Print Inspection: T91Y

The findings of the re-licensure survey conducted 10/30/23 through 11/02/23 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 re-licensure survey of 11/02/24, conducted 3/12/24 through 3/14/24, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

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 revisit to the re-licensure survey of 11/02/23, conducted 07/08/24 through 07/10/24, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

Surveyor: Ferguson, Krissa

The findings of the third revisit to the re-licensure survey of 11/02/23, conducted 10/02/24 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 Home and Community Based Services Regulations OARs 411 Division 004.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the fourth revisit to the re-licensure survey of 11/02/23, conducted 01/16/25 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, OARs 411 Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.

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:

The "Resident Council Minutes" dated 07/28/23, 09/29/23 and 10/27/23 were reviewed. Comments included:

* On 07/28/23- "Concern that no one answers call lights or that it is 20 minutes to an hour later"; and

* On 09/29/23- "Complaint that call lights aren't answered in a timely manner, this has been a continual issue."

Although there was a documented response to the complaint on call light response times after the 07/28/23 meeting, call lights continued to be a problem brought forward at the next Resident Council meeting on 09/28/23. The meeting minutes on 10/27/23 lacked documentation of resolution to agenda topics from the previous month.

A group interview was conducted on 10/30/23 at 3 pm. Five alert and oriented residents attended the group interview and provided information on services received in the community. Residents expressed concerns in the area of long delays for call light response times. Responses included:

"When they are low on staff it's not uncommon to wait 45 minutes to an hour"; and

"I waited on the toilet today for 30 minutes."

During an interview with Resident 6 on 10/31/23 at 10:30 am, Resident 6 stated s/he used the emergency call light one time and the response time was greater than an hour.   

During an interview with Staff 1 (ED) on 11/01/23 at 9:10 am, she confirmed the call system was  "...quite old and likely original to the building." She was not aware of a system in place to review call light response times.

The facility lacked documented evidence that resident complaints were responded to and resolution was reached related to long call light response times.

The need to ensure the facility implemented effective methods of responding to and resolving resident complaints was discussed with Staff 1 on 11/02/23. She acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure the residents' were treated with dignity and respect in a homelike environment related to food choice and delivery service regarding meal service for residents who ate in their apartments. Findings include, but are not limited to:

In a group interview conducted on 10/30/23 at 3 pm, and in various one on one interviews, facility residents made the following statements:

* "My meals are delivered cold.";

* The resident showed the facility's weekly menu which showed there was one main menu in each meal, but there was no other choices of food;

* "The only option is to refuse" as there are no alternatives available for room tray delivery service.;  

* "It's always a surprise as to what food I will get because if they run out of food in the dining room we get whatever they can find.";

* "There is no say in what gets delivered. They short people who get food delivered because we often don't get the same food or the same dessert.";

* "If you want something else, it's a big deal if you refuse a meal. They make you feel guilty about having to go back to the kitchen to get something different.";

* "Residents in the dining room got big napoleon sandwiches for dessert and we got popsicles.";

* "The other day they had coconut shrimp on the menu but I got chicken parts." This resident was told that after the residents in the dining room got served "second and third servings there was no coconut shrimp left for delivery.";

* "There is no method in place for selecting alternative food for residents that eat in their rooms.";

* Staff, "walk in, put tray on counter and walk out.";

* "I can't get eggs any way I want, only if you are in the dining room.";

* Did not like the use of styrofoam containers to receive meals;

* "I hate eating off of Styrofoam and plastic utensils."; and

* "I don't eat fish but they deliver it anyway."

During meal observations on 10/31/23 and 11/01/23 the following was noted:

* Dietary staff delivered meals to residents who ate in their apartments in styrofoam clamshell containers, styrofoam cups and with plastic cutlery; and

* Residents were served meals without being offered a choice or alternative if the meal was refused.

In a 10/31/23 interview with Staff 20 (Server), she relayed the facility did not offer menu choices to residents who ate in their apartments stating ..."we just bring them what we have..."

During an interview on 11/02/23 at 10:20 am with Staff 1 (ED) and Staff 6 (Wellness Services Director, LPN), Staff 1 acknowledged that there needs to be a system in place to ensure residents who ate in their apartments had meals of their choosing and were not served on styrofoam with plastic utensils. She also acknowledged residents have a right to eat in their apartments if they choose.

The facility's failure to ensure resident's rights were protected was discussed with Staff 1 and Staff 6 on 11/02/23. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure the residents' were treated with dignity and respect in a homelike environment related to food choice and delivery of services regarding meal service for residents who chose to receive meals in their apartments. This is a repeat citation. Findings include, but are not limited to:

The facility stated meal times were as follows:

* Breakfast 7:30-9:30 am;

* Lunch 11:30-1:30 pm; and

* Dinner 4:00 - 6:30 pm.

During meal delivery for lunch on 03/12/24 and breakfast and lunch on 03/13/24 the following was noted:

* Multiple leftover plates with covers were stacked on the floor in the hallway and on a community table.  In multiple residents' apartments observed several plates and covers stacked on their kitchen counters. Interviews with multiple residents confirmed dishes were not collected timely following meals and were sometimes left in their room overnight or for several days.

*During two lunch deliveries, observations showed soup, utensils and/or dessert were not consistently being offered to residents.

* Inconsistent use of various systems for meal delivery were observed that included using one staff versus using two staff to deliver the meals. The facility also lacked a consistent system to identify residents who had ordered an alternative meal. On 03/13/24 no system was used to identify residents who had special orders and four residents returned the lunch special because it was not what they had ordered.

* On 3/13/24 the dessert offered at lunch in the dining room was a root beer float. Root beer floats were not offered to residents who received room trays. Popsicles were provided instead.

On 03/12/24 an interview with Staff 29 (Server) stated a new "ticket" system had been recently implemented to allow residents to choose an alternative meal for breakfast, lunch and dinner. The residents received all seven tickets at the beginning of the week, along with the weekly menu.  Staff 29 reported, "The tickets are confusing the residents because the order on the paper goes breakfast, dinner then lunch. Residents are ordering items for dinner thinking they are for lunch."

On 03/13/24 an interview with Staff 1 (ED) indicated resident rosters were used to keep track of which residents were getting three daily meals but acknowledged the roster was not consistently being used.  A resident roster was not used during 3 of 3 meal delivery observations between 03/12/24 and 03/13/24. On 03/13/24 at 3:30 pm a copy of the resident roster for breakfast and lunch on 03/13/24 was received. The roster indicated which residents ate in the dining room for breakfast and lunch and did not identify the residents who were served in their rooms or who had refused a meal.

On 3/14/24 Staff 8 (Dining Director) reported the ticket system was implemented "this week" to select alternative options for residents who ate in their rooms.

Various one on one interviews and comments made by unsampled residents regarding meals delivered to their rooms between 03/12/24 and 03/14/24 included:

* "My food is cold, we don't get warm food.";

* "Running out of food is a big deal. Sometimes we don't get what they serve in the dining room because they run out. Or we get a smaller portion.";

* "Sometimes they forget to deliver food to some residents' rooms.";

* "It can be 10:30 before I get breakfast [an hour past serving time]...and dinner is sometimes around 7:00 [30 minutes past serving time].;

* "The print on these tickets is too small, I can't read it.";

* "We're not real sure how to use the tickets. Some people throw them out because they don't know what to do with it.";

* "I turned my ticket in to the cook and it got lost.";

* "We weren't told if you still get a meal if you don't fill out the ticket so I wasn't sure if I would be delivered a meal today.";

* "One day they served cheesecake in the dining room and they ran out so I didn't get any.";

* "I have too many dishes in my room, can you take them away?";

* "I ordered a BLT [bacon, lettuce and tomato] on the ticket but they gave me the special [tuna fish sandwich] anyway.";

* "I wanted my sandwich on white bread, not wheat.";

* "Last night they brought me the salmon special and I had ordered chicken tenders.";

* "When are you going to pick that up? For the last four days no one has picked up these dishes."; and

* "I want ice cream, not popsicles."

During an interview on 03/13/24 at 2:10 pm with Staff 1 and Witness 1 (Consultant LPN), Staff 1 acknowledged that the meal delivery system needed more work to determine whether the newly implemented systems were effective and to ensure residents who ate in their apartments received meals of their choosing in a timely manner, and have their meal trays picked up consistently.

