Print Inspection: XC9W

The findings of the change of ownership survey, conducted 06/06/23 through 06/08/23, 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 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 first re-visit to the change of ownership survey of 06/08/23, conducted 02/26/24 through 02/28/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

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 06/08/23, conducted, 04/23/24, are documented in this report. It was determined the facility was in 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.

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

During the change of ownership survey, conducted 06/06/23 through 06/08/23, oversight to ensure the quality of services rendered in the facility was found to be ineffective, based on the number of citations.

Refer to deficiencies in the report.

Facility administrator to complete retraining of Administrator duties, oversight, and responsibilities with company Operations Specialist or other designated representative.

Ongoing oversight and review from company operations specialist or other designated representative.

Bi-weekly meetings to be held with the Administrator and operations team to review for compliance and understanding.

Facility Administrator and designated company operational support.

Based on observation, interview, and record review, it was determined the facility failed to ensure 1 of 1 sampled resident (#6) was treated with dignity and respect related to ADL needs. Findings include, but are not limited to:

Resident 6 was admitted to the facility in 12/2020 with diagnoses including anxiety and blindness.

Review of the resident's service plan, dated 05/06/23, showed the resident required ongoing assistance with orientation to his/her environment due to vision impairment. The resident could see only shadows and preferred to have his/her apartment brightly lit. Staff were instructed to "occasionally place things back where they go," so the resident could locate items. The service plan indicated staff were to orient the resident to the food items served to him/her, which was not consistently implemented. The service plan did not give staff direction on how to assist the resident with orientation to his/her environment to foster independence.

Observations of the resident between 06/06/23 and 06/08/23 showed the resident stayed primarily near his/her apartment unless s/he was with another friend who assisted the resident around the facility and outside.

Additional observations of the resident's apartment showed two love seats placed side-by-side, which left a small pathway to the living room. The living room had multiple plastic tub lids across the floor, boxes of items stacked behind the love seats, and a metal clothing stand partially tipped over onto a pile of personal items.

In interviews between 06/06/23 and 06/08/23 the following was noted:

* The resident stated s/he lived at the facility for several years and moved from an apartment on the first floor to the current apartment on the second floor in the last 5-6 months. The resident indicated s/he felt isolated so far away from everything. The resident stated s/he had several things that were still not unpacked or put away and that s/he had a terrible time trying to find many of his/her things. The resident was frustrated by the set-up and "feels lost in all of it." The resident further indicated s/he was not sure where the stairway or elevator were but had a general idea, s/he doesn't go downstairs alone. The resident stated s/he moved apartments to deal with concerns about a man in the attic coming into his/her apartment and someone spraying him/her with poison, but nothing changed.

* Staff 13 (CG), Staff 15 (MT/CG), and Staff 18 (CG) indicated the resident was alert and oriented and could direct his/her own care. The resident had some delusions around someone spraying him/her with poison that were difficult to deal with. The staff further indicated the resident had no real vision and needed assistance to get around the facility and outside. The staff all stated they were not aware of any specific orientation being done when the resident moved to the new apartment upstairs. Staff 15 and Staff 18 indicated they physically escorted the resident to and from the dining room and did not think the resident could find the downstairs on his/her own. None of the staff interviewed could say how much direction the resident had been given around the current apartment set-up, but indicated the resident did not like personal items touched more than was necessary.

* Staff 1 (Executive Director) indicated the resident was part of the discussion for the move to help with his/her fears. Staff 1 believed the resident was involved in the set-up of the apartment and oriented to the area around him/her, but could not say for sure when it occurred and what it involved. Staff 1 was shown the current set-up in the apartment and agreed it needed attention.

The need to ensure a resident was treated with dignity and respect around their individualized needs for accommodations for vision impairment was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Director/RN), and Staff 7 (Regional RN) on 06/08/23. They acknowledged the findings.

Resident 6 was moved to a studio apartment on 6/27/23. She was oriented to the new apartment. We discussed what furniture and possessions she wanted in the new apartment. Resident 6 is aware how to navigate to med station, elevator, activities and other areas.

The system will be corrected by utilizing care staff task sheets when special needs residents are identified.

The service plan will specify weekly checks that will include any assistance with orientation to the environment.

Resident Care Coordinator is responsible for monitoring resident care needs.    

Based on observation, interview, and record review, it was determined the facility failed to ensure unescorted departures from the facility and staff-to-resident altercations were promptly investigated to rule out abuse and/or neglect for 2 of 2 sampled residents (#s 1 and 6). Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 02/2021 with diagnoses including confusion.

Observations of the resident, interviews with staff, and review of the resident's 02/20/23 service plan, 03/16/23 through 06/06/23 temporary service plans, progress notes, physician communications, and incident investigations were completed.

The resident was noted to be confused, required one staff assistance for ADL care, and needed frequent redirection by staff to stay inside the facility. The resident had some statements of self-harm, harm towards others, and hallucinations with agitation. The resident was unable to find his/her way home if s/he exited the facility, so staff were asked to keep the resident away from the front doors.

Review of the resident's records showed the following:

* A progress note dated 03/22/23 indicated the resident was found outside "wandering" towards the street. The note further indicated the resident walked back to the facility, it was unclear who found the resident by the street and helped him/her return to the facility.  

* A progress note dated 05/20/23 indicated the resident was very agitated, trying to leave the building. The resident stated "going home, walk right out and make a left."

* A progress note dated 05/22/23 indicated the resident was very agitated and confused. The resident was swearing at staff, attempting to leave the facility, and making statements of shooting himself/herself in the head.

* A progress note dated 05/23/23 indicated the resident stated s/he was going home and had car keys in his/her pocket. The noted further indicated the resident "tried to run out the door to go home."

There was no additional information within the progress notes about the incidents and what occurred. No investigations were completed to determine when and if the resident exited the facility, the staff response to the resident incidents and follow-up action related to the incidents.

In an interview on 06/08/23, Staff 1 (Executive Director) and Staff 2 (Health Services Director/RN) were unable to provide additional information on the incidents and how many times the resident may have exited the facility unescorted or statements of harm to self or others.

The need to ensure all incidents were promptly investigated to rule out abuse and/or neglect was discussed with Staff 1, Staff 2, and Staff 7 (Regional RN) on 06/08/23. The staff acknowledged the findings.

2. Resident 6 was admitted to the facility in 12/2020 with diagnoses including anxiety and hallucinations.

Observations of the resident, interviews with staff, and review of the resident's 05/06/23 service plan, 03/11/23 through 06/07/23 temporary service plans, progress notes, physician communications, and incident investigations were completed.

The resident was noted to be alert and oriented with intermittent confusion. The resident had hallucinations and delusions around being poisoned. The resident could make his/her needs known and direct his/her care but was fearful of a man in the attic entering his/her apartment and spraying the resident with poisonous substances. The resident was blind, with the ability to see shadows only. The resident could get very agitated with staff around his/her delusions.

Review of the resident's records showed the following:

* A progress note dated 05/07/23 indicated the resident was agitated in the hall, demanding to know who was in the activity room. The resident continued to yell at staff and called them names. The documentation noted one of the staff told the resident they had already told him/her who was in the activity room when they brought them over; this agitated the resident further and yelling continued. The note indicated the MT and CG separately spoke to the resident to make peace with him/her.

There was no additional documentation or investigation of the incident between the resident and staff. No investigation was completed to determine if staff acted appropriately and to rule out any verbally inappropriate comments, staff response to the resident incident, and follow-up action related to the incident.

In an interview on 06/08/23, Staff 1 (Executive Director) and Staff 2 (Health Services Director/RN) were unable to provide additional documentation on the incident. Staff 1 indicated he investigated the incident at the time to rule out any verbal abuse but could not locate the investigation.  

The need to ensure all incidents were promptly investigated to rule out abuse and/or neglect was discussed with Staff 1, Staff 2, and Staff 7 (Regional RN) on 06/08/23. The staff acknowledged the findings.

Resident 1 will be evaluated for a higher level of care, potential memory care placement due to elopement risk. ISP to increase room checks, 1-2x hourly. All parameter doors connected to alarm/pager system.

Resident 6, additional staff training on how to deal with difficult behaviors and situations.

System correction by promptly performing an investigation when an IR is completed. Rule out any abuse/neglect.

Review IR submissions daily, investigate within 24 hours.

Responsible party is Resident Care Coordinator and Executive Director.  

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements and were completed prior to the resident being admitted to the facility for 1 of 1 sampled resident (#5) and quarterly evaluations were completed in a timely manner, were relevant to the needs and current condition of the resident, and were available to staff for 5 of 5 sampled residents (#s 1, 2, 3, 4 and 6) whose evaluations were reviewed. Findings include, but are not limited to:

1. Resident 5 was admitted to the facility in 04/2023 with diagnoses including a chronic obstructive pulmonary disease and pulmonary hypertension.

