Print Inspection: SEKD

The findings of the re-licensure survey conducted 01/03/23 through 01/06/23 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 first revisit to the relicensure survey of 01/06/23, conducted 06/13/23 through 06/15/23 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

MCCMemory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the second re-visit to the re-licensure survey of 01/26/23, conducted 01/02/24 through 01/04/24, 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 third revisit, to the re-licensure survey of 01/26/23, conducted 03/20/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Based on observation, interview and record review, it was determined the facility failed to provide effective administrative oversight to ensure quality of care and services rendered in the facility. Findings include, but are not limited to:

During the first revisit to the relicensure survey of 01/06/23, conducted 06/13/23 through 06/15/23, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the severity and number of citations.

Refer to deficiencies in report.

Management team will meet on a regular basis to ensure facility corrects and remains in compliant in all reported deficiencies. This will be monitored on a weekly and as needed basis.

This will be completed by July 30th, 2023.

The Administrator and/or Office Manager will be responsible in monitoring that this correction is complete.  

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. Findings include, but are not limited to:

A tour of the facility completed on 01/03/23 revealed the facility lacked a copy of the most recent survey, including all revisits and plans of correction.

When requested, Staff 1 (Interim Administrator) and Staff 3 (Chief Financial Officer) were unable to produce a copy of the survey.

The need to ensure all required postings were in an accessible and conspicuous location for the public was discussed with Staff 3 on 01/05/23. He acknowledged the findings.

A copy of recent surveys, revisits, and plans of correction will be readily available for residents, visitors, and inspection. This will be in a folder clearly labeled and located at building 1 lobby area. It will be monitored and updated on an as needed basis whenever there is a survey, revisit, and plan of correction done.

This will be completed by March 7th, 2023. The Interim Administrator, Facility Manager, Office Manager, and/or Human Resource will be responsible in monitoring that this correction is complete.

Based on interview and record review, it was determined the facility failed to implement effective methods of responding to and resolving resident complaints. Findings include, but are not limited to:

During a group interview, conducted on 01/04/23, with five unsampled residents, multiple complaints or concerns were identified. The complaints included:

* There were not enough activities or scheduled activities often did not occur;

* Multiple issues with meals: food was cold, menu was switched without prior notification and residents were unaware of alternatives available to main menu items; and

* Laundry items were often misplaced and residents were not offered a replacement. Residents often received clothing items in their baskets that did not belong to them.

Residents stated they were not aware of a process to address and resolve concerns.

In an interview on 01/04/23, Staff 1 (Interim Administrator) and Staff 3 (Chief Financial Officer) acknowledged the facility did not currently have a procedure for documenting resident complaints and how the facility attempted to resolve the complaints.

The need to ensure the facility implemented effective methods of responding to and resolving all resident complaints was discussed with Staff 1 and Staff 3 on 01/04/23. They acknowledged the findings.

A grievance policy will be implemented and explained to current & new residents. A suggestion box with forms will be available in each building's dining area for residents to voice their grievances and suggestions. It will be monitored on a daily & as needed basis if residents make it aware they have a grievance or suggestion.

This will be completed by March 7th, 2023. The Interim Administrator, Facility Manager, Office Manager, and/or Human Resource will be responsible in monitoring that this correction is complete.

Based on observation and interview, it was determined the facility failed to ensure medical records were kept confidential. Findings include, but are not limited to:

During an interview on 06/13/23 with Staff 20 (CG) it was revealed Staff 20 and other staff members were using personal cell phones to access resident service plans that contained confidential identifying information about the residents.

In an interview on 06/14/23, Staff 19 (MT) was observed to access resident images and information on their personal cell phone.

The failure to ensure resident medical records were kept confidential was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 06/15/23. They acknowledged the findings.

A document will be created for staff to sign stating they will not access resident's confidential information with their personal devices. This will be monitored on an as needed basis and upon hiring new staff.

This will be completed by July 30th, 2023.

The Administrator, Office Manager, Facility manager, and/or Human Resource Manager will be responsible in monitoring that this correction is complete.  

Based on observation, interview and record review it was determined the facility failed to ensure the kitchen was clean and in good repair, in accordance with the Food Sanitation Rules OAR 333-150-0000. Findings include, but are not limited to:

The kitchen was toured on 01/04/23 and 01/05/23. The following was identified:

a. Food Storage

* The bottom shelf of the refrigerator and freezer units, located in the dry storage section of the kitchen, were in need of cleaning;

* The freezer's handle was in disrepair;

* The reach in cooler had cut up vegetables and a bag of peppers that weren't dated;

* Uncooked bacon was stored above fresh vegetables;

* There were fruit flies observed in the dry storage area; and

* Scoops were observed inside the large flour bin and inside the ice machine.

b. Food Preparation

* There were no pasteurized eggs available for soft-cooked entrees.

c. Food Service

* Staff were not cleaning the probe thermometer with alcohol wipes to sanitize after use.

d. Sanitation and Equipment

* Staff were not using a sanitized wiping cloth to clean food and non-food surfaces;

* The can opener, located inside the dry storage room, had built up food debris present;

* The warewashing machine sanitized with chemicals and Staff 17 (Cook) verified she did not check the machine to ensure sanitization;

* There were testing strips available to staff, but staff weren't aware if the testing strips were for the dishwasher and weren't using them;

* None of the garbage cans were observed to have lids and they were not separate from the food storage areas; and

* The freezer, refrigerator and garbage can in the dry food storage area had debris located on the outer part of the equipment.

e. Cleaning and Repair

* The cloth part of the rug, located in the dry storage area, was lifting from the rubber mat which could cause a fall hazard;

* Build up dirt and debris was observed throughout the kitchen and dry storage floors where the floor and walls meet;

* The cupboard located in the dry storage area was in need of cleaning and the cupboard baseboards were coming off;

* The spice shelf in the food prep area was in need of cleaning; and

* The walls and doors of the kitchen were in need of cleaning.

The above areas were discussed with Staff 1 (Interim Administrator), Staff 3 (Chief Financial Officer) and Staff 4 (Office Manager) on 01/05/23. The findings were acknowledged.

Staff will be instructed & reminded of proper food storage and overall kitchen cleanliness & sanitation. Management will look into purchasing pasteurized eggs, oversee all repairs, and updating supplies & equipment. It will be monitored on a weekly and as needed basis.

This will be completed by March 7th, 2023. The Interim Administrator, Chief Financial Officer, and/or Facility Manager will be responsible in monitoring that this correction is complete.

Based on interview and record review, it was determined the facility failed to ensure resident evaluations contained all required elements and were updated within 30 days of move in to the facility, and quarterly evaluations were not completed timely or reflective of resident care needs for 3 of 4 sampled residents (#s 1, 2 and 3) whose evaluations were reviewed. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 10/2022 with diagnoses including diabetes and end stage renal disease.

a. The move-in evaluation lacked the following elements:

* Cultural preferences/traditions;

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

* Laundry;

* Pain, including pharmacological and non-pharmacological interventions as well as how pain is expressed;

* Recent losses;

* Unsuccessful prior placements;

* History of alcohol and drug use; and

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

b. The initial evaluation, dated 10/07/22, was not updated as needed during the 30 days following the resident's move into the facility.

The need to ensure new move-in evaluations contained all required elements and were updated within 30 days following the resident's move into the facility was discussed with Staff 1 (Interim Administrator) and Staff 9 (RCC/MT) on 01/06/23. They acknowledged the findings.

2. Resident 1 was admitted to the facility in 07/2018 with diagnoses including tetraplegia (paralysis below the neck) and depression.

His/her quarterly evaluation was completed on 11/22/22. The evaluation failed to be reflective of the resident's current condition in the following areas:

* Adaptive devices;

* Emergency evacuation instructions;

* Third party provider services;

* Diet orders;

* Psychotropic medications; and

* Psychosocial needs.

The need to ensure the quarterly evaluation was reflective of the resident's condition was discussed with Staff 1 (Interim Administrator) on 01/05/23. She acknowledged the findings.

3. Resident 2 was admitted to the facility in 12/2018 with diagnoses including chronic respiratory failure, dementia, and major depressive disorder.

Resident 2's quarterly evaluation, due in 10/2022, was not completed. His/her quarterly evaluation, completed in 07/2022 was reviewed and failed to be reflective of the resident's current condition in the following areas:

* Assistive/adaptive devices;

* Vision status;

* Sleep patterns;

* Diet orders;

* Outside services received;

* Oxygen flow rate; and

* Ambulation status.

