Print Inspection: S6WW

The findings of the re-licensure survey conducted 06/13/22 through 06/15/22 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 06/15/22, conducted 10/19/22 through 10/20/22, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, and OARs 411 Division 004 Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the second revisit to the re-licensure survey of 06/15/22, conducted 02/21/23 through 02/27/23, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, and OARs 411 Division 004 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

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 third re-visit to the re-licensure survey of 06/15/22, conducted 06/21/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 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 fourth re-visit to the re-licensure survey of 06/15/22, conducted 08/16/23, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Based on observation and interview, it was determined the facility failed to ensure required postings were displayed in a routinely accessible and conspicuous location to residents and visitors, and available for inspection at all times. Findings include, but are not limited to:

The facility was toured on 06/13/22 at 1:50 pm and the following was observed:

* Facility staffing plan, manger on duty, and facility license were not posted in a place accessible or conspicuous to residents and visitors; and

* The most recent re-licensure survey, including all revisits was not posted.

The need to ensure all required postings were in a routinely accessible and conspicuous location was reviewed with Staff 1 (Administrator) and Staff 16 (Regional Maintenance Director) on 06/15/22. They acknowledged the findings.

1.Facility staffing plan and the binder containing the survey report is visible and available to the public for viewing on the outside of the reception desk.

2.Receptionist to ensure postings are in the same location for viewing when he/she arrives every morning.

3.It is monitored daily

4. Receptionist and Administrator

Based on observation and interview, it was determined the facility failed to ensure required postings were displayed in a routinely accessible and conspicuous location to residents and visitors, and available for inspection at all times. This is a repeat citation. Findings include, but are not limited to:

The facility was toured on 10/19/22 at 9: 00 am and the following were not observed to be accessible at all times or located in a conspicuous location:

* Facility license;

* The name of the administrator or designee in charge. The designee in charge must be posted by shift or whenever the administrator is out of the facility; and

* A copy of the most recent re-licensure survey, including all revisits and plans of correction as applicable.

The need to ensure all required postings were in a routinely accessible and conspicuous location was reviewed with Staff 18 (Administrator) on 10/20/22. She acknowledged the findings.

1. Facility staffing plan and the binder containing the survey report is available on the outside of the front desk reception on a table for easy access and viewing.

2. Receptionist are in the same location for viewing when she gets in every day.

3. Monitored daily

4. Receptionist and Administrator

Based on observation and interview, it was determined the facility failed to ensure required postings were displayed in a routinely accessible and conspicuous location to residents and visitors and available for inspection at all times. This is a repeat citation. Findings include, but are not limited to:

The facility was toured on 02/21/23. The following were not observed to be accessible at all times or located in a conspicuous location:

* Facility license; and

* A copy of the most recent re-licensure survey, including all revisits and plans of correction as applicable.

The need to ensure all required postings were in a routinely accessible and conspicuous location was reviewed with Staff 19 (Administrator/RN) on 02/22/23. She acknowledged the findings.

Based on observation and interview, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the immediate health, safety or welfare of residents. Resident 2 smoked while wearing oxygen.  Findings include, but are not limited to:

Resident 2's current service plan, dated 06/06/21, noted the resident smoked. The resident was alert and oriented.

On 06/14/22 at 12:30 pm Resident 2 was observed in the smoking area with two other residents. Resident 2 had a nasal cannula in place attached to a portable oxygen tank, and was observed lighting and smoking cigarettes.

The tank of concentrated oxygen and tubing next to an open flame created a fire hazard.

Staff were notified, and at 1:15 pm ensured the oxygen tank was turned off. Staff 1 (Administrator) and Staff 2 (Health Services Director) created an immediate plan of correction. educated the resident on the risks of smoking with oxygen and updated Resident 2's service plan to require staff to immediately notify the Administrator if the resident was observed smoking with oxygen on.

In interview on 06/14/22, the need to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents was discussed with Staff 1 and Staff 2. They acknowledged the findings.

1.Immediate action was taken. Resident was counseled on smoking with o2 on. Service plan updated for staff to immediately notify administrator if smoking while oxygen is turned on.

2. Administrator issued warning letter to resident stating that if he does not comply he will be issued a move out notice.

3.Daily monitoring by the staff

4.ALL STAFF. And ongoing follow and monitoring by the Resident Services Director, The Health Services Director and the Administrator.

Based on observation and interview, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the immediate health, safety or welfare of residents. This is a repeat citation. Findings include, but are not limited to:

Upon entering the facility on 10/19/22 at 9:00 am, there was a sign posted on the front door that notified the public of a confirmed COVID case in the building.

The facility's interior environment was toured on 10/19/22. At approximately 11:00 am, a box was observed outside of apartment 226. The box was uncovered and lined with black plastic. The contents of the box were observed to be used Personal Protection Equipment (PPE) such as disposable gowns, gloves and masks.

On 10/19/22 at 11:13 am, the uncovered box of contaminated PPE was discussed with Staff 18 (Administrator) who acknowledged the PPE should have been stored in a closed receptacle.

1. Immediate action was taken to ensure the safe removal of the PPE station that had the uncovered garbage can containing soiled PPE. As the individual was released from covid quartentine.

2. Infection control specialist to ensure that anytime a PPE station is set up a closed garbage container accompanies it.

3. Daily monitoring of covid quarentined units as needed.

4. The Health Service Director / Infection control specialist and the Administrator.

Based on interview and record review, it was determined the facility failed to promptly investigate incidents to rule-out abuse, failed to document all required areas of an investigation, failed to take measures necessary to protect residents and prevent the reoccurrence of abuse and failed to report to the local Seniors and People with Disabilities (SPD) office if abuse or neglect could not be ruled out for 2 of 2 sampled residents (#s 3 and 4) with a resident-to-resident altercation and a fall with injury. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 07/2017 with diagnoses including Bipolar Type I Disorder.

The Incident Report dated 06/05/22 stated that a non-sampled resident made sexually inappropriate comments to Resident 3 and touched his/her knee.

Temporary Service Plans for Resident 3 and the non-sampled resident were reviewed and there were no interventions documented to protect Resident 3 or to prevent additional altercations from occurring.

In the Incident Report and during an interview on 06/15/22, Resident 3 stated that s/he felt safe in the facility and knew to use his/her pendant to alert staff if s/he felt endangered.  

During an interview with Staff 1 (Administrator) on 06/14/22, she confirmed that the incident was not reported to the local SPD office and that interventions were not put in place to protect the resident. Staff 1 also confirmed there was no documented evidence the administrator had reviewed the incident.

The surveyor requested the incident be reported to the local SPD office and confirmation of reporting was received prior to survey exit.

The need to report incidents immediately to the local SPD office, to take measure to protect residents and to prevent the reoccurrence of abuse and the need to demonstrate administrator review was discussed with Staff 1 and Staff 2 (Health Services Director) on 06/14/22 at 11:17 am. They acknowledged the findings.

2. Resident 4 was admitted to facility 01/2021 with a diagnosis including anoxic bran injury and Parkinson's disease.

The resident's service plan identified him/her at risk for falls. Interventions in place included reminding resident to use call light and wait for staff assistance, adjusting four wheeled walker to a U walker and providing a wheelchair for ambulation.

Review of Resident 4's record noted unwitnessed injury or non-injury falls on 04/02/22, 05/19/22 and 05/23/22. There was no documented evidence how the facility determined the unwitnessed falls were not the result of neglect or abuse.

The need to thoroughly investigate all incidents, to rule out suspected abuse and/or neglect and report to the local SPD office if abuse/neglect could not be ruled out, was discussed with Staff 1 (Administrator), and Staff 2 (Health Services Director) on 06/15/22. They acknowledged the findings.

1. All incidents will be investigated and documented to rule out abuse. If the facility cannot rule out abuse then it will be reported to APS.

2. All incidences will be reviewed by the administrator to ensure abuse is ruled out.

3.As needed per incident.

4. Health Services Director, Resident Services Director and Administrator.

Based on interview and record review, it was determined the facility failed to ensure incidents and reports of suspected abuse were thoroughly investigated to rule out abuse for 1 of 1 sampled residents (# 2) whose record was reviewed. This is a repeat citation. Findings include but are not limited to:

Resident 2 was admitted to the facility in 01/2020.

A progress note dated 10/10/22 revealed Resident 2 was observed in the unit of an unsampled resident. The unsampled resident was noted to have a cognitive deficit. The unsampled residents pants were noted to be off when Resident 2 was observed in the unit.

The investigation by the facility lacked the following required elements:

* Response of staff at the time of the event; and

* Administrator's review.

In an interview with Staff 18 (Administrator) on 10/19/22, she confirmed the event was not thoroughly investigated including determining if staff were following each resident's service plan at the time of the event.

The need to ensure incidents of suspected abuse were thoroughly investigated to rule out abuse and neglect was discussed with Staff 18 and Staff 19 (Health Services Director) on 10/20/22. They acknowledged the findings.

The facility was directed to self-report the incident to the local SPD office. Confirmation of the report was received on 10/20/22 prior to survey exit.  

1. All incidents will be investigated and documented to rule out abuse. If the facility canot rule out abuse then it will be reported to APS.

2. All incidences will be reviewed by the team at daily stand up meetings to ensure abuse has either been ruled out or reported.

3. As needed per incident.

4. Resident Service Director, Health Service Director, Administrator.

Based on interview and record review, it was determined the facility failed to conduct an immediate investigation of a fall with injury or document an immediate investigation that reasonably ruled out abuse for 1 of 1 sampled resident (#13) reviewed for a fall with injury. This is a repeat citation. Findings include, but are not limited to:

Resident 13 was admitted to the facility in March 2019 with diagnoses including chronic obstructive pulmonary disease and diabetes.

A review of the resident's clinical records, from 12/04/22 through 02/21/23 revealed s/he had a fall on 12/05/22, resulting in injuries.  The 12/05/22 progress note stated "Resident has been placed on alert due to an injury fall. Resident was going through fridge by door when caregiver opened door, resident jolted backwards and fell on [his/her] back hitting [his/her] hair and splitting [his/her] head. Pressure was applied to bleeding and resident was sent out".

There was no documented evidence the facility immediately investigated the fall with injury to rule out abuse nor was the incident reported to the local SPD office.

On 02/23/23 the incident on 12/05/22 was reviewed with Staff 19 (Administrator/RN). The facility was directed by a surveyor to report the incident from 12/05/22 which involved care staff. The facility provided confirmation the incident had been reported to the local office on 02/23/23.

