Regency Woodland

Based on interview and record review, conducted during a site visit on 08/06/25, the facility's failure to fully implement and update an Acuity-Based Staffing Tool (ABST) was substantiated for 1 of 1 sampled residents (#1). Findings include, but are not limited to:A review of the facility's ABST indicated the following deficiencies:· Not evaluating all residents quarterly; and · Not accurately capturing care needs and time reflected in Resident 1's service plan.A review of the facility's ABST, including the last update dates, indicated 22 of 26 residents had not been evaluated quarterly.A review of Resident 1's service plan dated 07/23/25 indicated the following:· Staff were to monitor the resident for "signs and symptoms of hypoglycemia" and to take the resident's weight and blood pressure daily;· Staff were to escort the resident to and from activities up to 4x daily and to and from meals up to 3x daily when requested; and· Staff were to help brush the resident's hair daily in the am and pm.A review of Resident 1's ABST profile indicated 0 minutes for the following activities of daily living (ADLs): · Monitoring physical conditions and symptoms;· Ambulating or escorting the resident; and· Time spent assisting with grooming.An interview with Staff 1 (Registered Nurse) indicated the following:· Staff regularly monitored Resident 1 for physical conditions. Staff 1 had spent approximately half an hour observing the resident change his/her dressing for a skin wound on 08/06/25; · Staff escorted Resident 1 to and from meals and activities regularly. When staff see the resident leave his/her room, staff would assist by escorting. Staff also assisted when requested by Resident 1 via his/her call light. Staff 1 estimated that staff spent about 2 minutes at least 2-3 times per day escorting the resident; and· Resident 1 was independent with grooming and did not need assistance with hair brushing. Staff 1 indicated that brushing Resident 1's hair was on the daily task sheet, but did not believe that staff regularly, if ever, performed this task.The findings of the investigation were reviewed and acknowledged by Staff 1.The facility failed to accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan, and the facility failed to update and document the ABST evaluation for each resident no less than quarterly.

Based on interview and record review, conducted during a site visit on 08/06/25, the facility's failure to fully implement and update an Acuity-Based Staffing Tool (ABST) was substantiated for 1 of 1 sampled residents (#1). Findings include, but are not limited to:A review of the facility's ABST indicated the following deficiencies:· Not evaluating all residents quarterly; and · Not accurately capturing care needs and time reflected in Resident 1's service plan.A review of the facility's ABST, including the last update dates, indicated 22 of 26 residents had not been evaluated quarterly.A review of Resident 1's service plan dated 07/23/25 indicated the following:· Staff were to monitor the resident for "signs and symptoms of hypoglycemia" and to take the resident's weight and blood pressure daily;· Staff were to escort the resident to and from activities up to 4x daily and to and from meals up to 3x daily when requested; and· Staff were to help brush the resident's hair daily in the am and pm.A review of Resident 1's ABST profile indicated 0 minutes for the following activities of daily living (ADLs): · Monitoring physical conditions and symptoms;· Ambulating or escorting the resident; and· Time spent assisting with grooming.An interview with Staff 1 (Registered Nurse) indicated the following:· Staff regularly monitored Resident 1 for physical conditions. Staff 1 had spent approximately half an hour observing the resident change his/her dressing for a skin wound on 08/06/25; · Staff escorted Resident 1 to and from meals and activities regularly. When staff see the resident leave his/her room, staff would assist by escorting. Staff also assisted when requested by Resident 1 via his/her call light. Staff 1 estimated that staff spent about 2 minutes at least 2-3 times per day escorting the resident; and· Resident 1 was independent with grooming and did not need assistance with hair brushing. Staff 1 indicated that brushing Resident 1's hair was on the daily task sheet, but did not believe that staff regularly, if ever, performed this task.The findings of the investigation were reviewed and acknowledged by Staff 1.The facility failed to accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan, and the facility failed to update and document the ABST evaluation for each resident no less than quarterly.