The need to ensure residents received services in a manner that treated them with dignity and respect was discussed with Staff 1, Staff 23 (Wellness Services Director), Staff 25 (Regional Director of Operations) and Witness 1 on 03/14/24. They acknowledged the findings.

1) Dining Service Director (DSD) will ensure that dirty dishes are collected from common areas and resident rooms following each meal. DSD is working to ensure consistent offerings between meals taken in the dining room and meals delivered, meal orders are taken day before and with respect to food prereferences, that portion sizes are appropriate, and that meals are delivered timely so that food is served hot.

2) DSD provided training to stafff on providing dignified dining services on 3/30/2024. Staff will continue to complete Resident Rights training upon hire, as well residents will be educated on Resident Rights via Resident Handbook and signed policy in their file. DSD will complete daily meal roster checking of who received and who refused to ensure all residents receive meals. Concerns will be addressed daily during stand-up, and investigated by Executive Director (ED) or other designee. ED will routinely monitor dining services and attend the food committee meeting.

3) Daily during stand-up meetings, monthly food committee meetings.

4) Dining Services Director and Executive Director are responsible for this plan of correction.   

Based on observation, interview, and record review, it was determined the facility failed to ensure the residents were treated with dignity and respect in a homelike environment related to meals in the dining room and meal service for residents who chose to receive meals in their apartments. This is a repeat citation. Findings include, but are not limited to:  

Meal service in the dining room and delivery of trays was observed for breakfast and lunch on 07/09/24 and 07/10/24 and the following was noted:

* During breakfast delivery on 07/09/24, Resident 16 was served biscuits and gravy, scrambled eggs and hashbrowns. During an interview on 07/08/24 s/he reported that Staff 8 (Dining Director) filled out his/her meal tickets and "all I want is toast and fruit every morning." Resident 16 indicated this was the second day in a row she did not receive toast and fruit.  

*On 07/09/24 and 07/10/24 observations during lunch delivery showed no effective system to return dishes from apartments to the dining room. On 07/09/24 dirty dishes were stacked on counters, cabinets and boxes in 50% of resident apartments and on 07/10/24 in 52% of resident apartments who received meal service. Additionally, various plates, trays and clam shell covers were observed sitting out in common areas that included a tray with two clam shell covers and ants crawling along the edges of the plates and on the tray.

*On 07/10/24 Staff 29 (Server) returned to the kitchen at 12:50 pm after delivering meals to the residents on the first floor. Nine plates of cheeseburgers with potato wedges were observed on the food line waiting to be delivered to the second floor residents who ate in their apartments. Staff 29 labeled the meals and covered eight of the nine plates with saran wrap. During an interview with Staff 29, he indicated that he had to use the saran wrap for the remaining plates because "we didn't have any more covers, they must be in their apartments." Twenty-one minutes later the meal cart left the kitchen for delivery to residents on the second floor. The last delivery ended at 1:24 pm and survey requested the remaining tray that was leftover. The cheeseburger and potato wedges were tested with a thermometer and not palatable with a temperature of 97.1 degrees Fahrenheit (F) and 87.8 degrees F, respectively.

*On 07/09/24 and 07/10/24 multiple sampled and unsampled residents did not receive what they had ordered for breakfast and/or lunch. Other residents had requested a drink and/or utensils and Staff 29 either took the drink from another tray or returned after delivery service was completed to deliver utensils, drinks and/or the correct food item. On 07/09/24 Staff 29 indicated "we don't bring drinks on the cart and I don't know why." On 07/10/24 Staff 29 reported "I know that this resident likes apple juice and coffee but since no drinks were circled on the meal ticket I'm told not to deliver them drinks."

*On 07/09/24 during lunch, Staff 8 offered the choice of jello or a frozen dessert to two residents who sat at a table in the dining room. Jello was the only dessert option for residents who received lunch in their apartments.

*On 07/10/24 an unsampled resident requested utensils during breakfast and lunch delivery, additional utensils were not available on the cart.

*The lunch menu for 07/10/24 had popsicles listed for dessert. Observed residents in the dining room received yogurt topped with fruit. Residents on the first floor were delivered fresh fruit cups and residents on the second floor randomly received the fresh fruit cups while others received yogurt topped with fruit. During an interview with Staff 29 indicated that "we only had 12 popsicles left so we changed the dessert to yogurt and fruit. I am not sure why some residents didn't receive the yogurt with the fruit."

On 07/09/24 at 2:00 pm observed Staff 21 (Server) removing dirty dishes from apartments. She stated "We pick up after lunch and dinner, sometimes after breakfast but we don't always have time so the caregivers will pick up the plates."

Resident Council Minutes from 06/28/24 were reviewed and identified the following:

* Residents were not consistently being served what they had ordered according to their meal ticket requests;

* Coffee was not consistently being delivered by all staff who deliver the meals; and

* Meal delivery food was "often cold."

Various one on one interviews and comments made by sampled and unsampled residents regarding meals delivered to their rooms between 07/08/24 and 07/10/24 included:

*"I got biscuits today without any gravy."

* "You gave me a taco and I can't eat that because of my teeth."

* "When are you picking up these trays?"

* "Do you have a drink for me? Oh never mind."

* "We can only get real eggs every other day. If we want eggs on the other days we have to eat that liquid stuff they make into scrambled eggs. Why can't I just get eggs how I want?"

* "I believe that [Staff 8] has to pacify the owners and save money on the budget so that's the reason we can only have eggs every other day."

* "I ask for milk and they tell me they'll bring it but they never do."

* "They only serve me half a cup of milk and half a cup of coffee. Why?"

* "If I order eggs it is served cold."

* "I didn't order a hot dog, I wanted a turkey sandwich."

* "You gotta take the other tray away before you can put my lunch on the table."

* "I ordered yogurt because I wanted yogurt for breakfast, instead I got 3 fried eggs."

* "I gave up and make my own coffee now because they never bring it when I order it."

* "Lunch was cold today, I did not eat it".

* "You inspectors should look in the kitchen, the food is bad. Bad."

* "Last night they brought me dinner and didn't even ask if I wanted anything to drink."

*" They are inconsistent with being able to meet my special diet, sometimes I do and sometimes I don't."

* "She didn't get what she ordered for breakfast, she got biscuits and gravy and hashbrowns but she's on a special diet and can't eat all those things. She wanted yogurt and cream of wheat and didn't get that."

* "You never know what you will get. It may be on the menu but when you ask for it they are out of it."

* "Sometimes I'll be eating in the dining room and they'll just set a plate down in front of me before I even have the chance to order what I want."

* "The menu is a waste of paper."

* "I don't feel we are treated with respect. They only see us as money."

* "As far as I'm concerned, we are money in the bank to them. We're written off by the owners. We provide their salary but we are still people and functional and deserve more respect."

* "Until the dust settles I'm not confident in my home."

During an interview with Staff 31 (ED) and Witness 2 (Consultant) on 7/10/24 they acknowledged the facility was still working on a system for picking up room trays and delivering warm food that was not cold and was what was ordered.   

The need to ensure residents received services in a manner that treated them with dignity and respect was discussed with Staff 1 and Witness 2 on 07/10/24 at 3:30 pm. They acknowledged the findings.

1)The Dining Service Director (DSD) and Executive Director (ED) have introduced a new protocol to guarantee the prompt collection of dishes. A fixed schedule for tray retrieval has been instituted, mandating adherence by all staff members. Additionally, a verification system has been implemented for caregivers and servers to confirm the collection of meal trays post each dining period. Additionally, created a new system to ensure the delivery of menu items as selected by residents.

2)Meal tickets are meticulously examined during the daily Jumpstart meeting to confirm the accurate documentation and execution of residents' dining preferences by the staff. Routine inspections are carried out to verify the timely clearance of all dishes. Immediate action is taken to rectify any discrepancies. Furthermore, staff training sessions are conducted regularly to reinforce the importance of resident rights and service standards.

3)The ED and DSD diligently oversee the tray collection process on a daily basis, engaging with residents to ensure their meal requests and preferences are consistently met.

4) The ED assumes responsibility for conducting random audits throughout the week to maintain service quality, while the DSD provides daily supervision of meal ticket accuracy and tray services.

