All employees will be required to turn in first aid and abdominal thrust certifications upon hire, and ongoing upon expiration of certification.  

4. This will be evaluated monthly and as needed for new hires.  The ED is responsible for completing and monitoring this.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 sampled direct care staff (#s 11 and 12) completed and documented a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care setting, including training on chronic diseases in the facility population and dementia training. Findings include, but are not limited to:

Staff training records were reviewed with Staff 1 (Executive Director) on 03/03/22. There was no documented evidence of the required annual training for long term staff for Staff 11 (Care Partner) or Staff 12 (MT).

The need to ensure direct care staff completed the required annual training was completed, documented and the records retained was reviewed with Staff 1 on 03/03/22. She acknowledged the findings.

1. ED will perform an initial audit for all employees records. Secondly, a new system will be implimented assigning inservice trainings to employees who are lacking CEUs.

2.Initially, it will be corrected with an audit, and checked monthly and as needed for new hire to ensrue compliance.  

3. All employees will be required to turn in one CEU from Oregon Care Partners per month, in addition to on site trainings; therefore, meeting the minimum 12 CEU per year requirement.  

4. This will be evaluated in an ongoing basis, daily, weekly and monthly depending on new hires, training, and monthly inservices.  The ED is responsible for completing and monitoring this.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted in accordance with Oregon Fire Code (OFC) and fire and life safety instruction to staff was provided on alternate months. Findings include, but are not limited to:

Review of fire drill and fire and life safety records for 09/2021 through 02/2022 identified the following deficiencies:

* Fire drills were not being conducted and recorded every other month;

* Fire and life safety instruction for staff was not being conducted and documented on alternate months of the fire drills; and

* The facility was not relocating residents during fire drills so there was no documentation of the following required components:

- Location of the simulated fire origin;

- Escape route used;

- Problems encountered and comments relating to residents who resisted or failed to participate in the drills;

- Evacuation time-period needed; and

- Number of occupants evacuated.

The need to ensure the facility conducted fire drills per the OFC and provided fire and life safety instruction to staff on alternate months was reviewed with Staff 1 (Executive Director) and Staff 5 (Maintenance Director) on 03/02/22. They acknowledged the findings.

On 3/9/2022, ED updated the fire drill form to include route/alternate route, problems encountered and comments relating to residents who declined participation in the drills, evacuation time-period and number of occupants evacuated.

1. ED created a calendar that details the safety meeting topics and fire drills on a rotating monthly schedule.  

2. The fire drill form was updated to meet CBC requirements and a calendar was created outlining fire drills and safety meetings on an alternating monthly schedule.  Fire and emergency evacuation information was updated on service plans for all residents and will be reviewed quarterly at service plan meetings.  

3. This fire drills and safety meetings will occur once monthly alternating between fire drill and safety meetings, fire drills and safety meetings will be performed by the Maintenance Director.  The ED will follow up to ensure compliance.

4. The Maintenance Director will be responsible for this correction and the ED will follow up to ensure compliance.    

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements were being met. Findings include, but are not limited to:

Fire and life safety records, reviewed between 09/2021 through 02/2022, revealed the facility lacked documented evidence of the following:

* Alternate exit routes were used during fire drills;

* Fire and life safety training for residents at least annually that included general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire;

* A written record of fire safety training, including content of the training sessions and the residents attending; and

* There was no documented evidence the facility identified residents who were unable or unwilling to participate in the fire drills therefore, there was no documented evidence immediate changes were made to ensure the evacuation standard was met.

The need to ensure alternate exit routes were used during fire drills, fire and life safety instruction was provided to residents at least annually and documentation of residents who declined to participate in fire drills with the changes made to ensure the facility was able to maintain the evacuation standard was discussed with Staff 1 (Executive Director) and Staff 5 (Maintenance Director) on 03/02/22. They acknowledged the findings.

On 3/9/2022, ED updated the fire drill form to include route/alternate route, problems encountered and comments relating to residents who declined participation in the drills, evacuation time-period and number of occupants evacuated.

1. The Health Services Director will audit the service plans for residents and update the fire/emergency evacuation section to reflect their willingness to participate in fire/evacuation drills.  