The need to ensure quarterly evaluations were completed timely and reflective of the resident's current condition was discussed with Staff 1 (Interim Administrator) on 01/05/23. She acknowledged the findings.

Resident evaluations will include necessary information and be updated within 30 days of move in, quarterly, and/or if there are any change of condition to ensure resident's care needs are being followed. It will be monitored depending on the resident's move in date, 30 day, quarterly, and/or change of condition.

This will be completed by March 7th, 2023. The Interim Administrator, Resident Care Coordinator, and/or Nurse will be responsible in monitoring that this correction is complete.

4. Resident 3 was admitted to the facility in 10/2022 with diagnoses including diabetes and end stage renal disease.

The current service plan, dated 12/02/22, was reviewed. The service plan was not reflective of the resident's current status or did not provide clear direction to staff in the following areas:

* Monitoring of weight loss, skin and pain;

* The level assistance needed with grooming, dressing, bathing, bowel movement tracking, mobility devices and transfers;

* Meal and hydration tracking;

* Activity preferences and accommodations needed to participate;

* Ostomy assistance;

* Siderails; and

* Current fall interventions and precautions.

During an interview on 01/04/23, Staff 7 stated the resident's colostomy is changed every four days and as needed, bowel movements are recorded in the computer system, side rails are not available, assistance of one person for ADLs is required and meals are logged if less than 50 percent is eaten.

The need to ensure service plans were reflective of residents' current status and provided clear direction to staff related to the provision of care was discussed with Staff 1 (Interim Administrator) and Staff 9 (RCC/MT) on 01/06/23. They acknowledged the findings.

3. Resident 4 was admitted to the facility in 04/2022 with diagnoses including dementia and atrial fibrillation.

The current service plan, dated 11/03/22, was reviewed. The service plan was not reflective of the resident's current status or did not provide clear direction to staff in the following areas:

* The level of meal assistance needed and nutritional supplements;

* Mechanical soft diet texture (following swallow evaluation) and pills taken crushed with applesauce;

* Activity preferences and accommodations needed to participate; and

* Current fall interventions and precautions.

During interviews on 01/05/23, direct care staff stated the resident's apartment door is kept open for safety, a chair alarm and bed alarm are in use daily, and the resident is offered toileting assistance and wellness checks every two to three hours.

The need to ensure service plans were reflective of residents' current status and provided clear direction to staff related to the provision of care was discussed with Staff 1 (Interim Administrator) and Staff 9 (RCC/MT) on 01/06/23. They acknowledged the findings.

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

1. Resident 1 was admitted to the facility in 07/2018 with diagnoses including tetraplegia, neurogenic bowel and bladder and depression.

The current service plan, dated 11/03/22, was reviewed. The service plan was not reflective of the resident's current status or did not provide clear direction to staff in the following areas:

* The level of assistance needed with bathing, grooming, dressing, oral care, emergency evacuation, housekeeping and transfers;

* Assistive/adaptive devices needed;

* Catheter care;

* Third party services received;

* Behaviors;

* Activity preferences and accommodations needed to participate; and

* Side rails.

During an interview on 01/04/23, Staff 15 (CG) stated Resident 1 required total assistance for ADLs, caregivers empty the catheter bag in the urinal and report the amount of urine to the MT, the resident had no behaviors toward care staff and did not have side rails on his/her bed.

The need to ensure service plans were reflective of residents' current status and provided clear direction to staff related to the provision of care was discussed with Staff 1 (Interim Administrator) on 01/05/23. She acknowledged the findings.

2. Resident 2 was admitted to the facility in 12/2018 with diagnoses including chronic respiratory failure, dementia and major depressive disorder.

The current service plan, dated 06/21/22, was reviewed. The service plan was not reflective of the resident's current status or did not provide clear direction to staff in the following areas:

* The level of assistance needed with bathing, dressing, grooming, oral care, transfers, mobility, orientation, evacuation, transportation, housekeeping, nebulizer treatments and oxygen care;

* Assistive/adaptive devices;

* Day and evening routine preferences;

* Activity preferences and accommodations needed to participate;

* Thoughts of suicide; and

* Non-drug interventions for depression.

During an interview on 01/05/23, Staff 9 (RCC/MT) stated the resident is not suicidal, does not have nebulizer treatments, and is on four liters of oxygen.

The need to ensure service plans were reflective of the resident's current status and provided clear direction to staff related to the provision of care was discussed with Staff 1 (Interim Administrator) on 01/05/23. She acknowledged the findings.

Resident service plans will include all necessary information and be regularly updated to ensure resident's current care needs are being followed. It will be monitored depending on the resident's move in date, 30 day, quarterly, and/or change of condition.

This will be completed by March 7th, 2023. The Interim Administrator, Resident Care Coordinator, and/or Nurse will be responsible in monitoring that this correction is complete.

Based on observation, interview and record review, it was determined the facility failed to ensure the service plan was reflective of residents' current care needs, provided clear directions to staff regarding the delivery of services, and the service plan was completed with updates and changes as appropriate within the first 30-days for 1 of 2 sampled residents (#5) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 5 was admitted to the facility in 05/2023 with diagnoses including paroxysmal atrial fibrillation, chronic diastolic (congestive) heart failure, and renal failure. Resident 5 was dependent on renal dialysis.

Observations were made of the resident's care on 06/14/23. Interviews with facility staff and the resident's daughter were conducted. The current service plan dated 04/27/23 was reviewed.

Resident 5's family members sat with the resident every day for approximately four to six hours to assist with ADLs, including bathing on Sunday. Resident 5 was unable to communicate with facility staff due to a language barrier but used gestures and notes on the wall for simple requests. Family members translated when present.

a. Resident 5's service plan was not reflective of the resident's current needs and lacked clear instructions to staff in the following areas:

* Eating;

* Dental status;

* Bathing and personal hygiene;

* Mobility;

* Delivery of services during hours when family members were not present;

* How side rails were to be used and monitored for safety; and

* Dialysis port monitoring and precautions.

b. The service plan dated 04/27/23 was not completed with updates and changes as appropriate within the first 30-days. In an interview on 06/13/23, Staff 1 (Administrator) stated Staff 9 (RCC/MT) was working on an update, but it was not received prior to the time of survey exit.

The need to ensure the service plan reflected residents' current needs, provided clear instructions to staff regarding delivery of services, and was completed with updates and changes as appropriate within the first 30-days was reviewed with Staff 1 and Staff 2 (RN) on 06/15/23. They acknowledged the findings. No further information was provided.

Management team to meet with medication techs and/or caregivers to ensure resident service plan includes all necessary information and be regularly updated so that resident's current care needs are being followed. This will be monitored depending on the resident's move in date, 30 day, quarterly, and/or significant change of condition.

This will be completed by July 30th, 2023.

The Administrator, Resident Care Coordinator, and/or Nurse will be responsible in monitoring that this correction is complete.

2. Resident 1 was admitted to the facility in 07/2018 with diagnoses including impaired mobility, tetraplegia (paralysis from the neck down) and a neurogenic bladder. The resident's progress notes dated 07/13/22 through 01/02/2023 were reviewed. The following changes in condition were identified:

* On 08/24/22, a progress note stated there was blood in the resident's urine. The facility RN directed staff to begin monitoring on 08/30/22, six days after the incident occurred.

* On 09/01/22, the facility documented the wound care that was provided to the resident's coccyx by the HHRN. On 09/06/22, the facility RN documented Resident 1 reported to her, "that [his/her] buttock skin issue has closed/resolved." There was no documented evidence the RN observed the area for verification.

* On 09/21/22 a progress note stated Resident 1 had returned from the hospital and, "[S/he] has medication changes." There was no further information and no documentation the resident was monitored for the change in medications.

* On 10/30/22, an MT documented, "Morning medtech noticed [the resident's] bottom is getting red and has a deep sore forming." The facility RN noted the phone call from the facility and provided interventions to staff. She also documented that the area will be monitored "weekly until resolved." There was no additional documentation of the facility RN monitoring the resident's skin.

* On 11/04/22 the facility documented that the HHRN provided wound care and the wound was healing. On 11/10/22 the facility RN took the resident off of skin monitoring without documented evidence she observed the wound.

* On 12/03/22 a progress note reported that the resident was sent to the hospital as his/her catheter was "clogged." Resident 1 returned on 12/04/22. There is no documented evidence of the facility monitoring the resident after returning from the hospital.

The need to ensure the facility documents resident specific instructions or interventions, communicates those instructions or interventions to staff on each shift, documents weekly progress until the condition resolves and has a resident monitoring and reporting system that is implemented 24 hours a day, seven days a week was discussed with Staff 1 (Interim Administrator) and Staff 9 (RCC/MT) on 01/06/23. They acknowledged the findings and no additional information was provided.