Based on observation, interview, and record review, it was determined the facility failed to ensure the residents were treated with dignity and respect in a homelike environment related to meal service for residents who chose to receive meals in their apartments. This is a repeat citation. Findings include, but are not limited to:  

Interviews with staff, residents and observation of meal service and delivery of trays was observed for lunch on 10/02/24, the following was noted:

* Tray line was first observed from approximately 12:00 pm to 12:42 pm. Three room trays, including cups of tea, lemonade and/or milk, were on top of the hot cart with covers in place at noon. Dining room plates were served and delivered while the room cart waited with only part of the room trays served and loaded. Dining room orders included chef salads, hamburgers and the chicken Alfredo pasta dish. Room orders were plated slowly after multiple dining room orders were fulfilled. The hot cart took approximately 45 minutes to fully load before delivery of the meals to the residents in apartments began.

* Staff 29 (Server) indicated he was told by the cook all the residents eating in their apartments ordered the pasta for lunch, so all the trays were the same. He indicated he was not picking up dishes right now but just delivering the lunch trays. Staff 29 further indicated caregivers also picked up the dishes from meals when they had time.

* Multiple unsampled residents did not receive what they had ordered for lunch. Residents with apartments at the start of the delivery route and at the end indicated the meal was not hot and drinks were not cold.

*The lunch menu for 10/02/24 indicated lunch included; vegetable medley soup, spaghetti with marinara meat sauce, garlic green beans, garlic bread, pear fruit medley and a chocolate éclair for dessert. The items being served from the kitchen were short pasta (orzo) with Alfredo sauce, ½ slice of toast,1-2 slices of baked chicken on top of the pasta and a cookie. Residents who ate outside the dining room were not made aware of the changes to the menu or allowed to adjust menu cards.

* Staff 34 (Cook) indicated he was most likely making a shepherd's pie for dinner with a dinner roll. He indicated the current items listed on the menu were not correct due to some shortages of supplies. He did not have a specific way to notify those who ate in apartments, they would just get the main food item even if it was different than what was listed on the meal card for ordering.

Resident Council Minutes from 08/20/24 were reviewed and included the following:

* A resident did not get their meal delivered today;

* Room trays are only getting half cups of fluids; and

* Milk is always warm on room trays.

During the entrance interview, the facility identified 15 residents who received meal trays to their apartments and that were alert and oriented. Eleven of the identified residents, plus three additional residents observed during meal delivery were interviewed on 10/02/24. The residents made the following comments and statements regarding the room trays:

* "Mystery meals."

* "Things are not hot."

* "The menu cards are pointless; I never get what I order."

* "I can't even tell what it is."

* "Looks terrible."

* "Sometimes the staff fill out the order cards and sometimes they don't ...you get whatever shows up."

* "Taste is tolerable."

* "Lukewarm at best."

* "Milk is not cold."

* "Slop."

* "Once in a blue moon will I get what I ordered."

* "Too much pasta, need some meat and veggies."

* It's all a joke, never get what I ordered."

* Visually "unappetizing."

* Too much turnover, staff don't know what they are doing, "don't seem to care."

* "Last night dinner did not even show up."

* "I ordered cereal and got scrambled eggs with toast."

* "Apple juice and orange juice are rarely an option."

* "My drinks are only ever half full."

* "What am I paying for."

* "Meals served in the dining room are cold too."

* "The menu is a waste of paper."

* "I don't feel we are treated like humans, just supposed to eat whatever given."

* "The owner is out of state and doesn't care."

* "I am just a dollar sign."

* "Disappointing that nobody cares."

Multiple residents indicated it was very difficult to get apple juice and orange juice. The residents wanted more meat, potatoes, and vegetables rather than pasta repeatedly. Two residents indicated they ask for yogurt but were told no. Three residents indicated they frequently ask for hot cereal but are given something totally unrelated. Residents indicated they were trying to stock up on items they can't get from the kitchen. Residents indicated they were not made aware of changes in what was being served ahead of time, something different would just show up on the tray. The residents interviewed unanimously indicated the food delivered to resident rooms continued to be a problem with items being cold, not what was ordered, poor taste, poor quality and a lack of choices being offered and honored. The residents expressed a high level of frustration around the meal delivery issues.

Meal cards located in the kitchen were reviewed for lunch orders. There appeared to be an order in place for each resident despite several who had indicated they did not complete a ticket on their own or with staff. Five residents who specifically stated they had not completed an order for the 10/02/24 lunch meal had meal tickets completed in the kitchen which indicated "regular lunch." Two of the five residents had indicated they ordered hot cereal for breakfast, but the meal cards indicated "regular breakfast."

In an interview on 10/02/24, Staff 33 (ED) indicated she had been at the facility for about three weeks. She was still tweaking the system to ensure resident meals and delivery were maintaining quality and resident rights were respected. She had added an additional dining/serving staff for two of the meals and an additional caregiver to help with workload. Staff 33 stated they had lost a cook very recently who walked off the job and there were additional problems with their food supplies. The cook covering and any other staff filling in, covered the meals with whatever items they could locate in the kitchen. The goal of service was hall trays and dining room orders were being served at the same time. She was unsure why the first floor serving/delivery took so long.

The need to ensure residents received services in a manner that treated them with dignity and respect was discussed with Staff 23 (Health Services Director/LPN) and Staff 33 (ED) on 10/02/24 at 3:00 pm. They acknowledged the findings.

OAR 411-054-0027 (1) Resident rights and Protection

1. Actions taken to correct the rule violations include:

a) New Dining Services Director started October 14, 2024

b) Implement dining staff meeting before meals, led by the cook or Dining Services Director to discuss daily menu, expectations, sanitation, and review meal tickets

c) Provide server training on temperature requirements and room tray expectations

d) Implement meal order tickets identifying daily entrees and alternate entrée options for all 3 meals

e) Modify in room dining delivery process to include additional staff to expedite delivery service

f) Closely monitor to ensure all meal service experience provided is satisfactory.

2. System will be corrected so this violation will not happen again by:

a) Re-training culinary staff on food safety guidelines, customer service and how and why to utilize meal tickets

b) Announce prior to lunch and dinner reminders of meal times and any changes in the meal

c) Post daily and weekly menu in the dining room and on communtiy boards

closely monitor to ensure all three meal service experiences provided are satisfactory.

d) Meal order tickets are printed for all residents in house with daily specials and alternates and any menu changes will be delivered and reviewed daily by care staff for the following day choices with each individual resident

3. These areas needing correction will be evaluated daily during morning manager meeting, daily dining department meetings, Quality Improvement Meetings and monthly during Resident Council and Resident Food Committee meetings.

4. Exeutive Direcctor, Dining Services Director will be responsible for monitoring systems and resident feedback.

Based on observation, interview, and record review, it was determined the facility failed to investigate incidents or injuries of unknown cause to rule-out abuse, document all required areas of an investigation and report to the local SPD office, if abuse or neglect could not be ruled out, for 1 of 1 sampled resident (#4) with incidents or injuries of unknown cause. Findings include, but are not limited to:

Resident 4 moved to the facility in 07/2015 with renal insufficiency, osteoarthritis, and osteoporosis.  

Observations of the resident, interviews with staff, and review of the resident's 10/16/23 service plan, temporary service plans, charting notes, and incident investigations were completed and revealed the following:

a. A charting note dated 08/12/23 noted the resident had a "scratch" on his/her head "almost healed and 2-3 small bruises on temporal area the right side without knowing how it happened."

b. On 08/16/23 a charting note stated Resident 4 was observed to have "dried blood on [his/her] face/nose area but couldn't remember having a bloody nose or falling."

In an interview with Staff 6 (Wellness Services Director, LPN) on 10/30/23 at 2:20 pm, she stated there was no documented evidence the incidents had been investigated at the time of the occurrence including all required components, nor was there evidence the occurrence had been reported to the local SPD office if abuse and/or neglect was not ruled out.  

At the request of the survey team, the above incidents were reported to the local SPD office and confirmation was received.

The need to ensure injuries of unknown cause were immediately investigated, contained all required areas of documentation, including if abuse and neglect could be ruled out and if not, the injuries were reported to the local SPD office, was discussed with Staff 1 (ED) and Staff 6 on 11/02/23. They acknowledged the findings.

2.  Resident 6 was admitted to the facility in 2021 with diagnoses including acute cholecystitis (inflammation of the gall bladder).                                                                                                  

Resident 6's service plan, updated 10/03/23, temporary service plans and facility charting notes dated 08/01/23 through 10/30/23 were reviewed. Interviews with care staff and resident were conducted and observations were made. The resident's service plan was not reflective of the resident's care needs and lacked specific instruction to staff in the following areas:

* Dietary preferences; and

* Use of a side rail.