The resident's move-in evaluation was reviewed, staff were interviewed, and the following was identified:

a. The resident was admitted to the facility on 04/12/23, and his/her move-in evaluation was dated 04/13/23.

b. The following elements were missing from the resident's move-in evaluation:

* Customary routines: sleeping, eating, bathing;

* Interests, hobbies, social, leisure activities;

* Spiritual, cultural preferences and traditions;

* Physical health status including list of current diagnoses;

* Mental health issues, including presence of depression, thought disorders, or behavioral or mood problems; history of treatment; and effective non-drug interventions;

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

* Dental status;

* Pain, including pharmaceutical and non-pharmaceutical interventions;

* Indicators or nursing needs including potential for delegated nursing tasks;

* Complex medication regimen;

* History of dehydration or unexplained weight loss or gain;

* Recent losses; and

* Elopement risk of history.

In an interview with Staff 4 (RCC) on 06/07/23, she stated she remembered the admission evaluation being conducted prior to the resident's admission date, but she was unable to provide any documentation dated prior to the move-in date.

The need to complete move-in evaluations prior to residents moving into the facility and to address all required elements in each evaluation was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Director/RN), and Staff 7 (Regional RN) on 06/08/23. They acknowledged the findings. No additional information was provided.

2. Service plans, progress notes, temporary service plans, and incident reports were reviewed for five sampled residents (#s 1, 2, 3, 4, and 6), interviews were conducted, and observations were made. The most recent quarterly evaluations for Residents 1, 2, 3, 4, and 6 were reviewed, and the following was identified:

* Evaluations for 5 of 5 residents did not accurately reflect their needs and current conditions; and

* The most recent quarterly evaluation for Resident 3 had not been printed and added to the binder where evaluations and service plans were available to staff.

The need to ensure move-in evaluations contained relevant and current information about residents' needs and conditions and were available to staff was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Director/RN), and Staff 7 (Regional RN) on 06/08/23. They acknowledged the findings.

1. Resident Corrections

#5  The resident's current Evaluation and Service Plan will be reviewed and updated by a Service Planning Team to address all the resident's needs, conditions, and prefereces. The Service Plan will be reviewed with staff, and placed in the Service Plan Binder in a location that is accessible to all staff.

#1 Resident will be re-evaluated and the Service Plan will be reviewed and updated by a Service Planning Team to address all the resident's needs, conditions, and prefereces. The Service Plan will be reviewed with staff, and placed in the Service Plan Binder in a location that is accessible to all staff.

#2 Resident will be re-evaluated and the Service Plan will be reviewed and updated by a Service Planning Team to address all the resident's needs, conditions, and prefereces. The Service Plan will be reviewed with staff, and placed in the Service Plan Binder in a location that is accessible to all staff.

#3 no longer resides in the community

#4 Resident will be re-evaluated and the Service Plan will be reviewed and updated by a Service Planning Team to address all the resident's needs, conditions, and prefereces. The Service Plan will be reviewed with staff, and placed in the Service Plan Binder in a location that is accessible to all staff.

#6 Resident will be re-evaluated and the Service Plan will be reviewed and updated by a Service Planning Team to address all the resident's needs, conditions, and prefereces. The Service Plan will be reviewed with staff, and placed in the Service Plan Binder in a location that is accessible to all staff.

2.  Pre-Move In Evaluations will be performed prior to move in. If any fields are found blank when entering the eval into SPA the Executive Director will be notified. The Executive Director will ensure the PreMove In Eval is completed in its entirety before move in and that the evaluation date is correctly recorded in SPA.  The Service Plan generated from the PMI eval will be reviewed by the Service Planning Team who will notify the Executive Director of incomplete items noted on the Service Plan.

PMIs and Service Plans will be reviewed by the Health Services Director prior to move in to ensure the Service Plan reflects all the resident's needs, conditions, and preferences.

3. The Executive Director and the Health Services Director will log their review of each PreMove In Evaluation for the next 60 days.

4. The Executive Director and the Health Services Director are responsible for compliance   

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 to staff regarding care and services and were implemented by staff for 5 of 5 sampled residents (#s 1, 2, 3, 4 and 6). Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 02/2021 with diagnoses including congestive heart failure and cognitive impairment.

Observations of the resident, interviews with staff, and review of the service plan available to staff, dated 02/20/23, showed the service plan was not reflective of the resident's current care needs, consistently implemented by staff and did not provide clear direction to staff in the following areas:

* Wheelchair and walker use and transport by staff;

* Call light use;

* Falls and safety interventions;

* Oxygen use, care, and tubing safety;

* ADL assistance needed;

* Agitation and threats of self-harm;

* Exit seeking, confusion, and wandering from the facility; and

* Evacuation assistance.

The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (ED), Staff 2 (Health Services Director/RN), and Staff 7 (Regional RN) on 06/08/23. The staff acknowledged the findings.

2. Resident 4 was admitted to the facility in 07/2019 with diagnoses including tremors and diabetes.

Observations of the resident, interviews with staff, and review of the service plan available to staff, dated 02/14/23, 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:

* Walker and cane use;

* Edema;

* Refusals of meals, weight loss, and food alternatives; and

* Medication refusals;

The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (ED), Staff 2 (Health Services Director/RN), and Staff 7 (Regional RN) on 06/08/23. The staff acknowledged the findings.

3. Resident 6 was admitted to the facility in 12/2020 with diagnoses including anxiety and blindness.

Observations of the resident, interviews with staff, and review of the service plan available to staff, dated 05/06/23, showed the service plan was not reflective of the resident's current care needs, not consistently implemented by staff and did not provide clear direction to staff in the following areas:

* Orientation, mobility, and escort assistance;

* Returning items to their assigned location due to blindness;

* Refusals of care assistance, including showers;

* Agitation and aggression towards staff;

* Delusions, paranoia, and hallucinations;

* Orientation to food items on plate each meal;

* Dislike of and anxiety related to loud noises;

* Use of fingers and not utensils for all meal types related to cultural preference; and

* Key use.

The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Director/RN), and Staff 7 (Regional RN) on 06/08/23. The staff acknowledged the findings.

4. Resident 2 was admitted to the facility in 05/2022 with diagnoses including diabetes, rheumatoid arthritis, and osteoarthritis.

The resident's service plan, dated 04/21/23, interim service plans, progress notes dated 03/17/23 through 06/01/23, incident reports, and physician communication forms were reviewed, and the resident and staff were interviewed. The following areas of the service plan were not reflective of his/her current status and care needs and/or did not provide instruction to staff on all shifts:

* Cognitive status;

* Behavior problems to include non-pharmacological interventions;

* Toileting assistance instructions;

* Pain to include non-pharmacological interventions;

* Skin conditions and history;

* Evacuation assistance;

* Self-administration of medications;

* Oxygen use care and instructions for staff;

* Delegation for insulin administration; and

* Fall history and interventions.

The need for the service plan to accurately reflect the resident's current status and care needs and to provide clear instruction to staff regarding the provision of care was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Director/RN), and Staff 7 (Regional RN) on 06/08/23. They acknowledged the findings.

5. Resident 3 was admitted to the facility in 09/2022 with diagnoses including a closed hip fracture which required surgery with routine healing and hearing loss.

The resident's service plan, dated 04/21/23, progress notes dated 03/17/23 through 06/01/23, and interim service plans were reviewed, and the resident and staff were interviewed. The following areas of the service plan were not reflective of the resident's current status and care needs:

* Eating meals in his/her apartment rather than the dining room;

* Diet needs;

* Dental status;

* Personal caregiver schedule;

* Participation in activities;

* Frequency s/he was weighed;

* Transfer assistance needed;

* Assistance needed with ADLs;

* A fall on 03/30/23; and

* The use of side rails.

There were no instructions to staff about how frequently the resident should be showered or how and when to engage him/her in activities.

The need for the service plan to accurately reflect the resident's current status and care needs and to provide clear instruction to staff regarding the provision of care was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Director/RN), and Staff 7 (Regional RN) on 06/08/23. They acknowledged the findings.

1. Resident Corrections

# 1 will be re-evaluated and the service plan updated to address all the resident's needs, conditions and preferences including mobility and fall prevention interventions, Oxygen use, care, and safety, the ADL (Activities of Daily Living) assistance needed, and will include a behavioral plan and interventions to implement with agitation and self-harm threats, exit seeking, confusion, wandering, and evacuation assistance needs.

 #2 will be re-evaluated and the service plan updated to address all the residents needs, conditons, and preferences including cognitive status, inclusion of non-pharmacological intervention for both pain and behaviors, skin condition and history, toileting assistance

#3 no longer resides in the community

#4 will be re-evaluated and the service plan updated to address all the residents needs, conditons, and preferences incluging mobility/ walker & cane use, care of edema and notifications to Med Tech/nurse, refusal of meals, weight loss, food alternatives, and medication refusals.

#6 will be re-evaluated and the service plan updated to address all the residents needs, conditons, and preferences including accomodations for her blindness especially orientation of her room/surroundings, the importance of returning items to a location assigned by the resident, orienting resident to location of food on plate and dining implements. A behavioral plan with interventions to address anxiety, agitation, aggression, delusions, paranoia and hallucinations wil be created by the Service Planning Team. Service Plan will inform team that residents preference to scoop food using a sm piece of bread-type food is the cultural norm for her and is to be supported.  Service plan will be updated to reflect residents needs/preferences r/t use of a room key.

