Print Inspection: T0KJ

The findings of the re-licensure survey conducted 04/19/22 through 04/21/22 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 re-visit to the re-licensure survey of 04/21/22, conducted 11/30/22 through 12/02/22, 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

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 04/19/22, conducted 03/23/23 through 03/24/23, 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 third revisit to the re-licensure survey of 04/21/22, conducted 06/22/23 through 06/23/23, 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 interview and record review, it was determined the facility failed to thoroughly investigate incidents to rule out suspected abuse or neglect for 2 of 4 sampled residents (#1 and 2) who experienced falls. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 2018 with diagnoses including left arm amputation.

The resident's most recent evaluation and service plan noted s/he was at risk for falls and utilized a transfer pole to assist transferring in and out of bed. The facility had previously identified the transfer pole as a device with potentially restraining qualities, noting the distance the transfer pole was to be placed from the bedside and evaluated the resident's ability to use the transfer pole safely.

Progress notes dated 01/19/22 through 04/19/22 were reviewed and revealed the resident experienced a fall on 02/22/23.

Facility staff charted "Resident found on floor ...his/her head was stuck between the bed and the [transfer] pole."

The resident was noted to have experienced significant pain after the fall.

The facility lacked documented evidence the incident was thoroughly investigated including the placement and safety of the device at the time of the resident's fall and subsequent entrapment.  

On 04/21/22 the need to ensure incidents were thoroughly investigated to rule out abuse and neglect or reported to the local SPD office when abuse and neglect could not be ruled out was discussed with Staff 1 (Administrator) and Staff 3 (RCC). They acknowledged the findings. As requested, the fall was reported to the local SPD office before the survey concluded.

2. Resident 2 was admitted to the facility in 2021 with diagnoses including Parkinson's disease and had multiple unwitnessed falls.

During an interview with Staff 12 (CG) s/he stated Resident 2's mobility fluctuated throughout the day and the resident was often dependent on staff for assistance with transfers and ambulation related to safety. Staff 12 stated the resident would frequently try to transfer him/herself independently.

A review of Resident 2's incident reports, PT and OT assessments and progress notes dated 01/20/22 through 04/19/22 revealed s/he had six unwitnessed falls. The incident reports did not document the information needed to immediately rule out abuse and neglect, including whether the service plan was being followed. The reports also lacked verification the incidents had been reviewed by the Administrator.

During an interview with Staff 1 (Administrator) on 04/21/22, the process for reporting and investigating incidents was discussed. Staff 1 acknowledged the incident reports did not include a review of the PT/OT assessments following the falls, documentation needed to sufficiently rule out abuse or neglect as well as the date and review of the Administrator.

The need to ensure investigations contained the required documentation was discussed with Staff 1 (Administrator) and Staff 3 (RCC) on 04/21/22. They acknowledged the findings.

1. Administrator reviewed  each event for Resident 1 and 2 that had the potential to be abuse/neglect and  reported it to APS if appropriate.

2. Administrator or designee will review each event that has the potential to be abuse/neglect. That person will complete the investigation and sign it off as complete  or report it to APS.The Administrator or designee will use the Abuse Decision Tree from DHS when reviewing incidents to determine if they need to be reported.

3. This process will be used on all events that have the potential for abuse or neglect.

4. Administrator or designee.  Incident reports will be reviewed by the Quality Assurance committee to ensure compliance.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and provided clear direction regarding the delivery of services for 3 of 6 sampled residents (#s 2, 4 and 5) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 2/2022 with diagnoses which included diabetes and depressive disorder.

Review of the clinical record, observations, and an interview with Resident 4 were made during the survey. The current service plan, dated 03/16/22, revealed it was not reflective of his/her needs and lacked clear direction regarding the delivery of services in the following areas:

* Disruptive behaviors, aggression, anxiety and irritability; and

* Side rail use.

The need to ensure the service plan was reflective of Resident 4's current needs and provided clear direction to staff was discussed with Staff 1 (Administrator) on 04/20/22 at 2:10 pm. She acknowledged the findings.

2. Resident 2 was admitted to the facility in late 2021 with diagnoses including Parkinson's disease.

Review of the clinical record, observations, and an interview with Resident 2 were made during the survey. The current service plan, dated 04/14/22, revealed it was not reflective of his/her needs and lacked clear direction regarding the delivery of services in the following areas:

* transfer ability and need for staff assistance;

* need for assistance with bathing/showers;

* ambulation status and need for staff assistance for safety;

* use of a transfer pole; and

* current fall interventions.

The need to ensure the service plan was reflective of Resident 2's current needs and provided clear direction to staff was discussed with Staff 1 (Administrator) on 04/21/22. She acknowledged the findings.

3. Resident 5's records were reviewed during the survey. Resident 5's service plan was not reflective in the following areas:

* The oxygen setting and who was to provide care and cleaning of oxygen tubing and cannula;

* Foley catheter care and instructions;

* Instructions to staff for resident's signs and symptoms of anxiety; and

* Instructions to staff on what to look for with safety of side rails.

The need to ensure service plans were reflective of resident needs and included clear direction for staff was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 04/21/22. They acknowledged the findings.

1. Administrator and RN's reviewed service plans for Resident's 2, 4 and 5 and updated them to reflect current care needs.  

2. Administrator or designee will conduct a training with staff members who are completing services plans with an emphasis on specific interventions that are current and reflective of each resident's care needs. Housing Leadership will review the resident roster and determine which service plans need an immediate review due to the complex nature of the resident needs. Those service plans will be reviewed within the next 45 days. All others will be reviewed at change of condition or regularly scheduled service plan review date.

3. Administrator or designee will review service plans for accuracy and to ensure they are reflective and specific to each resident.

4. Administrator or designee will audit 5% of service plans each month to ensure compliance.

3. Resident 1 was admitted to the facility in 2018 with diagnoses including infection of skin including subcutaneous tissue.

The resident's 01/19/22 through 04/19/22 progress notes and ADL Logs were reviewed and revealed the resident experienced the following changes of condition:

* The resident experienced ongoing open areas to his/her perineal area;

* 02/08/22 "Large area of bubbled skin on anterior aspect of right lower leg"; and

* 02/22/22 "Sediments in catheter."