The need to ensure service plans were reflective of the resident's care needs and provided clear caregiving instructions was discussed with Staff 1 (ED) and Staff 6 (Wellness Services Director, LPN) on 11/01/23. They acknowledged the findings.

3. Resident 2 was admitted to the facility in 2021 with diagnoses including hypertension and alcohol use disorder.

Resident 2's service plan, updated 09/21/23, temporary service plans and facility charting notes dated 08/01/23 through 10/30/23 were reviewed.  Interviews with care staff and the resident were conducted.

Resident 2 was observed on 10/31/23 to have two areas of skin breakdown to the right lower extremity. The resident's service plan was not reflective of the resident's care needs and lacked specific instruction to staff in the following area:

* Skin status.

The need to ensure service plans were reflective of the resident's care needs and provided clear caregiving instruction was discussed with Staff 1 (ED) and Staff 6 (Wellness Services Director, LPN) on 11/01/23.  Staff acknowledged the findings.

4. Resident 5 moved into the facility in 07/2021 with diagnoses including chronic obstructive pulmonary disease and sleep apnea.

Resident 5's service plan, updated 09/21/23, temporary service plans and facility charting notes dated 08/01/23 through 10/26/23 were reviewed. Interviews with care staff were conducted and observations were made. The resident's service plan was not reflective or failed to provide clear instruction to staff in the following areas:

* Oxygen use including setting of oxygen and care instruction;

* Use of C-collar (a neck brace to support spinal cord and head);

* Use of full dentures;

* Use of a power wheelchair for ambulation;

* Use of a CPAP machine (to use air pressure to keep breathing airways open while sleeping); and

* Use of a grab bar.

The need to ensure service plans were reflective of the resident's care needs and provided clear caregiving instructions was discussed with Staff 1 (ED) and Staff 7 (RCC) on 11/01/23. They acknowledged the findings.

5. Resident 7 moved into the facility in 07/2021 with diagnoses including essential hypertension.

Resident 7's service plan, updated 08/30/23, temporary service plans and facility charting notes dated 08/01/23 through 10/30/23 were reviewed. Interviews with care staff and the resident were conducted and observations were made. The resident's service plan was not reflective or failed to provide clear instruction to staff in the following areas:

* Use of a side rail.

The need to ensure service plans were reflective of the resident's care needs and provided clear caregiving instructions was discussed with Staff 1 (ED) and Staff 7 (RCC) on 11/01/23. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction regarding the delivery of services and/or were implemented for 6 of 7 sampled residents (#s 1, 2, 3, 5, 6 and 7) whose service plans were reviewed.  Findings include, but are not limited to:

1.  Resident 1 was admitted in 10/2023 with diagnoses including Alzheimer's disease.

The 10/11/23 service plan which was available to staff, was not reflective of the resident's current needs and lacked clear instruction to staff in the following areas:

* Assistance with ADLs including dressing and shower assistance; and

* Behavioral interventions, including confusion, wandering and hallucinations.

The need to ensure service plans were reflective of resident's needs and provided clear instruction to staff was discussed with Staff 1 (ED) and Staff 6 (Wellness Services Director, LPN) on 11/02/23. No additional information was provided.

6. Resident 3 moved into the facility in 03/2023 with diagnoses including hypertension and osteoarthritis.

Resident 3's service plan, updated 10/11/23, temporary service plans and facility charting notes dated 08/01/23 through 10/30/23 were reviewed. Interviews with care staff and resident were conducted and observations were made.

a. Resident 3's service plan failed to reflect the resident's care needs and lacked specific instruction to staff in the following areas:

* Ability to ambulate to and from meals;

* Ability to make bed;

* Skin status; and

* Equipment used for showers and toileting.

b. On 10/12/23 and 10/13/23 Resident 3 was seen in the emergency room. A TSP (Temporary Service Plan) was created on 10/13/23 with interventions to "check vitals X 3 days." There was no documented evidence the intervention was implemented.

The need to ensure service plans were reflective of the resident's care needs and provided clear caregiving instructions and were implemented and updated was discussed with Staff 1 (ED) and Staff 6 (Wellness Services Director, LPN) on 11/02/23. They acknowledged the findings.

2. Resident 11 was admitted in 11/2020 with diagnoses including Type II diabetes.

The 10/12/23 service plan, which was available to staff, was not updated quarterly as required. On 03/13/24, Witness 1 (Consultant LPN) stated they were "working on it" and provided updated service plan during the survey.

The need to ensure service plans were updated quarterly was discussed with Staff 1 (ED), Staff 23 (Wellness Services Director) and Witness 1 on 03/14/24.

Based on observation, interview, and record review, it was determined the facility failed to ensure resident service plans were readily available to staff, provided clear direction to staff regarding the delivery of services and failed to ensure service plans were updated quarterly for 2 of 4 sampled residents (#s 8 and 11) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 8 was admitted to the facility in 03/2023 with diagnoses including hypertension and chronic atrial fibrillation.

a. The "service plan binder" direct care staff reportedly used to access the resident service plans was reviewed on 03/12/24. The service plan located in the binder for Resident 8 was dated 09/11/23.

On 03/12/24, Staff 1 (ED) provided a copy of a service plan for Resident 8, updated 03/08/24. The 03/08/24 service plan was not included in the service plan binder available to staff.

b. Observations, interviews with the resident and staff and review of the service plan available to care staff, dated 09/11/23, showed the service plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas:

* Assistance needed with toileting;

* Assistance needed with evacuation;

* Assistance needed with transfers;

* Current assistive device utilized for mobility; and

* Use of side rails on resident's bed.

The need to ensure the current service plan was readily available to staff, reflective of residents' current care needs was discussed with Staff 1, Staff 23 (Wellness Services Director) and Witness 1 (Consultant LPN) on 03/14/24. They acknowledged the findings.

1) Residents #8 will be evaluated and service plan updated upon return from rehab and #11 service plans have been updated to reflect residents' current needs and updated to provide clear instructions to care staff. All service plan binders have been updated with most recent plans to ensure that the paper copies are readily available to care staff.

2) A plan has been developed to ensure timely placement of service plans in the service plan binder that is available to care staff.

3) Weekly review of all new service plans that have been completed.

4) Resident Care Coordinator, Wellness Services Director, and Executive Director are responsible for this plan of correction.

3. Resident 2 was admitted to the facility in 04/2021 with diagnoses including hypertension and alcohol use disorder.

During the acuity interview on 10/30/23 at 9:20 am, Staff 6 (Wellness Services Director, LPN) stated Resident 2 had skin concerns to the lower bilateral extremities and refused care.

The most current evaluation dated 09/21/23 noted the resident had a history of cellulitis on the right leg. The area was noted to be reddened and warm to the touch. Staff were directed to monitor the resident's skin and report any changes. The current service plan, dated 09/21/23, was not reflective of the resident's current skin status and there was no documented instructions to staff regarding provision of care.

Progress notes from 08/01/23 through 10/25/23 were reviewed and there was no documented evidence the facility was monitoring the status of the resident's skin. The current MAR dated 10/01/23 through 10/30/23 had no documented evidence of treatment being provided.

During interviews with Staff 10 (MT) and Staff 18 (MT) on 10/30/23, they stated there was no current treatment being applied to the resident's skin and neither staff had observed the resident's lower extremities.

Resident 2 was observed during the survey on 10/30/23 and 10/31/23 to have swollen lower extremities and was noted to have a band-aide to the right lower extremity.  

During an interview with Staff 6 (Wellness Services Director, LPN) on 10/30/23 at 3:45 pm, she stated the resident refused to have his/her skin "looked at." There was no documented evidence the resident had been refusing care.

During a skin observation on 10/31/23 at 10:05 am, Resident 2 was noted to have two wounds. A "healing 1.2 X 2 X 0.1 cm wound on the inner right calf..." and a "0.1 by 0.1 area on the bottom of the outer right foot."

Resident 2 was evaluated to have a history of cellulitis and was to be monitored with changes reported to staff.  There was no documented evidence the resident's skin had been monitored and the resident was observed with skin breakdown.  

Monitoring Resident 2's skin based on evaluated needs was discussed with Staff 1 (ED) and Staff 6 on 11/01/23 at 12:12 pm. Staff 6 verified Resident 2's skin was an ongoing issue and there was no documented evidence the skin had been monitored.