The facility's failure to report incidents of suspected abuse/neglect or injuries of unknown cause, or to conduct an immediate investigation of an injury of unknown cause and document that abuse was ruled out, was discussed with Staff 19 on 02/22/23. She acknowledged the findings.

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

On 06/13/22 at 9:26 am, the kitchen was observed to need cleaning and repair in the following areas:

* Entrance door and door frame had chipped paint, gouges;

* The vent above the entrance door had dust, metal tape and damage;

* Scuffs along walls to entrance into the kitchen;

* Dent in wall behind kitchen door;

* Countertop to the left of the juice machine missing laminate, exposing wood underneath;

* Shelf in cabinet underneath juice machine had gouges and laminate was broken;

* The side of the ice machine had food debris;

* The wall behind rinse sink in dishwasher area had black matter build up;  

* Walls throughout the kitchen had food debris, splatters and spills;

* Cabinets under drink service area missing laminate sides on multiple doors, exposing wood underneath;

* Cabinets next to walk-in refrigerator were missing three handles;

* Upper and lower cabinets throughout the kitchen were sticky to the touch and had debris build-up;

* Underneath equipment and shelves floor had food debris, dirt, and condiment packets;

* Baseboards had black matter build up;

* Underneath shelves of steam table had food debris build up;

* The hood above the warewasher had rust discoloration around the rim;

* Warewasher had metal tape on dirty side door frame;

* High limit indicator light broken on the warewasher;

* Garbage cans throughout the kitchen were not covered and located in food prep areas;

* Commercial mixer had dried food debris located on guard;

* Gouge in wall above utility closet;

* Utility closet doors had gouges and peeling paint;

* Gouges in corner next to walk-in refrigerator;

* Drain underneath microwave table had black debris around edge;

* Door and door frame into dry storage had gouges and scuffs;  

* Convection oven had debris on top and side of oven;

* Food debris observed on side of stove and wall behind;

* Microwave had grease and debris on outside and debris on the inside;

* Observation of an wood tabletop with gouges which constituted an uncleanable surface;

* Multiple colored cutting boards were observed to have deep grooves, which deemed them uncleanable;

* Small frying pan with roux and slotted spoon, covered in plastic wrap was sitting on bottom shelf of the steam table;

* Cupboards to the left and above the wooden table were in need of cleaning and repair;

* Walk-in refrigerator missing handle on the inside; and

* Mop and broom next to counter in food prep area.  

Observations made on 06/13/22 at 11:30 am revealed the following:

* Staff 10 (Kitchen Help) opened the warewasher, took out a clean cooking sheet and placed it on clean side of dish area to dry. He then touched dirty trays to put them through the warewasher and started a new cycle. Staff 10 then touched the clean cooking sheet and a bowl and put them away in the kitchen. No handwashing was observed from staff from dirty to clean dish sections.  

* A staff member washed their hands with gloves on, dried their gloved hands with paper towels and returned to their task.  

* A staff member rinsed a knife off in a prep sink and dried it off with a paper napkin then placed it back on the magnetic knife rack.

The kitchen was toured on 06/13/22 with Staff 4 (Dietary Manager) and all observations were reviewed.

The need to ensure the kitchen was maintained in accordance with the food and sanitation rules was discussed on 06/15/22 at 12:44 pm while the kitchen was toured with Staff 1 (Administrator) and Staff 16 (Regional Maintenance Director). They acknowledged the findings.

1. The areas identified in the kitchen have been addressed and corrected through a combination of repair or replacement, as needed to ensure that all surfaces are clean, smooth, seamless and no structural material is exposed. In addition, the community provides enhanced, ongoing staff  training and routine spot checks to insure proper use of kitchen appliances and kitchen cleanliness protocols consistent with heatlh codes maintained to prevent re-occurrence.

2. The dietary manager has implemented a written cleaning schedule for kitchen staff to appropriately address the above noted deficiencies. This schedule is to be tracked in a written log and is to be reviewed and assessed for compliance by the Administator no less than  monthly.

3.Monthly

4. Dietary manager and Administrator  

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

On 10/19/22 at 10:01 am, the kitchen was observed to need cleaning and repair in the following areas:

* Entrance door and door frame had chipped paint and gouges;

* The entrance door frame's black seal was in disrepair;

* The foyer outside of the kitchen had black matter along the baseboards;  

* The vent above the entrance door was in disrepair;  

* Scuffs along walls to entrance into the kitchen;

* Dent in wall behind kitchen door;

* Countertop to the left of the juice machine missing laminate, exposing wood underneath;

* Shelf in cabinet underneath juice machine had gouges, the laminate was broken and there was empty juice bags present;

* The wall behind rinse sink in dishwasher area had black matter build up;  

* Cabinets under drink service area missing laminate sides on multiple doors, exposing wood underneath;

* Cabinets next to walk-in refrigerator were missing three handles;

* Upper and lower cabinets throughout the kitchen were sticky to the touch and had debris build-up;

* Baseboards had black matter build up;

* Commercial mixer had dried food debris located on the guard;

* Gouge in wall above utility closet;

* Utility closet doors had gouges and peeling paint;

* Gouges in corner next to walk-in refrigerator;

* Drain underneath microwave table had black debris around edge;

* Door and door frame into dry storage had gouges and scuffs;  

* Observation of a wood tabletop with gouges which constituted an uncleanable surface;

* Multiple colored cutting boards were observed to have deep grooves, which deemed them uncleanable; and

* Cupboards to the left and above the wooden table were in need of repair.

The need to ensure the kitchen was maintained in accordance with the food and sanitation rules was discussed on 10/20/22 at 11:37 am Staff 28 (Dietary Manager) and on 10/20/22 at 12:11 pm with Staff 18 (Administrator). They acknowledged the findings.

1. The areas identified in the kitchen are being addressed and corrected through a combination of repair and replacement to ensure all surfaces are cleanable, smooth and no structural material exposed.

2. The dietary supervisor has implemented a written schedule and hired additonal staff to address the deficiencies.

3. Weekly

4. The Dietary supervisor and Administrator

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

On 02/21/23 at 10:30 am, the kitchen was observed to need cleaning and repair in the following areas:

* Entrance door and door frame had chipped paint and gouges;

* The entrance door frame's black seal was in disrepair;

* The foyer outside of the kitchen had black matter along the baseboards;    

* Scuffs along walls to entrance into the kitchen;

* Dent in wall behind kitchen door;

* Countertops next to the handwash sink and to the left of the iced tea machine were missing laminate, exposing wood underneath;  

* Cabinets next to walk-in refrigerator were missing three handles;

* Upper and lower cabinets throughout the kitchen were sticky to the touch and had debris build up;

* Gouge in wall above utility closet;

* Utility closet doors had gouges and peeling paint;

* Gouges in corner next to walk-in refrigerator;

* Drain underneath microwave table had black debris inside and around edge;

* Door and door frame into dry storage had gouges and scuffs;  

* Observation of a wood tabletop with gouges which constituted an uncleanable surface;

* Cupboards to the left and above the wooden table were in need of repair; and

* Floor throughout the kitchen had black sticky build up on the surface.

The need to ensure the kitchen was maintained in accordance with Food Sanitation Rules was discussed on 02/21/23 at 1:24 pm with Staff 28 (Dietary Manager) and on 02/22/23 at 3:01 pm with Staff 19 (Administrator/RN). They acknowledged the findings.

3. Resident 2 was admitted to the facility in 01/2020. The resident's most recent evaluation dated 01/27/20 was reviewed and revealed the facility failed to update the evaluation at least quarterly.

In a 06/15/22 interview with Staff 2 (Health Services Director), she acknowledged  the facility was behind in performing quarterly updates for many of the facility's residents.

The need to perform evaluations at least quarterly with updates to health status, needs and preferences for Resident 6 was discussed with Staff 1 (Administrator) and Staff 2 on 06/15/22. They acknowledged the findings.

4. Resident 6 was admitted to the facility in 04/2021. The resident's most recent evaluation dated 04/01/21 was reviewed and revealed the facility failed to update the evaluation at least quarterly.

In a 06/15/22 interview with Staff 2 (Health Services Director), she acknowledged the facility was behind in performing quarterly updates for many of the facility's residents.

The need to perform evaluations at least quarterly with updates to health status, needs and preferences for Resident 6 was discussed with Staff 1 (Administrator) and Staff 2 on 06/15/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure initial move-in evaluations included all required elements, or that a quarterly evaluation was completed timely, for 4 of 5 sampled residents (#s 2, 4, 5 and 6). Findings include, but are not limited to:

1. Resident 5's move-in evaluation lacked information regarding the following required elements:

* Indicators of nursing needs;

* Emergency evacuation ability;

* Environmental factors that impact a resident's behaviors;

* The new move-in evaluation was not dated and did not indicate who was involved in the evaluation process; and

* The move in evaluation was not updated within the first 30 days.

In an interview with Staff 2 (Health Services Director) on 06/14/22 at 12:50 pm, she stated that the previous RCC was in charge of the new move-in evaluations as well as a 30-day update.

The move-in evaluation and the need to complete all required components was reviewed with Staff 1 (Administrator) and Staff 2 on 06/15/22. They acknowledged the findings.

2. Resident 4's quarterly evaluation had not been completed since 11/12/2020.

In an interview with Staff 1 (Administrator) on 06/14/22 at 1:00 pm, she acknowledged that the facility was behind in completing quarterly evaluations.

The need to complete timely, quarterly evaluations was discussed with Staff 1 and Staff 2 (Health Services Director) on 06/15/22. They acknowledged the findings.

1. Evaluation Move-in Form has been completed in its entirety.

2. A Nurse will now be required to review and sign off that the Evaluation Move-in form, done by the RSD, is complete.

3. Each time that a resident is evaluated.

4. Adminstrator and Facility Nurse to ensure compliance.

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 (# 9) whose new move-in evaluation was reviewed and failed to complete quarterly evaluations for 2 of 3 sampled residents (#s 2 and 8), whose evaluations were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 2's clinical record contained an evaluation completed on 04/06/21. The next quarterly evaluation would have been due on 07/06/21. There was no documented evidence of any evaluation completed after 04/06/21.

The need to ensure a quarterly evaluation was completed timely was discussed with Staff 18 (Administrator), Staff 19 (Health Services Director) and Staff 20 (RN) on 10/20/22. They acknowledged the findings.

2. Resident 8's clinical record contained an evaluation completed on 01/16/19. The next quarterly evaluation would have been due on 04/16/19. There was no documented evidence of any evaluation completed after 01/16/19.