2. Resident Service Plans will be created based on the Multidisciplinary Evaluation, updated prior to the due date, and will address all current needs, conditions and preferences including the current physical and cognitive needs for assistance, including who, what, when, how and how often, a service is to be performed with clear instructions as to how to perform the service according to the resident's wishes.  Service Plans will be created/updated by the Service Planning Team.  Service Plans will be in place before move-in, updated within the first 30d, and quarterly there after or as a Change in Condition arises and will be accessible to staff at all times.  

3. The Executive Director and Health Services Director will log their review of 10% of all Service Plans to ensure updates are made and instructions are clear.

4. The Executive Director, Health Services Director and Resident Care Coordinator are responsible for compliance

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs, and provided clear directions to staff regarding the delivery of services for 2 of 2 sampled residents (#s 8 and 10) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 10 was admitted to the facility in 06/2013 with diagnoses including diabetes, peripheral neuropathy, diabetic retinopathy, and chronic kidney disease stage 3. Resident 10 was dependent on renal dialysis.

Interviews with the resident and staff, and review of the current service plan revealed Resident 10's service plan was not reflective of the resident's current needs or lacked clear instructions to staff in the following areas:

* Right eye chronic impairment;

* Dental status and use of assistive devices;

* Recent losses;

* Instructions on signs and symptoms of hypo- and hyperglycemia to report;

* Instructions on to whom to report skin impairments;

* Instructions on to whom to report weight gain or loss;

* Instructions on signs and symptoms of depression to report while on anti-depressant therapy;

* Dialysis port monitoring and precautions; and

* Instructions for signs and symptoms of complications to report while monitoring the dialysis port.

The need to ensure the service plan reflected residents' current needs and provided clear instructions to staff regarding delivery of services was reviewed with Staff 22 (Executive Director) and Staff 24 (RCC) on 02/28/24. They acknowledged the findings. No further information was provided.

2. Resident 8 moved into the facility in 03/2005 with diagnoses including chronic pain and had recently been hospitalized with pneumonia and experienced multiple falls.

Observations and interviews with the resident and staff and review of the current service plan, dated 02/11/24, 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:

* Recent falls and current fall interventions;

* Assistance needed with toileting;

* Assistance needed with grooming tasks and dressing; and

* Interventions to be tried when the resident refused bathing.

The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 22 (ED) and Staff 24 (RCC) on 02/28/24. They acknowledged the findings.

1.  Resident Corrections

#8 has passed away.

#10 Service plan will be updated/corrected to include resident specific instructions regarding right eye chronic impairment, dental status and use of assistive devices, recent losses, signs and symptoms of hypo-and hyperglycemia to report, instructions on whom to report skin impairments, instructions on whom to report weight loss or gain, instructions on signs and symptoms of depression to report while on anti-depressants therapy, Dialysis port monitoring and precautions, and instructions for signs and symptoms complications to report while monitoring the dialysis port.

2. Resident Service Plans will be reviewed by Interdisciplinary Team Meeting to ensure all regulated components are included on a resident's service plan.  

3. Service Plans will be evaluated quarterly or upon significant change of conditions.

4. The Executive Director, Health Services Director and Resident Care Coordinator are responsible for compliance

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team which consisted of the resident, the resident's legal representative if applicable, any person of the resident's choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services to the resident for 5 of 5 sampled residents (#s 1, 2, 3, 4, and 6) whose service plans were reviewed.  Findings include, but are not limited to:

Resident 1, 2, 3, 4, and 6's most recent service plans lacked evidence that a Service Planning Team reviewed and participated in the development of the service plans.

On 06/08/23, the need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Director/RN), and Staff 7 (Regional RN). The staff acknowledged the findings.

1. Resident Corrections

#1 current Service Plan will be reviewed by a Service Planning Team and updated as needed

#2 current Service Plan will be reviewed by a Service Planning Team and updated as needed

#3 no longer resides in the community

#4 current Service Plan will be reviewed by a Service Planning Team and updated as needed

#6 current Service Plan will be reviewed by a Service Planning Team and updated as needed

2. The Executive Director, Resident Care Coordinator, Health Services Director, Lifestyles Director will be trained on requirement of a team to participate in Service Planning using OAR 411-054-0036 (5) Training will be logged.

A Servcie Planning Team will be assembled applicable to resident need and choice, and may include the Executive Director or designee, the resident, the resident's legal representative, the Resident Care Coordinator, at least 1 care staff, and anyone the resident requests to actively participate in the process. The PCP, Case Manager(s), and family/friends of the resident's choosing will be invited in advance.  The Health Services Director will participate if the resident is receiving nursing services or has a current COC. The Service Planning Team will review evals/re-evals and plan for care that addresses all the resident's needs, conditions, and preferences with clear instructions including who, what, where, when, why, how, and how often a service is to be proviced.  All Service Planning Team members will sign the Service Plan and a copy will be placed in the Service Plan Binder where is is accessable to all care staff.

3.  Health Services Director will log the audit of 4 recently updated Service Plans per month for the next 60 days.   

4. The Executive Director and the Health Services Director are responsible for compliance.

3. Resident 1 was admitted to the facility in 02/2021 with diagnoses including congestive heart failure.  

Observations of the resident, interviews with staff, and review of the resident's 02/20/23 service plan, 03/06/23 through 06/06/23 progress notes, incident investigations, and physician communications were completed.

.

The resident experienced multiple short-term changes without documented progress noted until resolved and/or lacked resident-specific directions to staff in the following areas:

* Buttock pain;

* Exiting the facility unescorted when confused;

* Foot pain, contracture, and wound;

* Hallucinations, agitation, and anxiety;

* Medication changes;

* Falls, ER visits, and abdominal pain; and

* Statements of harming self and others.

The need to ensure short-term changes of condition had documentation of weekly progress until resolution and resident-specific directions to staff was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Director/RN), and Staff 7 (Regional RN) on 06/08/23. The staff acknowledged the findings.

4. Resident 4 was admitted to the facility in 07/2019 with diagnoses including diabetes.

Observations of the resident, interviews with staff and Resident 4, and review of the resident's 02/14/23 service plan, 03/16/23 through 06/06/23 progress notes, incident investigations, and physician communications were completed.

The resident experienced multiple short-term changes without documented progress noted until resolved and/or lacked resident-specific directions to staff in the following areas:

* Medication changes;

* Missed medications and refusals;

* Falls; and

* Elbow and knee pain.

The need to ensure short-term changes of condition had documentation of weekly progress until resolution and resident-specific directions to staff was discussed with Staff 1 (ED), Staff 2 (Health Services Director/RN), and Staff 7 (Regional RN) on 06/08/23. The staff acknowledged the findings.

5. Resident 6 was admitted to the facility in 12/2020 with diagnoses including anxiety and blindness.

Observations of the resident, interviews with staff and Resident 6, and review of the resident's 05/06/23 service plan, 03/11/23 through 06/07/23 progress notes, incident investigations, and physician communications were completed.

The resident experienced multiple short-term changes without documented progress noted until resolved and/or lacked resident-specific directions to staff in the following areas:

* Missed medications and refusals;

* Sleep deprivation, hallucinations, and statements of being poisoned;

* Statements of feeling unsafe and needing police; and

* Agitation and yelling at staff.

The need to ensure short-term changes of condition had documentation of weekly progress until resolution and resident-specific directions to staff was discussed with Staff 1 (ED), Staff 2 (Health Services Director/RN), and Staff 7 (Regional RN) on 06/08/23. The staff acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure changes of condition were evaluated to determine and document what actions or interventions were needed, to communicate the actions or interventions to staff on each shift, to provide written resident-specific instructions or interventions to staff on each shift, to monitor residents consistent with their evaluated needs, and to note weekly progress until resolution for 5 of 5 sampled residents (#s 1, 2, 3, 4, and 6) who experienced changes of condition. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 05/2022 with diagnoses including diabetes, rheumatoid arthritis, diastolic heart failure, and osteoarthritis.

The resident's current service plan, dated 05/20/23, temporary service plans, skin record, progress notes dated 03/25/23 through 06/06/23, and incident reports were reviewed, and staff and Resident 2 were interviewed. The following changes of condition were identified:

* 03/23/23 - Open sore on stomach;

* 03/26/23 - Chest pain, with transport to ER;

* 03/28/23 - New medication Fluconazole;

* 04/08/23 - New medication Zinc Gluconate;

* 04/10/23 - All 08:00 pm medications not administered;

* 05/23/23 - Open sore on stomach;

* 05/21/23 - Fall with head strike, hematoma, fractured foot, and bruising;

* 05/24/23 - Pain in multiple areas, with lack of mobility; and

* Ongoing - Recurrent fungal rash to skin folds.

There was no documented evidence resident-specific actions or interventions were developed and communicated to staff on each shift or progress was noted at least weekly until resolution for these changes.