There was no documented evidence the facility monitored the changes of condition with progress noted at least weekly through resolution.  

On 04/21/22 the need to ensure Resident 1's changes in condition were monitored with progress noted at least weekly through resolution was discussed with Staff 1 (Administrator) and Staff 3 (RCC). They acknowledged the findings.

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

The resident's 01/19/22 through 04/19/22 progress notes and ADL Logs were reviewed and revealed the resident experienced the following changes of condition. following:

* 02/05/22 Eye surgery;

* 02/07/22 UTI;

* 02/11/22 Fall;

* 02/14/11 Pain to the right knee; and

* 02/26/22 Fall.

There was no documented evidence the facility monitored the changes of condition with progress noted at least weekly through resolution.  

On 04/21/22 the need to ensure Resident 3's changes in condition were monitored with progress noted at least weekly through resolution and fall interventions were reviewed for effectiveness effective was discussed with Staff 1 (Administrator) and Staff 3 (RCC). They acknowledged the findings.

Based on observation, 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 conditions monitored to resolution for 4 of 6 sampled residents (#s 1, 2, 3 and 5) who experienced changes of condition. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in late 2021 with diagnoses including Parkinson's disease. A review of the clinical record revealed the following:

Resident 2 experienced six falls between January and April, 2022. The facility failed to determine if service-planned interventions were effective or if new interventions were needed following each fall. Additionally, there was no documented evidence the facility monitored and documented on the progress of skin injuries sustained, following the falls on 02/03/22 and 04/08/22, at least weekly until resolved.

The need to ensure the facility monitored short term changes of condition with weekly progress noted until resolution and that fall interventions were reviewed to determine if they were effective was shared with Staff 1 (Administrator) and Staff 3 (RCC) on 04/21/22. They acknowledged the findings.

2. Resident 5 was admitted to the facility in May 2015 with diagnoses including hypertensive heart disease. A review of the clinical record revealed the following:

Resident 5 was placed on alert charting 03/14/22 for possible blood in stool and again on 03/16/22 for a fall with a cut to the left elbow. The facility failed to document on the progress of these changes at least weekly until resolved.

The need to ensure the facility monitored short term changes of condition with weekly progress noted until resolution was shared with Staff 1 (Administrator) and Staff 2 (RN) on 04/21/22. They acknowledged the findings.

1. Administrator and RN's reviewed changes of condition for Resident's 1, 2, 3 and 5 and determined if a change of condition was still current and if so, put new interventions in place. A managed risk agreement is under negotiation with facility and Resident 2.

2. Housing leadership will review the change of condition practices at Housing All Staff meeting on May 25th, 2022 to ensure that changes of condition and monitoring are communicated and documented timely. RN Manager will conduct significant change and temporary significant change training to include identification, reporting, monitoring, documentation and communication of changes. Housing leadership will review residents with potential changes of condition or need for increased monitoring at least 2x per week with Housing RN. Housing RN's will be responsible for documentation, Administrator will audit.

3. Adminstrator will audit 5% of charts monthly.

4. (See #3 above)  

2. Resident 8 was admitted to the facility in 04/2017 with diagnoses including multiple sclerosis.

The resident's progress notes dated 09/01/22 through 11/30/22 were reviewed.

a. The following short-term changes of condition lacked documented evidence they were evaluated to determine if any actions or interventions were needed:  

* 09/06/22 - resident complained of dizziness and left toe injury; and

* 11/14/22 - painful back mole.

b. The following changes of condition lacked documented evidence they were monitored, at least weekly, through resolution:

* 09/06/22 - resident complained of dizziness and left toe injury;

* 10/26/22 - increased pain to low back and request for lidocaine patch;

* 11/04/22 - fall with hip fracture;

* 11/12/22 - right pinky toe swollen and filled with pus; and

* 11/14/22 - painful back mole.

The need to ensure changes of condition were evaluated to determine if any actions or interventions were needed and, if so, were communicated to staff on each shift and were monitored through resolution was discussed with Staff 1 (Administrator) on 12/02/22. She acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure changes of condition were evaluated and referred to the facility RN as needed, actions and interventions developed and communicated to staff, changes monitored and documented at least weekly through resolution for 2 of 2 sampled residents (#s 7 and 8) whose records were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 7 was admitted to the facility in 10/2021 with diagnoses including Parkinson's disease.

A review of the resident's current service plan, progress notes and weight records since 08/31/22 showed the following:

a. Weight log, provided on 12/01/22, showed the following weights for Resident 7:

* 08/15/22: 249.6 pounds;

* 09/28/22: 255 pounds;

* 10/19/22: 238.6 pounds;

* There was no weight obtained for the month of November; and

* 12/01/22: 246.3 pounds (weight obtained during the survey per request).

b. Progress notes reviewed showed the following:

* 10/04/22: weighted utensils missing, "prt having increased amount of tremors which prevent them to eat.";

* 11/03/22: complaints of nausea and stomach pain;

* 11/04/22: refused dinner;

* 11/05/22: refused dinner;

* 11/08/22: refused dinner;

* 11/09/22: refused breakfast and lunch.

c. During an interview on 12/01/22, Resident 7 stated s/he was dependent upon "Boost" supplements for nutrition because his/her hand tremors prevented him/her from eating. "Today I finally got a sandwich I could eat because it was ham and cheese, grilled, so it held together." During an interview with direct care staff the same day, staff stated they did not usually bring the resident breakfast because s/he "doesn't want it" and reported the weighted utensils are sometimes not available. There was no documented evidence the resident's weight loss had been evaluated or reported to the facility RN. In an interview on 12/02/22, Staff 2 (RN) confirmed she had not been informed of the weight loss.

The clinical record and interviews revealed Resident 7 experienced a 16 pound weight loss (or 6.43% of body weight) in one month, from 09/28/22 to 10/19/22. This represented a severe loss of weight. The facility failed to evaluate the resident, refer to the facility RN, document the change and update the service plan as needed.

The need to ensure changes of condition were evaluated and referred to the facility RN as needed was discussed with Staff 1 (Administrator) and Staff 2 on 12/02/22. They acknowledged the findings.

1. Administrator and RN's reviewed changes of condition for resident's #7 and #8, and determined if a change of condition was still current and if so, put new interventions in place.