The need to ensure a quarterly evaluation was completed timely was discussed with Staff 18 (Administrator), Staff 19 (Health Services Director) and Staff 20 (RN) on 10/20/22. They acknowledged the findings.

3. Resident 9's move-in evaluation, dated 09/26/22, lacked information regarding the following required elements:

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

* Housekeeping and laundry;

* List of treatments;

* Complex medication regimen;

* Recent losses;

* Unsuccessful prior placements;

* Elopement risk or history; and

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

The move-in evaluation was reviewed with Staff 18 (Administrator), Staff 19 (Health Services Director) and Staff 20 (RN) on 10/20/22. They acknowledged the findings.

1. Evaluation Move-in Form has been completed in its entirety.

2. The nurse and the RSD will be responsible to perform evaluations together to ensure both care and medical pieces are accuratley captured.

3. Each time that a resident is evaluated.

4. Adminstrator and Facility Nurse to ensure compliance.

2. Resident 2 was admitted to the facility in 01/2021 with diagnoses including chronic obstructive pulmonary disease. The resident's 06/06/21 service plan and temporary service plans were reviewed and were not reflective of the resident's needs and lacked clear direction to staff in the following area:

* Oxygen use including risks of smoking while using oxygen and safety protocols.

The facility failed to update the resident's service plan quarterly.

The need to ensure service plans were reflective of resident's needs, provided clear instruction to staff and were updated quarterly was discussed with Staff 1 (Administrator) and Staff 2 (Health Services Director) on 06/15/22. They acknowledged the findings.

3. Resident 6 was admitted to the facility in 04/2021 with diagnoses including dementia and chronic obstructive pulmonary disease. The resident's 07/13/21 service plan and temporary service plans were reviewed and were not reflective of the resident's needs and lacked clear direction to staff in the following areas:

* Oxygen use;

* Dental status;

* Risks associated with side rail use; and

* Mobility aids.

The facility failed to update the resident's service plan quarterly.

The need to ensure service plans were reflective of resident's needs, provided clear instruction to staff and were updated quarterly was discussed with Staff 1 (Administrator) and Staff 2 (Health Services Director) on 06/15/22. They acknowledged the findings.

4. Resident 3 was admitted to the facility in 07/2017 with diagnoses including Bipolar Type I Disorder, depression and malnutrition.

Review of the most current service plan dated 07/29/21 and observations and interviews conducted between 06/13/22 and 06/15/22, revealed Resident 3's service plan was not reflective, did not provide clear instruction to staff, and/or was not followed in the following areas:  

* Housekeeping;

* Cognition / Memory;

* Emergency evacuation ability;

* Remind to Meals / Dining Room / Weight Loss;

* Social Activity;

* ADLs - Shower / Hygiene / Dressing;

* Assistive Devices;

* Falls / ER Visits;

* Skin;

* Mental health issues / Behaviors; and

* Diabetes.

The need to ensure service plans were reflective of the identified needs and preferences of the resident, provided clear direction to staff regarding delivery of services, were followed by staff and were updated quarterly was discussed with Staff 1 (Administrator) and Staff 2 (Health Services Director) on 06/14/22 at 11:17 am. They acknowledged the findings.

5. Review of Resident 4's most current service plan dated 11/12/20, observations and interview with staff between 06/13/22 and 06/15/22 revealed the resident's service plan was not current, reflective of the resident's status and lacked clear instructions to staff in the following areas:

* Use of gait belt when ambulating;

* Wheelchair use as a mobility device; and

* Routine toileting assistance.

The need to ensure service plans were updated quarterly, reflective of current care needs and included clear direction to staff was discussed with Staff 1 (Administrator) and Staff 2 (Health Services Director) on 06/15/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were updated quarterly, reflective of residents' current status and care needs and provided clear instruction to staff for 5 of 6 sampled residents (#s 1, 2, 3, 4 and 6). Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 09/2015 with diagnoses including primary cerebellar degeneration and cerebellar ataxia.

Resident 1's current service plan, dated 04/12/21, and temporary service plans dated 04/27/22 through 06/02/22, failed to reflect the resident's care needs and lacked specific instruction to staff in the following areas:

* Bedbound status;

* Use of heel suspension boots;

* Fully dependent with all ADLs;

* Alcohol use;

* Wound care;

* Pain management, including medicating before wound care;

* Frequency and method of repositioning;

* Correct use and precautions related to side rail use; and

* Assistance needed with meals.

The need to ensure service plans were reflective of the resident's current care needs, updated with changes and provided clear direction to staff was discussed with Staff 1 (Administrator) and Staff 2 (Health Services Director) on 06/15/22. They acknowledged the findings.

1. All Service Plans have been updated to reflect residents' current needs.

2.  The interdisciplinary team consisting of ADM, RN, & RSD will meet no less than once per week to go over the on-going needs and service planning of  residents.  RSD will have checklist addressing all areas of concern to ensure that it is reflected accurately on the service plan.  RSD to collaborate with RN to ensure all care and health needs are accurate reflection of residents needs.  Service plan to include full instructions as necessary to communicate to the staff what they need to know in order to best care for the residents.  Through organization of time, duties and consistent communication as outlined above.

3. Evaluation will occur on a monthly basis.

4. Administrator to ensure compliance.

2. Resident 2 was admitted to the facility in 01/2020 with diagnoses including chronic obstructive pulmonary disease.

The resident's most recent service plan was dated 04/06/21. The next service plan review would have been due on 07/06/21. There was no documented evidence of a service plan review with updates made after 04/06/21.

The need to ensure service plans were reviewed and updated at least quarterly was discussed with Staff 18 (Administrator), Staff 19 (Health Services Director) and Staff 20 (RN) on 10/20/22. They acknowledged the findings.

3. Resident 8 was admitted to the facility 01/2019 with diagnoses including dementia.

Review of the resident's most recent service plan, dated 08/31/22 revealed it was not reflective of his/her most current needs regarding diet texture. The service plan noted the resident was to receive a pureed diet. Review of the resident's clinical record revealed a 06/15/22 physician's order which instructed facility staff to offer him/her a mechanical soft diet.

The need to ensure service plans were reflective of residents' current needs was discussed with Staff 18 (Administrator), Staff 19 (Health Services Director) and Staff 20 (RN) on 10/20/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were updated quarterly, reflective of residents' current status and care needs and provided clear instruction to staff for 3 of 4 sampled residents (#s 2, 7 and 8) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 7 was admitted to the facility in 07/2021 with diagnoses including adult failure to thrive, Alzheimer's dementia with behavioral disturbance, and a closed wedge compression fracture of the T10 vertebrae.

Resident 7's current service plan, dated 07/06/21, and temporary service plans dated 10/13/22, failed to reflect the resident's care needs and lacked specific instruction to staff in the following areas:

* Visual impairment; and

* Oral status.

Interview with Staff 21 (Resident Care Coordinator) on 10/20/22 revealed the quarterly service plans had not been completed for Resident 7.

The need to ensure service plans were reflective of the resident's current care needs, updated quarterly with changes and provided clear direction to staff was discussed with Staff 18 (Administrator) and Staff 19 (Health Services Director) on 10/20/22. They acknowledged the findings.

All care conferences are on the schedule to be updated.

2. The interdisciplinary team consisting of ADM, RN, & RSD will meet no less than once per week to go over the on-going needs and service planning of residents. RSD will have checklist addressing all areas of concern to ensure that it is reflected accurately on the service plan. RSD to collaborate with RN to ensure all care and health needs are accurate reflection of residents needs. Service plan to include full instructions as necessary to communicate to the staff what they need to know in order to best care for the residents. Through organization of time, duties and consistent communication as outlined above.

3.Evaluation will occur on a monthly basis.

4.Administrator to ensure compliance

Based on interview and record review, it was determined the facility failed to ensure residents who had changes of condition were evaluated, resident-specific instructions or interventions developed, and the condition monitored, for 1 of 1 sampled resident (# 3) who experienced a resident to resident altercation. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 2017 with diagnoses including depression.

An incident report dated 06/04/22 noted a non-sampled resident approached Resident 3 and made "...unwanted sexual advances..." and touched the resident's knee.

A temporary service plan dated 06/04/22 noted the resident felt safe in the community and would use the call pendant if assistance was needed to alert staff.

There was no documented evidence the facility determined or documented actions or interventions needed for the resident nor was the change of condition monitored through resolution.

The change of condition and lack of subsequent monitoring was reviewed with Staff 1 (Administrator) and Staff 2 (Health Services Director) on 06/14/22 at 11:50 am. Staff acknowledged the findings.

1. RN has assessed Resident 3.  RN and RSD have updated the service plan and documented interventions.

2. Nursing has developed a system using a spreadsheet to monitor short and long term change of condition.

3. Evaluation to occur monthly.

4.  Administrator to ensure compliance.

Based on observation, interview and record review, it was determined the facility failed to ensure residents who had short-term changes of condition were evaluated, resident-specific instructions or interventions were developed and the condition was monitored through resolution for 3 of 4 sampled residents (#s 2, 7 and 8) who experienced changes of condition. This is a repeat citation. Findings include, but are not limited to:

1. Resident 7 was admitted to the facility in 07/2021 with diagnoses including dementia.  

Interviews with staff and review of the resident's 07/06/21 service plan, temporary service plan dated 10/13/22 and progress notes dated 09/21/22 through 10/17/22 were reviewed.

On 10/02/22, Resident 7 was noted to complain of severe pain from a previous fall and requested to be sent to the emergency department. On 10/03/22, it was noted the resident had been admitted to the hospital and diagnosed with a UTI.

On 10/05/22, Resident 7 was placed on alert charting related to returning from the hospital.  

A pain assessment dated 10/05/22 noted the resident's pain was "less than daily" was "excruciating" occurred throughout the day and there were "many" possible causes or related conditions.

There was no documented evidence actions or interventions were developed and communicated to staff related to Resident 7's pain nor were there instructions to staff related to monitoring for signs and symptoms of a UTI.  

During an interview on 10/19/22 at 11:35 am Resident 7 was observed to be sitting comfortably in his/her wheelchair with no indication s/he was in pain. When Resident 7 was asked whether or not his/her pain was managed well, s/he stated it had been.

Resident 7's change of condition and lack of actions or interventions developed and communicated to staff was discussed with Staff 18 (Administrator) and Staff 19 (Health Services Director). No additional information was provided.

2. Resident 2 was admitted to the facility in 01/2019 with diagnoses including chronic obstructive pulmonary disease.

Review of Resident 2's records revealed s/he complained of shortness of breath on 08/16/22.