The need to determine, document, and communicate to staff specific actions or interventions for short-term changes of condition and to monitor progress and document at least weekly through resolution was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Director/RN), and Staff 7 (Regional RN) on 06/08/23. They acknowledged the findings.

2. Resident 3 was admitted to the facility in 09/2022 with diagnoses including a closed hip fracture which required surgery with routine healing and hearing loss.

The resident's 04/21/23 service plan, 03/17/23 through 06/01/23 progress notes, interim service plans, incident reports and investigations, and physician communications were reviewed, and the resident and staff were interviewed. The following was identified:

* 03/30/23 - Non-injury fall; and

* 04/25/23 - Non-injury fall.

An investigation of the 03/30/23 fall was not documented until 04/04/23, at which time it was indicated the resident was reminded to use his/her call light to request help.

After the 04/25/23 fall, the resident told staff s/he had "felt some vertigo" since the previous day. There was no documented evidence new interventions were developed and implemented or there was any follow-up related to the resident's statement of experiencing vertigo.

The need to promptly evaluate changes of condition, develop actions or interventions, monitor interventions for effectiveness, and develop new interventions as needed was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Director/RN), and Staff 7 (Regional RN) on 06/08/23. They acknowledged the findings.

1. Resident Corrections

#2 events documented from 3.23.23 - 5.24.23 are resolved. The recurrent fungal rash in skin folds will be monitored weekly and updates to the Service Plan and medication instructions made as needed.

#3 no longer resides in the community

#1 Monitor resident for the listed and/or new conditions and follow up according to the protocols for COC. Document actions.

#4 Monitor resident for the listed and/or new conditions and follow up according to the protocols for COC. Document actions.

#6 Monitor resident for missed and/or new conditions and follow up according to the protocols for COC. Document actions.

2. The Health Services Director and Resident Care Coordinator were trained on their role re resident Changes of Condition both Short Term and Significant, on 6.12.23 using the OAR Compliance Guidelines for COC. Follow up training on same is scheduled for 7.5.23.  The Health Services Director is registered for the July 11 - 13 2023 Role of the RN Class. The Health Services Director and Resident Care Coordinator retrained Resident Assistants and Med Techs to identify, document, and notifiy Health Services Director/Resident Care Coordinator/Executive Director re resident status changes. The the Health Services Director and Resident Care Coordinator will read the 24HR Communication notes and Chart Notes in QMar every morning to identify and respond to resident changes. The OAR Compliance Guidelines for COC will be at hand in the 24Hr Communication Binder for reference.  Each resident in AL and MC is discussed weekly in High Risk Mtg involving the Health Services Director, Executive Director, Resident Care Coordinator, and Memory Care Administrator for MC residents.  The OAR Compliance Guidelines for COC will be at hand in the High Risk Binder for reference.

3. 10% of resident charts will be audited in July by Health Services Director, Executive Director, Memory Care Administrator, & Resident Care Coordinator to see if COC's were properly identified, timelines followed, and condition documented correctly using ISPs (Interim Service Plans), QMar, Alert Charting, and SPA to update Service Plan.  The Audit will be logged.

4. The Executive Director and Health Services Director are responsible.

3. Resident 3 was admitted to the facility in 09/2022 with diagnoses including a closed hip fracture which required surgery with routine healing and hearing loss.

Resident 3's facility record, including the current service plan, progress notes, and interim service plans, all between 03/17/23 and 06/01/23, and weights from 01/02/23 through 06/08/23 were reviewed. Staff and the resident were interviewed.

The following was identified:

* 01/02/23 - 134 lbs.;

* 03/16/23 - 123.6 lbs.;

* 04/11/23 - 120 lbs.; and

* 04/16/23 - 116 lbs.

Between 01/02/23 and 04/11/23 the resident lost 14 lbs., or 10.45% of his/her total body weight in 90 days. This constituted a significant change of condition.

Between 03/16/23 and 04/16/23 the resident lost 7.6 lbs., or 6.14% of his/her total body weight in 30 days. This constituted a significant change of condition.

On 04/11/23 and 04/28/23 interim service plans were written instructing staff to encourage the resident to eat lunch and dinner in the dining room.

There was a progress note dated 04/28/23, written by Staff 4 (RCC), which indicated she had spoken with the resident's physician regarding his/her weight loss.

On 05/12/23 an interim service plan was written which instructed staff to "offer food that is in cupboards/kitchen [sic] to resident every time they go in [resident's] room. (offer squeezable apple sauce) [sic].

In an interview on 06/07/23, Staff 15 (MT/CG) reported the resident received health shakes twice a day, staff offered food frequently, and s/he "usually" ate meals in his/her room.

The resident was interviewed on 06/08/23 and asked about his/her significant weight changes. S/he indicated s/he was "never hungry" and had "no appetite." S/he stated, "I force myself to eat to stay alive." Resident 3 indicated it hurt to chew, due to bone fragments in his/her gums after having all his/her teeth removed many years ago. S/he reported it hurt to bite down on his/her dentures, so s/he didn't wear them anymore. The resident said s/he did not eat any solid food and requested a puree diet because it's easier to eat.

There was no documented evidence an RN had completed a significant change of condition assessment for the significant weight loss.

On 06/08/23, at 8:45 am, survey observed the resident being weighed by staff; s/he weighed 123 lbs. On 05/08/23 the resident's weight was recorded as 113 lbs. The resident experienced a 10 lb. weight gain, or 8.85% of his/her total body weight, in 30 days. In an interview on 06/08/23, the RN was alerted to the resident's significant weight gain.

The need to ensure there was an RN assessment of all significant changes of condition which documented findings, resident status, and interventions made as a result of the assessment was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Director/RN), and Staff 7 (Regional RN) on 06/08/23. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure an RN assessment was completed in a timely manner and documented findings, resident status, and interventions made as a result of the assessment for 3 of 3 sampled residents (#s 1, 3 and 4) who experienced significant changes of condition. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 02/2021 with diagnoses including edema and congestive heart failure.  

Weight records, dated 03/05/23 through 06/02/23, and progress notes, dated 03/16/23 through 06/06/23, indicated the resident experienced the following:

* A 10.8 pound gain between 05/02/23 and 05/08/23, which constituted a 8.98% gain in less than a week; and

* An 8.6 pound loss between 05/08/23 and 06/02/23, which constituted a 7.02% loss in one month.

Progress notes, temporary service plans, and physician communications dated 03/16/23 through 06/06/23 indicated the resident had experienced a recent decline in cognition and ADL abilities, as well as an increase in confusion and exit seeking. The resident had edema and took a diuretic daily to help with fluid retention.  

Multiple observations of the resident between 06/06/23 and 06/08/23 showed the resident attended only two of the five meal opportunities observed. The resident required staff escort to meals in his/her wheelchair and could eat independently once served.

The resident ate 100% of the meals observed in the dining room. Intake amounts were unknown by staff for any meal items delivered to the resident's room when s/he declined to come to the dining room. The resident was able to request food and fluids but was inconsistent with his/her requests.

In interviews between 06/06/23 and 06/08/23, Staff 15 (MT/CG) and Staff 18 (CG) indicated the resident's intake varied and that s/he ate better when in the dining room. The staff further indicated the resident had good days and bad days. The resident could sometimes do more for himself/herself and other days needed full assistance from staff for ADLs. The staff stated the resident was able to eat and drink on his/her own consistently with minimal reminders.

In interview on 06/08/23, Staff 2 (Health and Wellness Director/RN) indicated she had not completed an assessment of the changes.

The facility failed to ensure an RN assessment was completed for the weight losses and gains from May 2023 to June 2023 which documented findings, resident status, and interventions made as a result of the assessment.

The need to ensure an RN assessment was completed which documented findings, resident status, and interventions made as a result of the assessment was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Director/RN), and Staff 7 (Regional RN) on 06/08/23. The staff acknowledged the findings.

2. Resident 4 was admitted to the facility in 07/2019 with diagnoses including diabetes.  

Weight records, dated 02/17/23 through 06/03/23, and progress notes, dated 03/13/23 through 06/06/23, indicated the resident experienced the following:

* A 20.8-pound loss between 02/04/23 and 05/05/23, which constituted a 11.56% loss in three months; and

* A 10.2-pound loss between 04/21/23 and 05/19/23, which constituted a 6.02% loss in one month.

The resident's most current weight on 06/03/23 reflected a 4.6-pound, 2.51% gain from the weight on 05/19/23. This was not a significant weight gain for the resident.

Progress notes, temporary service plans, and physician communications dated 03/13/23 through 06/06/23 indicated the resident had frequent meal refusals as well as medication refusals. The resident was able to direct his/her own care and was independent with the majority of his/her ADLs.

Multiple observations of the resident between 06/06/23 and 06/07/23 showed the resident ate meals only in his/her apartment. The resident was not observed to leave the apartment for activities or meals. One afternoon meal was observed for the resident in which s/he ate greater than 75%.

In interview on 06/06/23, Resident 4 indicated s/he had no concerns with care or treatment by staff. The resident indicated s/he ate all meals in his/her apartment at this time. The resident stated s/he was independent with his/her meals and ADLS. The resident stated s/he could call for assistance when it was needed but otherwise kept to himself/herself.