The findings of the re-licensure survey, conducted 06/10/24 through 06/14/24, 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 for Home and Community Based Services Regulations.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a dayA situation was identified where there was a failure of the facility to comply with the Departments rules that was likely to cause a resident serious harm. An Immediate Plan of Correction was requested in the following areas:OAR 411-054-0025 (4) Facility Administration: Operation; andOAR 411-054-0055 (1)(f-h) Treatment Orders.The facility put an Immediate Plan of Correction in place during the survey.
The findings of the first re-visit to the re-licensure survey of 06/14/24, conducted on 10/14/24, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Based on observation, interview, and record review, it was determined the facility failed to provide effective administrative oversight to ensure the quality of services rendered in the facility. Findings include, but are not limited to:1. Situations were identified which constituted an immediate plan of correction to residents' health and safety in the following areas:* C160: OAR 411-054-0025 (4) Facility Administration: Operation; and* C303: OAR 411-054-0055 (1)(f-h) Treatment Orders.An Immediate plan of correction was requested on 06/12/24. The facility provided a plan of correction on 06/12/24 at 1:25 pm. The immediate risk was addressed, however the facility will need to evaluate the overall system failures associated with the licensing violation. 2. Refer to deficiencies in the report.

Based on observation, interview, and record review, it was determined the facility failed to exercise reasonable precautions against any condition which could threaten the health, safety or welfare of residents for 1 of 1 sampled resident (#3) who required a modified diet texture. Resident 3 received inaccurate diet textures, placing him/her at risk for aspiration, choking and/or death. Findings include, but are not limited to:Resident 3 was admitted to the facility 02/2024 with diagnoses including stroke with left sided hemiplegia. Resident 3's clinical record was reviewed, interviews were conducted with staff and the resident, and observations were made. The following was identified: During the acuity interview on 06/10/24, Staff 2 (RN) indicated that no residents in the facility required a modified diet texture. Resident 3 had a signed physician order dated 02/16/24 for a mechanical soft diet texture. The resident was admitted to the facility seven days later, on 02/23/24. The resident's 30-day evaluation, dated 03/21/24, and quarterly evaluation, dated 06/06/24, stated the resident required a mechanical soft diet texture. The resident's lunch was observed being prepared and plated by Staff 16 (Cook) on 06/11/24 at 12:50 pm. He stated the kitchen staff were not aware of any modifications that needed to be made when preparing or plating food for Resident 3. The meal consisted of a 2 inch by 2 inch brownie, spaghetti and red sauce with noodles up to 1 1/2 inches long, ground beef chunks up to 3/4 inch in size, and a whole dinner roll. Prior to the meal being served to the resident, on 6/11/24 at 12:52 pm, Staff 1 (Executive Director) and Staff 2 were asked by the survey team whether the meal appeared appropriately plated for a resident with an order for a mechanical soft diet texture. Staff 1 stated that the facility did not provide meals with a mechanical soft diet texture. Resident 3 was observed with the meal. The resident was served while lying in bed in his/her room. The head of the bed was elevated approximately 30 degrees, and the resident had slid down the bed, so that when the meal was placed onto the over-bed tray table, the resident was unable to see over the top of the plate. During the 50 minutes s/he was observed, the resident attempted to eat only his/her brownie. The resident was observed to have difficulty feeding him/herself including difficulty coordinating lip and tongue movement in order to get food into his/her mouth, and difficulty keeping food in his/her mouth while swallowing. Approximately 30% of the food the resident attempted to eat ended up on his/her shirt. The resident was observed making coughing and hacking sounds twice during the time s/he was observed. The resident attempted to drink from his/her straw cup and demonstrated difficulty closing his/her lips around the straw and greater than 50% of the liquid spilled out the left side of his/her mouth when attempting to swallow. During an interview on 06/11/24 at 1:58 pm, Staff 14 (MT) and Staff 18 (MT) stated the resident had difficulty swallowing and needed his/her medications administered in pudding in order to swallow them safely.These observations and interviews were reviewed with Staff 1 and Staff 2 on 06/11/24 at 3:20 pm. They stated that none of the cooking staff were trained in how to prepare a mechanical soft diet texture. During this interview, they stated they would make sure the resident received the correct diet texture at dinner and all meals moving forward. At 3:56 pm, Staff 1 provided the survey team with the information that had been used to educate cooking staff which included a short handout and a video which described how to modify meat textures, but did not describe the other components of mechanical soft diet texture. There was no documentation of any education provided to care staff or updates made to the resident's service plan. Staff 1 and Staff 2 stated that for dinner the resident would be served refried beans and Spanish rice with ice cream for dessert. They stated the resident requested the main menu item which was a chicken quesadilla, but they told him/her they could not modify this for his/her diet texture needs. At 5:10 pm on 06/11/24, the resident was served a bowl of refried beans, Spanish rice with no sauce or gravy, and ice cream. The resident again demonstrated difficulty getting food to his/her mouth and keeping food in his/her mouth when attempting to swallow, with approximately 30% of the food s/he attempted to eat ending up on his/her face and shirt. The resident ate three bites of beans, two bites of rice, and a small bowl of ice cream. The resident coughed and spit out food one time, which occurred while attempting to eat a bite of the rice. On 06/12/24 at 10:43 am, an immediate plan of correction was requested to address the increased risk for choking and/or death due to modified diet texture orders not being followed and the resident's difficulty eating independently. The facility provided a plan of correction on 06/12/24, prior to survey exit. The immediate risk was addressed, however the facility will need to evaluate the overall system failures associated with the licensing violation. The need to ensure the facility exercised reasonable precautions against any condition which could threaten the health, safety, or welfare of residents was discussed with Staff 1 and Staff 2 on 06/11/24 through 06/14/24. They acknowledged the findings. The above findings were reported to APS by the survey team on 06/21/24 at 1:21 pm.