The facility lacked documented evidence interventions were determined, implemented, communicated to staff on each shift and made part of the Resident 2's  permanent record for the resident's shortness of breath.

In 10/19/22 interviews with Staff 19 (Health Services Director) and Staff 21 (RCC) they confirmed the facility's failure to document what interventions were determined, implemented and communicated to staff on each shift regarding Resident 2's shortness of breath.

The requirement to provide written communication of the change of condition, and interventions to care staff on each shift, was discussed with Staff 18 (Administrator), Staff 19 and Staff 21 on 10/20/22. They confirmed the findings.

3. Resident 8 was admitted to the facility in 01/2019 with swallowing difficulties due to a diagnosis of benign neoplasm of parotid gland.

The resident's 11/07/18 prior to move-in evaluation, 08/31/22 service plan, 2022 weight records and 10/01/22 through 10/19/22 MAR were reviewed and revealed Resident 2 was noted to be at risk for weight loss.  

The resident's MAR included instruction for staff to weigh the resident every two weeks. The instruction was discontinued on 10/06/22.

Review of the resident's weight record revealed the facility last recorded his/her weight on 07/14/22.

In a 10/20/22 interview with Staff 19 (Health Services Director), she stated she was unsure as to why the instruction to record Resident 2's weight was discontinued, and reported it must have been accidental.

There was no documented evidence the facility monitored the resident for his/her risk of weight loss.

The need to ensure Resident 2's risk for weight loss was monitored consistent with his/her evaluated need and service plan was discussed with Staff 18 (Administrator), Staff 19 and Staff 21 (RCC) on 10/20/22. They acknowledged the findings.

1. RN has assessed and implemented and communicated all interventions as well as updating the service plan.

2.Nursing reviews daily at stand up to monitor and follow up

3. Evaluation to do monthly

4. Administrator to ensure compliance

3. Resident 12 was admitted to the facility in November 2019 with diagnoses including chronic pain and diabetes.

Resident 12's progress notes and temporary service plans between 12/29/22 and the time of the survey 02/21/23 were reviewed and noted the following:

* New routine medication: staff directed to chart any signs and symptoms of adverse reactions;

* Rash on left breast: instructions to staff were to treat as ordered;

* Left arm and left side of neck rash: instructions to staff were to treat as ordered; and

* Rash on neck without instructions or directions to staff.

A progress note dated 02/21/23 by the facility RN noted a "chronic red, yeasty rash under [his/her] left breast [due to] sweat..."

During interviews with caregiving staff on 02/21/23 and 02/22/23 they stated the resident currently had a rash under the left breast that was being treated with barrier cream that was kept in the resident's apartment.

Resident 12 had short term changes of condition and the facility failed to determine and document resident specific actions or interventions to staff related to describing what adverse reactions were, and identifying the treatment for the skin.

The changes of condition and lack of resident specific interventions was discussed with Staff 19 (Administrator/RN) on 02/22/23.  No additional information was provided.

2. Resident 6 was admitted to the facility in April 2021 with diagnoses including chronic obstructive pulmonary disease and dementia. The resident was noted to be at risk for falls.  

Review of the resident's 12/04/22 through 02/21/23 progress notes revealed the resident experienced the following changes of condition:

* 12/04/22 - Medication change, increase Namenda (for dementia) to 10 mg twice daily;

* 12/22/22 - Fall with pain to both knees;

* 12/30/22 - Emergency room visit and medication change, begin prednisone (for chronic obstructive pulmonary disease) 60 mg daily;

* 01/02/23 - Sores to both buttocks;

* 02/04/23 - Fall with bruises to lower extremities; and

* 02/05/23 - Coffee spill with burns to lower left abdomen.

The facility failed to show documented evidence resident specific interventions were developed and communicated to staff on all shifts for Resident 6's falls and burns. In addition, the resident was not monitored with progress noted at least weekly through resolution regarding the falls, emergency room visit, med changes and sores to both buttocks.

Short-term changes of condition and monitoring was discussed with Staff 19 (Administrator/RN) on 02/22/23. She acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure short term changes were evaluated, resident specific interventions were developed, communicated to staff on each shift and reviewed for effectiveness related to falls, skin issues and medication changes for 4 of 4 sampled residents (#s 6, 12, 13 and 14) whose records were reviewed. Resident 13 continued to experience injury and non-injury falls. This is a repeat citation. Findings include, but are not limited to:

1. Resident 13 was admitted to the facility in March 2019 with diagnoses including COPD (chronic obstructive pulmonary disease) and diabetes.

The resident's 12/02/22 service plan identified Resident 13 as a high fall risk and had fall interventions including encourage no-skid socks, keep walker within reach, encourage resident to wear call pendant at all times, encourage resident to keep floor free of debris and assist resident in picking items off the floor.

A review of the resident's progress notes indicated the resident had fallen four times between 12/05/22 and 02/21/23. The following incidents were documented:

*  12/05/22 - Resident had a fall with injury, hit back of head and split head;

*  12/27/22 - Resident called care staff and was found on floor next to chair in his/her kitchen;

*  01/07/23 - Resident had a fall resulting in bruise to back of head and tailbone; and

*  02/21/23 - Resident had a fall hitting his/her head and a skin tear to arm.

During an observation on 02/22/23, Resident 13's apartment was noted to be cluttered on the counters and pathways near the sofa.

In a 02/22/23 interview with Staff 35 (CG), she stated that Resident 13 was very resistant to having staff clean his/her unit or throw anything away.

There was no documented evidence the facility reviewed service planned interventions in place at the time of each fall to determine if they had been implemented and/or continued to be effective. There was also no documented evidence new actions or resident specific interventions were determined and/or implemented after each fall and communicated to staff.  Resident 13 continued to experience injury falls.

The need to ensure existing service planned interventions were reviewed to determine if they were in place and/or continued to be effective after each fall, or if new actions or resident specific interventions were determined and/or implemented and communicated to staff for Resident 13's falls was discussed with Staff 19 (Administrator/RN) on 02/23/23. She acknowledged the findings.

4.  Resident 14 was admitted to the facility November 2022 with diagnoses including type 2 diabetes, below knee amputation, and rhabdomyolysis.

The resident's 12/04/22 through 02/21/23 clinical records, including progress notes and service plan, were reviewed.

Medication changes were documented in Temporary Service Plans (TSPs) as follows:

* 12/14/22 Lisinopril;

* 12/27/22 Insulin increased;

* 01/04/23 Increase insulin; 28 units of Glargine; 20 units of lispro;

* 01/18/23 Basaglar increase 30u BID; Admelog increase 22u TID; and

* 02/01/23 Insulin Glargine increase from 32u to 35 units; plus new med Atorvastatin.

The TSPs were initiated but lacked actions or interventions needed for the resident related to medication changes.

In an interview with Staff 30 (MT) on 02/22/23 she reported that if a TSP didn't state what to monitor, she would ask the nurse.

There was no documented evidence in the resident's record the facility had determined resident specific staff interventions for the short term changes of condition.

The need to ensure the facility determined resident-specific interventions and communicated them to staff on all shifts for short term changes of conditions was discussed with Staff 19 (Administrator/RN) on 02/22/23. She acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to conduct an RN assessment that included findings, resident status and interventions made as a result for 1 of 1 sampled resident (# 3) who experienced a significant change of condition related to weight fluctuations. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 2017 with diagnoses including depression, malnutrition and heart failure.

Resident 3's weight records noted the following:

*03/16/22 119 pounds;

*03/30/22 125.8 pounds;

*04/27/22 123.6 pounds;

*05/11/22 126.4 pounds; and

*06/08/22 118.4 pounds.

Between 03/16 and 03/30/22 Resident 3 gained 6.8 pounds or 5.4% of his/her body weight in one month. Between 05/11 and 06/08/22 the resident lost 8 pounds or 6.3% of his/her body weight in one month. Resident 3 experienced a significant change of condition related to weight fluctuations.

The surveyor requested Resident 3's weight during survey and was noted to be 121.6 pounds a 3.2 pound weight gain from the previous weight.

Review of the current physician orders and 06/01 through 06/13/22 MAR noted the resident had an order for mechanical soft diet texture and received a nutritional supplement three times a day.

Resident 3 was observed during two meals. Resident 3 received a regular textured chicken breast for lunch on 06/14/22 and a regular textured sausage link for breakfast on 06/15/22.

Resident 3 experienced a significant change of condition related to weight fluctuations and there was no documented evidence an RN assessment was completed to include findings, resident status nor review of interventions in place. The weight fluctuations were discussed with Staff 1 (Administrator) and Staff 2 (Health Services Director) on 06/14/22. Staff acknowledged the findings.

1. The RN has assessed Resident 3 for significant change of condition related to weight loss and has reviewed and signed the service plan for the resident.

2. A program of enhanced coordination of care, including participation of the RN in all weekly clinical meetings and follow-up with entries in the communication logs, has been implemented so that any significant change of condition receives immediate RN notification and interventions are implemented in a timely manner.

3. Resident assessments occur quarterly, unless otherwise indicated through daily review of communication system with care staff and med techs.

4.  Administrator to ensure compliance.

Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules, for 1 of 1 sampled resident (# 9) who received insulin injections by unlicensed facility staff. Findings include, but are not limited to:

During the acuity interview on 10/19/22, Resident 9 was identified to be administered insulin injections by non-licensed staff.

Initial delegation records for Staff 24, 27, 30 and 31 (MAs), reviewed on 10/20/22, lacked documentation in the following areas:

* An RN assessment of the resident's condition;

* Rationale that the task could be safely delegated to the CG;

* Rationale for how frequently the client should be reassessed by the RN; and

* Rationale for how frequently the unlicensed person(s) should be supervised and reevaluated based on the competency of the caregiver.

A plan to address the delegation of Resident 9 was requested from the facility on 10/20/22. Staff 19 (Health Services Director) submitted the plan to the survey team on 10/20/22 at 1:40 pm.

The need to ensure all staff who administered insulin injections were appropriately delegated in accordance with OSBN Division 47 Rules was discussed with Staff 18 (Administrator), Staff 19 and Staff 20 (RN) on 10/20/22 at 2:15 pm. They acknowledged the findings.

1. RN has completed and updated all necessary delegations.

2. Upon move in and quarterly review the delegations will be scheduled accordingly.

3. Monthly

4. RN and Administrator  

Based on observation and interview, it was determined the facility failed to ensure it  complied with masking requirements as prescribed in OAR 333-019-1011. Findings include, but are not limited to:

Per Oregon Administrative Rule 333-019-1011(6), (8) and (10), persons employed in an assisted living or residential care facility are required to wear  medical grade face masks while in the facility except when the employee is alone in a closed room.