In interview on 06/08/23, Staff 2 (Health Services Director/RN) indicated the resident was alert and oriented and directed his/her own care. The resident was actively trying to lose weight and had worked out a plan with his/her physician. Staff 2 stated this information was not documented and she had not completed an assessment of the resident's weight loss.  

The facility failed to ensure an RN assessment was completed for the weight losses and gains from February 2023 to May 2023 which documented findings, resident status, and interventions made as a result of the assessment.

The need to ensure an RN assessment was completed which documented findings, resident status, and interventions made as a result of the assessment was discussed with Staff 1 (ED), Staff 2 (Health Services Director/RN), and Staff 7 (Regional RN) on 06/08/23. The staff acknowledged the findings.

1. Resident Corrections

#1 Note missed need for significant COC for weight changes. Resident will be evaluated for listed and any/all conditions and actions taken and documented according to findings, including initiating ISPs, Alert Charting, notification of PCP and family, RN assessment to be performed if Significant COC is found, and weekly monitoring documented in QMAR.

#3 no longer resides in the community

#4 Note missed need for significant COC for weight changes. Resident will be evaluated for listed and any/all conditions and actions taken and documented according to findings, including initiating ISPs, Alert Charting, notification of PCP and family, RN assessment to be performed if Significant COC is found, and weekly monitoring documented in QMAR.

2. The Health Services Director and Resident Care Coordinator were trained on COC on 6.12.23 using the OAR Compliance Guidelines for short term and significant COC. Follow up training on same is scheduled for 7.5.23.  

The Health Services Director is registered for the July 11 - 13 2023 Role of the RN Class. The Health Services Director and Resident Care Coordinator will retrain Resident Assistants and Med Techs to identify, document, and notifiy Health Services Director/Resident Care Coordinator/Executive Director re resident status changes. The the Health Services Director and Resident Care Coordinator will read the 24HR Communication notes and Chart Notes in QMar every morning to identify and respond to resident changes. The OAR Compliance Guidelines for COC will be at hand in the 24Hr Communication Binder for reference.  Each resident in AL and MC is discussed weekly in High Risk Mtg involving the Health Services Director, Executive Director, Resident Care Coordinator, and Memory Care Administrator for MC residents.  The OAR Compliance Guidelines for COC will be at hand in the High Risk Binder for reference.  A Short Term and Significant COC Checklist has been developed to faciliate all steps in the COC process.

3. 10% of resident charts will be audited in July by Health Services Director, Executive Director, Memory Care Administrator, & Resident Care Coordinator to see if COC's were properly identified, timelines followed, condition evaluated/assessed and documented, staff instructed using ISPs and Alert Charting, PCP and family notified, and weekly monitoring documented in SPA.   

4. The Executive Director and Health Services Director are responsible for compliance.  

Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care were completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules, for 1 of 1 sampled resident (# 2) who received subcutaneous 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 06/06/23, Resident 2 was identified to be diabetic and administered insulin and non-insulin subcutaneous injections by non-licensed staff.

Resident 2's insulin administration record and MARs, reviewed from 05/01/23 through 06/06/23, revealed insulin had been administered by Staff 13 (MT), Staff 16 (MT), Staff 17 (MT), and Staff 19 (MT) on multiple occasions, and Victoza (anti-diabetic medication) had been administered subcutaneously by Staff 16 and 19 on multiple occasions.

a.  Staff 13, 16, 17, and 19's initial delegations to administer insulin to Resident 2, completed on 05/24/23, 03/21/22, 05/31/22, and 08/09/22, respectively, lacked documentation in the following areas:

* Nursing assessment and condition of the resident, to include determination that the resident's condition remained stable and predictable;

* Rationale that the task could be safely delegated to the caregiver; and

* Frequency the client should be reassessed, including rationale.

b. The most recent periodic inspection, supervision, and re-evaluation of the delegation of insulin for Staff 16 and Staff 19, completed 04/21/22 and 11/12/22, respectively, lacked documentation in the following areas:

* Nursing assessment and condition of the resident, to include determination that the resident's condition remained stable and predictable; and

* The initial re-evaluation was not completed within 60 days of the initial delegation for Staff 19.

c. Victoza subcutaneous injections were administered by Staff 16 and Staff 19 on multiple occasions between 05/01/23 and 06/06/23, without documentation that Staff 2 (Health Services Director/RN) had completed initial delegations for either staff.

The need to ensure staff who administered subcutaneous injections were delegated in accordance with OSBN Division 47 Rules was discussed with Staff 2 on 06/07/23, and with Staff 1 (Executive Director), Staff 2, and Staff 7 (Regional RN) on 06/08/23. They acknowledged the findings. Staff  2 initiated the delegation process for administration of the Victoza for Staff 16 and 19 on 06/08/23.

1. Resident Corrections

#2 Resident has had a comprehensive assessment by the Health Services Director and has been determinted stable and predictable for insulin Delegation. The delegatee was skill checked by Health Services Director observing administration of the injectable medication.  Documentation was completed and the next evaluation date is logged.  

2.  The Health Services Director will be trained on Delegations by the Regional Nurse using OAR 411-054-0045 (1)(f)(B) RN

Delegation and Teaching, and the DHS's Office of Licensing and Regulatory Oversight

RN Delegation in Community Based Care Settings

Self-study Course. The Health Services Director is attending the Role of the RN Class 7.11 - 13 2023.

The need for Delegation is identified via evaluation of the resident. The Health Services Director/RN will perform a comprehensive assessment of the resident to determine they are stable and predictable related to the task to be delegated and docment the assessment in QMar.  The RN will evaluate the ability and willingness of the unlicensed person to perform the task and document this on the Frontier form designated for this purpose. The RN will provide task related training and a quiz on the material to the delagatee.  A return demonstraton of the task is observed by the RN.  The task related training and quiz will be repeated not less than annually.  The reassessment of the resident will occur not less than quarterly or with COC.  Observation of the task frequencu will be determined by the nurse depending on the abililty and reliability of the delegatee but not less than every 180 days.

3. A compliance audit of the Delegation Binder will be performed and logged by the Regional RN by July 5th and quarterly x 2.

4. The Health Services Director and Executive Director are responsible for compliance  

Based on observation, interview, and record review, it was determined the facility failed to maintain infection prevention and control protocols to ensure a safe and sanitary environment related to rinsing of soiled laundry. Findings include, but are not limited to:

A flushing rim sink was required for staff to use when rinsing out soiled laundry. Soiled laundry consists of clothing and/or linens which have been soiled by blood, urine, fecal matter, or other body fluids.

Observations of the first and second floor laundry rooms showed a standard utility sink in each. The sinks were discolored and stained. The laundry room doors were both open and accessible to residents in the assisted living facility.

Additional observations of the storage room, next to the medication room, showed the presence of an eyewash station and a sink located on the floor with a standard drain. The sinks had regular drains with no flushing ability.

Observations of the supply room on 06/07/23, located in the nurses station, showed the door was locked. Medication technician staff were the only staff with keys to the room. Once the supply room was opened, a flushing rim sink was visible, along with personal protective equipment (PPE) consisting of gloves, a plastic apron, and goggles. Additionally, there was a separate handwashing sink with soap and paper towels.

In an interview on 06/06/23, Staff 20 and 21 (Housekeeping) indicated they did laundry for all the assisted living residents, as well as facility linens. The staff indicated care staff also did laundry as needed for residents. Staff 20 and 21 stated when soiled items needed rinsed, they used the sink located in the second-floor laundry room and then would clean out the sink. The staff were unaware of any other area to rinse soiled laundry. Staff 21 indicated the first-floor laundry was reserved for memory care staff to do their residents' laundry.

In interviews on 06/08/23, Staff 15 (MT/CG) and Staff 18 (CG) indicated when they had soiled laundry that needed to be rinsed, they utilized the floor sink in the storage room next to the medication room. The staff were unaware of a flushing rim sink or other area to rinse out soiled laundry. The staff further stated care staff did not have keys to the supply room which was also near the medication room.

In interview on 06/06/23, Staff 1 (Executive Director) was initially unaware of a flushing rim sink in the facility. Staff 1 showed the surveyor the floor sink in the storage area which had a standard drain. Staff 1 was subsequently able to locate the appropriate sink and PPE set up in the supply room near the medication room.

The need to ensure the facility staff understood how to follow proper infection control practices when handling soiled items and had access to the flushing rim sink and handwashing station was discussed with Staff 1 on 06/07/23. He acknowledged the findings.  

1.  Not resident/staff specific

Supplies to be relocated from the supply room next to nurses station to allow access to flushing rim sink for rinsing out soiled laundry. This will serve as designated location for rinsing of soiled linens in appropriate, flushing rim sink.

Utility sinks in laundry rooms will be cleaned and inspected during weekly laundry room audits.

2. Resident Assistants, Med Techs, Environmental Service associates will be retrained on infection control using Frontier protocols on handling soiled linen specifically, what requires rinsing prior to being laundered, and how, and where to rinse. Training will be logged.