3. Resident 2 was admitted to the facility in 12/2018 with diagnoses including chronic obstructive pulmonary disease and dementia. The resident's progress notes dated 07/03/22 through 12/28/22 were reviewed. The following changes of condition were identified:

* On 11/06/22 Staff 9 (RCC/MT) noted that the resident was complaining of having a cold. The facility's RN gave staff directions on what symptoms to monitor on 11/10/22, four days after the resident reported not feeling well.

* Resident 2 was placed on alert charting due to a fall and hitting his/her head. The facility RN provided monitoring instructions to staff. There was no documented evidence the resident was monitored weekly through resolution.

* On 12/08/22, an MT noted the resident had a fever of 100.4 degrees. There was no documented evidence the resident was monitored weekly through resolution.

The need to ensure the facility documents resident specific instructions or interventions, communicates those instructions or interventions to staff on each shift, documents weekly progress until the condition resolves and has a resident monitoring and reporting system that is implemented 24 hours a day, seven days a week was discussed with Staff 1 (Interim Administrator) and Staff 9 on 01/06/23. They acknowledged the findings and no additional information was provided.

Based on interview and record review, it was determined the facility failed to evaluate changes of condition, determine resident-specific actions or interventions needed, provide written communication of those interventions to staff on each shift, monitor the conditions to resolution and/or have a resident monitoring and reporting system that is implemented 24 hours a day, seven days a week for 3 of 3 sampled residents (#s 1, 2 and 4) who experienced changes of condition. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 04/2022 with diagnoses including atrial fibrillation and dementia.

A review of the resident's record revealed s/he experienced the following short term changes of condition:

* 11/10/22: new medication, furosemide, was started related to swelling in lower extremeties. The record lacked evidence of direction to staff to monitor the resident related to the change and there was no evidence the resident was monitored following the new medication or swelling to lower extremities;

* 11/17/22: new medication, hydralazine for blood pressure control, was started. The record lacked evidence the resident was monitored following the change in medication;

* 12/03/22: the resident experienced a fall and was placed on alert monitoring. On 12/06/22, the facility RN identified new fall interventions as a result of a fall evaluation. The record lacked evidence the new interventions were communicated to staff on all shifts and monitored for effectiveness. In addition, a review of the incident report following the fall revealed the facility did not determine interventions as a result of the investigation; and

* 12/03/22: the resident sustained a cut and bruising to face and head following a fall. The record lacked evidence the skin injuries were monitored, at least weekly, until resolution.

The need to ensure a system for documenting and monitoring changes of condition through resolution and communicating changes and interventions to staff was discussed with Staff 1 (Interim Administrator) and Staff 3 (Chief Financial Officer) on 01/05/23. They acknowledged the findings.

Resident change of condition, instructions, falls, hospital visits, needed monitoring, and all other progress notes will be communicated by charting an observation on the Alis system and a Daily Stand Up for each shift will be printed out for staff to read. It will be monitored on a daily and as needed basis.

This will be completed by March 7th, 2023. The Interim Administrator, Resident Care Coordinator, Facility Manager, Office Manager, and/or Nurse will be responsible in monitoring that this correction is complete.  

2. Resident 6 was admitted to the facility in 07/2021 with diagnoses including chronic kidney disease.

Interviews with staff and the resident, review of the service plan dated 04/24/23 and progress notes dated 03/13/23 through 06/13/23 were reviewed.

The resident experienced multiple short-term changes of condition without documented evidence resident-specific instructions or interventions were developed and communicated to staff, nor was the condition monitored at least weekly to resolution in the following areas:

* 03/22/23 - five small open areas on right shin;

* 04/12/23 - discontinuation of CPAP (continuous airway pressure) machine; and

* 06/10/23 - starting of home health services.

The need to ensure short-term changes of condition had documented evidence the condition was evaluated, resident-specific instructions or interventions were developed and communicated to staff and the condition was monitored at least weekly to resolution was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 06/15/23. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed for a significant change of condition, and failed to determine what resident-specific action or intervention was needed for a resident following a short-term change of condition, communicate the determined action or intervention to staff, document progress until the condition resolved, and ensure a resident monitoring and reporting system was implemented 24-hours a day for 2 of 2 sampled residents (#s 5 and 6) who experienced changes of condition. Resident 5 experienced the onset of acute continuous bleeding, which put the resident at serious risk. This is a repeat citation. Findings include, but are not limited to:

1. Resident 5 was admitted to the facility on 05/08/23 with diagnoses including paroxysmal atrial fibrillation, chronic diastolic (congestive) heart failure, and renal failure. Resident 5 was dependent on renal dialysis.

Review of clinical records, including the service plan dated 04/27/23, progress notes from 05/08/23 through 06/13/23, and outside provider notes, revealed the following information:

* On 05/09/23, Resident 5 was hospitalized with COVID-19 and returned to the facility on 05/11/23 with an order to continue taking Eliquis (blood thinner) 5mg one tablet by mouth twice daily.

* According to the MAR, eight doses of Eliquis were not administered from 05/13/23 through 05/17/23 due to the medication not being available. Administration of Eliquis was resumed on 05/17/23 during the evening med pass.

* On 05/18/23 at 2:37 pm, Staff 10 (MT) noted in a progress note "observed resident bleeding a lot from the mouth. Bleeding appeared to be from the gums and teeth ..."

* On 05/24/23 at 3:39 pm, Staff 9 (RCC/MT) noted in a progress note "Daughter also requested if someone can come out to check [Resident 5's] stool test as it was black color today."

* On 05/25/23, Staff 10 documented while assisting Resident 5 with breakfast, " ...resident was bleeding from [his/her] right nostril." At 1:30 pm, Staff 10 "noted that resident was bleeding, not a lot of bleeding, but slow bleeding" from the dialysis port. Per Resident 5's daughter's report, at 3:35 pm "it seemed like resident is still bleeding." Staff 10 informed swing shift Staff 19 (MT) "...resident has been bleeding for hours, very slow but still persisting and she might need to get sent out."

* On 06/09/23 at 9:38 pm, Staff 21 (MT) noted the dialysis RN informed Staff 21, "[Resident 5] would need to be sent out to ED for black stool ..."

* On 06/09/23, Resident 5 was sent to the hospital and diagnosed with a rectal bleed. S/he returned to the facility the same day with an order to discontinue Eliquis.

In an interview on 06/14/23 at 10:40 am, Staff 19 indicated facility staff, including the facility nurse and administrator, used cell phone text message group chats to communicate resident status changes. Staff 19 was unable to find any text message notifying other facility staff of Resident 5's bleeding on 05/25/23.

In a phone interview on 06/14/23 at 1:46 pm, Staff 2 (RN) stated it was the "MT's responsibility to follow the care plan, and the care plan addresses bleeding."

In an additional interview on 06/15/23 at 10:45 am, Staff 2 confirmed she was not notified of Resident 5's bleeding.

Between 05/18/23 and 06/09/23, there was no documented evidence the facility developed any interventions, implemented routine monitoring or informed staff of the resident's bleeding.

Resident 5 had a significant change of condition related to the four episodes of bleeding resulting in an ED visit. There was no documented evidence the facility evaluated the resident, referred to the facility nurse, documented the change, and updated the service plan as needed.

The significant change of condition and the need to evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed was reviewed with Staff 1 (Administrator), Staff 2 and Staff 3 (Chief Financial Officer) on 06/15/23 at 10:45 am and 2:30 pm. They acknowledged the findings, and no further information was provided.

Resident change of condition, instructions, falls, hospital visits, needed monitoring, and all other progress notes will continue to be communicated by charting an observation on the Alis system and a Daily Stand Up for each shift will be printed out for staff to read. In addition, facility will remind staff to alert management of any significant issues to management in a timely manner by text or phone call. These include falls, bleeding, wounds, etc. This will be monitored on a daily and as needed basis.

This will be completed by July 30th, 2023.

The Administrator, Resident Care Coordinator, Facility Manager, Office Manager, and/or Nurse will be responsible in monitoring that this correction is complete.  