2. Fire/evacuation will be discussed with residents upon admission and then once quarterly at service plan meetings. The fire drill form was updated to meet CBC requirements and ensure compliance.

3. Fire/evacuation will be discussed with the residents initially with the Maintenance Director, upon admission and then quarterly at their service plan meetings.

4. The Maintenance Director and ED are responsible for this correction.

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

The interior of the building was toured on 03/02/22. The following areas needed repair:

* On the 1st floor - the door and wall to residential hall next to the stairwell, with carpet stains evident on the floor next to the damaged door;

* On the 2nd floor -  carpet stains in front of rooms 202, 203, 204, 205, 212, and 214 with a small section of carpet missing next to the bookshelf in the 2nd floor lounge;

* On the 3rd floor - carpet stains in front of rooms 302, 311, 314, and 317, with ceiling tiles on the service hallway water stained and damaged;

* The floor in the kitchen under the dishwasher was wet from an ongoing water leak; and

* The elevator carpet showed stains and rough edges / damage noted on the wall panels.

The condition of the carpets, elevator, doors and floors were reviewed with Staff 1 (Executive Director) and Staff 5 (Maintenance Director) They acknowledged the areas needed repair.

1. All holes were patched 3/11/22 and sanded, textured and painted by 3/18/22.

All carpets in the community were cleaned by the Maintenance Director from 3/8/22 to 3/11/22 and we are getting a bid for new flooring to be installed.

The kitchen dishwasher is scheduled to be repaired by 5/3/2022.

2. The Maintenance Director will conduct routine rounds frequently and will meet with the ED weekly to check progress on ongoing repairs.  

3. The Maintenance Director will conduct routine rounds of the community.

4.  The Maintenace Director and the ED are responsible for the completion and continued monitoring of these corrections.

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

The interior of the building was toured on 05/19/22 at 2:18 pm. The following areas needed cleaning and/or repair:

First Floor -

* Walls near room 100 and 101 had staining and black/brown drips;

* Corner across from room 102 had gouging which exposed drywall;

* Handrail across from room 100 was rough to touch and posed risk for skin tear;

* Ceiling tiles in the 100 hall were missing;

* Plastic bin was acting as doorstop at lower entrance of stairs increasing risk for falls;

* Elevator paneling was chipped with rough edges; and

* Employee door at end of 100 hall was scuffed.

Second Floor -

* Rooms 203, 205, 208, 211, 212, 217 and 218 had spills, stains, gouges and/or paint chipping on doors;

* Walls near the assisted bathing room and room 207 had drips and stains;

* Handrail to the right of room 201 had exposed bare wood and was rough to touch which posed a risk for skin tears;

* Corner near the elevator had chipped drywall; and

* Nurse's station desk had a gouge near the elevator.

Third Floor -

* Rooms 301, 302, 304 and 311 had gouges and paint chipping;

* Baseboard to the right of room 312 was not flush with adjacent piece of baseboard;

* Handrail near rooms 303 and 314 had exposed bare wood;

* Wall to right of room 313 had a red stain;

* Wall across from room 302 had white stains; and

* Exit door of the activity room had scuff marks near the flooring.

The need to ensure all interior materials and surfaces were kept clean and in good repair was reviewed with Staff 1 (Executive Director) on 05/19/22 at 3:15 pm. She acknowledged the findings.

1. First Floor - Corner guards to be placed on the corners to prevent further damage by visually impaired resident who takes that path to exit to the common area.  

Ceiling tiles were replaced on 5/19.

Handrails will be sanded and stained in the areas they are rough.

The wall near the staircase exit will be repaired and a sturdy door stop will be installed.

Employee door at end of hall was cleaned and will be re-painted with a "scuff-proof" paint to help prevent wear and tear.

Second Floor - All doors on the second floor will be assessed by the maintenance director and will be repaired and re-painted with "scuff-proof" paint to help prevent wear and tear.  

Handrails will be sanded and stained in the areas that they are rough.

The corner near the elevator will be repaired and a corner guard will be installed to further protect the area from unintentional damage.

The nurses station desk will be repaired, sanded and re-stained.

Third Floor - All doors on the third floor will be assessed by the maintenance director and will be repaired and re-painted with "scuff-proof" paint to help prevent wear and tear.