Based on interview and record review, it was determined the facility failed to ensure a daily program of social and recreational activities that were based upon individual and group interests and physical, mental, and psychosocial needs was provided for residents. Findings include, but are not limited to:A group interview was conducted with nine of the 28 residents residing at the facility on 06/11/24. During the group interview, residents stated very few activities occurred during the week, and no activities occurred on weekends. Multiple residents stated they were "always bored" and "lonely".During an interview with Staff 6 (Activities) on 06/13/24 at 2:05 pm, she stated that she was in the facility assisting with activities three days per week, and she assisted with other duties including setting up medical appointments and driving the facility bus on her other scheduled work days. She stated four days per week, residents were responsible for leading all activities. Upon review of the activities calendar for the week of 06/09/24 through 06/15/24, 23 activities were scheduled. Of these activities, 13 were designated "resident-led". Staff 6 described that this meant the resident's were responsible for setting up and leading the activity, and no staff member would be present to ensure the activity occurred or assist the residents with activity set-up. The need to ensure a daily program of social and recreational activities that were based upon individual and group interests and physical, mental, and psychosocial needs was provided for residents was reviewed with Staff 1 (Executive Director) 06/14/24 at 11:30 am. She acknowledged the findings.

Based on observations, interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed and/or failed to ensure signed physician or other legally recognized practitioner orders were documented for all medications and treatments the facility was responsible for administering for 3 of 3 sampled residents (#s 1, 2 and 3) whose orders were reviewed. Resident 3 did not receive the correct diet as ordered by his/her physician, placing him/her at significant risk of aspiration, choking and/or death. Findings include, but are not limited to:1. Resident 3 was admitted to the facility in 02/2024 with diagnoses including stroke with left sided hemiplegia. a. The resident had a signed physician order for mechanical soft diet texture dated 02/16/24. The resident was observed being provided a meal which did not adhere to mechanical soft diet texture on 06/11/24. On 06/11/24 at 12:52 pm, Staff 1 (Executive Director) stated that the facility did not provide meals with a mechanical soft diet texture. While attempting to eat on 06/11/24, the resident was observed to have difficulty feeding him/herself including difficulty coordinating lip and tongue movement in order to get food into his/her mouth, and difficulty keeping food in his/her mouth while swallowing. The resident was observed making coughing and hacking sounds twice while attempting to eat the meal which did not adhere to physician's orders.On 06/12/24, an an immediate plan of correction was requested. The facility provided a plan of correction on 06/12/24 at 1:25 pm. The immediate risk was addressed, however, the facility will need to evaluate the overall system failures associated with the licensing violation.Refer to C160. b. The resident's MARs, dated 05/01/24 through 06/10/24, and physician orders were reviewed.There was no documentation that the facility had a signed order for the following medications which were listed on Resident 3's MAR: * PRN glycerin suppository (for constipation); * PRN Mylanta, 30 ml by mouth every four hours (for gastrointestinal upset); and* PRN acetaminophen 500 mg, 1 tablet by mouth every four hours (for pain or fever). The need to ensure all orders were carried out as prescribed, and signed physician or other legally recognized practitioner orders were documented