Based on observation, interview, and record review, it was determined the facility failed to ensure short-term changes of condition had determined actions or interventions for the residents, communicated the actions or interventions to staff on all shifts, monitored each resident consistent with evaluated needs and service plan, and documented with weekly progress noted until the condition resolved for 4 of 7 sampled residents (#s 2, 3, 5 and 7 ) who experienced short-term changes of condition. Findings include, but are not limited to:

Resident 5 moved into the facility in 07/2021 with diagnoses including atrial fibrillation and chronic obstructive pulmonary disease.

1. Resident 5's 08/01/23 through 10/26/23 facility progress notes, and Temporary Service Plans (TSPs) showed the following changes of condition:

* 08/15/23: Experiencing cold like symptoms;

* 08/24/23: Return to the facility from the hospital or emergency visit;

* 08/28/23: Visit to the hospital "for Afib" (an irregular heart rate);

* 10/11/23: On a new nerve and muscle pain medication; and

* 10/21/23: Emergency visit due to complaints of shortness of breath.

There was no documented evidence the changes were monitored at least weekly through resolution.  

The need to ensure short-term changes of condition were monitored with weekly progress noted until resolution was reviewed with Staff 1 (ED) and Staff 7 (RCC) on 11/01/23. They acknowledged the findings.

2. Resident 7 was admitted in 07/2021 with diagnoses including Type I diabetes and seizure disorder.

Resident 7's clinical record and charting notes, reviewed from 08/01/23 through 10/30/23, showed the following changes of condition:

* 08/01/23: Discontinued an anti-depressant medication;

* 08/03/23: Started on a new anti-depressant medication; and

* 09/01/23: A fall.

There was no documented evidence the changes were monitored at least weekly through resolution.  

The need to ensure short term changes of condition were monitored with weekly progress noted until resolution was reviewed with Staff 1 (ED) and Staff 7 (RCC) on 11/01/23 at 11:30 am. They acknowledged the findings.

4. Resident 3 moved into the facility in 03/2023 with diagnoses including hypertension and osteoarthritis.

The resident's current service plan, dated 10/11/23, temporary service plans and progress notes, dated 08/01/23 through 10/30/23, and staff were interviewed. The following was noted:

a. The following short-term changes of condition lacked documentation of actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, and weekly progress noted until condition resolved:                     

* 08/03/23- Start of carbamide peroxide (for earwax buildup); and

* 08/23/23- Change diclofenac location (for pain) to include right knee.

b. The following short-term changes of condition lacked documented evidence the changes were monitored at least weekly through resolution:

* 07/27/23- Rash under right breast;

* 07/27/23- Right ear pain;

* 10/12/23- Second shingles vaccine;

* 10/14/23- Increased dosage of furosemide (for edema) for two days; and

* 10/17/23- Carbamide peroxide.

c. On 10/21/23 Resident 3 had a non-injury fall and was put on alert. There was no documented evidence actions or resident-specific instructions or interventions were identified, implemented and communicated to staff on all shifts, and monitored interventions for effectiveness.

The need to evaluate changes of condition, implement interventions for changes, and monitor the changes at least weekly until resolution, was discussed with Staff 1 (ED) and Staff 6 (Wellness Services Director, LPN) on 11/02/23. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure 1 of 1 sampled resident (# 2) who experienced a significant change of condition was assessed by the RN to include findings, resident status, and interventions made as a result of the assessment. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 2021 with diagnoses including hypertension and alcohol use disorder.

The most current evaluation dated 09/21/23 noted the resident had a history of cellulitis on the right leg. The area was noted to be reddened and warm to the touch. Staff were directed to monitor the resident's skin and report any changes.

During a skin observation on 10/31/23 at 10:05 am, Resident 2 was noted to have an open "healing 1.2 X 2 X 0.1 cm wound on the inner right calf..." The open wound constituted a significant change of condition requiring an RN assessment.

There was no documented evidence an RN assessment had been completed which included findings, resident status, and interventions made as a result of the assessment.

The lack of RN assessment for Resident 2's open skin wound was discussed with Staff 1 (ED) and Staff 6 (Wellness Services Director, LPN) on 11/01/23 at 12:12 pm. No additional information was provided.

Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules, for 1 of 1 sampled resident (#2) who received insulin injections by unlicensed facility staff. Findings include, but are not limited to:

According to OSBN Division 47 Administrative Rules, delegation means an RN authorizes an unlicensed person to perform tasks of nursing care and indicates the authorization in writing. The delegation process includes nursing assessment of the client in a specific situation, evaluation of the ability of the unlicensed persons, teaching the task and observing the staff demonstrate the task.

During the acuity interview on 10/30/23, Resident 7 was identified to be administered insulin injections by non-licensed staff.

Resident 7's MARs, reviewed from 10/01/23 through 10/30/23, revealed the resident received Lantus (insulin to treat diabetes) once daily and Novolog (insulin to treat diabetes) three times daily. The insulin had been given by Staff 14 (MT), Staff 17 (MT) and Staff 18 (MT) on multiple occasions.

Delegation records and the MAR for Resident 7 were reviewed during the survey and  revealed Staff 14, 17 and 18 had no documented evidence required areas were completed by the facility RN in accordance with the Oregon Administrative Rules adopted by the Oregon State Board of Nursing in chapter 851, division 047.

During the survey, Staff 5 (RN) was not able to be interviewed relating to delegation and supervision of special tasks of nursing care.

On 11/01/23 and 11/02/23, the need to ensure all staff who administered insulin injections were appropriately delegated and supervised in accordance with OSBN Administrative Rules was discussed with Staff 1 (ED), Staff 6 (Wellness Services Director, LPN) and Staff 7 (RCC). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure information and interventions provided on-site by outside service providers were communicated to staff and service plans adjusted if necessary for 2 of 3 sampled residents (#s 2 and 3) who received outside services. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 2021 with diagnoses including hypertension and alcohol use disorder.

An outside provider note dated 10/25/23 noted "...apply betadine to anterior right leg and right sub 1st metatarsal head wounds and dress with bandage every other day until healed..."

During interviews with Staff 10 (MT) and Staff 18 (MT) on 10/30/23, they stated there was no current treatment being applied to the resident's skin and neither staff had observed the resident's lower extremities.

Resident 2's service plan, updated 09/21/23, temporary service plans, facility charting notes dated 08/01/23 through 10/30/23 and 10/01/23 through 10/30/23 MARs were reviewed. There was no documented evidence the outside provider note had been reviewed nor was there evidence the facility staff were updated in order to provide supplemental care.

Coordination of care with outside service providers was discussed with Staff 1 (ED) and Staff 6 (Wellness Services Director, LPN) on 11/01/23 at 12:12 pm. Staff acknowledged the findings.

2. Resident 3 moved into the facility in 03/2023 with diagnoses including hypertension and osteoarthritis.

Interviews with staff and resident, review of the service plan dated 10/11/23, temporary service plans, progress notes and outside provider notes dated 08/01/23 through 10/30/23 were completed. The following recommendations were made from the outside service providers who visited 08/03/23 through 10/17/23:

* 08/15/23- Resident 3 received R ear lavage treatment for wax removal. Recommendations included to "Please call [outside service provider] for any ear pain, bleeding, changes in hearing or discomfort."

* 08/29/23- "Notify [outside service provider] if rash doesn't improve, getting worse or for any changes/concerns/questions."

* 09/12/23- "Notify [outside service provider] if (rash) does not resolve or worsens."

* 10/02/23- "C/O R ear- having difficulty ...Rash under R breast and ...groin/pannus ...Please call [outside service provider] if rash spreading or worsening or not improving."

On 10/31/23 an interview with Resident 3 indicated that there was no longer a rash under the breast but s/he still has ongoing "discomfort" in the right ear.

During an interview on 11/02/23 Staff 6 (Wellness Services Director, LPN) confirmed the service plan was not updated related to the resident's skin.        

The facility lacked documented evidence the information and interventions were communicated to direct care staff.

The need to ensure staff were informed of on-site outside provider information and interventions and the service plan adjusted if necessary was reviewed with Staff 1 and Staff 6 on 11/02/23. They acknowledged the findings.

2. Observations were made in the facility dining hall during lunch service on 10/31/23. The following was noted:

Staff 20 (Server) and Staff 21 (Server) were observed delivering beverages and meals from the facility's kitchen and meal preparation area to the resident's seated in the dining area. On multiple occasions Staff  20 and Staff 21 gathered used plates, cups and silverware from tables with gloved hands. The staff then placed the dishes in the soiled dish bin, retrieved a cloth from the sanitization bucket and wiped down tables in the dining area. Staff 20 and Staff 21 continued to serve the residents' beverages and food while wearing the same pair of gloves and without performing proper hand hygiene.