The baseboard near 312 was fixed on 5/19

Handrails will be sanded and stained in the areas they are rough.

The walls on the third floor were cleaned and will be spot cleaned as needed.

The exit door of the activity room will be sanded and painted with a "scuff-proof" paint to prevent wear and tear.

2. The Maintenance Director will routinely check the community for signs of wear and tear and repair items as needed.

3. The initial repairs, painting and staining will correct the problem areas completely.  The Maintenacne Director will routinely check the community for future signs of wear and tear and repair items as needed.

4. The Maintenance Director will be responsible to see that the repairs are completed and the Executive Director will follow up on the completion of this task.

Based on observation and interview, it was determined the facility failed to ensure the HVAC system was maintained and that covers of wall heaters did not exceed 120 degrees Fahrenheit (F) when installed in locations that were subject to incidental contact by individuals. Findings include, but are not limited to:

The interior of the building was toured on 03/02/22 and revealed:

1. Staff 1 (Executive Director) and Staff 5 (Maintenance Director) stated the facility used a central furnace to heat hallways and common areas in the building, and the thermostat on the first floor had not been working properly for approximately 4 weeks. Staff 1 stated a repair person was waiting on parts to be able to complete the repair.

Observations on 03/03/22 and 03/04/22 showed residents in the dining room, some wearing coats. The dining room air temperature was measured at 68 degrees F on 03/04/22, and staff acknowledged residents complained about the temperature of the common areas and dining room during cold weather in the month of February.  

2. Room 213 had a wall heater in the living room.  When the heater was turned on and tested with a thermometer, the metal surface of the heater reached 152 degrees F. The heater was located where a resident could come into incidental contact with the hot surface of the heater.

Room 310 had a wall heater in the living room. When the heater was turned on and tested with a thermometer, the metal surface of the heater reached 155 degrees F. The heater was located where a resident could come into incidental contact with the hot surface of the heater.

The facility acknowledged that all of the resident rooms and public bathrooms had the same type and model of heater, and there was not a system in place to test the heaters for exceeding 120 F.

The requirement to maintain a properly functioning heating system and the risk posed by the hot surface of the wall heaters was discussed with Staff 1 and Staff 5 on 03/03/22. They acknowledged the need to complete repairs of the central furnace and that the surface of the heaters exceeded 120 degrees F.

(1)

1. As a temporary measure, small heating units are in place to help maintain a reasonable temperature in the dining room when residents are present at meals.  The Maintenance Director has a bid from Hunter Davidson, we are waiting for scheduling for completion.

2. Once changed, the HVAC computer should last for some time, repairs will be fixed as needed.  

3.  Once updated, the machine will be evaluated quarterly by the Maintenance Director to ensure that it is operating correctly.

4.  The Maintenance Director will be responsible for this correction and ensuring compliance.  

(2)

1. A 3ft area was taped around the cadet heaters as a visual aid to discourage and prevent incidental contact with the heaters while they are operational.

2.  Community ownership will work on an agreed upon solution with Facility Planning and Safety.

3. Once corrected, heating units will be monitored quarterly by the maintenance Director.

4. Community ownership will be responsible for the initial resolution via PTAC units or heat bars being installed into resident apartments and common areas.  Ongoing, the Maintenance Director will be responsible for quarterly monitoring of the units for compliance.   

Based on observation, interview and record review, it was determined the facility failed to ensure the HVAC system was maintained and that covers, grates, or screens of wall heaters did not exceed 120 degrees Fahrenheit (F) when installed in locations that were subject to incidental contact by individuals. This is a repeat citation. Findings include, but are not limited to:

The interior of the building was toured on 05/19/22 and revealed the following:

1. Staff 1 (Executive Director) stated that the HVAC system, that was confirmed to not be working properly during the first survey in 03/2022, continued to not work and would require extensive repair. According to documentation provided, there was no set date for that process to begin.

Observation of the dining room showed three portable heating units placed around the room acting as the primary heating source. Per interview with Staff 1 on 05/19/22, the kitchen staff plugs all heaters in upon arrival each morning and unplugs all heaters at night. Two of the three heaters were operating during the survey. When the heaters were tested with the surveyors' thermometers, the unit closest to the kitchen on the service counter was 204 degrees F and the unit near the door to the conference room was 214.5 degrees F. These units were located where residents could come into incidental contact with the hot surfaces.