Observations made in the kitchen and the nursing charting area during the survey revealed multiple staff failed to wear a medical grade face mask while in the facility.

The observations and the need to ensure staff wore medical grade face masks while in the facility was reviewed with Staff 19 (Administrator/RN) on 02/22/23. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances for 1 of 1 sampled resident (#1) whose MAR and Controlled Substance Disposition log were reviewed for accuracy. Findings include, but are not limited to:

Resident 1 was prescribed oxycodone 20 mg/ml concentrated liquid 0.25 ml (0.5 mg) by mouth every 4 hours as needed for pain, shortness of breath or distress as an end of life comfort measure. The following discrepancies were noted:

* Observation of the medication bottle with Staff 7 (MT) indicated 17 ml was remaining. The Controlled Substance Disposition log indicated 21.5 ml was remaining.

* Oxycodone administered 06/01/22 at 3:36 pm and 06/02/22 at 4:07 pm per the MAR were not documented on the Controlled Substance Disposition log.

* Oxycodone was administered 06/07/22 at 1:39 pm and 1:54 pm per the MAR. The Controlled Substance Disposition log had one entry on 06/07/22 at 1:49 pm.

The need to ensure narcotic disposition logs and MARs were accurate and that a system was in place for accurately tracking controlled substances was discussed with Staff 1 (Administrator) and Staff 2 (Health Services Director) on 06/15/22. They acknowledged the findings.

1. RN corrected the Controlled Substance Disposition Log to match actual amount remaining in the bottle; she also corrected the Log to match the MAR for 6/1/22 and 6/2/22; last, she corrected the Log to match the MAR administration for 6/7/22.   

2. Review with all med techs proper procedure for dispensing and recording of narcotics, and monitor to ensure compliance.

3. RN to review Controlled Substance Disposition Log weekly.

4. Administrator to ensure compliance.

Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 2 of 2 sampled residents (#s 7 and 11) whose MARs and Controlled Substance Disposition logs were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 11 was admitted to the facility in 07/2021 with diagnoses including osteoporosis.  

Review of the 10/01/22 through 10/20/22 MAR and the resident's Controlled Substance Disposition logs were reviewed and noted the following:

The 10/01/22 through 10/20/22 MAR and the resident's Controlled Substance Disposition logs were reviewed and noted the following:

* Oxycodone (a narcotic pain medication) 5 mg tablets, PRN, every four hours;

* On 10/17/22 at 12:00 pm and 9:00 pm, and on 10/18/22 at 12:00 pm, 4:00 pm, and 8:00 pm, 5 mg of Oxycodone was administered but not recorded on the MAR.

Comparison of the medication bubble pack to the disposition logs, showed the amount of medication left was reflected accurately on the log.

The need to ensure narcotic disposition logs accurately reflected the medications administered was discussed with Staff 18 (Administrator) and Staff 19 (Health Services Director) on 10/20/22. Staff verified the findings and acknowledged additional investigation needed to be completed.

2. Resident 7 was admitted to the facility in 07/2021 with diagnoses including a closed wedge compression fracture of the T10 vertebrae.   

Review of the 10/01/22 through 10/20/22 MAR and the resident's Controlled Substance Disposition log was reviewed and noted the following:

* Tramadol (narcotic pain medication) 50 mg every six hours by mouth as needed for pain;

* On 10/16/22 (no time indicated) and 10/18/22 at 4:00 pm 50 mg of tramadol was administered but not recorded on the MAR.

Comparison of the medication bubble pack to the disposition logs, showed the amount of medication left was reflected accurately on the log.

The need to ensure narcotic disposition logs accurately reflected the medications administered was discussed with Staff 18 (Administrator) and Staff 19 (Health Services Director) on 10/20/22. Staff verified the findings and acknowledged additional investigation needed to be completed.

1.RN audited Narcotic logs and emar to reconcile any discrepencies

2. Review, counsel and instrcut all med techs appropraite procedure fro dispensing and recording narcotics.

3. RN to audit weekly

4. Administrator to ensure compliance

Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 1 of 1 sampled resident (#11) whose MAR and Controlled Substance Disposition Log were reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 11 was admitted to the facility in July 2021 with diagnoses including osteoporosis.

Resident 11 had an order for oxycodone 5 mg tab every four hours as needed for pain.

The Controlled Substance Disposition Log and MAR reviewed from 02/01/23 through 02/20/23 revealed staff signed the drug disposition log that the medication was given up to five times a day. However, the MAR lacked documented evidence the resident received the medication up to five times a day.

Comparison of the medication bottle to the disposition logs showed the amount of medication left was reflected accurately on the log.

The need to ensure accurate tracking of controlled substances was discussed with Staff 19 (Administrator/RN) and Staff 27 (Nurse Assistant) on 02/22/23. Staff verified and acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 1 of 5 sampled residents (# 3) whose orders were reviewed. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 07/2017 with diagnoses including malnutrition.

The most current physician orders dated 07/13/21 and the most current service plan dated 07/29/21 indicated Resident 3's diet was mechanical soft with extra gravy.

Resident 3 was observed during two meals. Resident 3 received a regular textured chicken breast for lunch on 06/14/22 and a regular textured sausage link for breakfast on 06/15/22. This surveyor requested Resident 3 receive mechanical soft meals.

During interviews on 06/14/22, Staff 11 (CG) and Staff 4 (Dietary Manager) reported that they were unaware that Resident 3 required mechanical soft textures.

The need to ensure physician orders were carried out as prescribed was discussed with Staff 1 (Administrator) and Staff 2 (Health Services Director) on 06/15/22 at 10:20 am. They acknowledged the findings.

1. Care plan was updated to reflect Mechanical Soft Diet. Dietary Manager notified of Mechanical Soft Diet, as were the rest of the Kitchen staff, and the Care Staff.

2. List posted in Kitchen showing all residents' diet orders:  all Kitchen staff made aware of the List's existence and location.

3. Monthly, and as needed if physician changes the diet order for any resident.

4. Dietary Manager, RN, RSD, and Administrator to ensure compliance.

Based on interview and record review, it was determined the facility failed to ensure signed physician's orders were in place for all medications and treatments administered to the residents for 1 of 2 sampled residents (# 9) whose MARs were reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 9 was admitted to the facility in 09/2022 with diagnoses including respiratory failure.

The resident's 10/01/22 through 10/19/22 MARs and physician's orders were reviewed.  

There was no documented evidence of a physician's order in the resident's medical chart for oxygen 1.5-2 LPM (Liters Per Minute) via nose cannula to maintain oxygen saturation above 92%.

Resident 9 had an order for Metoprolol Tartrate 25 mg (an immediate release medication for blood pressure) but was being given Metoprolol Succinate 25 mg (an extended release medication for blood pressure).

The need to ensure signed physician's orders were in place and followed for all medications or treatments was discussed with Staff 18 (Administrator), Staff 19 (Health Services Director) and Staff 20 (RN) on 10/20/22. They acknowledged the findings.

1. All physican orders have been audited and updated.

2.A new team member has been designated to ensure all physician orders will be accurately reflected in the emar and  carried out accordingly.

3.Monthly Audits

4.RN and Admin  

Based on observation, interview and record review, it was determined the facility failed to ensure written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record for all medications and treatments that the facility was responsible for administering for 2 of 5 sampled residents (#s 6 and 11) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 6 was admitted to the facility in 2021 with diagnoses including chronic obstructive pulmonary disease and dementia. The resident was noted to have skin breakdown on his/her perineal area.

A review of the resident's records, including 01/2023 and 02/01/23 through 02/21/23 MARs, physician's orders dated 02/08/23, and observation of the resident identified the following:

The resident's 02/01/23 through 02/21/23 MAR noted the following orders:

* Oxygen (for chronic obstructive pulmonary disease) via nasal cannula with continuous oxygen at two liters per minute;

* Vitamin B complex (a supplement) one tablet daily; and

* Calmoseptine ointment (for coccyx wound) one gram topically to coccyx redness/wound three times daily, routinely until coccyx wound resolved and for one week afterwards, then change to three times daily PRN for perineal area redness.

Observations made of the resident on 02/21/23 and 02/22/23 found him/her utilizing an oxygen concentrator with the oxygen level set at two liters per minute.

The 02/03/23 signed physician's orders lacked orders for the oxygen, vitamin B complex and Calmoseptine ointment.

During an interview on 02/22/23, Staff 27 (Nurse Assistant) confirmed the lack of orders for the oxygen, vitamin B and Calmoseptine ointment.

The need to ensure written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record for all medications and treatments that the facility was responsible for administering was reviewed with Staff 19 (Administrator/RN) on 02/22/23. She acknowledged the findings.

2. Resident 11 was admitted to the facility in 03/2022 with diagnoses including hypertension and congestive heart failure.

The resident's 02/01/23 through 02/21/23 MARs and physician's orders were reviewed and the following medications lacked documented evidence of a signed physician's order:

* Nitrostat (for chest pain), 0.4 mg tablet PRN; and

* Carvedilol (for hypertension), 6.25 mg tablets.

During an interview on 02/21/23, Staff 27 (Nurse Assistant) confirmed the lack of signed orders for Nitrostat and carvedilol.

The need to ensure signed physician or other legally recognized practitioner orders were documented in the resident's facility record for all medications was discussed with Staff 19 (Administrator/RN) on 02/22/23. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused consent to an order, for 1 of 2 sampled residents (#13) who had documented medication or treatment refusals. Findings include, but are not limited to:

Resident 13 had current physician orders for:

* Ketoconazole cream (used to treat skin conditions) to be applied two times a day;

* Triamcinolone acetonide cream (used to treat skin conditions) to be applied one time a day; and

* Proair HFA (an inhaler) to be used four times a day.

Resident 13's MARs were reviewed from 02/01/23 through 02/21/23. Staff documented the resident refused the ketoconazole cream on 10 occasions, the triamcinolone cream five times, and the Proair inhaler 11 times during the time period reviewed.

There was no documented evidence the facility consistently notified the physician or practitioner when Resident 13 refused to consent to their order.

The need to ensure the facility notified physicians or practitioners of medication or treatment refusals was reviewed with Staff 19 (Administrator/RN) on 02/22/23. She acknowledged the findings.

2. Resident 7 was admitted to the facility 07/2021 with diagnoses including a closed wedge compression fracture of the T10 vertebrae.

Resident 7's 10/01/22 through 10/20/22 MAR was reviewed and identified the following:   

*Resident 7 had PRN pain medications including Tylenol and tramadol without clear parameters regarding what medication to administer first.