ESD will add proper care of laundry to their section of General Orientation.

3. ESD will monitor & log proper function and cleanliness of the rinse sink weeklyfor 60  days and Quarterly thereafter

4. ESD, Executive Director, and Infection Control Specialist

Based on interview and record review, it was determined the facility failed to ensure signed physician orders were implemented as directed by the residents' physician for 2 of 5 sampled residents (#s 1 and 4) whose MARs/TARs were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 02/2021 with diagnoses including congestive heart failure.

The resident's 03/16/23 through 06/06/23 progress notes, 04/12/23 signed physician orders, 04/12/23 through 06/06/23 physician communications, and the 05/01/23 through 06/06/23 MAR/TAR were reviewed.

The 04/12/23 physician orders and 05/01/23 through 06/06/23 MARs/TARs showed the following:

* An order for Digoxin 125 mcg tablet, 0.5 tablet daily. Hold if heart rate was less than 60 beats per minute.

The resident's heart rate was not recorded on 11 occasions from 05/01/23 through 05/24/23 to determine if the medication should have been held or administered. The medication was held on 05/07/23 with no heart rate recorded.

The need to ensure the facility administered all medications and treatments as ordered by the physician was discussed with Staff 1 (ED), Staff 2 (Health Services Director/RN), and Staff 7 (Regional RN) on 06/08/23. The staff acknowledged the findings.

2. Resident 4 was admitted to the facility in 07/2019 with diagnoses including insulin-dependent diabetes.

The resident's 03/13/23 through 06/06/23 progress notes, 04/07/23 signed physician orders, 04/07/23 through 06/06/23 physician communications, and the 05/01/23 through 06/06/23 MARs/TARs were reviewed.

The 04/07/23 physician orders and 05/01/23 through 06/06/23 MARs/TARs showed the following:

* An order for Novolog insulin 5 units, three times a day after meals for blood sugar control.

The Novolog was not signed as given on eight occasions in May 2023.

The Novolog was signed and noted zero units were given on 16 occasions in May 2023 and five times in June 2023, without any indication as to why it was not administered as ordered.

* An order for Metformin 1000 mg, one tablet twice daily for blood sugar control. The medication was to be administered with a small snack if the resident refused to eat a meal.

The medication was not administered as ordered on seven occasions in May 2023, without any documentation to indicate why it was not administered or if a snack was offered as ordered by the physician.

The need to ensure the facility administered all medications and treatments as ordered by the physician was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Director/RN), and Staff 7 (Regional RN) on 06/08/23. The staff acknowledged the findings.

1. Resident Corrections

#1 Review current MAR to ensure proper instructions are in place, HRs are being recorded, and parameters are being followed

#4 Review current MAR to ensure proper instructions are in place, BG is being recorded and parameters are being followed

2. Med Techs will be retrained on how to take an accurate HR, the reason the HR is needed and how to follow the accompanying parameter instructions. Med Techs will also be retrained on the requirement of following PCP orders, STOP and ask, and recording VS in QMar. Training logs and skills checklists will be used

Med Techs will be coached on the training as identified thru monitoring (below)

3. The Health Services Director will monitor compliance in QMar daily x7, weekly x4, and monthly there after.

4. The Health Services Director and Executive Director are responsible for compliance.

2. Resident 4 was admitted to the facility in 07/2019 with diagnoses including diabetic neuropathy.  

Review of the resident's 03/13/23 through 06/06/23 progress notes, physician communications, and the 05/01/23 through 06/06/23 MARs showed the following:

* An order for Ibuprofen 400 mg, take one tablet PRN three times a day for pain; and

* An order for Tramadol 50 mg, take one tablet every eight hours PRN for pain.

There was no direction for staff on which medication to use first or if the resident was able to self-direct.

* An order for a Bisacodyl suppository PRN for constipation.

There was no direction for staff on when to use the bowel medication or if the resident was able to self-direct.

The need to ensure PRN medications had resident specific parameters for administration was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Director/RN), and Staff 7 (Regional RN) on 06/08/23. The staff acknowledged the findings.

3. Resident 2 was admitted to the facility in 05/2022 with diagnoses including diabetes and diastolic heart failure.  

Review of the resident's 03/25/23 through 06/06/23 progress notes, physician communications, and the 05/01/23 through 06/06/23 MARs showed the following:

* An order for Furosemide (Lasix) 20 mg daily as needed for edema; and

* An order for Potassium Chloride ER 20 meq daily as needed with Lasix.

There was no clear instructions for staff on how to determine when to administer the Furosemide and Potassium Chloride ER for edema.

* Novolog Insulin was ordered to be administered three times daily on a sliding scale dosage which was based on the resident's blood glucose level (CBG).

There was no documentation on the MAR of how many units of sliding scale insulin were administered on multiple occasions between 05/01/23 and 06/06/23.

The need to ensure the MAR was accurate and PRN medications had resident-specific instructions for administration was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Director/RN), and Staff 7 (Regional RN) on 06/08/23. The staff acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure residents' MARs were complete, accurate, and provided clear instruction and parameters for administration of PRN medications for 3 of 5 sampled residents (#s 2, 3, and 4) whose MARs were reviewed. Findings include, but are not limited to:

1. A review of Resident 3's 05/01/23 through 06/06/23 MARs identified s/he had prescriptions for two PRN pain relief medications:

* Acetaminophen 325 mg; and

* Hydrocodone/APAP 5-325 mg.

There were no resident-specific parameters instructing staff on the sequence in which to administer the PRN pain medications.

The need for resident-specific parameters for multiple PRN pain medications was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Director/RN), and Staff 7 (Regional RN) on 06/08/23. They acknowledged the findings.

1. Resident Corrections

#3 no longer resides in the commuity

#4 resident specific instructions re the sequence of PRN medication and when to use the medication has been added to QMar for the order

#2 clear resident specific instructions re determining when to give PRN Lasix/KCL have been added to QMar

All Resident PRN orders will be reviewed by 7.3.23 and instructions added.

2. Health Services Director and Resident Care Coordinator will be retrained re the need for clear orders and order instructions for Med Techs.  Health Services Director & Resident Care Coordinator will be trained re use of reports in QMar to verify all PRNs have instructions.   A training log will be used.  

The LN doing 3rd checks will be responsible for adding / ensuring resident specific instructions are present for all PRNs QMar. The Med Techs will be retrained to expect resident specific instructions to be followed re the sequence of using PRN medication when 2 or more medications are available to a resident for the same purpose. Training Log and skills checklist will be used.

Med Techs will be coached on the training when exceptions are identified

3. LN will monitor compliance in QMar daily x7, weekly x4, and monthly there after.

4. The Health Services Director and Executive Director are responsible for compliance

Based on interview and record review, it was determined the facility failed to ensure MARs provided clear instruction and parameters for administration of PRN medications for 1 of 1 sampled resident (# 8) who was receiving multiple medications for the same reason. This is a repeat citation. Findings include, but are not limited to:

A review of Resident 8's 02/01/24 through 02/26/24 MAR identified s/he had prescriptions for the following PRN medications:

1. Aquaphor ointment as needed for nose bleeds; and

   Nasal saline spray as needed for nose bleeds.

2. Polyethylene glycol as needed for constipation; and

   Milk of Magnesia as needed for complaint of constipation.

There were no resident-specific parameters instructing staff on the sequence in which to administer the PRN medications.

The need for resident-specific parameters for multiple PRN medications prescribed for the same reason was discussed with Staff 22 (ED) and Staff 24 (RCC) on 02/28/24. They acknowledged the findings.

1. Resident Corrections

#8 Has passed away.

2. Health Services Director and Resident Care Coordinator will review all MARs and ensure clear orders and order instructions are written for Med Techs.  Resident Care Coordinator will run reports weekly in QMar to verify all PRNs have instructions.

The LN, doing 3rd checks, will be responsible for adding /ensuring resident specific instructions are present for all PRNs QMar. The Med Techs will be retrained on ensuring resident specific instructions are documented in MAR and on following the sequencing of using PRN medication when two or more medications are available to a resident for the same purpose.

3. LN & RCC will monitor compliance in QMar weekly

4. The Health Services Director, Resident Care Coordinator and Executive Director are responsible for compliance

Based on observation, interview, and record review, it was determined the facility failed to ensure residents who chose to self-administer medications had a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications and an evaluation completed upon move-in, and at least quarterly thereafter, to assure their ability to self-administer medications for 1 of 1 sampled resident (# 2), reviewed for self administration of PRN nitroglycerin and Lotrimin. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 05/2022 with diagnoses including diabetes and diastolic heart failure.

During the acuity interview on 06/06/23, it was identified that Resident 2 self-administered his/her own PRN nitroglycerin for chest pain.

The resident's 03/25/23 through 06/06/23 progress notes, evaluations, physician's orders, and the 05/01/23 through 06/06/23 MARs were reviewed.