Based on observation, interview, and record review, it was determined the facility failed to ensure residents who experienced short term changes of condition were evaluated to determine if actions or interventions were needed, actions or interventions were communicated to staff on each shift and documented at least weekly with progress noted until the condition resolved, and residents were monitored consistent with evaluated needs for 2 of 2 sampled residents (#s 1 and 8), who experienced short term changes of condition. This is a repeat citation. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 07/2018 and had a current diagnosis of a stage two pressure ulcer on the right buttock.

a. Interviews and reviews of the resident's progress notes dated 09/01/23 through 01/02/24, MAR's dated 12/01/23 through 01/02/24, service plan dated 12/13/23 and temporary service plans revealed the resident experienced the following short term changes of condition:

* 10/02/23 - Skin tears to left elbow and left knee;

* 11/24/23 - Redness of the left eye; and

* 12/11/23 - New medication order: hydrocodone/acetaminophen 5/325 mg every six hours PRN. The medication was administered to the resident on 12/16/23.

There was no documented evidence the facility determined and documented resident specific actions or interventions needed related to the skin concerns or medication change, communicated interventions to staff on each shift, or monitored the conditions with progress noted at least weekly through resolution.

b. The resident was noted to have a reoccurring rash to the back and scapula.

The record lacked documented evidence the facility monitored the resident for the rash consistent with his/her evaluated needs.

The need to ensure the facility had a system to monitor each resident consistent with evaluated needs, determine and document what actions or interventions were needed for the resident's short term changes of condition, ensure actions or interventions were communicated to staff on each shift, and documented at least weekly until the conditions resolved was discussed with Staff 3 (RCC) on 01/03/24 and with Staff 1 (Administrator) on 01/04/24. They acknowledged the findings.

2. Resident 8 was admitted to the facility 04/2022 with diagnoses including carotid stenosis and diabetes peripheral neuropathy associated with Type 2 diabetes.  

Resident 8's progress notes and facility records dated 11/01/23 through 01/02/24 were reviewed and revealed the following:

* 11/12/23 - "resident suddenly felt dizzy while walking going to the dining table...felt like [s/he] was going to vomit" was noted;

* 12/13/23 - "pt is pale and reports feeling weak and lightheaded...instructed pt that if [his/her] symptoms worsen and or [s/he] develops chest pain or SOB [s/he] should go to the ED." was noted; and  

* 12/15/23 - "This morning when I checked [him/her] in the bathroom throwing up and having some diarrhea".

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

The need to ensure residents were evaluated, actions or interventions needed were determined and monitoring was documented at least weekly through resolution was discussed with Staff 1 (Administrator) on 01/04/24. The findings were acknowledged.

Care staff will be reminded to alert management team of any changes and/or concerns by text or phone call in a timely manner. Staff to make observation/progress notes on the Alis system and Daily Stand Ups will be printed to ensure all staff are aware of the changes and/or concerns. This is to include but not limited to illnesses, falls, wounds, rashes, etc.

Once information is given the management team will create short term changes in condition and will place residents on alert for monitoring.

This will be monitored on a daily and as needed basis.

This will be completed by February 16th, 2024.

The Administrator, Resident Care Coordinator, Site Manager, Office Manager, and/or Nurse will be responsible in monitoring that this correction is complete.   

Based on interview and record review, it was determined the facility failed to provide health services including an Oregon licensed nurse who was regularly scheduled for onsite duties at the facility, assure an adequate number of nursing hours relevant to the acuity of the resident population, and ensure an RN assessment was completed for 1 of 1 sampled resident (# 5) who experienced a significant change of condition. Findings include, but are not limited to:

1. Resident 5 was admitted to the facility in 05/2023 with diagnoses including paroxysmal atrial fibrillation, chronic diastolic (congestive) heart failure and renal failure. Resident 5 was dependent on renal dialysis.

Review of Resident 5's progress notes, dated 05/25/23 revealed the resident had continuous bleeding. The bleeding constituted a significant change in condition requiring an RN assessment.

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

During a phone interview on 06/14/23 at 1:46 pm, Staff 2 (RN) acknowledged an RN assessment had not been completed for the bleeding.

The need for the facility RN to conduct an assessment when a resident experienced a significant change of condition, was reviewed with Staff 1 (Administrator) and Staff 2 on 06/15/23. They acknowledged the findings. No further information was provided.

2. During an interview on 06/15/23 at 10:45 am, Staff 1 (Administrator), Staff 2 (RN), and Staff 3 (Chief Financial Officer) were asked about the facility RN duties and onsite hours. Staff 2 stated she worked at the facility about 40 hours per month and tried to be at the facility about four to five hours per week, if needed.  She stated, "I have other facilities, I'm part time" and "The acuity is pretty heavy."

Review of Staff 2's job description, dated 03/16/22 revealed Staff 2's position had no regularly scheduled hours to assure an adequate number of nursing hours relevant to the census and acuity of the resident population.

There was no documented evidence Staff 2 had regularly scheduled hours for onsite duties at the facility.

The need to ensure the facility provided health services including an Oregon licensed nurse who was regularly scheduled for onsite duties, assure an adequate number of nursing hours relevant to the census and acuity of the resident population, was reviewed with Staff 1 and Staff 2 on 06/15/23. They acknowledged the findings. No further information was provided.

Facility nurse will be scheduled regular on site hours weekly to ensure nursing hours are relevent to the census and acuity of the resident's population and that resident's needs are being met. This will be monitored on a weekly basis.

This will be completed by July 30th, 2023.

The Administrator, Chief of Financial Operations,  and/or Nurse will be responsible in monitoring that this correction is complete.  

Based on observation, interview, and record review, it was determined the facility failed to ensure the RN completed a significant change of condition assessment, which included findings, developed interventions based on the condition of the resident, and updated the service plan for 1 of 1 sampled resident (#8) who experienced a significant change of condition. This is a repeat citation. Findings include, but are not limited to:

During the acuity interview on 01/02/24, the facility stated Resident 8 had a recent decline and required increased assistance with ADL care.

A "Nurse's Note" dated 11/17/23 stated "Resident received bad news from [his/her] urologist stating that [s/he] has cancer. Unknown as to which type of cancer as they need to run more tests."

An additional "Nurse's Note" dated 11/28/23 stated "I extended alert for resident as [s/he] is continuing to decline."

In an interview on 01/02/24 Staff 7 (MT) explained the resident had significantly declined within the last two months with increased weakness noted by changes in mobility and increased need for ADL assistance.

Observations and interviews with Resident 8 on 01/03/24 revealed s/he had recently been diagnosed with cancer and was no longer able to ambulate without his/her wheelchair. Resident 8 noted s/he had increasingly been relying on staff for ADL support in the areas of mobility and bathing assistance.

In an interview with Staff 1 (Administrator) and Staff 9 (RCC) it was confirmed an RN assessment including findings and interventions based on the condition of the resident had not been completed and the service plan had not been updated for Resident 8.

The need for an RN assessment which included the required components was discussed with Staff 1 on 01/04/24. The findings were acknowledged.

The facility has hired a new nurse who will be scheduled to work regular weekly on site hours.

This will ensure that resident's needs are being met and nursing assessments, services plans, and changes of condition are written and updated in a timely manner.

This will be monitored on a weekly and as needed basis.

This will be completed by February 16th, 2024.

The Administrator, Chief of Financial Operations, Resident Care Coordinator, and/or Nurse will be responsible in monitoring that this correction is complete.  

Based on observation and interview, it was determined the facility failed to implement and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment related to ADL and catheter care for 1 of 1 sampled resident (#1). Findings include, but are not limited to:

Resident 1 was admitted to the facility in 07/2018 with diagnoses including tetraplegia (paralysis from the neck down) and neurogenic bowel and bladder.

Observations and interviews with staff during the survey revealed s/he had a catheter and s/he was dependent on staff for catheter management and ADLs.

a. Resident 1 was observed in bed at 10:12 am on 01/05/23. Staff 10 (MT) was observed entering Resident 1's room and taking his/her blood pressure without first performing hand hygiene. Staff 10 was subsequently observed leaving Resident 1's room without performing hand hygiene, walking to the med cart, and placing the blood pressure monitor on the cart without sanitizing it.

b. At 10:19 am the same day, this surveyor observed two caregivers (Staff 15 and 18) provide ADL care to Resident 1. Staff 18 failed to perform hand hygiene prior to donning gloves for care. Staff 15 failed to change gloves and sanitize hands after emptying the catheter bag into the urinal and prior to touching the resident's door handle. Both caregivers doffed contaminated gloves and donned new gloves without performing hand hygiene in between while providing ADL cares to the resident.

The above observations were discussed with Staff 1 (Interim Administrator) on 01/06/23. She acknowledged appropriate infection control practices were not implemented. No further information was provided.

Staff will be instructed and reminded of the infecton prevention protocols regarding hand hygiene. It will be monitored on a daily and as needed basis.