Interviews with non-sampled residents during the meal service revealed " ...it's always cold in here," " ....it's always chilly in here ..." and "my ankles are always cold." The ambient temperature in the dining room was measured with the surveyor's thermometer and was noted to be 69.5 degrees F.

2. Individual resident apartments and common area bathrooms were noted to have cadet style wall heaters.  

Room 213 had a functioning wall heater in the living room. The heater was located where a resident could come into incidental contact with the hot surface of the heater. Per the facility's plan of correction, the facility was to place and maintain tape on the floor surrounding the heater to alert resident to the presence of the wall heater. Room 213 did not have tape present.

The assisted bathing room on the second floor had a wall heater near the entrance. When the heater was turned on and tested with the surveyor's thermometer, the metal surface of the heater reached 199.0 degrees F. The heater was located where a resident could come into incidental contact with the hot surface of the heater and no tape was present.

The requirement to maintain a properly functioning heating system and the risk posed by the hot surfaces of the wall heaters and portable heating units was discussed with Staff 1 on 05/19/22 at 2:00 pm. She acknowledged the findings and presented an immediate plan to replace all non-programmable thermostats with programmable thermostats and to limit temperatures each thermostat can reach. This plan was accepted by the survey team.

1.

(1)ED submitted bid for extensive repair to HVAC system to the state for funding assistance through the Long Term Capital Improvement and Emerency Preparedness program Phase 2.

(2) Maintenance Director to change out all the non-programable thermostats with thermostats that are programable.  Temperatures will be capped at a level that keeps the cadet heaters from reaching temperatures greater than 120 degrees F.  

2.

  (1) The extensive repair to our existing HVAC system will resolve this violation.  

  (2) Apartments will be audited by the maintenance director routinely to ensure that the heaters do not exceed 120 degrees F and re-calibrate the thermostat if is found to exceed that temperature.  The Maintenacne Director will audit the resident apartments and common bathrooms to ensure that the tape around the heaters has not been removed and will replace tape if it has been.

3.

 (1) Once the repair is completed on our existing HVAC unit, the upgraded equipment will be evaluated quarterly and as needed to ensure it is functioning properly.

 (2) The resident apartments will be audited on a monthly basis during colder months and bi-monthly basis in warmer months by the Maintenacne Director to ensure that the tape around the heater is in place and that the heaters are not exceeding 120 degrees F and will be recalibrated if they are found to exceed that temperature.

4.

 (1) The Ownership is responsible for the extensive repair needed for the HVAC unit in the community. ED will follow up on progress and monitor the status of our grant application through the Long Term Capital Improvement and Emergency Preparedness program Phase 2.

 (2)The Maintenance Director is responsible for the installation of the programable thermostats community-wide and the monthly/bi-monthly audits for proper temperature and tape placement.  ED will follow up to ensure the monthly/bi-monthly audits are completed.

Based on observation and interview, it was determined the facility failed to ensure a manually operated emergency call system was provided in each resident bathroom, central bathing room, and public-use restroom.

The facility was toured on 03/02/22, and observations showed:

* The 1st floor public-use restroom did not have an emergency call system; and

* The 2nd floor central bathing room did not have an emergency call system.

The findings were reviewed with Staff 1 (Executive Director), and Staff 5 (Maintenance Director) on 03/03/22, they acknowledged the findings.

1. Pull cord call system boxes were ordered from Wireless Nurse Call Systems, inc.  The boxes arrived on 3/11/22.  It was determined that an additional receiver was required and that part was ordered on 3/21/22.  Once received, the pull cords will be installed in the 1st floor public use restroom and the 2nd floor resident bathing room.

2. Pull cord call boxes will be installed after receipt of the receiver is delivered to the community from Wireless Nurse Call Systems, inc.  The installation of these boxes will correct the violation.

3. Call system stations are tested quarterly by the Maintenance Director.

4. On 3/11/22, the ED ordered pull cords for the 1st floor public bathroom and 2nd floor resident bathing room.  The additional required part was ordered on 3/21/22 and, upon receipt, both will be paired to the wireless call system and will be tested quarterly by the Maintenance Director.