On 06/06/23 at 03:30 pm while interviewing Resident 2, s/he showed the surveyor a bottle of nitroglycerin on the counter in the bathroom. The resident reported that s/he also administered topical Lotrimin, which was kept in the room, for a fungal rash.

There was no documented evidence a self-administration evaluation had been completed, and there was no physician's order for Resident 2 to self-administer the nitroglycerin or Lotrimin.

The need to ensure residents who self-administered their medications had a physician's order and were evaluated upon move-in and at least quarterly thereafter was discussed with Staff 1 (Executive Director) and Staff 2 (Health Services Director/RN) on 06/06/23. Staff 2 verified the findings.

1. Resident Corrections

#2 Self med evaluation for nystatin and nitro was preformed and the PCP was faxed to obtain that order however they have not responded so at this point we have removed those medications until we receive that order.

2. Health Services Director and Resident Care Coordinator will be retrained re the regulatory stipulations of Self Medication using OAR 411-054-0055 (5). A training log will be used.  

Residents who wish to administer their own medication(s) will be evaluated at a minimum of at Move In and Quarterly thereafter using a standard Frontier Self Medication Evaluation tool. A PCP order will be obtained identifying which/all medications the resident is approved to self administer prior to innitiating self administration.

The signed, dated self med evaluation will be attached to the resident's file and the PCP order for self medication will be added to the MAR so it is renewed every 90days.

3. The Health Services Director will direct the evaluation of each resident currently self administering medication usining the standard Frontier Self Medication Evaluation tool.  If the resident is determined by Health Services Director to have the ability to self administer some/all of their medication, a corresponding PCP order will be obtained.  If the resident is deemed not safe to self administer some/all of their medication, the resident, family, and PCP will be advised of the findings and the resident's medication will be provided by the community. The ability to self administer medication will be reevaluated quarterly for residents who wish to do so, or as their condition changes in an effort to facilitate their independence and safe medication administration.

4. Health Services Director and Executive Director are responsible for compliance

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

Resident 3 was identified during the acuity interview on 06/06/23 to have side rails on his/her bed. The resident's clinical record was reviewed and staff were interviewed.

Half side rails were observed on both sides of the resident's hospital bed in the up position on 06/08/23.

There was no documented evidence an assessment of the devices with restraining qualities had been completed by an RN, PT, or OT.

The lack of an assessment by an RN, PT, or OT for the resident's side rails was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Director/RN), and Staff 7 (Regional RN). They acknowledged the findings.

1. Resident Corrections

#3 A Postural Support Device with Restraining Qualities Assessment was performed on 6.10.23 and found to be incompliance.  Resident has since discharged from the community.

2. Health Services Director, Resident Care Coordinator, MCD, Executive Director & Marketing Director will be retrained re the regulatory stipulations for a resident to have a supportive device. Health Services Director will be trained re administering the Postural Support with Restraining Properties assessment tool.  Trainining Logs will be used.

Supportive Devices currently in place will be identified through a room by room check and safe use of the device will be assessed via the Postural Support Device with Restraining Qualities Assessment and re-assessed Quarterly there after.  Approved devices will be added to the Service Plan including use instructions for staff and re-assessed no less than quarterly and with COC.  Devices found to be un-safe will be removed and the Health Services Director will work with the resident, RP, and PCP to identfy a safe device that meets the resident needs. The PreMoveIn Eval will be used to identify supportive devices so they can be assessed at move in, added to Service Plan, and staff trained in their use.  

3. A team of directors will walk the community monthly looking for Supportive Devices to report to the Health Services Director. Completion of this task will be logged in the Survey Binder.  The records of Resident(s) identified as having a Supportive Device will be reviewed by the Health Services Director to ensure that a current Postural Support Device with Restraining Qualities Assessment is on file and the Service Plan includeds the device and instructions for use.

4. Resident Care Coordinator, Health Services Director, and Executive Director are responsible for compliance

Based on interview and record review, it was determined the facility failed to update the Acuity-Based Staffing Tool (ABST), no less than quarterly and following a significant change of condition, for 5 of 5 sampled residents (#s 1, 2, 3, 4, and 6), whose ABST data was reviewed. Findings include, but are not limited to:

Review of five sampled residents' records, interviews with staff, and interviews and observations of the residents noted ABST entries were not reflective of the current care needs.  The ABST data showed multiple areas which reflected zero minutes when the resident required limited to extensive staff assistance with those activities.

During an interview with Staff 1 (Executive Director) on 06/08/23, he stated the ABST data was generated from the service plan.  Staff 1 acknowledged the service plans for the sampled residents were not reflective; therefore, the ABST data was not accurate and potentially created inaccurate staffing calculations.  

Inaccuracies on resident entries for the ABST tool and potentially inaccurate staffing calculations were discussed with Staff 1, Staff 2 (Health Services Director/RN), and Staff 7 (Regional RN) on 06/08/23. They acknowledged the findings.

Refer to C 260.

The Service Plan Team, Executive Director, MC Administrator, Health Services Director, Resident Care Coordinator, and Lifestyle director will address resident overdue and current service plans, including change of conditions. Re-evaluate all resident ADL to reflect care needs.

Health services support will provide training on how to correctly enter ADL care in ALF to consider all shifts and related services are accounted for and documented.

The RCC will update task lists and related procedures to accommodate resident care needs. As updates are completed, check resident ABST score to determine if tool reflects care needs. Check for service plan accuracy and evaluate for ABST improvements.

Base staffing ratio on the ABST tool recommendations and evaluate if care needs are being met.

The Service Plan Team is responsible for reviewing and signing off on all service plans quarterly.   

Based on interview and record review, it was determined the facility failed to ensure pre-service orientation was completed prior to beginning job responsibilities for 4 of 4 new staff (#s 10, 12, 14, and 17) and pre-service dementia care training was completed prior to providing care to residents for 2 of 4 new staff (#s 12 and 17) whose training records were reviewed. Findings include, but are not limited to:

Staff training records were reviewed on 06/07/23.

a. There was no documented evidence Staff 10 (CG), Staff 12 (CG), Staff 14 (MT), or Staff 17 (MT), hired 05/02/23, 03/07/23, 04/09/23, and 05/03/23, respectively, completed one or more of the following elements of pre-service orientation:

* Infectious Disease Prevention training; and

* Written, signed job description.

b. There was no documented evidence Staff 12 or staff 17 completed one or more of the following pre-service dementia care topics:

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

* Techniques for understanding, communicating, and responding to behaviors and reducing the use of antipsychotics;

* Strategies for addressing social needs and engaging them in meaningful activities; and

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

The need to ensure all new staff complete the required pre-service training within the specified time frames was discussed with Staff 1 (Executive Director) on 06/08/23. He acknowledged the findings.

Review infectious disease and dementia pre-service training content in Relias to match OAR requirement. Include additional necessary training in pre-service list of required training before staff perform duties.

Business Office Manager is responsible for all paperwork and checking for training requirements before staff is able to start on the floor.

Written job descriptions are normal part of new hire packet. All related paperwork will be completed at the time of hire. Business Office Manager is responsible party to ensure compliance.

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff (#s 10, 12, 14, and 17) demonstrated competency in all assigned job duties within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed on 06/07/23.

There was no documented evidence Staff 12 (CG), Staff 14 (CG), Staff 14 (MT),or Staff 17 (MT) demonstrated competency in the following assigned duties within 30 days of hire:

* Role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Changes associated with normal aging;

* Identification, documentation, and reporting of changes of condition;

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

* General food safety, serving, and sanitation;

* Other duties as assigned (e.g., med pass, treatments); and

* First aid/abdominal thrust.

In interviews on 06/08/23, Staff 1 (Executive Director) reported he was unable to locate any competency checklists for the new hires reviewed, and Staff 2 (Health Services Director/RN) stated she did not have competency checklists for MT's. Staff 2 provided a written plan for observing competency demonstration in med passes with all MT's.

The need for new staff to demonstrate competency in all assigned duties within 30 days of hire was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Director/RN), and Staff 7 (Regional RN) on 06/08/23. They acknowledged the findings.

1. Resident Corrections

#10 All items on the job specific skills check list will be observed and the checklist completed

#12 All items on the job specific skills check list will be observed and the checklist completed

#14 All items on the job specific skills check list will be observed and the checklist completed

#17 All items on the job specific skills check list will be observed and the checklist completed

2. A new hire checklist will be implemented that incudes preservice training and training that must be completed within the first 30 days of employment. First Aid/abdominal thrust training has been scheduled for 7/28/2023-7/29/2023 and will occur monthly.

A job specific competency checklist which identifies competencies that must be completed preservice and those that must be completed within 30 days will be maintained in the Health Services Office until completed. The job specific skills check list will include the dates of skills checked as competent, signed by the trainer and trainee. The Scheduling Coordinator/designee will not schedule the new employee until the pre-service skills checklist is completed. Scheduling Coordinator/designee will not schedule the new employee beyond day 30 unless the required items identified on the job specific skills checklist have been completed. When the pre-service items and the items required within 30d have been completed, the checklist will be added to the employee file in the Business Office.