This will be completed by March 7th, 2023. The Interim Administrator, Chief Financial Officer, and/or Facility Manager (Infection Control Specialist) will be responsible in monitoring that this correction is complete.

Based on interview and record review, it was determined the facility failed to ensure medications administered by the facility were documented by the same person who administered the medication and staff who administer medications visually observe the resident take the medication for 2 of 4 sampled residents (#s 1 and 2) whose records were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 07/2018 with diagnoses including impaired mobility. The resident's 12/01/22 through 01/06/23 MARs and physician's orders were reviewed. There were two topical treatments ordered by the physician. These treatments were signed on the MAR as being administered by the MTs.

In an interview on 01/04/23 at 10:30 am, Staff 15 (CG) confirmed she applied the treatments.

The need to ensure the same staff person that administered the physician ordered treatments was the person who documented that they administered the treatments was discussed with Staff 1 (Interim Administrator) and Staff 9 (RCC/MT) on 01/06/23. No additional information was provided.

2. Resident 2 was admitted to the facility in 12/2018 with diagnoses including altered mental status and dementia. The resident's 12/01/22 through 01/03/23 MARs, physician's orders and progress notes dated 07/03/22 through 12/28/22 were reviewed. The following was identified:

* On 09/15/22 Staff 9 (RCC/MT) noted that the resident didn't take his night time medications and stated the resident said that "[s/he] forgot and was asleep." The progress note further indicated it wasn't the first time that had happened and instructed staff to observe Resident 2 take the medications and "not just leaving meds on [his/her] table." Staff 9 noted that when the resident did not get the night time medications, his/her mood was different the next day.

* The facility documented on a note left by an outside provider on 09/19/22. The outside provider reported finding the resident's night time medications on his/her table. The provider instructed staff to ensure the resident took their medication before the MT left the room.

The need to ensure staff visually observe residents take their medications was discussed with Staff 1 (Interim Administrator) and Staff 9 on 01/06/23. They acknowledged and findings.

Resident's topical creams will be applied by the proper staff member and/or the facility will request clear instructions from physician's on who can administer. Medication techs will be instructed and reminded not to leave any medication in resident's rooms. It must be visually observed that the medication was taken. If refused they must offer up to three times then mark it as refusal with a note/reason. It will be monitored on a daily and as needed basis.

This will be completed by March 7th, 2023. The Interim Administrator, Resident Care Coordinator, and/or Nurse will be responsible in monitoring that this correction is complete.

Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed and written, and signed physician or other legally recognized practitioner orders were documented in the resident's facility record for all medications and treatments that the facility is responsible to administer for 2 of 4 sampled residents (#s 1 and 2) whose orders were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 07/2018. Resident 1's 12/01/22 through 01/03/23 MARs and physician's orders were reviewed and revealed the following:

a. The most recent signed order directed the facility to administer the following medications:

* Ibuprofen, PRN for pain;

* Metamucil, PRN for bowel care; and

* Tizanidine, for muscle spasms.

The medications were not transcribed to the resident's MAR.

b. The following medications were on the resident's MAR:

* Aquaphor, skin moisturizer;

* Ciprofloxacin, antibiotic;

* Culturelle, supplement;

* Triad cream, wound care;

* Acetaminophen, PRN for pain; and

* Ondansetron, nausea/vomiting.

There was no documented evidence of a physician's or other legal prescriber order located in the resident's medical chart.

c. There were physician's orders for the facility to apply zinc oxide barrier cream three times a day and as needed. There was no documented evidence staff were following the order as prescribed.

The need to ensure physician orders were carried out as prescribed and 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 is responsible to administer was discussed with Staff 1 (Interim Administrator) and Staff 9 (RCC/MT) on 01/06/23. No additional information was received.

2. Resident 2 was admitted to the facility in 12/2018. The resident's 12/01/22 through 01/03/23 MARs and physician's orders were reviewed and revealed the following:

a. An electronically signed order dated 11/07/22 instructed staff to administer a nutritional supplement twice daily, in the morning and mid afternoon. The nutritional supplement was not transcribed in the resident's MAR.

b. The following medications were on the resident's MAR:

* Iprat-albut nebulizer treatment, shortness of breath;

* Natural balance tears, for dry eyes;

* Ondansetron, nausea/vomiting;

* Polyethylene glycol powder, bowel care; and

* Proctosol cream, hemorroidal itching.

There was no documented evidence of a physician's or other legal prescriber order located in the resident's medical chart.

The need to ensure physician orders were carried out as prescribed and 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 is responsible to administer was discussed with Staff 1 (Interim Administrator) and Staff 9 (RCC/MT) on 01/06/23. No additional information was received.

Resident's signed physician's medication list will be requested on a regular basis to ensure all medicine is correct. It will be monitored on a quarterly and as needed basis.

This will be completed by March 7th, 2023. The Interim Administrator, Resident Care Coordinator, Nurse, and/or Office Manager will be responsible in monitoring that this correction is complete.

Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed for 1 of 2 sampled residents (#5) whose orders were reviewed. The facility did not notify Resident 5's primary care physician of continuous bleeding, constipation, and chest pain, which put the resident at serious risk. This is a repeat citation. Findings include, but are not limited to:

Resident 5 was admitted to the facility in 05/2023 with diagnoses including paroxysmal atrial fibrillation, and chronic diastolic (congestive) heart failure, renal failure. Resident 5 was dependent on renal dialysis.

Review of Resident 5's current physician orders, MARs and progress notes from 05/09/23 through 06/13/23 revealed the following:

Resident 5 had an order to receive Eliquis (blood thinner) 5mg one tablet by mouth twice daily and to notify primary care physician immediately if any of the following side effects occurred while taking Eliquis:

* Blood in the eyes;

* Blood in the urine;

* Bloody or black, tarry stools;

* Bruising or purple area on the skin;

* Confusion;

* Constipation;

* Coughing up blood;

* Decreased alertness;

* Difficulty swallowing;

* Dizziness;

* Fainting;

* Fast heartbeat; and

* Headache or if they have a fall or bleeding doesn't stop.

Resident 5's progress notes revealed the following:

* On 05/25/23, Staff 10 (MT) revealed while assisting Resident 5 with breakfast, " ...resident was bleeding from [his/her] right nostril." At 1:30 pm, Staff 10 "noted that resident was bleeding, not a lot of bleeding, but slow bleeding" from the dialysis port. Per Resident 5's daughter's report, at 3:35 pm "it seemed like resident is still bleeding." Staff 10 informed swing shift Staff 19 (MT) " ...resident has been bleeding for hours, very slow but still persisting and she might need to get sent out."

* On 05/23/23, the "Daughter was also concerned of [Resident 5] being constipated."

* On 05/25/23 at 4:52 am, Resident 5's daughter requested PRN Senna for constipation due to Resident 5 being unable to have a bowel movement. PRN Senna was administered at 9:46 am. Before 12:00 pm, "daughter requested to get Miralax for the resident, saying the resident was still constipated, no result from Senna."

In an interview on 06/14/23 at 10:40 am, Staff 19 confirmed she did not notify the PCP of the continued bleeding or constipation.

There was no documented evidence the facility immediately notified Resident 5's primary care physician of the continual bleeding and occurrence of constipation while taking Eliquis. Resident 5 was sent to hospital on 06/09/23 and was diagnosed with a rectal bleed. S/he returned the same day with an order to discontinue Eliquis.

b. Resident 5's hospital discharge order, dated 05/11/23 included an instruction to call the doctor immediately in case of chest pain.

Resident 5's progress note, dated 05/30/23 noted, the "family reported ... resident was complaining of chest pain."

There was no documented evidence the facility notified the doctor of chest pain, and the family had the facility administer PRN Tramadol for the resident's chest pain.

The need to ensure medication orders were carried out as prescribed was reviewed with Staff 1 (Administrator), Staff 2 (RN), and Staff 3 (Chief Financial Officer) on 06/15/23 at 10:45 am and 2:30 pm. They acknowledged the findings, and no further information was provided.

Resident's signed physician's medication list will continue to be requested on a regular basis to ensure all medicine is correct. In addition, staff to be reminded to notify resident's primary care physician of any health changes, issues, and/or concerns. This will be monitored on a quarterly and as needed basis.

This will be completed by July 30th, 2023.

The Administrator, Resident Care Coordinator, Nurse, and/or Office Manager will be responsible in monitoring that this correction is complete.