for all medications and treatment's the facility was responsible to administer was reviewed with Staff 1 and Staff 2 (Wellness Director/RN) on 06/11/24 through 06/14/24. They acknowledged the findings.2. Resident 2 was admitted to the facility in 05/2024 with diagnoses including dementia, COPD and hypertension. Resident 2's MARs, dated 05/26/24 through 06/10/24, and all physician's orders were reviewed. On 06/08/24, the facility made the following changes to Resident 2's MAR:* Added PRN tramadol 50 mg (for pain); and * Discontinued daily cholecalciferol (for Vitamin D deficiency). There was no documented evidence the facility had a signed physician's order for the above changes. The resident was administered PRN tramadol four times between 06/08/24 and 06/10/24. During an interview with Staff 2 (Wellness Director/RN) on 06/12/24 at 3:21 pm, she stated the facility had made changes to the MAR based on an after-visit summary which was not signed by a physician. The need to ensure all orders were carried out as prescribed, and signed physician or other legally recognized practitioner orders were documented for all medications the facility was responsible to provide, was reviewed with Staff 1 (Executive Director) on 06/14/24 at 11:30 am. She acknowledged the findings.
3. Resident 1 was admitted to the facility in 11/2021 with diagnoses including heart failure and dementia.Resident 1's MAR and signed physician's orders were reviewed. A signed physician order, dated 05/20/24, indicated the resident was to receive Sertraline 25mg at bedtime for depression. Record review indicated the facility failed to transcribe the medication to the MAR and had not been administering the medication.During an interview on 06/14/24, Staff 2 (Wellness Director/RN) reported the facility had missed the order and Resident 1 had not been receiving the medication.On 06/14/24, the need to ensure all medications and treatments were being administered as prescribed was discussed with Staff 1 (Executive Director) and Staff 2. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 long-term direct care staff (#s 8, 9, 11 and 14) completed and documented a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care (CBC) setting, including six hours related to dementia care. Findings include, but are not limited to:Staff training records were reviewed on 06/13/24 and 06/14/24. Staff 8 (CG), hired 08/13/21, Staff 9 (CG), hired 04/12/22, Staff 11 (CG), hired 08/14/21, and Staff 14 (MT), hired 02/21/22, lacked documented evidence of completing a minimum of 12 hours of in-service training annually, based on date of hire, including six hours related to dementia care. The need to ensure all direct care staff complete and document a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a CBC, including six hours related to dementia care, was discussed with Staff 1 (Executive Director and Staff 3 (Business Office Manager) on 06/14/24 at 11:00 am and 11:30 am, respectively. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure residents were instructed on fire and life safety procedures within 24 hours of admission and annually. Findings include, but are not limited to:On 06/10/24 and 06/11/24, facility fire and life safety records were reviewed and lacked documented evidence the following required elements were completed:*Instruction to Resident 2 on fire/life safety procedures within 24 hours of admission; and*A written record, including content, of annual instruction to Resident's 1 and 4 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.During a group interview on 06/11/24 at 2:00 pm, eight unsampled residents indicated they had not been instructed annually 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.On 06/14/24 at approximately 12:00 pm, the need to ensure residents were provided instruction per the Oregon Fire Code was discussed with Staff 1 (Executive Director). She acknowledged the findings.