2. Housing leadership will review the change of condition practices at Housing All Staff meeting on 1/4/2022 to ensure that changes of condition and monitoring are communicated and documented timely. Housing leadership will review residents with potential changes of condition or need for increased monitoring at least 2x per week with Housing RN. Housing RN's will be responsible for documentation, Administrator will audit.

3. Adminstrator will audit 5% of charts monthly.

4. Administrator

Based on interview and record review, it was determined the facility failed to ensure interventions were developed and communicated to staff on each shift and the conditions were monitored through resolution for 1 of 3 residents (# 10) who experienced short-term changes of condition. This is a repeat citation. Findings include, but are not limited to:

Resident 10 moved into the facility in 2016 with diagnoses including anemia. A review of the clinical record revealed the following:

Progress notes and "Physical Therapy Assessment" notes were reviewed and revealed the resident had experienced the following changes of condition:

* 02/13/23: " ...half a dime sized red bruise ...near medial malleolus";

* 02/21/23: "Resident on alert for right hand bruise";

* 02/23/23: "Resident [has] two [small] sore in both sides of buttocks ..."; and

* 02/24/23: Medication change, start furosemide 40 mg tablet, take one tablet by mouth twice daily on Monday, Wednesday, Friday and Saturday, give second dose in early afternoon (for edema).

There was no documented evidence the facility monitored the changes of conditions with progress noted at least weekly through resolution.

The need to ensure Resident 10's short term changes of condition were monitored  with progress noted at least weekly through resolution was discussed with Staff 1 (Administrator), Staff 2 (RN) and Staff 15 (Resident Care Supervisor). They acknowledged the findings.

1. Housing RN's has requested clinical records from provider and has performed an assessment. A significant change of condition plan has been implemented.

2. Housing leadership has held a repeat training for the change of condition practices with Housing RN's. Housing leadership has implemented a new tracking tool for the RN's that will review potential changes of condition or need for increased monitoring. This tracking tool will be reviewed at least 2x per week with Housing RN's. Housing RN's will be responsible for documentation, Administrator will audit.

3. Adminstrator will audit 5% of charts monthly.

4. Administrator

3. Resident 3 was admitted in 2021. The resident experienced low vision and was noted to require assistance with meals.

The resident's 03/19/22 through 04/19/22 MAR was reviewed and revealed the following:

On 03/23/22 the facility RN noted "resident has lost 19.6 pounds in the last 2.5 months. 01/12/22 172.3 pounds [and] 03/25/22 152.7 pounds."

Weight records for Resident 3 were requested and were recorded as:

* 01/12/22 172.3 pounds;

* 03/25/22 152.7 pounds; and

* 04/21/22 160.8 pounds.

The resident experienced a loss of 12.06 % of  his/her total body weight between 01/2022 and 03/2022. This constituted severe weight loss and required an RN assessment.

There was no documented evidence the facility RN completed a significant change of condition assessment for the overall decline in health which included documented findings and resident status.

On 04/21/22 the requirement to ensure an RN assessment was completed for residents who experienced significant changes of condition was discussed with Staff 1 (Administrator) and Staff 3 (RCC). They acknowledged the findings.

2. Resident 2 was admitted to the facility in late 2021 with diagnoses including Parkinson's disease.

Progress notes, dated 03/15/22, showed Resident 2 was sent out to the hospital after experiencing a fall and for evaluation and treatment of potential renal failure. The resident returned to the facility on 03/18/22 with a Foley catheter. The decline in the resident's condition and a new Foley catheter represented a significant change of condition.

In an interview on 04/20/22, Staff 1 (Administrator) provided a report from the "Clinic RN" who assessed Resident 2 upon his/her return to the facility on 03/18/22. The assessment included a statement "Foley catheter draining concentrated yellow urine". The assessment lacked interventions made as a result of the assessment and did not provide any instructions to staff on assistance the resident would need with care and monitoring of the new catheter.

The need to ensure an RN assessment was completed which documented findings, resident status and interventions made as a result of the assessment for significant changes of condition was discussed with Staff 1 (Administrator) on 04/21/22. She acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure an RN assessment for 3 of 4 sampled resident (#2, 3 and 5) who had significant changes of condition had been completed.  Findings include, but are not limited to:

1. Resident 5 was admitted to the facility in May 2015 with diagnoses including hypertensive heart disease.

Review of the resident's 02/22/22 through 04/19/22 progress notes, physician faxes and service plan showed the following:

The resident was admitted to the hospital 03/26/22 and returned to the facility on 04/08/22 with an "end of life" diagnosis.

Resident 5 had a significant change of condition due to a new diagnosis of "end of life". There was no documented evidence the RN had completed an assessment.

The need to have an RN assessment for a significant change of condition was reviewed with Staff 1 (Administrator) and Staff 2 (RN) on 04/21/22. They acknowledged the findings.

1.Administrator and RN's reviewed significant changes of condition for Resident's 2, 3 and 5 and the RN completed signfiicant changes of condition assessments.

2.Housing leadership will review the change of condition practices at Housing All Staff meeting on May 25th, 2022 to ensure that changes of condition and monitoring are communicated and documented timely.

Housing leadership will review residents with potential changes or condition or need for increased monitoring at least 2x per week with Housing RN. Housing RN's will be responsible for documentation, Administrator will audit.

3. Adminstrator will audit 5% of charts monthly.

4. (See #3 above)

Based on interview and record review, it was determined the facility failed to have a system to coordinate care with outside providers in order to ensure the continuity of care for 1 of 2 sampled residents (#2) who received services from an outside provider. Findings include, but are not limited to:

Resident 2's clinical record was reviewed during the survey. Outside provider notes from Occupational and Physical therapy were reviewed and the following was revealed:

a. On 01/03/22, OT met with Resident 2, following a fall, and made recommendations for staff to assist the resident with showers and to provide contact guard assistance with shower transfers and ambulation. There was no evidence these recommendations had been reviewed and communicated for facility staff to follow.

b. On 02/23/22 and 03/18/22, Resident 2 was again assessed by OT and recommendations were made related to fall interventions, use of a transfer pole and determination of a safe transfer method for staff to follow. There was no evidence these recommendations had been reviewed and communicated for facility staff to follow.