2. Resident 1's 12/01/22 through 01/03/23 MARs and physician's orders were reviewed. The resident refused the following medications on 12/29/22:

* Cuturelle, supplement;

* Fibercon, bowel care;

* Fluoxine, antidepressant;

* Triamicinolone, redness/itching;

* Vitamin B, supplement;

* Vitamin C, supplement; and

* Vitamin D, supplement.

There was no documented evidence the facility notified the physician of the resident's refusal to consent to orders.

The need to ensure the physician or prescriber was notified when a resident refused consent to an order was discussed with Staff 1 (Interim Administrator) and Staff 9 (RCC/MT) on 01/06/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to notify the physician when a resident refused to consent to orders for 2 of 2 sampled residents (#s 1 and 4) who had documented refusals. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 04/2022 with diagnoses including atrial fibrillation. Review of the current physician's orders did not provide any instruction on the physician's preference of when to be notified of any refusals. The resident's 12/01/22 through 01/04/23 MARs revealed the resident refused to consent to orders for the following medications:  

* 01/02/23 - apixaban, atorvastatin, donepezil, ferrous sulfate, metoprolol and pantoprozole.

The clinical record lacked evidence the physician was notified of the refusals. In an interview on 01/06/23, Staff 1 (Interim Administrator) verified there was no system in place to ensure physicians were notified of refusals.

The need to ensure the physician or prescriber was notified when a resident refused consent to an order was discussed with Staff 1 and Staff 9 (RCC/MT) on 01/06/23. They acknowledged the findings.

Resident physicians will be notified of all medication refusals and/or be requested of when they prefer to be notified of medication refusals. It will be monitored on an as needed basis.

This will be completed by March 7th, 2023. The Interim Administrator, Resident Care Coordinator, and/or Nurse will be responsible in monitoring that this correction is complete.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included reason for use, medication specific instructions and included resident-specific parameters for PRN medications for 2 of 4 sampled residents (#s 1 and 2) whose medications were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 07/2018. The resident's 12/01/22 through 01/03/23 MARs and physician's orders were reviewed and the following inaccuracies were identified:

a. The following medications lacked a reason for use:

* Aquaphor;

* Ciprofloxan;

* Fibercon;

* Lisinopril;

* Potassium; and

* Triamcinolone cream.

b. There were no clear directions to staff regarding where to apply the triamcinolone cream.

c. Resident 1 had two PRN pain medications listed on the MAR; acetaminophen and hydrocodone. There were no clear directions to staff on which medication to offer first.

The need to ensure medications the facility was responsible to administer included a reason for use, clear directions to staff were provided for each medication and PRN medications included resident specific parameters with discussed with Staff 1 (Interim Administrator) and Staff 9 (RCC/MT) on 01/06/23. No additional information was provided.

2. Resident 2 was admitted to the facility in 12/2018 with diagnoses including chronic obstructive pulmonary disease (COPD). The resident's 12/01/22 through 01/03/23 MARs and physician's orders were reviewed and the following inaccuracies were identified:  

a. Vitamin D lacked a reason for use.

b. On 12/22/22, there was no documented evidence the following medications were administered:

* Fluticasone, allergies;

* Spiriva, COPD;

* Symbicort, COPD;

* Venlafaxine, anxiety/depression; and

* Vitamin D.

In an interview on 01/06/23, it was identified that Staff 10 (MT) forgot to document the medications as administered.

c. Resident 2 had two PRN bowel medications listed on the MAR; bisacodyl suppository as needed once a day for bowel care and polyethylene glycol powder as needed three times a day for no bowel movement in two days. There were no clear directions to staff on which medication to offer first.

The parameter for the bisacodyl suppository directed unlicensed staff to administer after 12 hours of giving a bisacodyl tablet. There was no bisacodyl tablet listed on the resident's MAR, nor was there a signed physician's order for the tablet.

The need to ensure medications the facility was responsible to administer included a reason for use, the MAR was accurate relating to being signed when medications were administered and PRN medications included resident specific parameters with discussed with Staff 1 (Interim Administrator) and Staff 9 (RCC/MT) on 01/06/23. They acknowledged the findings.

Resident's signed physician's medication list will be requested on a regular basis to ensure all medicine, instructions, PRN parameters, etc is correct. It will be monitored on a quarterly and as needed basis.

This will be completed by March 7th, 2023. The Interim Administrator, Resident Care Coordinator, and/or Nurse will be responsible in monitoring that this correction is complete.

2. Resident 6 was admitted to the facility in 07/2021 with diagnoses including chronic kidney disease.

Resident 6's 06/01/23 through 06/13/23 MARs were reviewed and revealed the following:

Medications without reason for use:

* Amlodipine (for high blood pressure);

* Calcium carbonate (for heartburn);

* Furosemide (for edema);

* Hydralazine (for blood pressure);

* Hydrochlorothiazide (for blood pressure);

* Nystatin (for fungal infections); and

* Pantoprazole (for gastric reflux).

Medications without clear administration parameters for unlicensed staff:

* PRN polyethylene glycol;

* PRN senna; and

* PRN milk of magnesia (all for constipation).

The need to ensure residents' MARs had reasons for use and resident-specific parameters for medications was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 06/15/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure residents' MARs included reason for use and provided resident-specific parameters for PRN medications for 2 of 2 sampled residents (#s 5 and 6) whose MARs were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 5 was admitted to the facility in 05/2023 with diagnoses including paroxysmal atrial fibrillation, chronic diastolic (congestive) heart failure and dependence on renal dialysis.

Resident 5's MARs from 05/09/23 through 06/13/23 and physician orders were reviewed, and revealed the following:

The following medications lacked documented reasons for use:

* Aspirin (anti-inflammatory);

* Calcium Carbonate Antacid (antiacid);

* Cyanocobalamin (supplement);

* Folic Acid (supplement);

* Melatonin (for insomnia);

* Pantoprazole Sodium (for gastric reflux);

* Sevelamer HCl (to lower high blood phosphorus in dialysis);

* Vitamin D3 (supplement); and

* Dialyvite RX multivite (supplement).

The need to ensure the medication record for each resident the facility administered medications included reasons for use was reviewed with Staff 1 (Administrator) and Staff 2 (RN) on 06/15/23 at 2:30 pm. They acknowledged the findings. No further information was provided.

Resident's signed physician's medication list will continue to be requested on a regular basis to ensure all medicine, instructions, PRN parameters, etc is correct. In addition, facility to request physicians to include diagnosis/reasons for use on all medication.

This will be requested prior to move in and monitored on a quarterly and as needed basis.

This will be completed by July 30th, 2023.

The Administrator, Office Manager, Resident Care Coordinator, and/or Nurse will be responsible in monitoring that this correction is complete.

Based on interview and record review, it was determined the facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support. Findings include, but are not limited to:

During an interview with Staff 6 (Facility Manager) on 01/02/24 at 2:30 pm it was revealed that the facility did not have MT's scheduled between the hours of 9:30 pm and 6:30 am. Staff 6 stated there was an "on-call" MT who lived onsite that was available if needed, but there was not a MT scheduled on-shift between the hours of 9:30 pm and 6:30 am.

On 01/02/24 the staff schedule for the week of 01/01/24-01/07/24 for Building 1 and Building 2 provided by the facility was reviewed and revealed there was not a MT scheduled between the hours of 9:30 pm and 6:30 am.

On 01/02/24, the survey team requested Staff 3 (Chief Financial Officer) and Staff 9 (RCC) provide confirmation a MT would be scheduled for the evening shift and going forward. At 4:00 pm an updated schedule was provided demonstrating a MT was scheduled for Building 1 and Building 2 for that evening and going forward.

The need to ensure the facility had qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident was discussed with Staff 3 and Staff 9 on 01/02/24, and Staff 1 (Administrator) on 01/03/24. They acknowledged the findings.

The facility has scheduled medication techs for the overnight shift from 9:30pm to 6:30am to ensure that resident's needs are being met 24 hours.

This will be monitored on a daily and as needed basis.

This has been completed as of January 2nd, 2024.

The Administrator, Chief of Financial Operations, Resident Care Coordinator, Site Manager, and/or Office Manager will be responsible in monitoring that this correction is complete.  

Based on observation, interview and record review, the facility failed to update the ABST (Acuity Based Staffing Tool) before a resident moved in, with a significant change of condition and quarterly. Findings include, but are not limited to:

On 01/05/23 at 1:40 pm, the ABST was reviewed with Staff 1 (Interim Administrator) and Staff 4 (Office Manager). Resident 1, 2, 3 and 4's information was requested.

Resident 3 was admitted to the facility in 10/2022. The resident had not been added to the facility's ABST.