Based on interview and record review, conducted during a site visit on 05/22/24, it was confirmed the facility failed to implement a service plan that reflects the resident's needs for 1 of 2 sampled residents (#1). Findings include, but are not limited to:During an interview on 05/22/24, Staff 1 (ED) indicated s/he was aware the behavioral service plan wanted the staff to check on Resident 1 every two hours. Staff 1 indicated the facility does not always check on Resident 1 every two hours due to increasing his/her behaviors. Witness 1 indicated in the complaint on 12/07/23, the facility was not complying with Resident 1's behavioral service plan. Staff 1 indicated to Witness 1 the facility does not need to be checking on Resident 1 every two hours and that s/he needed to be in a behavioral/special needs facility. A review of Resident 1's behavioral service plan dated 09/05/23, indicated staff are expected to "check in" on resident 1 at least every two hours to ensure needs are met to prevent behaviors. A review of Resident 1's quarterly evaluation dated 02/28/24 and service plan dated 02/20/24 had not indicated staff were to check on Resident 1 every two hours. It was confirmed the facility failed to implement a service plan that reflects the resident's needs.On 05/22/24, the findings were reviewed with and acknowledged by Staff 1.Verbal plan of correction: The facility will change Resident 1's service plan to match his/her behavioral service plan.

The findings of the kitchen inspection, conducted 01/11/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.
The findings of the revisit to the kitchen inspection of 01/11/24, conducted 05/16/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation, record review, and interview, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:Observations of the main facility kitchen and dining room beverage service, food storage, preparation areas and service on 01/11/24 revealed splatters, spills, drips, dust and debris noted on: - Interior of cabinets, drawers; - Walls under ware washing machine; - Interior of microwave; - Open stainless steel shelving throughout kitchen; - Fan blades and cage; - Metal storage racks throughout kitchen; - Ovens; - Interior of refrigerators and freezers; - Utility room walls and floors; - Floors under major appliances; - Windows and portable AC unit behind microwave; and - Canned goods in dry storage room.The following areas/items were found needing repair: - Reach in refrigerators in kitchen not registering 41 degrees; - Ware washing machine wash cycle temperature gauge not registering 150 degrees; - Ware washing machine rinse cycle temperature gauge not consistently registering 180 degrees; - Freezer with evidence of temperature irregularity and damaged seal; and - Multiple small holes around pipes or conduit were found. Areas needing sealing to prevent entry points for possible pests.* Dining room beverage area found with areas of chipped paint and cabinetry in disrepair.* Main kitchen cabinetry with interior and exterior areas of exposed wood edges resulting in a surface that is not smooth or cleanable. Hinges on multiple cabinets were not operating correctly. Many shelves in cabinets/cupboards with damage and not smooth, cleanable surfaces. * Dry storage room door was unsecured for several hours. Door opened to resident care area hallway where entry by non-kitchen/authorized staff could occur. * Multiple cutting boards were found with deep scoring and staining. * Multiple sauté pans were found with deep scoring and flaking of non-stick surface material. * Multiple items in refrigerators/freezers were not covered and/or dated when prepared or opened. Mayonnaise container was found expired.* Items in freezer not stored to allow for adequate air circulation. Multiple items were found with visible signs of freezer burn.* Multiple items in dry storage were observed not securely sealed and/or not labeled and/or not dated. Multiple items were found expired and/or removed from manufacturer packaging without labeling or date marking. Several dry goods bins were found with lids ajar and scoops left in food product.* Ware washing machine was found below 150 degrees during multiple wash cycles between 10:15 am and 11:15 am. Ware washing machine was found below 180 degrees during multiple rinse cycles between 10:15 am and 11:15 am* Multiple kitchen staff found without hair or facial hair restrained as required.Staff 2 (Dietary Services Director) and the surveyors toured the kitchen. Staff 2 acknowledged the above findings.At approximately 2:00 pm, the above areas in need of cleaning, repair and attention were reviewed with Staff 1 (Executive Director). S/he acknowledged the findings.