In an interview on 04/21/22, Staff 1 (Administrator) and Staff 3 (RCC) explained the facility would be modifying their process for reviewing outside provider notes that would include having the notes reviewed by facility staff.

The need to coordinate on-site health services with outside service providers, ensure that staff were informed of new interventions, and that the service plan was adjusted if necessary was discussed with Staff 1 and Staff 3 on 04/21/22. They acknowledged the findings.

1. Housing RN will review each After-Visit Summary or Visiting Provider Form for any changes in plan of care. RN will summarize changes in EMR and ensure the service plan is updated as needed. RN reviewed resident 2's outside service provider information and updated service plan as needed.

2. Administrative Assistant will audit resident appointment schedules and request medical records for review as needed. (All residents at Glendoveer receive care through the PACE organization, which is part of the same Providence service line.)

3. Administrative Assistant performs the appointment audit weekly.

4. Housing Leadership will review completed resident appointments at least 2x per week.  

Based on interview and record review, it was determined the facility failed to have a system to coordinate care with outside providers to ensure the continuity of care for 1 of 2 sampled residents (#8) who received services from an outside provider. This is a repeat citation. Findings include, but are not limited to:

Resident 8 was admitted to the facility in 04/2017 with diagnoses including hip fracture and was receiving home health services of PT.

Home Health visit notes indicated the outside provider had left the following recommendations for care:

* 11/10/22 - Posterior hip precautions and instructions regarding an abductor wedge.

There was no documented evidence the facility had reviewed the recommendations and communicated them to staff.

The need to coordinate on-site health services with outside service providers, ensure staff were informed of new interventions and the service plan adjusted, if necessary, was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 12/02/22. They acknowledged the findings.

1. Housing RN will review each After-Visit Summary or Visiting Provider Form for any changes in plan of care. RN will summarize changes in EMR and ensure the service plan is updated as needed.

2. Administrative Assistant will audit resident appointment schedules and request medical records for review as needed. (All residents at Glendoveer receive care through the PACE organization, which is part of the same Providence service line.)

3. Housing Leadership and PACE Care Team will begin bi-weekly Care Coordination Meetings beginning 1/5/22.

4. Administrative Assistant will perform the appointment audit weekly.

5. Housing Leadership will review completed resident appointments at least 2x per week.

Based on interview and record review, it was determined the facility failed to coordinate care with outside providers in order to ensure the continuity of care for 1 of 2 sampled residents (# 10) who received services from an outside provider. This is a repeat citation. Findings include, but are not limited to:

Resident 10 was admitted to the facility in 2016. The resident was noted to have experienced a skin condition to his/her coccyx.

Resident 10's clinical records identified the resident was to received PT and OT services for lower extremity weakness

A review of the record indicated PT recommended the following interventions:

03/13/23 - "Encourage rest in bed one to two hours in afternoon for pressure relief to bottom...please position at side lying on bed for one to two hours every afternoon with pillows behind back..this is the only position of comfort and gives [him/her] a break from pain and pressure off coccyx...remind [resident] to keep towel roll at low back in recliner and wheelchair."

On 03/23/23 at 2:40 pm, Staff 1 (Administrator) confirmed staff had not been instructed to encourage the resident to rest for one to two hours in the afternoon, using the positioning recommended by PT, or to remind the resident to keep a towel roll at low back when in recliner and wheelchair.  

The facility lacked an effective system to ensure outside service provider recommendations were communicated to staff to allow for supplemental care.

On 03/24/23, the need to ensure on-going coordination of care for residents receiving on and off site health services was discussed with Staff 1 and Staff 15 (Resident Care Supervisor).  They acknowledged the findings.

1. Housing RN will review each After-Visit Summary or Visiting Provider Form for any changes in plan of care. RN will summarize changes in EMR and ensure the service plan is updated as needed.

2. Administrative Assistant will audit resident appointment schedules and request medical records for review as needed. (All residents at Glendoveer receive care through the PACE organization, which is part of the same Providence service line.) Meeting held between PACE program manager and Administrator to facilitate improved Coordination of Care communications between PACE clinic and Housing.

3. Housing Leadership and PACE Care Team has begun monthly Care Coordination Meetings beginning 1/5/22.

4. Administrative Assistant will perform the appointment audit weekly.

5. Housing Leadership will review completed resident appointments at least 2x per week.

Based on interview and record review, it was determined the facility failed to ensure physician's orders were carried out as prescribed for 1 of 1 sampled resident (#8) whose orders were reviewed. Findings include, but are not limited to:

Resident 8 was admitted to the facility in 04/2017 with diagnoses including chronic pain.  

Resident 8's current physician's orders were reviewed and revealed the following:

* Oxycodone HCL 5 mg by mouth four times daily at 8:00 am, 12:00 pm, 4:00 pm and 8:00 pm for pain; and

* Oxycodone HCL 5 mg by mouth nightly as needed for pain separate from scheduled oxycodone doses by at least four hours.

According to the resident's 11/2022 MAR, the resident received his/her PRN oxycodone outside the parameters on the following dates:

* 11/04/22 - administered at 6:10 am;

* 11/10/22 - administered at 4:36 am;

* 11/17/22 - administered at 4:27 am; and

* 11/20/22 - administered at 10:11 pm.

The need to ensure physician's orders were followed was reviewed with Staff 1 (Administrator) and Staff 2 (RN) on 12/02/22. They acknowledged the findings.

1. MAR to be immediately reviewed and corrected by Housing RN for resident #8.

2. All resident MAR's will be reviewed by RN Manager for order accuracy and administration.

3. Housing RN will perform quarterly audits of resident MAR during resident quarterly assessments. RCS will perform weekly audits of missed/refused medications to ensure accuracte sign off.

4. RCS will review audits and correct any discrepancies with staff and PACE Long Term Care Pharmacy.

2. Resident 4 moved into the facility in 02/2022 and had diagnoses which included insulin dependent diabetes, psoriasis and keratitis (corneal inflammation).

Resident 4's MARs were reviewed for the time period of 04/01/22 through 04/19/22.