Resident 4 experienced two significant changes of condition in 09/2022 and in 10/2022. Not all of the increased care needs were reflective in the ABST document.

Per review of the tool online, the ABST was not updated for each resident quarterly.

The need to ensure the facility's ABST is updated before a resident moves in to the facility, when a resident experiences a significant change of condition and updated quarterly was reviewed with Staff 1 and Staff 4 on 01/05/23. They acknowledged the findings.

Acuity Based Staffing Tool will be updated as resident's care needs change, residents move in & out. It will be monitoried on a weekly and as needed basis.

This will be completed by March 7th, 2023. The Interim Administrator, Office Manager, Human Resource, and/or Resident Care Coordinator will be responsible in monitoring that this correction is complete.  

Based on interview and record review, the facility failed to review the ABST (Acuity Based Staffing Tool) before a resident moved in, with a significant change of condition and no less than quarterly. This is a repeat citation. Findings include, but are not limited to:

On 06/15/23 at 11:45 am, the ABST was reviewed with Staff 4 (Office Manager) and revealed the following:

a. Resident 5 was admitted to the facility on 05/08/23 and had a triggered significant change of condition on 05/25/23. The resident's ABST was not updated prior to move-in or following the significant change of condition.

b. Resident 6 admitted to the facility in 07/2021 and his/her ABST had not been reviewed and updated quarterly since 08/03/22.

c. The ABST for 18 unsampled residents had not been reviewed or updated quarterly since 08/2022.

d. The ABST for one unsampled resident who admitted to the facility in 12/2022 had not been reviewed and updated at move-in or quarterly.

The need to ensure the facility's ABST was updated before a resident moved into the facility, following a significant change of condition, and no less than quarterly was reviewed with Staff 1 (Administrator) and Staff 4 on 06/15/23. They acknowledged the findings.

Acuity Based Staffing Tool will continue to be updated as resident's care needs change and as residents move in & out. This will be used to ensure staffing needs are met. This will be monitored on a weekly and as needed basis.

This will be completed by July 30th, 2023.

The Administrator, Office Manager, Resident Care Coordinator, and/or Human Resource Manager will be responsible in monitoring that this correction is complete.  

Based on interview and record review, it was determined the facility failed to ensure the Acuity-Based Staffing Tool (ABST) was accurate and updated following a significant change of condition, for 2 of 2 sampled residents (#s 1 and 8), whose ABST data was reviewed. This is a repeat citation. Findings include, but are not limited to:

Review of Resident 1 and 8's records and interviews with staff and residents noted ABST entries were not reflective of the residents' current care needs. The ABST data showed multiple areas which reflected zero to two minutes when the residents required more extensive staff assistance with those activities.

During an 01/04/24 interview with Staff 1 (Administrator), she acknowledged the ABST had not been updated following Resident 8's significant change of condition and was not reflective of the actual care time needed to provide ADL assistance for Residents 1 and 8 which potentially created inaccurate staffing calculations.  

The need to ensure resident entries for the ABST were accurate was discussed with Staff 1 on 01/04/24. She acknowledged the findings.

Acuity Based Staffing Tool will continue to be updated as resident's care needs change and as residents move in & out. Management team along with care staff will conduct a time study to get updated times for each of the resident's ALDs. This will be used to ensure proper staffing needs are met.

This will be monitored on a weekly and as needed basis.

This will be completed by February 16th, 2024.

The Administrator, Resident Care Coordinator, Site Manager, and/or Office Manager will be responsible in monitoring that this correction is complete.

Based on interview and record review, it was determined the facility failed to ensure 1 of 1 newly hired staff (# 11) completed all required pre-service orientation training prior to beginning their job responsibilities and providing care for residents and 1 of 2 long-term staff (# 13) completed infectious disease prevention training prior to 07/01/22. Findings include, but are not limited to:

Staff training records were reviewed on 01/05/23 and revealed the following:

1. There was no documented evidence Staff 11, hired 11/15/22, completed one or more of the following required pre-service orientation elements prior to performing any job duties:

* Resident rights and values of CBC care;

* Abuse reporting requirements;

* Infectious disease prevention;

* Fire safety and emergency procedures; and

* Written job description.

2. There was no documented evidence Staff 13 (CG), hired 11/09/21, completed infectious disease prevention training prior to 07/01/22.

The need to ensure training is completed by newly hired and long-term staff within the required time frame was discussed with Staff 4 (Office Manager) and Staff 5 (Human Resources) on 01/05/23. They acknowledged the findings.

Newly hired staff will complete all training and documents prior to start date. It will be monitored on an as needed basis. All staff to complete or renew any expired certificates/training.

This will be completed by March 7th, 2023. The Interim Administrator, Facility Manager, Office Manager, and/or Human Resource will be responsible in monitoring that this correction is complete.  

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 8, 10 and 11) had documented demonstration of competency in all required areas within 30 days of hire. Findings include, but are not limited to:

Review of the facility's training records on 01/05/22 revealed the following:

1. There was no documented evidence Staff 8 (MT), hired 11/04/22, and Staff 11 (CG), hired 11/15/22, had demonstrated competency in all required areas and within 30 days of hire including:

* Role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Changes associated with normal aging;

* Identification, documentation and reporting of changes of condition;

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

* General food safety, serving and sanitation.

2. There was no documented evidence Staff 8 had completed First Aid/Abdominal Thrust.

3. There was no documented evidence Staff 10 (MT), hired 09/22/22, had demonstrated competency in medication pass.

The need to ensure staff demonstrated competency in all assigned job duties within 30 days of hire was discussed with Staff 4 (Office Manager) and Staff 5 (Human Resources) on 01/05/23. They acknowledged the findings.

Newly hired staff will complete all training & documents, and given all important instruction/information regarding residents within the 30 day required time frame of employment. It will be monitored on an as needed basis depending on the staff's hire date.

This will be completed by March 7th, 2023. The Interim Administrator, Facility Manager, Office Manager, and/or Human Resource will be responsible in monitoring that this correction is complete.  

Based on interview and record review, it was determined the facility failed to have a system in place to document annual training for 2 of 2 long-term staff (#s 6 & 13). Findings include, but are not limited to:

Annual training records were requested on 01/04/23 for Staff 6 (Facility Manager) and Staff 13 (CG). The facility was unable to provide documented evidence annual training had been completed for either staff member.  

During an interview on 01/05/23, Staff 4 (Office Manager) acknowledged while some of their records were lost in a fire in 2022, there was no current tracking system to monitor annual staff training.

The need to ensure 12 hours of annual in-service training was completed for long term staff was reviewed with Staff 4 and Staff 5 (Human Resources) on 01/05/23. They acknowledged the findings.

Inservice training hours will be tracked on a document to ensure 12  hours of annual training are being met by each long term staff member. It will be monitored on a monthly and as needed basis.

This will be completed by March 7th, 2023. The Interim Administrator, Facility Manager, Office Manager, and/or Human Resource will be responsible in monitoring that this correction is complete.  

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

Available fire drill records from 08/2022 through 12/2022 were reviewed. The facility lacked documentation that residents were being instructed on fire and life safety procedures within 24 hours of admission and at least annually.  

The need to document instruction to residents in fire and life safety procedures within 24 hours of move-in and annually thereafter was discussed with Staff 1 (Interim Administrator), Staff 9 (MT) and Staff 6 (Facility Manager) on 01/06/23. They acknowledged the findings.

Residents will be instructed of & sign the document for the fire drills and safety procedures. It will be monitored annually and 24 hr upon new resident move in.

This will be completed by March 7th, 2023. The Interim dministrator, Facility Manager, Office Manager, and/or Human Resource will be responsible in monitoring that this correction is complete.  

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

Refer to C260, C270, C303, C310, C361 and C513.

Management team will meet on a regular basis to ensure facility corrects and remains in compliant in all reported deficiencies. This will be monitored on a weekly and as needed basis.

This will be completed by July 30th, 2023.

The Administrator and/or Office Manager will be responsible in monitoring that this correction is complete.  

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

Refer to C 270, C 280, C 361, and C 513.

Facility Management team will continue to meet on a regular basis to ensure facility corrects and remains in compliant in all reported deficiencies.

This will be monitored on a weekly and as needed basis.  

This will be completed by February 16th, 2024.

The Administrator and/or Office Manager will be responsible in monitoring that this correction is complete.  