The findings of the on-site investigation conducted 09/27/2023 are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities. Abbreviations possibly used in this document:ADL: activities of daily livingCBG: capillary blood glucose or blood sugar CG: caregiverCS: Compliance Specialistcm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMT: Medication TechMAR: Medication Administration RecordMCC: Memory Care CommunityOT: Occupational TherapistPT: Physical TherapistPRN: as neededRCC: Resident Care CoordinatorRN: Registered Nurse

Based on interview and record review, conducted during a site visit on 09/27/23, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (#1). Findings include, but are not limited to: A review of Resident 1's Incident report, November 2021 and "Medication Form" dated 11/19/21 stated: "Resident 1 missed [his/her] 2 doses of Lorazepam on 11/19/21 however did receive 3rd does for the day. Medication was not ordered in a timely manner. Medication was sent from pharmacy STAT and a delivery driver brought it to the facility. New process for Narcotic is re-order date will be circled on the card. When the medication is punched the Med Tech will re-order. This should be when there is a seven-day supply left of the medication. Med Techs will be in-serviced and RCC to conduct weekly med cart audits to assure new process is followed. Abuse and neglect were ruled out." During an interview, Staff 1 (ED) confirmed s/he Staff 1 had not worked at the facility during the time of incident. The findings were reviewed with and acknowledged by Staff 1 (ED) on 09/27/23.It was confirmed the facility failed to carry out medication and treatment orders as prescribed.Verbal plan of correction: New process for Narcotic is re-order date will be circled on the card. When the medication is punched the Med Tech will re-order. This should be when there is a seven-day supply left of the medication. Med Techs will be in-serviced and RCC to conduct weekly med cart audits to assure new process is followed.

Based on interview and record review, it was confirmed that the facility failed to fully implement and update an acuity-based staffing tool (ABST). Findings include: Record review on 8/2/2022 of timecards for 6/16/2022-6/30/2022, posted staffing plan, ODHS ABST, and service plans for Resident #1-2 (R1 and R2). The posted staffing plan is not reflective of the ABST as it has not been fully implemented yet. Call light logs from 6/25/2022-6/30/2022 revealed multiple call light response times ranging from 25 minutes to 1 hour and 39 minutes. Both R1 and R2 indicate on the facilities ABST that these residents need 0 minutes for call light response time, reviewing them it indicates R1 pushed their button 26 times while R2 pushed it 33 times. In an interview on 8/2/2022 Staff #1 (S1) stated that they are using the ODHS ABST, however, they were not aware that it generated a staffing plan based on amount of caregiving time indicated with the tool.The above information was shared with S1 on 8/2/2022.Plan of Correction: The facility will speak with Policy Analyst (PA) to get further clarification on how to generate the staffing plan to they are in compliance with the ODHS ABST.

The findings of the re-licensure survey, conducted 7/19/21 through 7/21/21 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 livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day
The findings of the first revisit to the re-licensure survey of 07/21/21, conducted 10/19/21 through 10/21/21 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 livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day

The findings of the re-licensure survey conducted, 01/03/22 through 01/04/22, 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 licensee failed to provide effective oversight to ensure the quality of care and services that were rendered in the facility. Findings include, but are not limited to:During the re-licensure survey, conducted 7/19/21 through 7/21/21, oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number of citations.Refer to deficiencies in report.