The need to ensure the facility maintained infection prevention and control protocols to provide a safe, sanitary and comfortable environment was discussed with Staff 1 (ED) on 11/02/23. She acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure infection prevention and control protocols were maintained to provide a safe, sanitary and comfortable environment and failed to maintain proof of vaccination or documentation of a medical or religious exemption as required in OAR 333-019-1010(4). Findings include, but are not limited to:

1. Upon entrance to the facility on 10/30/23, the facility's documentation of monthly COVID-19 reporting on vaccination status to the Oregon Health Authority (OHA) for staff was requested. No information was provided.

On 11/02/23 at 10:00 am, Staff 1 (ED) confirmed the facility was unable to find documentation regarding the monthly COVID-19 reporting on vaccination status to OHA.

The need to ensure the facility reported monthly on COVID-19 vaccination status was reviewed with Staff 1 (ED) and Staff 6 (Wellness Services Director, LPN) on 11/02/23. They acknowledged the findings.

2. During the survey, meal observations were made of staff in the dining room. There were approximately 15 residents in the dining room for breakfast and lunch on 03/13/24. Staff was observed removing dirty dishes, touching and putting their hands in their pocket, and serving residents their meals without changing their gloves. Additionally, on multiple observation staff removed their dirty gloves, pulled gloves from the scrub, and donned them without performing hand hygiene.

The need to ensure universal precautions for infection control were exercised, including appropriate hand hygiene while serving meals to the residents, was discussed with Staff 1 (ED), Staff 23 (Wellness Services Director) and Witness 1 (Consultant LPN) on 03/14/24. The findings were acknowledged.

Based on observation and interview, it was determined the facility failed to establish and maintain effective infection prevention and control protocols to provide a safe, sanitary and comfortable environment for multiple non-sampled residents observed during meal service. This is a repeat citation. Findings include, but are not limited to:

1. During the survey, observations were made of staff during delivery service on 03/12/24 and 3/13/24. Staff was observed carrying drinks, plates, glasses, utensils, and desserts to residents in their rooms, touching door handles, elevator buttons, tying shoes, pulling up pants, putting their hands in the pocket to retrieve keys and serving residents their meals without consistently changing their gloves. When staff did remove their dirty gloves, there was no hand hygiene performed before donning new gloves.

The need to ensure universal precautions for infection control were exercised, including appropriate hand hygiene while serving meals to the residents, was discussed with Staff 1 (ED), Staff 23 (Wellness Services Director) and Witness 1 (Consultant LPN). They acknowledged the findings.

1) Hand hygiene was reviewed with staff present during survey re-visit.  Hand hygiene in-service will be completed for dining services on 4/3/2024.

2) Dining Service Director will oversee the dining staff are following infection control practices.

3) Daily monitoring and monthly training.

4) Dining Services Director and Executive Director are responsible for this plan of correction.  

Based on observation, interview, and record review, it was determined the facility failed to ensure the staff who administered medications visually observed the resident take the medication for 1 of 1 sampled resident (# 4) whose records were reviewed. Findings include, but are not limited to:

Resident 4 was admitted to the facility in 07/2015 with diagnoses including renal insufficiency.

The resident's 10/01/23 through 10/30/23 MARs and physician's orders were reviewed.

During an interview on 10/30/23 at 3:00 pm with Resident 4, pill cups with several pills in them were observed to be bedside and next to Resident 4's recliner. Staff 7 (RCC) was present at the time of the observation and confirmed the facility administered all of Resident 4's medications.

The need to ensure staff visually observe residents take their medications was discussed with Staff 1 (ED) and Staff 6 (Wellness Services Director, LPN) on 11/02/23. They acknowledged and findings.

Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed and signed physician or other legally recognized practitioner orders were in the resident's records for all medications and treatments the facility was responsible to administer for 2 of 7 sampled residents (#s 1 and 7) whose orders and MAR/TARs were reviewed. Findings include, but are not limited to:

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

The resident's 08/18/23 signed physician orders and 10/01/23 through 10/30/23 MAR/TAR were reviewed and showed the following:

* A physician order noted Novolog insulin 9 units subcutaneously was to be administered three times daily prior to meals and to "hold Novolog if blood sugar is under 80 or pt [resident] is not eating."

a. The MAR showed the Novolog insulin was held on 10/12/23 and 10/19/23 when the resident's CBG was 106 and 120 and the resident had a meal.  Novolog insulin should have been given to the resident as prescribed.

b. The MAR showed the Novolog insulin was administered on 10/14/23 when the resident's CBG was 48 and the insulin should have been held.

c. The MAR showed the Novolog was administered on 10/21/23 when the resident had not had a meal. The insulin should have been held as prescribed.  

d. A physician order noted glucose 8 gm as needed was to be administered when "blood sugars less than 60."

The MAR showed the resident experienced four occasions, 10/11/23, 10/13/23, 10/16/23 and 10/23/23, when the resident's blood sugar was less than 60. There was no documented evidence the glucose 8 gm had been administered as prescribed.

The need to ensure the facility administered all medications including insulin administration as prescribed was discussed with Staff 1 (ED) and Staff 7 (RCC) on 11/01/23. They acknowledged the findings.

2. Resident 5 was admitted to the facility in 10/2023.

Review of the 10/11/23 through 10/30/23 MARs and 10/10/23 physician orders revealed the following:

Resident 1 was administered Icelandic sea kelp 225 micrograms daily (for thyroid health) for which there was not a signed physician order in the resident's facility record.

The need to ensure the facility had an order for all medications administered was discussed with Staff 1 (ED) and Staff 6 (Wellness Director, LPN) on 11/02/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed for 4 of 7 sampled residents (#s 2, 8, 10 and 11) whose orders and MAR/TARs were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 11 was admitted to the facility in 11/2020 with diagnoses including Type II diabetes.

The resident's 02/05/24 signed physician orders and 03/01/24 through 03/12/24 MAR/TAR were reviewed and showed the following:

A physician order noted to apply Diclofenac 1 % four times daily for pain. The MAR had blanks and indicated "not given by facility." On 03/12/24 at 1:55 pm, Staff 26 (MA) confirmed they did not apply the cream to the resident as ordered.

The need to ensure the facility administered all orders as prescribed was discussed with Staff 1 (ED), Staff 23 (Wellness Services Director) and Witness 1 (Consultant LPN) on 03/14/24. They acknowledged the findings.

2. Resident 10 was admitted to the facility in 2021 with diagnoses including Parkinson's disease and kidney failure.

Physician orders dated 02/19/2024 and MARs for Resident 10, reviewed from 03/01/24 to 03/11/24, revealed the following orders were not followed:

* Carbidopa-Levodopa 25mg/100mg tab x 5 per day for Parkinson's Disease: one dose was not administered on 03/04/24, and two doses not administered on 03/05/24; and

* Atorvastatin 80 mg tab daily for high cholesterol: one dose was not administered on 03/04/24.

The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (Executive Director), Witness 1, Staff 23 (Wellness Services Director, LPN) and Staff 25 (Regional Director of Operations) on 03/14/24. They acknowledged the findings.

4. Resident 2 was admitted to the facility in 04/2021 with diagnoses including hypertension and alcohol use disorder.

The resident's 02/08/24 signed physician orders and 03/01/24 through 03/13/24 MAR/TAR were reviewed and showed the following:

A physician order for hydrochlorothiazide 25 mg (for blood pressure and edema), take two tablets every day. Additional instructions noted, "Hold for blood pressure below 100/60. Notify provider if blood pressure less than 100/60 or greater than 160/100."

The daily blood pressure readings did not appear on the 03/2023 MAR and the facility did not have documented evidence the blood pressure was being taken prior to administering the medication.

The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (Executive Director), Staff 23 (Wellness Services Director), Staff 25 (Regional Director of Operations) and Witness 1 (Consultant LPN) on 03/14/24. No additional information was provided.

3. Resident 8 moved into the facility in 03/2023 with diagnoses including atrial fibrillation and seizure disorder.

Physician orders, dated 08/23/23 and 11/08/23, and MARs dated 03/01/24 to 03/12/24 were reviewed. On 08/23/23, the physician orders included the following:

* Vitamin D-3, take 1 tablet daily (for supplement); and

* Ferrous sulfate, take 325 mg daily (for supplement).