Staff documented Resident 4 refused:

* Refresh Lacri-lube eye ointment (for keratitis) on eight occasions;

* Clobetasol ointment (for psoriasis) on one occasion; and

* Humalog insulin on one occasion.

There was no documented evidence the facility notified Resident 4's physician/practitioner of the refusals.

In an interview on 04/21/22 at 9:20 am, Staff 1 (Administrator) reviewed the record and acknowledged there was no documented evidence the facility had notified the physician/practitioner of the refusals.

Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused consent to orders for 2 of 2 sampled residents (#s 3 and 4), who had documented medication and treatment refusals. Findings include, but are not limited to:

1. Resident 3 was admitted in 2021 with diagnoses including rheumatoid arthritis.

The resident's 04/01/22 through 04/19/22 MAR was reviewed and revealed facility staff documented Resident 3 refused the following treatment orders:

* Diclofenac sodium gel (for pain) seven times; and

* Extra strength muscle rub (back pain) five times.

There was no documented evidence the facility notified Resident 3's physician of the refusals.

On 04/21/22 the requirement to notify the physician/practitioner when a resident refused consent to orders was discussed with Staff 1 (Administrator) and Staff 3 (RCC). They acknowledged the findings.

1. Administrative Assistant or designee will run a medication refusal report and fax to the primary care provider for Resident's 3 and 4

2. A medication refusal report will be run at least monthly and will be kept for review.

3. Resident Care Supervisor will audit monthly.

4. Administrator will nesure the monthly audit is completed.

Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused consent to orders for 1 of 1 sampled resident (#8), who had documented medication and treatment refusals. This is a repeat citation. Findings include, but are not limited to:

Resident 8 was admitted to the facility in 04/2017 with diagnoses including chronic pain.

The resident's 11/2022 MAR and TAR were reviewed and revealed facility staff documented Resident 8 refused the following orders:

* Lidocaine 5% patch (for pain) six times; and

* Ketoconazole 2% shampoo (for seborrheic dermatitis) two times.

There was no documented evidence the facility notified Resident 8's physician of the refusals.

On 12/02/22, the need to notify the physician/practitioner when a resident refused consent to orders was discussed with Staff 1 (Administrator). She acknowledged the findings. No additional information was provided.

1. Administrative Assistant or designee will run a medication refusal report and fax to the primary care provider for resident #8.

2. A MAR/TAR refusal report will be run daily (during the week) and once on Monday (for prior weekend) and will be sent to provider's office for review.

3. Resident Care Supervisor will audit monthly.

4. Administrator will ensure the monthly audit is completed.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate for 1 of 6 sampled residents (#4) whose medications and treatments were reviewed. Findings include, but are not limited to:

Resident 4 was admitted in 2/2022 with diagnoses which included diabetes.

The resident's MARs were reviewed from 04/01/22 through 04/19/22 and the following was noted:

a. Staff initialed that wound care was performed on the resident's abdomen each day from 04/01/22 thorough 04/18/22. However, in an interview with the resident on 04/20/22, s/he stated the abdominal wound was healed, and staff had not performed wound care for "a while".

In an interview on 04/20/22, Staff 3 (RCC) stated the wound care treatment had been discontinued in 03/2022. She was unsure why staff were signing for a treatment they were not performing. She acknowledged the MAR was inaccurate.

b. Resident 4 had an order for Clobetasol ointment to be applied twice a day on Saturdays and Sundays for psoriasis. According to the MAR, staff indicated on six occasions that they did not apply the ointment because it was "already done by the resident."

During an interview with Staff 7 (Lead Personal Care Attendant) on 04/21/22 at 10:10 am, she reviewed the MAR and stated that only staff applied the ointment. She explained that the resident had a PRN cream that s/he self-applied, and therefore refused application of the Clobetasol. She stated the MAR was inaccurate.

The need to ensure staff documented correctly on the MAR was shared with Staff 1 (Administrator) on 04/21/22 at 12:30 pm. She acknowledged the findings. No further information was provided.

1.Adminsiter and RN reviewed 4's MAR and TAR for accuracy.  

2. Housing Leadership will review accurate documentation practices at the Housing All Staff Meeting on May 25th, 2022.  Housing RN's will perform MAR/TAR audits with each service plan update.

3. Housing RN will audit quarterly or at change of condition.

4. Housing RN's.

Based on observation, interview and record review, it was determined the facility failed to evaluate a resident's ability to safely self-administer medication/treatment for 1 of 1 sampled resident (# 7) who self-administered medications. Findings include, but are not limited to:

Resident 7 was admitted to the facility in 10/2021 with diagnoses including Parkinson's disease and mood disorder.

Observations on 12/01/22 noted the resident had multiple over-the-counter medications on a bedside table, including acetaminophen, ibuprofen, Claritin and a sleep aide. There were also multiple bottles and a box of "Boost" nutritional supplements. The resident indicated s/he was administering the medications and explained how the medications were used. The resident reported all other medications were brought to him/her by staff.

Progress notes, dated 10/31/22 through 11/03/22, stated the resident was taking the medications as needed and may have been exceeding the recommended doses. Staff 2 (RN) confirmed she had spoken to Resident 7 on multiple occasions regarding the safety implications.

There was no documented evidence the resident had been evaluated to safely self-administer any of the medications or supplements and informed the physician.

The need to ensure resident's who self-administered medications were evaluated, at least quarterly, and a physician's order was obtained as needed was discussed with Staff 1 (Administrator) and Staff 2 on 12/01/22. They acknowledged the findings.

1. Self-Medication Assessment will be performed by the Housing RN for resident #7.

2. Housing RN's will audit resident panel and identify any residents who may be self-medicating. The Housing RN will perform a Self-Medication assessment for any resident's based on their findings. Staff notified to alert Housing RN's regarding any residents who may be self-medicating.

3. RCS will review list with staff quarterly and update the Housing RN's with any changes.

4. See #3 (above)

Based on interview and record review, it was determined the facility failed to ensure non-pharmacological interventions were attempted and documented to be ineffective prior to the administration of psychotropic medications for 1 of 2 sampled residents (#2) who received psychotropic medications. Findings include, but are not limited to:

Resident 2 was admitted to the facility in late 2021 with diagnoses including anxiety.