In an interview on 10/19/22, Staff 27 (MA) reviewed the resident's MAR. She confirmed the multiple PRN pain medications did not have resident specific instructions for staff as to which to administer first.  

The need to ensure the MAR included medication specific instruction and parameters for PRN medications was discussed with Staff 19 (Health Services Director) on 10/20/22. She acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure MARs were accurate, included specific instructions for PRN medications, and contained reasons for use for 2 of 2 sampled residents (#s 7 and 9) whose medications were reviewed. Findings include, but are not limited to:

1. Resident 9's 10/01/22 through 10/19/22 MAR was reviewed and identified the following:

a. Medications that lacked a reason for use:

* Aspirin;

* Atorvastatin calcium;

* Basaglar;

* Docusate sodium;

* Famotide;

* Gabapentin;

* Metolazone'

* Metoprolol Succinate;

* Potassium chloride;

* Torsemide;

* Vitamins B12, C 500 and D; and

* Zinc.

b. On 52 occasions between 10/01/22 and 10/19/22 staff documented multiple medications were "waiting on med delivery."

In an interview with Staff 19 (Health Services Director) on 10/20/22 at 9:30 am, staff were administering these medications to Resident 9 using house stock.

The need to ensure accurate MARs including documentation and reasons for use was discussed with Staff 18 (Administrator), Staff 19 and Staff 20 (RN) on 10/20/22. They acknowledged the findings.  

1. Full audit and review of the emar to ensure all parameters and diagnosis with documented reason for use  completed.

2.Updated written guidelines and teaching for med techs to follow to ensure all necessary information is documented in the emar to ensure proper parameters are in place as well as diagnosis, and PRN use guidelines.

3. RN to review daily as needed when reviewing medciations on all new orders.

4. RN and Admin   

Based on interview and record review, it was determined the Administrator failed to show documented evidence of a current Residential Care Facility Administrator license. Findings include, but are not limited to:

On 06/13/22, Staff 1 (Administrator) was asked to provide documentation of her Residential Care Facility Administrator license. Staff 1 revealed her license had expired.

The requirement to have a current Residential Care Facility Administrator was discussed with Staff 1 on 06/15/22. She acknowledged the findings.

1. Assumption Village will have a licensed Administrator by August 14, 2022

2. Facility will have a licensed Administrator on staff permanently.

3. Once, and to remain in compliance with any future rule changes.

4. CEO and Administrator to ensure compliance.

Based on interview and record review, it was determined the facility failed to implement an Acuity-Based Staff Tool (ABST) by July 1, 2022 to determine appropriate staffing levels for the facility. Findings include, but are not limited to:

On 02/22/23, Staff 19 (Administrator/RN) was asked to provide evidence the facility had implemented an ABST to determine appropriate staffing levels for the facility. Staff 19 acknowledged the facility had not implemented an ABST.

The need to ensure the facility implemented an ABST was reviewed with Staff 19 on 02/22/23 at 3:17 pm. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure pre-service dementia care training had been completed, with certification, prior to staff providing direct care to residents for 3 of 3 newly-hired direct care staff (#s 13, 14 and 17). Findings include, but are not limited to:

The facility's training records were reviewed on 06/14/22.

Staff 13 (CG) hired 03/08/22, Staff 14 (CG) hired 01/04/22, and Staff 17 (MT) hired 03/08/22, lacked documented evidence they had completed the required pre-service dementia training prior to providing direct care to residents.

The need to ensure all newly hired, direct care staff had the required pre-service dementia training prior to providing care to residents was reviewed with Staff 1 (Administrator). She acknowledged the findings.

1. Staff 13, 14, 17 will complete pre-service Dementia Training through Oregon Care Partners.  Moving forward, we will use some or all of the following Training Organizations:  Oregon Care Partners, Leading Age, Alzheimer's Association.

2.  The RSD will meet with each new hire, prior to the new hire's interacting with any residents, to provide them with a website link to the Training package.  The RSD will ensure that the Training has been completed, prior to allowing a new hire to work with residents.

3.  Evaluation will occur monthly.

4.  Administrator to ensure compliance by meeting with the RSD.

Based on interview and record review, it was determined the facility failed to ensure pre-service dementia care training had been completed, with certification, prior to staff providing direct care to residents for 4 of 4 newly-hired direct care staff (#s 22, 23, 25 and 26). This is a repeat citation. Findings include, but are not limited to:

Training records for Staff 22 (CG) hired 08/16/22, Staff 23 (CG) hired 08/16/22, Staff 25 (MA) hired 08/17/22 and Staff 26 (MA) hired 08/31/22, were requested on 10/19/22.

On 10/19/22 at 1:25 pm, Staff 18 (Administrator) stated there was no documented evidence the above staff members had completed the required pre-service dementia training prior to providing direct care to residents.

The need to ensure all newly hired, direct care staff had the required pre-service dementia training prior to providing care to residents was discussed with Staff 18 who acknowledged the findings.

1. Staff have been assigned all areas of training to be completed throug Oregon Care Partners.

2. Staff will not be able to start on the floor training until we have proof of documented completion of all necessary trainings.

3. Osverseeing department to ensure that trainings are completed prior to working.

4. Admin to ensure compliance

Based on interview and record review, it was determined the facility failed to ensure pre-service orientation training and pre-service dementia training had been completed for 1 of 3 newly-hired staff (#37). This is a repeat citation. Findings include, but are not limited to:

Staff training records were reviewed on 02/22/23.

Staff 37 (MT) was hired on 01/06/23.  

a. Staff 37's training records lacked documented evidence of completing orientation training prior to beginning job responsibilities in the following areas:

* Resident rights and values of CBC care;

* Abuse reporting requirements;

* Infectious Disease Prevention;

* Fire safety and emergency procedures; and

* Written job description.

b. Staff 37's training records lacked documented evidence of pre-service dementia training with certification, prior to beginning job responsibilities, in the following areas:

* Dementia disease process including progression of the disease, memory loss and psychiatric and behavioral symptoms;

* Techniques for understanding, communication and responses to distressful behavioral symptoms;

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

* Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food/fluids, preventing wandering, and the use of person-centered approach.  

The training program and requirements were discussed with Staff 19 (Administrator/RN) on 02/22/23. Staff 19 verified the staff member had not completed training prior to initiating job responsibilities.  

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 sampled newly-hired direct care staff (#s 13, 14 and 17) completed abdominal thrust and First Aid training within the required 30 days of hire. Findings include, but are not limited to:

Training records were reviewed with Staff 1 (Administrator) on 06/15/22 and revealed the following:

Training records for Staff 13 (CG) hired 03/08/22, Staff 14 (CG) hired 01/04/22, and Staff 17 (MT) hired 03/08/22, were reviewed on 06/15/22 with Staff 1(Administrator). She confirmed the above mentioned staff did not have abdominal thrust or First Aid training.

The need to ensure newly-hired direct care staff completed abdominal thrust and First aid training within 30 days of hire was reviewed with Staff 1 on 06/15/22. She acknowledged the findings.

1. Staff 13, 14, 17, and all staff will complete Abdominal Thrust and First Aid Training, with the program by American Healthcare Academy, within 30 days of starting work.

2.  RN will provide, to all new staff, a website link to American Healthcare Academy, and let new staff know that the Training must be complete within 30 days; RN will provide the actual date to each new hire, for when the Training must be complete.  Staff that don't complete the Training by the due date, will not be allowed to work.

3.  Monthly evaluation.

4.  Administrator to ensure compliance.

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 sampled newly-hired, direct care staff (#s 22, 23, 25 and 26) completed abdominal thrust and First Aid training within the required 30 days of hire. This is a repeat citation. Findings include, but are not limited to:

Abdominal thrust and First Aid training records for Staff 22 (CG) hired 08/16/22, Staff 23 (CG) hired 08/16/22, Staff 25 (MA) hired 08/17/22 and Staff 26 (MA) hired 08/31/22, were requested on 10/19/22.

On 10/19/22 at 1:25 pm, Staff 18 (Administrator) stated there was no documented evidence the above staff members had completed the required abdominal thrust and First Aid training.  

The need to ensure all newly hired, direct care staff had the required abdominal thrust and First Aid training was discussed with Staff 18 who acknowledged the findings.

1. Staff have been assigned all areas of training to be completed throug Oregon Care Partners.

2. Staff will not be able to start on the floor training until we have proof of documented dementia pre-inservice completion of all necessary trainings.

3. Osverseeing department to ensure that trainings are completed prior to working.

4. Admin to ensure compliance

Based on interview and record review, it was determined the facility failed to ensure 1 of 1 sampled newly-hired direct care staff (#37) completed all required training within 30 days of hire. This is a repeat citation. Findings include, but are not limited to:

Staff training records were reviewed on 02/22/23.  

Staff 37 (MT) was hired on 01/06/23 and failed to have documented evidence of competency demonstrated in all assigned job duties prior to working independently with residents in the following areas:

* Providing assistance with ADLs;

* Changes associated with normal aging;

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

* General food safety, serving and sanitation;

* Other duties as applicable (Med pass); and

* First Aid and abdominal thrust training.

The requirement to have documented demonstrated competency in all assigned job duties prior to working independently with residents was reviewed with Staff 19 (Administrator/RN) on 02/23/23. No additional information was provided.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 sampled newly-hired direct care staff (#s 42, 43, and 45) completed all required training within 30 days of hire. This is a repeat citation. Findings include, but are not limited to:

Staff training records were reviewed on 06/21/23.  

1. Staff 42 (MT) was hired on 04/17/23 and failed to have documented evidence of competency demonstrated in all assigned job duties prior to working independently with residents in the following areas:

* Role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Changes associated with normal aging;

* General food safety, serving and sanitation; and

* First Aid and abdominal thrust training.

2. Staff 43 (CG) hired 05/05/23 and Staff 45 (CG) hired 05/05/23 failed to have documented evidence of completed first aid/abdominal thrust within 30 days of hire.

The requirement to have documented demonstrated competency in all assigned job duties prior to working independently with residents was reviewed with Staff 19 (Administrator/RN) on 06/21/23.

1.

All staff files will be audited to ensure CPR/First Aide is active and current.

All staff within 30 days of hire will have their files audited for CPR/First aide and competency within their job duties.

2.

New hire files will be audited monthly for completion of all required trainings

3.

All new hire files will be audited weekly until compliance met

4.