These orders did not appear on the 03/2023 MAR and the facility did not have documented evidence the orders had been discontinued.

The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (Executive Director), Witness 1 (Consultant), Staff 23 (Wellness Services Director) and Staff 25 (Regional Director of Operations) on 03/14/24. No additional information was provided.   

1) Resident #2 has an order to take BP before administering hydrochlorothiazide. This order was reviewed with this resident and he has agreed to take his BP routinely to comply with the physician order. Additionally, staff have been trained on ensuring this medication has been given only if the BP has been collected per physician order.  For resident #8, we have received d/c orders for the ferrous sulfate and the vitamin D3. For resident #11, the MAR was updated to ensure all medications that are self-administered are documented as such. For resident #10 Training was done to ensure med-techs understand order processing and refill system to ensure all medications are available to be given as prescribed.

2) Third check system is in place and this system is reviewed several times per week in the clinical meeting. HWD has conducted training on how to process orders, and how to ensuring complete med passes to ensure all medications are administered as ordered. MAR training was done with med-techs to ensure they review qMAR for med-pass completion to ensure all medications are documented as given and medpass exceptions are followed up with apppropriately. Med-pass exception and variance reports are reviewed in the clinical meeting. Bi-weekly MAR audits will be completed to ensure all treatments and medications are given as ordered. Med-tech meetings are being scheduled weekly to review concerns and review training provided. HWD and RCC are performing med-pass competencies for the med-techs. MARs will be audited several times per week to ensure BP parameters are followed.

3) Daily monitoring in the clinical meeting and weekly auditing.

4) Wellness Services Director, Resident Care Corrdinator and Executive Director are responsible for this plan of correction.

2. Resident 2 was admitted to the facility in 04/2021 with diagnoses including hypertension and alcohol use disorder.

Resident 2 had a physician order for hydrochlorothiazide (to treat high blood pressure and fluid retention) every day with specific parameters to hold the medication for blood pressure below 100/60.  

Review of the 10/01/23 through 10/30/23 MAR noted 18 times vital signs were refused and the medication was given without documented evidence of whether the medication should be held or administered.

During an interview 10/30/23 at 1:15 pm, Staff 10 (MT) stated when residents' refused medications and treatments the physician was contacted.

In an interview on 10/31/23 at 12:12 pm, Staff 6 (Wellness Services Director, LPN) confirmed there was no documented evidence the facility notified Resident 2's physician related to refusals of vital signs to determine whether a medication should be given.

The need to notify the physician or other practitioner when a resident refused consent to medication or treatment orders was discussed with Staff 1 (ED) and Staff 6. No additional information was provided.

Based on interview and record review, it was determined the facility failed to notify the physician or other practitioner if a resident refused to consent to an order for 2 of 2 residents (#s 2 and 3) who had medication refusals. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 03/2023 with diagnoses including hypertension and osteoarthritis.

The resident's 10/01/23 to 10/30/23 MAR and progress notes dated 08/01/23 to 10/30/23 were reviewed, and interviews with staff were conducted. The following was identified:

On 10/14/23 staff documented on the MAR the resident refused to consent to the following orders:

* Potassium chloride (for low potassium);

* Furosemide (for edema);

* Acetaminophen (for pain);

* Calcium carbonate (for osteoporosis);

* Curcumin (for osteoarthritis);

* Fexofenadine (for allergies);

* Losartan (for hypertension);

* Metoprolol succinate (for hypertension);

* Multivitamin (for nutritional supplement);

* Sertraline (for depression/anxiety);

* Vitamin D3 (for nutritional supplement); and

* Omeprazole (for gastroesophageal reflex disease).

During an interview at 10:50 pm on 10/31/23, Staff 7 (RCC) confirmed the physician was not notified when the resident refused the medications.

The need to notify the physician when a resident refused consent to orders was discussed with Staff 1 (ED) and Staff 6 (Wellness Services Director, LPN) on 11/02/23. They acknowledged the findings.

2. Resident 6 was admitted to the facility in 2021 with diagnoses including acute cholecystitis (inflammation of the gall bladder).

Review of Resident 6's 10/01/23 through 10/30/23 MAR, noted the following medications were not administered by the facility:

* Flovent inhaler (reducing inflammation) twice daily;

* Spiriva respimate inhaler (for shortness of breath) twice daily;

* Albuterol inhaler (for shortness of breath) as needed; and

* Diclofenac gel (for pain) as needed.

During an interview on 10/31/23 at 10:30 am, Resident 6 stated s/he managed their own inhalers. The Albuterol, Spiriva respimate and Flovent inhalers were observed in the resident's apartment.

There was no documented evidence an evaluation of Resident 6's ability to administer their own medications had been completed nor was there a current physician order.

The lack of physician order and evaluation was discussed with Staff 6 (Wellness Services Director, LPN) on 11/01/23 at 12:12 pm. Staff 6 stated the self medication evaluation and request for a physician order was in process.

Based on observation, interview, and record review, it was determined the facility failed to evaluate a resident's ability to safely self-administer medications and have a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications for 2 of 2 sampled residents (#s 5 and 6) who chose to self-administer their medications. Findings include, but are not limited to:

1. Resident 5 moved to the facility in 07/2021 with diagnoses including tremors and chronic obstructive pulmonary disease.

During the acuity interview on 10/30/23, the resident was identified to self-administer his/her own medications.

The resident's room was toured on 10/31/23 and multiple bubble packs of medications were observed in the room.

a. The resident's clinical records were reviewed and showed the following:

* There was no signed physician order for the self-administration of the medications.

During the survey, a current physician or other legally recognized practitioner's written order of approval for self-administration of the prescription medications was requested. The facility obtained and provided a written order for self-administration of the prescription medication dated 10/31/23.

b. On 10/31/23, the resident's room was toured and an oxygen concentrator, with oxygen set at the rate of 4.5 L/minute was observed. The oxygen concentrator was on and running at the time of the observation.

The resident's clinical records were reviewed and showed the following:

* The resident's 08/24/23 order indicated "oxygen at 0-2 L/min by nasal cannula for a goal O2 sat [oxygen-bound hemoglobin in the blood] of 89%." The order further directed "do not raise oxygen over 2 liters per doctors [doctor's] order ..."; and

* The facility evaluated the resident's ability to safely self-administer medications on 09/21/23. The evaluation did not address the use of the oxygen status.

The failure to obtain physician's orders in a timely manner and complete the evaluation of the resident's ability to self-administer medications related to the oxygen use was discussed with Staff 1 (ED) and Staff 7 (RCC) on 11/01/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 3 of  3 newly-hired direct care staff (#s 9, 13 and 16) completed all required pre-service orientation and dementia training prior to beginning their job responsibilities. Findings include, but are not limited to:

Training records were reviewed with Staff 2 (Business Office Manager) on 11/01/23.

a. Staff 9 (MT) hired 08/17/23, lacked documented evidence of completing the following required elements for pre-service orientation training prior to beginning job duties:

* Infectious disease prevention training; and

* Written job description.

In addition, Staff 9 lacked documented evidence of completing the following required pre-service dementia training prior to beginning job duties:

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

* Techniques for understanding, communicating and responding to distressful behavioral symptoms, including, but not limited to, reducing use of antipsychotics;

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

* Specific aspects of dementia care and ensuring the safety of residents with dementia, including identifying and addressing pain, preventing wandering and elopement and the use of a person centered approach.

b. Staff 13 (CG) hired 07/27/23, lacked documented evidence of completing the following required elements for pre-service orientation training prior to beginning job duties:

* Infectious disease prevention training; and

*Written job description.

In addition Staff 13 lacked documented evidence of completing the following required pre-service dementia training prior to beginning job duties:

* Specific aspects of dementia care and ensuring the safety of residents with dementia, including identifying and addressing pain, preventing wandering and elopement and the use of a person centered approach.

c. Staff 16 (CG) hired 08/17/23, lacked documented evidence of completing the following required elements for pre-service orientation training prior to beginning job duties:

* Resident rights and the values of community based care;

* Abuse reporting requirement;

* Infectious disease prevention training;

* Fire safety and emergency protocols; and

* Written job description.

In addition, Staff 16 lacked documented evidence of completing the following required pre-service dementia training prior to beginning job duties:

* Dementia disease process including progression, memory loss, psychotic and behavioral symptoms;

* Techniques for understanding, communicating and responding to distressful behavioral symptoms, including, but not limited to, reducing use of antipsychotics;

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

* Specific aspects of dementia care and ensuring the safety of residents with dementia, including identifying and addressing pain, preventing wandering and elopement and the use of a person centered approach.