The resident's 04/01/22 through 04/19/22 MAR and physician orders were reviewed and the following was noted:

Resident 2 was prescribed Lorazepam PRN and Quetiapine PRN (use first) for anxiety. Resident 2 used both medications on a regular basis to control anxiety.

The facility lacked documented evidence that non-pharmacological interventions were attempted and ruled ineffective prior to administration of the medications and the MAR lacked information that the resident was able to self-direct use of the medications.

During an interview on 04/21/22, Staff 1 (Administrator) confirmed the MAR system did not have non-pharmacological interventions listed for staff to attempt and the facility had not documented the resident's ability to self-direct the use of the medications to control anxiety.

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        The need to ensure non-pharmacological interventions were attempted and documented to be ineffective prior to the administration of PRN psychotropic medications was discussed with Staff 1 and Staff 3 (RCC) on 04/21/22. They acknowledged the findings.

1.Resident 2 was reviewed by RCC for non-pharmalogicval interventions and MAR and service plan were updated with this information.

2. Resident Care Supervisor will perform an audit of all residents receiving psychotropic medications and Housing RN will ensure that non-pharmacological interventions are followed prior to administering medication. This will be completed by June 1, 2022.  The process of offering and documenting non-pharmacological interventiors prior to medication will be reviewed at the Housing All-Staff Meeting- May 25th, 2022. Housing RN will ensure there are non-pharmacological interventions listed for each psychotropic order.

3. Housing RN will review MAR and psychotropic medications at each service plan update.

4. Resident Care Supervisor will audit monthly to ensure compliance.

Based on interview and record review, it was determined the facility failed to ensure non-pharmacological interventions were attempted and documented to be ineffective prior to the administration of psychotropic medications for 1 of 1 sampled residents (#7) who received psychotropic medications. This is a repeat citation. Findings include, but are not limited to:

Resident 7 was admitted to the facility in 10/2021 with diagnoses including major depressive disorder.

The resident's 11/01/22 through 11/30/22 MAR and physician orders were reviewed and the following was noted:

Resident 7 was prescribed Clonazepam PRN for anxiety and it was administered to the resident on 11/03/22.

The facility lacked documented evidence non-pharmacological interventions were attempted and ruled ineffective prior to administration of the medications and the MAR lacked information the resident was able to self-direct use of the medications.

During an interview on 12/01/22, Staff 11 (MT) confirmed the MAR system did not have non-pharmacological interventions listed for staff to attempt and the facility had not documented the resident's ability to self-direct the use of the medications to control anxiety.

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        The need to ensure non-pharmacological interventions were attempted and documented to be ineffective prior to the administration of PRN psychotropic medications was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 12/02/22. They acknowledged the findings.

1. Resident #7 was reviewed by RN Manager for non-pharmacological interventions and MAR and service plan were updated with this information.

2. RN Manager will perform an audit of all residents receiving psychotropic medications and Housing RN will ensure that non-pharmacological interventions are followed prior to administering medication, or will document the resident's ability to self-direct. Housing RN will ensure there are non-pharmacological interventions listed for each psychotropic order.

3. Housing RN will review MAR and psychotropic medications at each service plan update.

4. Resident Care Supervisor will audit monthly to ensure compliance

Based on interview and record review, it was determined the facility failed to ensure an assessment by a PT, OT or RN for supportive devices with potentially restraining qualities  included all required components for 1 of 2 sampled residents (#5) who had a device with  restraining qualities. Findings include, but are not limited to:

Review of Resident 5's progress notes revealed the following:

* On 04/12/22, PT/OT recommended bilateral side rails and a fall mat for safety.

* On 04/13/22 an Occupational Therapist completed an assessment of supportive devices with restraining qualities. The facility failed to provide instruction to care providers on correct use of the device and review the the risks and benefits associated with the device to the resident.

The failure of the facility to ensure an assessment by a PT, OT or RN for all supportive devices with potentially restraining qualities included documenting risks and benefits with resident or their representative and instructing care staff on correct use and precautions related to the device was reviewed with Staff 1 (Administrator) and Staff 2 (RN) on 04/21/22. They acknowledged the findings.

1. RN reviewed resident 5 and completed an assessment for equipment with possibility of restraints.

2.Housing RN's will conduct an audit of all residents who have restraints/SDRQ's and ensure specific instructions are provided in the service plans.  This review will be completed prior to June 15, 2022.

Caregiver check of the restraints/SDRQ's will be completed monthly.

3. Housing RN's will review restraints/SDRQ's at each service plan update or when new equipment is added.

4. Housing RN's will audit at each service plan at their update.

Based on observation, interview and record review, it was determined the facility failed to ensure a resident was fully evaluated for use of a device with restraining qualities for 1 of 1 sampled resident (#8) who was using side rails. This is a repeat citation. Findings include, but are not limited to:

Resident 8 was admitted to the facility in 04/2017 with diagnoses including hip fracture.

Observations during the survey on 12/01/22 revealed Resident 8 had half-length side rails in the elevated position on the left side of the resident's bed.  

There was no documented evidence the following required elements of the evaluation were completed:

* Documentation of less restrictive alternatives prior to use of the device;

* Documentation the resident was informed of risks and benefits associated with the device; and

* Instruction provided to staff on the correct use and precautions of use of the device.

The need to ensure an evaluation with all required information was completed for devices with restraining qualities was reviewed with Staff 1 (Administrator) and Staff 2 (RN) on 12/02/22. They acknowledged the findings.

1. RN reviewed resident 8 and completed an assessment for equipment with possibility of restraints.

2. Housing RN's will conduct an audit of all residents who have restraints/SDRQ's and ensure specific instructions are provided in the service plans and that all required elements of evaluation are completed. Caregiver check of the restraints/SDRQ's will be completed monthly.

3. Housing RN's will review restraints/SDRQ's at each service plan update or when new equipment is added.

4. Housing RN's will audit at each service plan at their update

Based on interview and record review, it was determined the facility failed to ensure pre-service orientation and pre-service dementia training was completed prior to beginning work in the facility for 2 of 3 staff (#s 8 and 10) whose training records were reviewed. Findings include, but are not limited to:

Staff training records were reviewed on 04/21/22.

* Staff 10 (CG), hired 12/13/21, lacked documented evidence of having completed pre-service orientation and pre-service dementia training.