Administrator or designee

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 long term, direct care staff (#s 7 and 8) completed the minimum 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care setting which included six hours of dementia training. Findings include, but are not limited to:

Facility training records were reviewed on 06/14/22.

Staff 7 (MT) hired on 02/22/17, and Staff 8 (CG) hired on 01/22/16, did not have documented evidence of completing the required 12 hours of annual in-service training.

The need to ensure long-term, direct care staff had 12 hours of annual training which included six hours of dementia training was reviewed with Staff 1 (Administrator) on 06/15/22. She acknowledged the findings.

1.  A training spreadsheet to be made to provide a quick reference for all employees' training hours.  A year's worth of scheduled monthly in-services to be completed and rotated every January hereafter.

2.  The spreadsheet and scheduled meetings will be maintained in an organized fashion to be readily available when requested.  A copy of each training to be given to all employees.  All employees to receive their minimum of 12 hours of continuing education through facility.  This will be evidenced through documentation.  Supervisors to ensure staff member attends the mandatory trainings or to obtain written materials that will require a post-test for information received.

3.  Evaluation will occur monthly.

4.  Administrator to ensure compliance.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 long term, direct care staff (#s 24 and 26) completed the minimum 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care setting which included six hours of dementia training. This is a repeat citation. Findings include, but are not limited to:

Annual in-service training records for Staff 24 (MA) hired on 09/30/21, and Staff 27 (MA) hired on 10/09/15, were requested on 10/19/22.

On 10/19/22 at 1:25 pm, Staff 18 (Administrator) stated there was no documented evidence the above staff members had completed the annual in-service training.

The need to ensure all long term, direct care staff completed the minimum 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care setting which included six hours of dementia training was discussed with Staff 18 who acknowledged the findings.

1. A shared training drive has been created to access all of the employees training files.

2.Through monthly in-servicing and auditing of training records. Employees will be taken off schedule if not complete or up to date on trainings.

3.Monthly auditing and depatment review

4.Administrator to ensure compliance  

Based on interview and record review, it was determined the facility failed to ensure fire and life safety instructions to staff was provide on alternate months and failed to ensure written fire drill records included all required components. Findings include, but are not limited to:

The 12/20/22 through 06/13/22 fire and life safety records were reviewed on 06/14/22.

a. There was no documented evidence staff were receiving fire and life safety instruction on the alternating months of fire drills.  

b. The facility lacked consistent documentation of the required elements:

* Escape routes used;

* Problems encountered, comments relating to resident who resisted or failed to participate in drills;

* Evacuation time-period needed;

* Number of occupants evacuated; and

* Evidence of alternate routes were being used.

On 06/15/22 at 10:20 am, Staff 1 (Administrator) confirmed that the facility was not providing fire life safety instruction to staff every other month and was not relocating or evacuating residents during fire drills.

The need to ensure fire and life safety instruction was provided to staff on alternate months of fire drills and all required components were documented for fire drills was discussed with Staff 1 on 06/15/22. She acknowledged the findings.

1. Regional Maintenance Director will provide Fire & Life SafetyTraining to the entire staff .  When that is complete, we will hold an unannounced Evacuation Fire Drill, where all residents will be evacuated to a safe area.

2. We will conduct unnanounced Evacuation Fire Drills every other month, including reporting the Time to Evacuate building, number of staff participating; also, problems encountered.  We will provide Fire & Life Safety training to all staff every other month, including Escape Routes, Designated Place of Safety.

3. Every 2 months.

4.  Administrator and Regional Maintenance Director to ensure compliance.

Based on interview and record review, it was determined the facility failed to ensure fire drills, which included documented evidence of the required components, were conducted every other month and fire and life safety instruction to staff was provide on alternate months. This is a repeat citation. Findings include, but are not limited to:

The fire and life safety records were requested on 10/19/22.

On 10/19/22 at 12:45 pm, Staff 18 (Administrator) stated there was no documented evidence fire drills had been conducted every other month and fire and life safety training had been provided to staff on alternating months.    

The need to ensure the facility had fire drills every other month and fire and life safety instruction was provided to staff on alternate months of fire drills was discussed with Staff 18 on 10/20/22. She acknowledged the findings.

1. Maintenance department to provide fire life and safety training to all the staff.

2. Fire, life and saftey drills to be conducted every other month in different shifts.

3. It will be evaluated monthly

4. The maintenance director and the Admin

Based on interview and record review, it was determined the facility failed to re-instruct residents, at least annually, in 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. Findings include, but are not limited to:

On 06/15/22 at 10:20 am, Staff 1 (Administrator) confirmed the facility had not been providing annual fire and life safety training to residents.

The need to ensure fire and life safety instruction was provided to residents at least annually was reviewed with Staff 1 who acknowledged the findings.

1.  RSD will provide Fire & Life Safety Training to all residents.  

2. RSD will provide Fire & Life Safety Training within 24 hours of a new admission, to the resident.  RSD will hold annual re-instruction trainings, for all residents.

3. During the quarterly Care Plan Review, each resident will be re-instructed in Fire & Life Safety Training.

4. Administrator to ensure compliance.

Based on interview and record review, it was determined the facility failed to instruct residents within the first 24 hours of admission and re-instruct residents, at least annually, in 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. This is a repeat citation. Findings include, but are not limited to:

The fire and life safety records were requested on 10/19/22.

On 10/19/22 at 12:45 pm, Staff 18 (Administrator) stated there was no documented evidence that residents were instructed within the first 24 hours of admission and re-instructed residents, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills and designated meeting places outside the building or within a fire safe area in the event of an actual fire.

The need to ensure fire and life safety instruction was provided to residents within 24 hours of admission and at least annually was reviewed with Staff 18 who acknowledged the findings.

1. Resident Services Director will provide fire life and safety training to all current resdients.

2. Fire, life and safety training will occur on move in and annually for all residents.

3. Evaluation will occur monthly

4. RSD and Admin

Based on observation, 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 152, C 160, C 231, C 240, C 252, C 260, C 270, C 302, C 303, C 370, C 372, C 374, C 420, C 422, C 610, C 613, C 630 and C 655.  

1. Changing systems and structures of all areas of deficiencies.

2. The systems and structures have their own date of completion and evaluation time periods.

3. Montlhy review

4. Administrator

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

Refer to C152, C231, C240, C270, C302, C303, C370, C372, C610 and C613.  

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. This is a repeat citation. Findings include, but are not limited to:

Refer to C 372.

1.

comply with plan of correction

2.

completed audits for citations to ensure compliance

3.

to be completed daily until compliance met, followed by weekly x4,

monthly x 4 and quarterly

4.

Administrator or designee

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

The facility courtyards and sidewalks were observed on 06/14/22 and the following was identified:

* Drop-offs at approximately three to four inches in height along sidewalks that were not edged with grass around community; and

* The adjoining sidewalks adjacent to community gardens had an uneven surface that created a tripping hazard.  

The need to ensure the exterior pathways and accesses to the facility common use areas was discussed with Staff 1 (Administrator) and Staff 16 (Regional Maintenance Director) on 06/15/22. They acknowledged the findings.

1. Third-party contractor to perform work, to eliminate all sidewalk drop-off on property, as well as uneven sidewalk surfaces adjoining the community garden.

2. Regional Maintenance Director will inspect all sidewalks on property.

3.  Evaluation will occur on a 6-month basis during regular Maintenance Walk-Through Inspections.

4.  Director of Maintenance and Adminstrator to ensure compliance.

2. The facility was toured on 10/19/22 and the following was identified:

* The dumpster lid was open, which potentially could attract rodents and insects;

* The laundry room, room 126, had a sign posted to keep the door locked, it was unlocked and toxic materials were accessible to residents; and

* There was refuse throughout the facility grounds.

The need to ensure the exterior of the building was maintained in a manner to prevent the entry of rodents and insects, toxic materials were not easily accessed by residents and the facility grounds was free of litter was discussed with Staff 18 (Administrator) on 10/19/22. She acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure the exterior pathways and accesses to the facility common use areas were maintained in good repair, garbage was stored in covered refuse containers, chemicals were maintained in a locked storage area and the grounds were kept orderly and free of litter. This is a repeat citation. Findings include, but are not limited to:

1. The facility courtyards and sidewalks were observed on 10/19/22 and the following was identified:

* Drop-offs at approximately three to four inches in height along sidewalks that were not edged with grass around community.

The need to ensure the exterior pathways and accesses to the facility common use areas was discussed with Staff 18 (Administrator) on 10/19/22. She acknowledged the findings.

1. Contracts in place for exterior maintenance and repairs for drop offs and uneven surfaces.

2. Scheduled quartlerly walk through inspections.

3. Quarterly

4. Director of Maintenance and Adminstrator to ensure compliance.  

Based on observation and interview, it was determined the facility failed to ensure the exterior pathways and accesses to the common use areas were maintained in good repair, garbage was stored in covered refuse containers, chemicals were maintained in a locked storage area, and the grounds were kept orderly and free of litter. This is a repeat citation. Findings include, but are not limited to:

The facility grounds and laundry room were toured on 02/21/23 and the following was identified:

* There were drop-offs between three to four inches from the pavement to the planting beds at the corners and along the edges of multiple pathways around the perimeter of the building;

* The left dumpster lid was open, which potentially could attract rodents and insects;

* Laundry room 126, which had a sign posted to keep the door locked, was unlocked and toxic materials were accessible to residents; and

* There was refuse throughout the facility grounds.

The need to ensure exterior pathways and accesses to the common use areas were maintained in good repair, garbage was stored in covered refuse containers, toxic materials were not easily accessed by residents and the facility grounds were free of litter was discussed with Staff 19 (Administrator/RN) on 02/22/23. She acknowledged the findings.

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

Observations of the facility on 06/13/22 through 06/15/22 revealed the following:

a. Facility Wide

* Multiple resident rooms and facility doors had scrapes, gouges, and scuffs;

* Multiple stains on the carpet;  

* Elevator door frames had scuff marks and chipped paint;

* Elevator doors and inside walls had scuff marks; and

* Multiple walls had gouges, scuffs, and scratches.

b. First Floor

* Carpet bulging in hallway in-front of resident room 107, 108, and 106;

* A gouge in left side window seal in Activity Room;

* The bench and couch in lobby had torn fabric;

* In the female public restroom flooring tile was broken; and

* The baseboard next to the female public restroom was not attached to the wall.

c. Laundry Room 126

* The walls throughout the laundry room had splatters and spills;

* The cabinet doors missing laminate on the lower fronts;  

* Inside the cabinet the bottom had gouges and scrapes;

* Countertop front was missing the front laminate surface material;  

* Gouges on wall and corner to the right of the hopper; and

* The baseboard missing on both sides of the wall next to the dryers.

d. Dining Room

* The perimeter of the floor had black matter build-up;

* The pillar next to table 11 had gouges in the wood border and wall;

* Dining room chairs in disrepair, worn backs of chairs and arm rests exposing bare wood. Chair legs had dings and gouges;

* Gouges along wall next to table number five;   

* The vinyl flooring underneath table number five cracked and broken;

* Multiple dining room tables had napkins underneath one leg; and

* The baseboard was separated from wall at entrance next to reception desk and across from Village Cup.   

e. Village Cup

* The wall next to the kitchenette area had a dent; and

* The corners on half wall in and out of the kitchenette had gouges on both sides.