3. The Resident Care Coordinator will review the completed skills checklist for each new RA and Med Tech and approve in writing that the employee may be added to the schedule. The Health Services Director will compare the skills checklists, Resident Care Coordinator's written approval, and the schedule as each new employee is added to the HS team for 3 months, and quarterly thereafter.  

4. Scheduling Coordinator, Resident Care Coordinator, Health Services Director, and Executive Director are responsible for compliance

Based on interview and record review, it was determined the facility failed to provide fire and life safety instruction to staff on alternate months and document all required elements of fire drills, as required by the Oregon Fire Code (OFC). Findings include, but are not limited to:

Fire and life safety records were reviewed on 06/07/23 at 9:41 am.

There was no documented evidence staff were provided fire and life safety instruction on alternate months.

Fire drill documentation lacked the following required elements:

* Escape route used;

* Evacuation time period needed;

* Number of occupants evacuated; and

* Evidence alternate routes were used during fire drills.

The need to provide fire and life safety instruction to staff on alternate months and document all required elements of fire drills according to the OFC was discussed with Staff 1 (Executive Director) on 06/08/23. He acknowledged the findings.

Environmental Services Director will perform and document fire, life & safety training with staff on alternate months.

Improve fire drill documentation. Environmental Services Director Provide written documentation regarding escape route, evacuation time, number of occupants and alternate escape routes used.

The fire drill and training completion will be reviewed on a monthly basis.

Executive Director and Environmental Services Director are responsible for making sure fire drills and training are complete.

Based on interview and record review, it was determined the facility failed to ensure residents were re-instructed on fire and life safety procedures at least annually in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to:

Fire and life safety records were reviewed on 06/07/23 at 9:41 am.

There was no documented evidence of a written record, including content and residents attending, of annual re-instruction to residents on general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places inside or outside the building in the event of an actual fire.

The need to ensure residents were provided instruction as required by the OFC was discussed with Staff 1 (Executive Director) on 06/08/23. He acknowledged the findings.

Residents will be re-instructed annually on fire and life safety procedures. Resident training scheduled for 7/8/23.

Environmental Services Director will conduct and document annual review.

The Executive Director will be responsible for ensuring annual re-training is completed by checking and reviewing documentation monthly.

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

Refer to C260 and C310.

Please see C260 & C310

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

Observations of facility pathways, patio, and seating areas on 06/06/23 identified the following:

* Multiple drop-offs of 2-5 inches were noted along pathway edges around the perimeter of the facility and in the courtyard, as well as along the paths at exterior exit doors.

The need to ensure pathways around the facility were in good repair with no potential tripping hazards was discussed with Staff 1 (Executive Director) on 06/07/23. He acknowledged the findings.

Landscaping contractor to address facility pathway edges. The plan is to fill in and compact recessed areas and plant grass seed. Contractor is scheduled for 7/5/23. Environmental Services Director and Executive Director will confirm that the contractor solution is effective.

Environmental Services Director to complete weekly exterior audit of the community and to report any changes to Executive Director.

Environmental Services Director to evaluate and verify no signs of deterioration on pathway edges monthly.

Environmental Services Director and Executive Director to fulfill ongoing monitoring of pathway edges monthly.

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

Observations of the facility on 06/06/23 and 06/07/23 showed the following areas in need of cleaning or repair:

* Multiple walls, doors, and door frames in the facility had scrapes, dings, chips, missing pieces of plaster, spills, and/or black streaks;

* Chipped and scraped cupboards were observed in the first-floor nursing station;

* Three washing machines in the second-floor laundry room had severe rust around the interior and top edges of the machine. The edges of the metal were jagged and rusted and had separated, leaving openings in the metal surface;

* Walls in both the first floor and second floor laundry rooms were scrapped, dinged, or had spills. Cupboards in the laundry rooms had chips and scrapes, as well as spills on the interior shelves, a small hole was in the ceiling, and missing drywall was noted behind the washing machines;

* The first-floor laundry room had a broken light cover, and the flooring was pulling away from the drain;

* Urine and sour odors were noted in the upstairs halls nearest to rooms 214 and 231;

* Gouges and scrapes were noted to the elevator walls and floor;

* Long black gouges were noted to the dining room floor, debris and dead insects were noted in the light fixtures, and folded and stained cardboard was under a table base to stabilize it;

* Black/brown stains, of varying sizes from large to small, were noted in multiple areas, on both floors, in the hallways, outside the elevator, outside numerous resident rooms, and in the lower stairwell outside the nurse's station and within the nurse's station;

* Spills were noted on two chairs and one sofa in the lobby, benches near rooms 108, 110, 214, 220, and 222, and ripped chairs in the nurse's station;

* Room 229 had multiple stains on the carpet throughout the room, strong urine and musty odors, and soiled laundry/linens on the floor throughout the room, which created cluttered pathways;

* Rooms 203 and 221 had multiple stains on the living room carpets;

* Room 223 had stains on the carpet near the dining table and along the pathway, frayed carpet edges along the pathway to furniture, chipped/dinged/gouged wall corners and door frames, missing caulking around the toilet and shower, cracked and separating linoleum near the toilet edge, and a large chunk of the bathroom door was missing near the lower portion;

* An exterior door near the side of the building had a large section of rust with missing pieces;

* Room 102 had multiple stains to the carpet, dings and gouges to the wall corners, chips and scrapes to the counters and doorframes, strong urine odor in the room, and the kitchen counter had dirty/frayed duct tape loosely covering the corner edge; and

* A large hole in the wall was noted under the rails in the loft area on the second floor, facing the lobby.

The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (ED) on 06/07/23. He acknowledged the findings.

Community has onboarded an additional assistant environmental services employee, which will provide 7-day week support to ensure all observations are addressed.

Weekly schedule developed with Environmental Services Director and Executive Director to address;

Paint, patch and texture for walls, doors and other surfaces throughout the facility. Furniture cleaning to be completed in common areas and added to monthly cleaning schedule.

Nursing station and laundry room cabinets are to be cleaned, repaired and repainted. Walls in first floor and second floor laundry rooms are to be cleaned and repaired with drywall in areas noted (ceiling, behind washing machines).

First floor laundry room light cover to be replaced. Floor drain in first floor laundry room to be replaced and surrounding flooring repaired.

Second floor washing machines showing rust will be replaced. Washing machines to be inspected weekly during laundry room audit by Environmental Services Director.

Rm 214 and Rm 231 were evaluated for any potential cause of odors from carpets, soiled linens or other sources and addressed.

The elevator is cleaned, scratches on walls and floor to be evaluted for appropriate repairs needed. Elevator cleaning will be added as twice a week cleaning task for housekeeping or Environmental Services Director.

Bi-monthly carpet cleaning service scheduled for halls, common areas and resident rooms as needed, on a rotating schedule.

Rm 229 carpet completely cleaned and inspected at time of survey visit. Apartment carpet cleaning to be added to rotating professional cleaning schedule.

Identified resident room carpets have been cleaned, 203, 221, 223 and 102. Apartment carpet cleaning to be added to rotating professional cleaing schedule.

Additional repairs to be completed on room 102 to address noted concerns to include; replace with plank flooring, patch and repair work to walls/doors, finished with paint. Repairs to be completed on kitchen counters/cabinets. Apartment to be inspected on a rotating basis during Environmental Services weekly apartment audit.

Additional repairs to be completed on room 203 to address noted concerns to include; replace with plank flooring, patch and repair work to walls/doors, finished with paint. Bathroom door to be replaced. Linoleum in bathroom to be repaired or replaced as identified. Fresh bead of caulking will be placed around toilet and shower.

Ongoing program to address each resident room pantry cabinet repair and refresh. Include any outstanding flooring, caulking or other repairs as identified. To be monitored ongoing through weekly apartment audit.

Hole in wall under the rails in the loft area on the second floor to be repaired, patched, and painted.

Exterior doors to be assessed for repair or replacement. To be monitored weekly during exterior community audit by Evironmental Services Director.

Environmental Services Director to complete weekly apartment audits, weekly laundry audits, and interior audit of common areas. Environmental Services Director and Executive Director to ensure apartment deep clenaing schedule is in place. Any concerns will be communicated to the Executive Director for resolve.

All identified repairs, replacement of resident rooms will be monitored weekly for progress by the Executive Director.

Responsible party is the Evironmental Services Director. Executive Director will meet weekly to review progress of ongoing maintenance program.

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

Observations on 06/06/23 and 06/07/23 showed exit doors to the resident patio, outside the dining room, did not have an operational alarm or other acceptable system to alert staff when residents exited the building.

The need to ensure exit doors were equipped with a functional alarming device or other acceptable system was discussed with Staff 1 (Executive Director) on 06/07/23. He acknowledged the findings.

Contacted Gold Coast Security, contactors to affix alarm sensors to four doors that exit the dining room. Included are sensors to Hall 1 exit door and 2nd floor to 1st floor stair exit door. The sensors connect to pager/call alert system.

Weekly checks to confirm alert system is working for exit doors and resident call buttons.

Environmental Services Director is responsible for monitoring the alert pager/call system and Executive Director to verify implementation is effective.