* Staff 8 (CG), hired 02/07/22, lacked documented evidence of having completed pre-service orientation training.

The need for staff to complete all required pre-service orientation and dementia training before working with residents was reviewed with Staff 1 (Administrator) and Staff 3 (RCC) on 04/21/22. They acknowledged the findings.

1. Staff 8 and 10 had completed all required pre-service orientation and pre-service dementia training.

2. Resident Care Supervisor will perform an audit of all pre-service orientation requirements and will ensure that all orientation is completed.

Resident Care Supervisor will develop an orientation checklist and sign off on completion prior to caregiver starting work. RCS will provide a checklist to the Administrator for review.

3. Will be reviewed prior to caregiver work start date.

4. Administrator will review for completion of orientation.  

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 caregiving staff (#s 8 and 10) demonstrated satisfactory performance in all required areas within 30 days of hire. Findings include, but are not limited to:

Training records were reviewed on 04/21/22.

There was no documented evidence Staff 10 and 8 (CGs), hired 12/13/21 and 02/07/22 respectively, 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 ADL's;

* 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.

Additionally, there was no documented evidence Staff 10 had completed First Aid certification and abdominal thrust training within 30 days of hire.

The need to ensure staff had demonstrated competence in all job duties within 30 days of hire and completed First Aid certification and abdominal thrust training was reviewed with Staff 1 (Administrator) and Staff 3 (RCC) on 04/21/22. They acknowledged the findings.  

1. Staff 4 and 6 have completed all required annual training.

2. Resident Care Supervisor will perform an audit of all competency requirements and will ensure that all competencies are completed.

Resident Care Supervisor will utilize a competency checklist and sign off on completion prior to caregiver starting work. RCS will provide a checklist to the Administrator for review.

3. Will be reviewed prior to caregiver work start date.

4. Administrator will review for completion of competencies.

Based on interview and record review, it was determined the facility failed to have documented evidence that 12 hours of annual in-service training, including six hours related to the care of the dementia resident, was completed for 2 of 3 long-term staff (#s 4 and 6) whose training records were reviewed. Findings include, but are not limited to:

a. Staff 4 (CG), hired 03/29/21, failed to have documented evidence of completing six hours of annual in-service training related to the care of the dementia resident, between 03/2021 and 03/2022.

b. Staff 6 (Lead MT), hired 04/20/20, failed to have documented evidence of completing 12 hours of required in-service training's, including six hours related to the care of the dementia resident, between 04/2021 and 04/20/22.

The need to ensure staff completed required annual in-service training, based on anniversary dates of hire, was reviewed with Staff 1 (Administrator) and Staff 3 (RCC) on 04/21/22. They acknowledged the findings. No further information was provided.

1.Staff 8 and 10 have completed all required 30-day cometencies.

2. Resident Care Supervisor will perform an audit of all annual training requirements and will ensure that all training is completed.

Resident Care Supervisor will develop an annual training checklist and sign off on completion. RCS will provide checklist to Administrator for review.

3. Will be reviewed monthly based on date of hire.

4. Administrator will review monthly.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted according to the Oregon Fire Code (OFC). Findings include, but are not limited to:

Facility Fire and Life Safety records from 10/20/21 to 03/30/22 were reviewed on 04/20/22 at 1:00 pm. Fire drill records lacked documentation of the following required components:

* Location of simulated fire origin;

* The escape route used;

* Number of occupants evacuated; and

* Problems encountered and comments related to residents who resisted or failed to participate in the drills.

The need to ensure fire drills were conducted according to the Oregon Fire Code (OFC) and fire drill records included documentation of all required components was discussed with Staff 1 (Administrator) on 04/20/22 at 1:30 pm. She acknowledged the findings.

1. Administrator will ensure that all components required in OAR 411-054-0090 (1) (a-d) are included in each fire drill or life safety training and in the documentation of those drills/trainings.

2. See above

3. Monthly

4. Administrator

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted according to the Oregon Fire Code (OFC) and residents were provided fire and life safety training annually. Findings include, but are not limited to:

Facility Fire and Life Safety records from 10/20/21 to 03/30/22 were reviewed on 04/20/22 at 1:00 pm.  The facility lacked documented evidence of the following required components:

*Alternate escape routes were used during fire drills;

*Documentation of problems encountered with residents who declined to participate, and changes made to ensure the evacuation standard was met; and

*Documented evidence residents were provided training and instruction on fire and life safety annually.

The need to ensure alternate escape routes were used during fire drills, documentation of problems encountered with residents who declined to participate and changes made to ensure the evacuation standard was met, and residents were instructed on fire and life safety procedures annually, was discussed with Staff 1 (Administrator) on 04/20/22 at 1:30 pm. She acknowledged the findings.

1. Administrator will conduct a Fire/Life Safety Training for all residents by 5/30/22 and obtain resident signatures.

2. Training for residents will be conducted annually.

3. Annually by Administrator.

4. Administrator

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 citations in the report.

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: C 270, C 290 and C 540.

Refer to: C 270, C 290 and C 540.

Based on observation and interview, it was determined the facility failed to maintain the exterior of the building free of litter and refuse and the pathways accessible. Findings include, but are not limited to:

A tour of the facility was completed on 04/19/22. The following were identified:

* There were several garden hoses that were not put away and were on the walkway creating a tripping hazard to residents;

* Multiple broken toilets and chairs were stored in an outside HVAC area;

* The outdoor benches were missing a finished coat of paint/varnish and one bench had rotten wood on the seat; and

* There was a discarded couch on the side of the building.

A review of the environment was completed with Staff 1 (Administrator) on 04/20/22 at 8:45 am.

The need for all exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways to be accessible, maintained in good repair and that the RCF grounds were kept orderly and free of litter and refuse was discussed with Staff 1. She acknowledged the findings.

1. Administrator will ensure that items listed in survey are removed or repaired. Administrator will educate residents about how to get rid of unwanted items.

2. Administrator will perform monthly checks of building exterior to ensure grounds are clear of litter, refuse and ensure that pathways are accessible.

3. Monthly by Administrator.

4. 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. Findings include, but are not limited to:

The interior of the facility was toured on 04/19/22.