The need to ensure newly hired direct care staff completed all required pre-service orientation and dementia training prior to beginning their job responsibilities was reviewed with Staff 1 (ED) and Staff 6 (Wellness Services Director, LPN) on 11/02/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 2 of  3 newly-hired staff (#s 26 and 29) completed all required pre-service orientation prior to beginning their job responsibilities. This is a repeat citation. Findings include, but are not limited to:

Training records were reviewed with Staff 24 (Business Office Manager) on 03/14/24.

a. Staff 26 (MT) hired 01/30/24, lacked documented evidence of completing the following required elements for pre-service orientation training prior to beginning job duties:

* Resident rights and values of CBC care; and

* Fire safety and emergency procedures.

b. Staff 29 (Server) hired 11/01/22, lacked documented evidence of completing the following required elements for pre-service orientation training prior to beginning job duties:

*Abuse reporting requirements.   

The need to ensure newly hired staff completed all required pre-service orientation prior to beginning their job responsibilities was reviewed with Staff 1 (ED), Staff 23 (Wellness Services Director, LPN), Staff 25 (Regional Director of Operations) and Witness 1 (Consultant LPN) on 03/14/24. They acknowledged the findings.

1) Staff #26 and # 29 were given their training assignments for missing training. All staff records will be audited and necessary assignments given to staff for completion.

2) All pre-service orientation requirements will be assigned and progress will be monitored for completion before starting training on the floor.

3) Monthly tracking and quarterly auditing.

4) Business Office Manager and Executive Director are responsible for this plan of correction.

Based on interview and record review, it was determined the facility failed to ensure newly hired staff demonstrated satisfactory performance in all required areas within the first 30 days of hire for 2 of 3 direct care staff (#s 9 and 16). Findings include, but are not limited to:

Facility training records were reviewed with Staff  2 (Business Office Manager) on 11/01/23. The following was noted:

a. Staff 9 (MT), hired 09/17/23, lacked documented evidence of demonstrated satisfactory performance in the following required areas within 30 days of hire:

* Providing assistance with ADL's;

* Changes associated with normal aging;

* Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition;

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

* General food safety, serving and sanitation;

* First aid, abdominal thrust; and

* The ability to perform safe medication and treatment administration unsupervised.

The facility provided documentation of Staff 9's medication and treatment training on 11/01/23 prior to their next scheduled shift.

b. Staff 16 (CG), hired 08/25/23, lacked documented evidence of demonstrated satisfactory performance in the following required areas within 30 days of hire:

* The role of service plans in providing individualized resident care;

* Providing assistance with ADL's;

* Changes associated with normal aging;

* Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition;

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

* General food safety, serving and sanitation; and

* First aid, abdominal thrust.

The need to ensure new hire staff demonstrated satisfactory performance in all required areas within the first 30 days of hire was discussed with Staff 1 (ED) and Staff 6 (Wellness Services Director, LPN) on 11/02/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure documented evidence of the required 12 hours of annual in-service training, including six hours of dementia care training, was completed for 1 of 2 long term staff  (# 12) whose training records were reviewed. Findings include, but are not limited to:

Annual in-service training records were reviewed with Staff 2 (Business Office Manager) on 11/01/23. The following was noted:

Staff 12 (CG), hired on 12/11/14, lacked documented evidence of a minimum of 12 hours of in-service training annually, based on hire date, on topics related to the provision of care for persons in a community-based care setting, including training on chronic diseases in the facility population, and at least six hours of dementia care training.

The need to ensure long-term staff completed 12 hours of annual in-service training, including six hours of dementia care training was discussed with Staff 1 (ED) and Staff 6 (Wellness Services Director, LPN) on 11/02/23. They acknowledged the findings.

Based on record review and interview, it was determined the facility failed to ensure residents were instructed on general safety procedures, evacuation methods, responsibilities during fire drills and designated meeting places within 24 hours of admission and re-instructed at least annually. Findings include, but are not limited to:

On 10/31/23, Staff 4 (Building Services Director) was asked to explain the process of providing resident instruction upon admission and re-instruction annually. Staff 4 stated the facility's fire drill and safety procedures were not reviewed with the resident upon admission nor re-instructed at least annually.

The need to ensure residents were instructed on general safety procedures within 24 hours of admission and re-instructed at least annually was discussed with Staff 1 (ED) and Staff 6 (Wellness Services Director, LPN) on 11/02/23. They acknowledged the findings.

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

Refer to C200, C260, C295, C303, C370, C613 and C630.

1) Please refer to C200, C260, C295, C303, C370, C613, and C630.

2) ED will be working side by side with facility management to ensure compliance of aforementioned tags.

3) Daily.

4) ED will be responsible for this plan of correction.  

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

Refer to C200.

Refer to C200.

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

Refer to C 200.

C455 will be resolved through C200 systems and ongoing monitoring

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

The facility was toured on 10/30/23 at 10:30 am. The following areas were observed to need cleaning and/or repair:

* Second floor corridor had an unpleasant pervasive odor throughout the survey;

* Second floor staff laundry room had broken floor tiles;

* Unit 232 door had chipped paint;

* Carpet throughout the facility and inside unit 116 had black and brown stains; and

* Carpet in dining room had a long tear and was a potential trip hazard.

The need to ensure the facility was clean, in good repair and free from unpleasant odors was discussed with Staff 1 (ED) on 11/01/23. She acknowledged the findings.

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

The facility was toured on 03/12/24 at 10:30 am, and observations showed multiple areas that required cleaning and repair.

* Carpet inside unit 116 had black and brown stains;

* Unit 232 door had chipped paint; and

* Walls inside room 225 were damaged and the carpet required cleaning.

The need for a system to ensure resident rooms were maintained in good repair was discussed with Staff 1 (ED), Witness 1, Staff 23 (Wellness Services Director, LPN) and Staff 25 (Regional Director of Operations) on 03/14/24. They acknowledged the findings.

1) Drywall in unit 225 was promptly repaired and painted upon notice. Carpet in 116 has been cleaned, and will be cleaned routinely as a preventative measure. Unit 232's door has been repaired and is in good repair.  

2) The Executive Director and Building Service Director will conduct weekly walkthroughs of the community to identify maintenance needs.  Executive Director to review maintenance log for completion of tasks.

3) Weekly and monthly.

4) Building Services Director and Eecutive Director are responsible for this plan of correction.  

Based on observation and interview, it was determined the facility failed to ensure soiled linen areas included a flushing rim clinical sink with a handheld rinsing device. Findings include, but are not limited to:

The three facility laundry rooms were toured on 10/30/23. The following was noted:

Each laundry room was equipped with a utility sink. In a 10/30/23 interview with Staff 4 (Building Services Director), he reported the utility sinks were used to process soiled linens. He confirmed the facility did not have a flushing rim clinical sink with a hand held rinsing device.

The need to ensure the facility had a flushing rim clinical sink with a hand held rinsing device for processing soiled linen was discussed with Staff 1 (ED) on 11/02/23. She acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure soiled linen areas included a flushing rim clinical sink with a handheld rinsing device. This is a repeat citation. Findings include, but are not limited to:

The facility laundry rooms were toured with Staff 1 (Executive Director) and Witness 1 on 03/12/24. The following was noted:

On 03/12/24 Staff 1 acknowledged the facility had not yet installed a flushing rim clinical sink with a hand held rinsing device.

The need to ensure the facility installed a sink with a hand held rinsing device for processing soiled linens was reviewed with Staff 1, Witness 1, Staff 23 (Wellness Services Director, LPN) and Staff 25 (Regional Director of Operations) on 03/14/24. They acknowledged the findings.

1) A flushing rim sink has been ordered.  Install to occur after Facility Planning and Safety (FPS) approval.

2) Full walkthrough will be conducted evaluating for further needs.

3) Monthly.

4) Building Service Director and Executive Director are responsible for this plan of correction.  

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

Observations made on 10/30/23 revealed two second floor exit doors lacked an effective system for security purposes and first and second floor exit doors lacked an acceptable system to alert staff each time a resident exited the facility.  

The requirement to ensure exit doors were equipped with an operable alarming device or other acceptable system for security purposes and to alert staff when residents exited the facility was discussed with Staff 1 (ED) on 11/02/23. She acknowledged the findings.