During an Interview with Staff 1 (Administrator) on 06/15/22 at 10:20 am, she stated that "this area is currently closed, but [residents] want it open again." She confirmed the facility had plans to open the area soon.

f. Second Floor

* Chair next to weight scale upstairs leather had been worn off of seat;

* The wall leading to room 281 was gouged and scuffed;

* Chairs in sitting area by laundry room 288 were in disrepair with worn backs and arm rests exposing bare wood. The chair legs had multiple gouges and dents;

* Red and gold chair across from room 206 right arm rest was frayed;

* Corner damage to wall next to room 217 exposing material underneath;

* Laundry room 288 had hole in flooring measuring approximately one and a half inches by three inches; and

* Exposed hole in ceiling by resident rooms 278 and 276 measuring approximately 19 inches in length.

g. Exterior of building

* Multiple lights were damaged along walkways; and

* Multiple garden boxes were coming apart, wood splintered and pulling apart.

The need to ensure the interior building was clean and maintained in good repair was discussed with Staff 1 and Staff 16 (Regional Maintenance Director) on 06/15/22 at 12:00 pm. They acknowledged the findings.

1. We have contracts for the following:  Repair/repaint interior of building; Repair/replace flooring; and Replace carpet.  Lobby sofa will be repaired or replaced.  Worn chairs in Second Floor sitting areas will be removed.  For Dining Room tables, Table Wedges will be ordered.  Exterior lights, cited as hazard, will be removed.  Garden boxes will be repaired by Third Party Contractor.  Dining Room floor perimeter will be thoroughly cleaned.

2. Regional Maintenance Director will inspect interior and exterior of building, and grounds.

3. Every 6 months, during the 6-Month Walk-Through Inspection.

4. Regional Maintenance Director and Administrator will ensure compliance.

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

The facility was toured on 10/19/22 and the following was observed:

a. Facility Wide

* Baseboards had black matter present and were in need of cleaning;

* Multiple doors leading outside had chipping paint;

* Large hanging light fixtures had dead bugs present inside the glass shade;

* Multiple resident rooms and facility doors had scrapes, gouges, and scuffs;

* Multiple stains on the carpet;  

* Elevator door frames had scuff marks and chipped paint;

* The handrail located across the seasonal cork board had a small piece of metal sticking out;

* Elevator doors and inside walls had scuff marks; and

* Multiple walls had gouges, scuffs, and scratches.

b. First Floor

* Carpet bulging in hallway in-front of resident room 107, 108 and 106;

* A gouge in left side window seal in Activity Room;

* The bench and couch in lobby had torn fabric;

* The flooring in both public restrooms across from the activity room was in disrepair;

* The caulking was coming away from the toilets in both public restrooms;

* There lightbulbs in the female public restroom were not all in working order;

and

* The baseboard next to the female public restroom was not attached to the wall.

c. Laundry Room 126

* The walls throughout the laundry room had splatters and spills;

* The cabinet doors were missing laminate on the lower fronts;  

* The cabinet under the sink had gouges and scrapes and was in need of cleaning;

* Countertop front was missing the front laminate surface material;  

* Gouges on wall and corner to the right of the hopper; and

* The baseboard was missing on both sides of the wall next to the dryers.

d. Dining Rooms

* The perimeter of the floor had black matter build-up;

* Pillars and walls were in need of painting and repair;

* The baseboards were in need of cleaning;   

* The baseboards were in need of cleaning and repair located in the connecting hallway; and

* The vinyl flooring was cracked and scratched throughout.

e. Village Cup

* The wall next to the kitchenette area had a dent; and

* The corners on half wall in and out of the kitchenette had gouges on both sides.

f. Second Floor

* The wall leading to room 281 was gouged and scuffed;

* Corner damage to wall next to room 217 exposing material underneath;

* Laundry room 288 had hole in the flooring measuring approximately one and a half inches by three inches; and

g. Exterior of building

* Multiple lights were damaged along the walkways.

The need to ensure the interior and exterior of the building was clean and maintained in good repair was discussed with Staff 18 (Administrator) on 10/20/22 at 12:11 PM. She acknowledged the findings.

1.Contracts in place for all new flooring, replacing carpet with Marmoleum. Purchasing new common area furniture, and painting interior walls.

2. Maintenance Director has staff to run scheduled inspectiions on interior of the building monthly.

3. Quarterly

4. Maintenance director and Administrator

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

The facility was toured on 02/21/23 and the following was observed:

a. Facility-wide

* Multiple doors leading outside had chipped paint;

* Multiple resident room and facility doors and door frames had scrapes, gouges, and scuffs;

* Elevator doors, door frames and inside walls had scuff marks and chipped paint; and

* Multiple walls had gouges, scuffs, and scratches.

b. First Floor

* The carpet in the lounge next to the dining room was stained in multiple places;

* The left window frame in the activity room had a gouge on the corner with exposed metal;

* The flooring in both public restrooms across from the activity room was in disrepair;

* The caulking was coming away from the toilets in both public restrooms; and

* There light bulbs in the women's public restroom were not all in working order.

c. Laundry Room 126

* The walls throughout the laundry room had splatters and spills;

* The cabinet doors were missing laminate on the lower fronts;  

* The cabinet under the sink had gouges and scrapes and was in need of cleaning;

* The countertop front to the left of the sink was missing the front laminate surface material; and

* The wall to the right of the hopper had gouges and paint chips.

e. Village Cup

* The corners on the half wall in and out of the kitchenette had gouges on both sides.

f. Second Floor

* The wall to the right of room 281 was gouged and scuffed;

* The wall to the right of room 217 was gouged, exposing material underneath; and

* The floor in Laundry room 288 had a hole measuring approximately one and a half inches by three inches.

The need to ensure the interior of the building was kept clean and in good repair was discussed with Staff 19 (Administrator/RN) on 02/22/23. She acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure there was a separate area with closed containers to ensure the separate storage and handling of soiled linens and soiled clothing and failed to ensure a one-way flow of soiled linens and clothing that precludes the potential for contamination of clean linens and clothing. Findings include, but are not limited to:

The laundry room (room 126) was observed on 06/14/22. There was no area with closed containers to ensure the separate storage and handling of soiled linens and soiled clothing. There was no identified one-way flow for soiled linens from the soiled area to a clean area, creating the potential for contamination of clean linens and clothing.

Staff 1 (Administrator) confirmed on 06/15/22 at 10:20 am there was no formal process or policy for separating soiled and cleaned linens.

The need to ensure a separate storage and a one-way flow of soiled linens and soiled clothing was reviewed with Staff 1 on 06/15/22. She acknowledged the findings.

1. We will provide lined bins to accept soiled linens and soiled clothing, in Laundry Room 126, and label the bins "Soiled linens/clothing only".  Regarding the one-way flow for soiled linens from the soiled area to the clean area:  the process will be for staff to disinfect/clean all soiled items in the laundry sink, prior to placing into washer.  Soiled items will be washed separately from non-soiled items.  Laundry sink will then be cleaned and disinfected.

2.  Housekeeping Supervisor will provide training to all Housekeeping Staff.

3.  Monthly.

4.  Housekeeping Supervisor and Administrator to ensure compliance.  

Based on observation and interview, it was determined the facility failed to ensure there was a separate area with closed containers to ensure the separate storage and handling of soiled linens and soiled clothing and failed to ensure a one-way flow of soiled linens and clothing that precludes the potential for contamination of clean linens and clothing. This is a repeat citation. Findings include, but are not limited to:

The laundry room (room 126) was observed on 10/19/22. There was no area with closed containers to ensure the separate storage and handling of soiled linens and soiled clothing. There was no identified one-way flow for soiled linens from the soiled area to a clean area, creating the potential for contamination of clean linens and clothing.

The need to ensure a separate storage and a one-way flow of soiled linens and soiled clothing was reviewed with Staff 18 (Administrator) on 10/20/22. She acknowledged the findings.

1. Provided housekeeping bins to sort and labeled "soiled" and "clean" and trained staff.

2.Training will occur on hire and as needed for correcion.

3. Monthly

4. Housekeeping supervisor and Administrator

Based on observation and interview, it was determined the facility failed to ensure all exit doors were equipped with an alarming device or other acceptable system to provide security and to alert staff when residents exited the building. Findings include, but are not limited to:

The building was toured on 06/13/22 and 06/14/22. Observations and interviews with staff confirmed the doors by which residents could exit the facility did not have an acceptable system to alert staff when residents left the building.

An interview with Staff 1 (Administrator) on 06/15/22 at approximately 11:15 am revealed the doors had the capability to be alarmed 24 hours a day but were turned off when medications were being passed in the morning and turned back on when it became dark outside.  

The need to ensure exit doors were equipped with an alarming device at all times was reviewed with Staff 1 and Staff 2 (Health Services Director) on 06/15/22. They acknowledged the findings.

1.  All doors will now remain in "Alarmed" status 24 hours each day.

2.  See above.

3.  Daily by Med Techs, who will report any issues to Administrator.

4.  Adminstrator to ensure compliance.

Based on observation and interview, it was determined the facility failed to ensure all exit doors were equipped with an alarming device or other acceptable system to provide security and to alert staff when residents exited the building. This is a repeat citation. Findings include, but are not limited to:

The building was toured on 10/19/22. Observation confirmed the doors by which residents could exit the facility did not have an acceptable system to alert staff when residents left the building.

Staff 18 (Administrator) confirmed during an interview on 10/20/22 at approximately 12:45 pm that the alarms on all exit doors were not turned on.

The need to ensure exit doors were equipped with an alarming device or other acceptable system at all times was reviewed with Staff 18 on 10/20/22. She acknowledged the findings.

1. All doors to remain in an "alarmed" status 24 hours a day .

2. Through orientation and periodic trainings.

3. Daily during med tech rounds.

4. Administrator to ensure compliance.