Based on observation and interview, it was determined the facility failed to ensure all chemicals and toxic materials were maintained in a locked storage unit, pathways were free of tripping hazards, the grounds were free of refuse and needles and biohazards were not accessible to residents. Findings include, but are not limited to:

The interior and exterior of the facility was toured on 01/03/23 and 01/04/23. The following issues were observed:

* Multiple types of chemicals (bleach, citric acid solution) were observed easily accessible on a blue cart in the dialysis area;

* Carpet pre-spray, carpet adhesive and open paint cans were observed on the counters and inside the unlocked cupboards in the laundry room;

* An open sharps container with needles and biohazard material was observed easily accessible in the dialysis area;

* A long metal pipe was observed blocking a paved pathway on the facility grounds; and

* Chairs, mattresses, toilets and other refuse were observed in between a shed and Building 3.

The above findings were discussed with Staff 3 (Chief Financial Officer) on 01/05/23. He acknowledged the findings.

All chemicals will be placed and locked in proper storage. All other hazardous objects will be moved to another location not easily accessible or removed altogether. It will be monitored on a weekly and as needed basis.

This will be completed by March 7th, 2023. The Interim Administrator, Chief Financial Officer, and/or Facility Manager will be responsible in monitoring that this correction is complete.

Based on observation and interview, it was determined the facility failed to ensure all interior and exterior materials and surfaces (e.g., floors, walls, ceilings and furniture) and all equipment necessary for the health, safety and comfort of the resident was kept clean and in good repair. Findings include, but are not limited to:

The facility was toured from 01/03/23 through 01/06/23 and the following was identified:

1. Facility-wide:

* Baseboards had dirt buildup; and

* Multiple doors had stains, black scuffs, dings and paint chips.

2. Building 1 bathroom by exit door in the hall to the right:

* The floor was stained near the sink;

* Both sides of door had grime, stains and scuffs;

* There was a soda can on the towel bar;

* There were paint chips on all walls;

* The garbage can had splashes and grime buildup;

* There were brown smears on the accessible toilet seat;

* The toilet base had stains and black scuffs; and

* The walls by the sink had splashes and stains.

3. Building 1 bathroom in the first hall to the left of the lobby:

* There were soap stains on floor;

* The door frame had black scuffs and brown splashes;

* The toilet base had dust, stains and black hairs;

* The shower edge and drain had pink grime;

* The shower curtain had dark stains;

* The ceiling vent had dust buildup; and

* The ceiling and wall above the toilet had water damage.

4. Dialysis area:

* The hallway light was not working;

* The wall in front of the dialysis area had paint scuffs; and

* The floor in the dialysis area had an uneven surface and was taped down in areas.

5. Hallway to the far left of the lobby:

* There was water damage on the wall next to the electric panel and on the ceiling beam.

6. Laundry room:

* The sink had white splashes and stains;

* There was lint buildup around sink on countertop;

* The cabinet fronts had worn laminate and one drawer was missing;

* There were dirty garbage cans stored on the countertop;

* There were holes and paint scratches on the wall next to the light switch; and

* The floor had black and brown splashes and stains.

7. Hallway outside laundry room:

* The vent outside the laundry room had dust buildup; and

* There was a hole approximately 3 inches in diameter in the ceiling outside Room 114.

8. Bathroom near room 120:

* The seal was cracked around the sink;

* There were white splashes on floor;

* The walls had horizontal black and paint scuffs;

* There was black matter along the shower floor frame;

* There were paint chips and wall material chipping away near the baseboard by the shower;

* The toilet base had black scuffs and brown stains; and

* The ceiling vent was dusty.

9. Building 1 dining room:

* There were pink splashes on the wall and handrail in front of the dining room; and

* The storage cabinet had a broken drawer.

10. Building 2 lobby:

* The wall moulding had splashes, dirt buildup on ledges and black scuffs; and

* The wall to the left of the fish tank was dented with exposed metal.

11. Bathroom across from Room 202:

* The walls had multiple paint chips; and

* The toilet base and bowl had yellow stains.

12. Bathroom across from Room 211:

* The tile baseboard by the shower was damaged;

* The wall by to the left of the shower was chipped;

* The shower curtain had mildew stains;

* The shower light was not functioning; and

* The walls had horizontal paint chips, holes and black scuffs.

13. Building 2 dining room:

* The baseboards had black grime buildup;

* The walls had paint scuffs and multiple areas missing paint;

* One section of baseboard was missing; and

* The vent covers on the floor were dented and rusted.

The facility was toured with Staff 3 (Chief Financial Officer) on 01/05/23. He acknowledged the above findings.

Interior of facility will be cleaned and maintained in good repair. It will be monitored on a weekly and as needed basis.

This will be completed by March 7th, 2023. The Interim Administrator, Chief Financial Officer, and/or Facility Manager will be responsible in monitoring that this correction is complete.

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

The facility was toured on 06/13/23 and 06/14/23, and the following was identified in Building 1:

* The floor in the dialysis area had an uneven surface and was taped down in areas; and

* The floor in the kitchenette had a circular burn mark.

On 06/14/23, the facility was toured with Staff 3 (Chief Financial Officer), and he acknowledged the areas that needed to be repaired.

Facility floors will be replaced and maintained in good repair. This will be monitored on a weekly and as needed basis.

This will be completed by July 30th, 2023.

The Administrator, Chief Financial Officer, and/or Facility Manager will be responsible in monitoring that this correction is complete.

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

The facility was toured on 01/02/24, and the following was identified in Building 1:

* The floor in the dialysis area had an uneven surface and was taped down in areas; and

* The floor in the kitchenette had a circular burn mark.

On 01/02/24, the facility was toured with Staff 6 (Facility Manager) and he acknowledged the areas that needed to be repaired. Staff 3 (Chief Financial Officer) acknowledged the findings on 01/02/24.

Facility floors will be replaced and maintained in good repair.

This will be monitored on a weekly and as needed basis.

This will be completed by February 16th, 2024.

The Administrator, Chief of Financial Operations, and/or Site Manager will be responsible in monitoring that this correction is complete.

Based on observation and interview, it was determined the facility failed to ensure the capacity to seat 100% of the residents in Building 1's combined room. Findings include, but are not limited to:

Building 1's combined dining, activities, and living room was measured on 01/06/23 at 9:00 am. The room measured 318.24 square feet. This amounted to 13.26 square feet per resident at building capacity of 24 residents, and 15.9 square feet per resident at current census of 20 residents. There were two tables with the capacity to seat 12 residents.

In an interview on 01/05/23, Staff 1 (Interim Administrator) acknowledged the inadequate square footage per resident and stated they had been considering offering meals in shifts to accommodate the residents.

The need to ensure a minimum of 30 square feet per resident for a combined dining, activities, and living room was discussed with Staff 1 (Interim Administrator) and Staff 3 (Chief Financial Officer) on 01/06/23. They acknowledged the findings.

Dining areas will have adequate seating for 100% of residents. It will be monitored on an as needed basis.

This will be completed by March 7th, 2023. The Interim Administrator, Chief Financial Officer, and/or Facility Manager will be responsible in monitoring that this correction is complete.

Based on observation and interview, it was determined the facility failed to ensure a flushing rim clinical sink with a handheld rinsing device and a hand wash sink or lavatory for soiled laundry. Findings include, but are not limited to:

During a tour of the facility laundry room on 01/03/23 at 11:00 am, one sink was observed that lacked a flushing rim and a handheld rinsing device. The laundry room lacked a separate hand wash sink.

In an interview on 01/04/23, Staff 3 (Chief Financial Officer) stated the facility's flushing rim clinical sink and soiled laundry processing room was currently under repair in another building and staff were not able to access it. Staff 3 acknowledged there was no alternative process in place to properly handle soiled laundry.

The need to ensure proper equipment for the handling of soiled laundry was discussed with Staff 3 on 01/05/23. He acknowledged the findings.

Housekeeping & caregiving staff will be instructed of the proper process for soiled linen. Facility to look into improving laundry equipment. It will be monitored on a daily and as needed basis.

This will be completed by March 7th, 2023. The Interim Administrator, Chief Financial Officer, and/or Facility Manager will be responsible in monitoring that this correction is complete.

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

A tour of the facility on 01/03/23 revealed the exit door alarms for Buildings 1 and 2 were inoperable and did not alert staff when doors were opened.

During a walk-through of the environment on 01/03/23 at 2:00 pm, Staff 3 (Chief Financial Officer) acknowledged the door alarms were not functioning.

All exit doors at buildings 1 & 2 will be checked to ensure they are properly working and have adequate alarms. It will be monitored on a weekly or bi weekly basis and replaced as needed.

This will be completed by March 7th, 2023. The Interim Administrator, Chief Financial Officer, and/or Facility Manager will be responsible in monitoring that this correction is complete.