The following issues were noted:

* The carpet throughout the building was stained and threadbare;

* Multiple armchairs had stains on the fabric;  

* The ceiling in the hallway between rooms 74 and 60 was in disrepair and hanging down;

* The common area bathroom had scrapes on the wall near the sink and was missing paint;

* There was a hole in the hallway wall near room 74;

* All wooden benches inside hallways were missing varnish/paint and were not a cleanable surface;

* There was a hole in the hallway wall outside room 463;

* Paint was missing on the wall by the north hall medication room; and

* A light bulb in the hallway (across from room 454) was out.

The facility was toured and the findings were reviewed with Staff 1 (Administrator) on 04/20/22. She acknowledged the areas needing cleaning and repair.

1. Administrator will work with Maintenance Team to repair issues listed in survey document.

2. Administrator will conduct a internal building review monthly and work with the Maintenance Team on any needed repairs.

3. Monthly

4. Administrator or designee.   

Based on observation and interview, it was determined the facility failed to provide heating systems capable of maintaining 70 degrees Fahrenheit in resident areas. Findings include, but are not limited to:

Observations during the survey from 11/30/22 through 12/02/22 revealed temperatures inside the building were consistently below 70 degrees during daytime hours. Temperatures obtained on 12/01/22 included the following:

* At 10:00 am, hallway near rooms 7 - 19 was 67.8 degrees;

* At 10:05 am, reception area and front TV lounge was 64.9 degrees;

* At 10:08 am, the main dining room was 67.8 degrees;

* At 10:15 am, the corridor near 400 hall was 61.9 degrees;

* At 10:20 am, the upper North TV lounge was 64 degrees.

Thermostats on the wall in the 400 hall read as follows: between 62 and 66.3 degrees.

In an interview on 12/01/22, Resident 7 stated the building had been very cold recently, and the heat in his/her room had recently been adjusted.

The need to ensure resident areas could be maintained at a minimum of 70 degrees was discussed with Staff 1 (Administrator) and Staff 14 (Maintenance Director) on 12/02/22. They acknowledged the findings.  

1. Maintenance has evaluated and made adjustments to the room temperature for resident #7 according to resident preference.

2. Property Management/Maintenance vendor has been notified of issues with heating in common areas.

Protective barriers for cadet heating system will be ordered and installed.

3. Administrator and Maintenance Technician will evaluate common areas monthly for maintaining appropriate temperature.

4. Administrator

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

The interior of the RCF was toured on 03/23/23 at approximately 12:30 pm.

The surveyor observed wall heaters in the hallways connecting the north and south sections of the building, located just below the handrails.

Only one heater was on at the time of observations, and it felt hot to the touch. The surface temperature of the heater was in excess of 155 degrees F. when measured with the surveyor's digital thermometer.

The wall heaters were discussed with Staff 14 (Maintenance Director). He confirmed the wall heaters were in use and exceeded 120 degrees F.

The findings were discussed with Staff 1 (Administrator) on 03/23/23 at 1:50 pm.  She acknowledged the need to address risks associated with heaters and stated she had already implemented a plan to have new safety covers fabricated and installed.

1. Maintenance has confirmed

2. Protective barriers have been installed as of 3/28/23.

3. Administrator and Maintenance Technician will evaluate common areas monthly for maintaining appropriate temperature.

4. Administrator

Based on observation and interview, it was determined the facility failed to ensure hot water temperatures in residents' units and common bathrooms were maintained within a range of 110 - 120 degrees Fahrenheit. Findings include, but are not limited to:

On 04/19/22 and 04/20/22 the surveyor measured water temperatures in occupied resident unit bathrooms and common bathrooms in the central and west halls of the building. Water temperatures were above 120 degrees Fahrenheit.

Water temperatures were reviewed with Staff 1 (Administrator) at 8:45 am on 04/20/22. She acknowledged the findings. On 04/20/22, Staff 1 confirmed she had placed a maintenance request to adjust the boiler. The facility did not have in-house maintenance and had to go through the corporation for all repair requests.

1. Maintenance personel have made an adjustment to the water heater temperature. Subsequent checks throughout the facility showed the temperatures are back within range.  

2. Administrator or designee will conduct monthly audit of water temperatures (8 rooms per month).

3. Monthly

4. Administrator  

Based on observation and interview, it was determined the facility failed to ensure hot water temperatures in residents' units were maintained within a range of 110 - 120 degrees Fahrenheit and plumbing systems conformed to the building codes in effect at the time of facility construction. This is a repeat citation. Findings include, but are not limited to:

On 12/01/22 at 12:09 pm, resident apartments were toured, and water temperatures were taken throughout the building.

a. Water temperatures were less than 110 degrees Fahrenheit in the following apartments:

* Room 350 - 102 degrees Fahrenheit;

* Room 451 - 102 degrees Fahrenheit;

* Room 552 - 101.8 degrees Fahrenheit; and

* Room 652 - 95.6 degrees Fahrenheit.

On 12/01/22 at 2:13 pm, Staff 14 (Maintenance Director) and this surveyor observed the primary thermostat for the boiler which first read approximately 106 degrees Fahrenheit and then dropped to 99 degrees. Staff 14 determined the boiler was not properly functioning and agreed to immediately request maintenance.

In addition, discolored (brown tinted) water was observed flowing from the sink and shower faucets in the following apartments:

* Room 350;

* Room 451; and

* Room 652.

The water temperatures and discolored water were reviewed with Staff 1 (Administrator) and Staff 14. The facility provided a plan to notify the residents of the problem and repair of the boiler, scheduled for 12/05/22.

The need to ensure water temperatures in residents' units were maintained within a range of 110 to 120 degrees Fahrenheit and water was clean and potable was discussed with Staff 1 on 12/02/22.  She acknowledged the findings.

1. All residents in North Hall were notified of temperature issues and potential for water discoloration on 12/2/22. Residents were provided bottled water per request.

2. Boiler repair scheduled for 12/5/22, Maintenance Tech will monitor boiler and perform random water temperature checks on North Hall every other day for 2 weeks or until water temperature has been deemed consistent. Maintenance to perform water checks for rooms with discolored water and coordinate futher interventions as needed.

3. Administrator will perform random water temp and color audits once per month.

4. Administrator