Based on observation, interview and record review, it was determined the facility failed to develop and conduct ongoing quality improvement programs that evaluated services, resident outcomes and resident satisfaction. Findings include, but are not limited to:Staff 1 (Executive Director), Staff 2 (RN) and Staff 3 (Regional RN) was asked about the facility's quality improvement program on 7/21/21. During the interview, Staff 1 stated the facility did not have a Quality Improvement Program. The need to ensure the facility had an effective method to evaluate services, resident outcomes and resident satisfaction was discussed. Staff 1 acknowledged the findings. Refer to the deficiencies in the report.
Based on observation, interview and record review, it was determined the facility failed to develop and conduct ongoing quality improvement programs that evaluated services and resident satisfaction. This is a repeat citation. Findings include, but are not limited to:Review of the facility's Quality Improvement policy, Resident Council minutes for September and October 2021 and interviews with sampled and non-sampled residents revealed the following: The facility's Quality Improvement policy was reviewed on 10/20/21. The policy stated a suggestion box to address ways to improve the quality of services provided in the community would be placed in an area where the individual can feel free to deposit their suggestions unnoticed and the suggestions would be reviewed weekly by the Executive Director. Additionally, the policy stated a Resident Council meeting would be held monthly and issues or concerns that were identified during the meeting would require a response/action from the Executive Director and the responses/actions would be documented and made available to all interested parties. During an interview on 10/20/21, Staff 1 (ED) stated the suggestion box was located in a resident use hallway near staff offices but the residents did not ever use the suggestion box.The facility's "Resident Council Minutes" forms included a section to address "Old Business" and stated during Resident Council meetings staff and residents were to review the facility's response to previously recorded issues/concerns and vote (by show of hands) to show if the facility's response had resolved the issues/concerns to the residents' satisfaction. The sections were left blank on the September and October forms.During resident interviews conducted 10/19/21- 10/21/21, multiple residents reported the facility did not have an effective procedure for addressing resident satisfaction related to dining and meal preferences, call light response times and general concerns with care and staff. The residents indicated they were not aware of a suggestions box or did not feel they could place suggestions unnoticed, residents were not informed of when Resident Council meetings would be held and residents were not aware of what response or action had been made by the facility to address the concerns that were reported in Resident Council meetings.The need to ensure the facility had an effective method to evaluate services and resident satisfaction was discussed with Staff 1 (ED) on 10/21/21. She acknowledged the findings.
1. Education on how to complete resident council and resident council documentation. Activities Manager will ensure full paperwork is completed. On the news letter for November, suggestion box location was announced. This will countinue to be announced in the news letter each month to ensure new residents know the location. Meeting times and locations are listed on the activity calendar each month and in the newsletter. News letter will include responses/actions for council meeting concerns. New binder for blank grievance pages at front desk, both residents and staff are able to fill out a grievance form and put under the Executive Directors door. This will allow the ED to address grievance. 2. Activity Director and Executive Director will review the news letter and calendar each month to ensure suggestion box location and meetings are announced. Once a week Executive Director will check the suggestion box. ED will inform the residents of suggestion replies at the next resident council. All received grievances will be investigated and addressed within 5 days.3. Suggestion box will be checked and addressed once a week. Resident Council will be held once a month and past grievences reviewed. All new grievences will be reviewed within 5 days.4. Activities director will complete calendar, announcements for meetings, and handing out newletter. ED will address grievance, response/actions from council meeting, and over see whole process

Based on observation and interview, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents. Findings include, but are not limited to: During the relicensure survey conducted 7/19/21 through 7/21/21, Oregon Department of Human Services (ODHS) infection control guidelines, which were established to protect the facility staff and residents from the spread of COVID-19 and made available to all facilities, were not being followed by the facility.Kitchen staff were observed to not be wearing face masks on multiple occasions during the survey.The need to ensure reasonable precautions were exercised to ensure the health, safety and welfare of residents and infection control practices to prevent the spread of COVID-19 were followed was discussed with Staff 1 (Executive Director), Staff 2 (RN) and Staff 3 (Regional RN) on 7/20/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure all incidents and injuries of unknown cause were investigated to rule out abuse and reported to the local SPD as suspected abuse when abuse was not reasonably ruled out for 1 of 1 sampled resident (#1) reviewed with injuries of unknown cause. Findings include, but are not limited to:Resident 1 was admitted to the facility in July 2019 with diagnoses including dementia. In a progress note dated 6/9/21, staff documented, "Resident had a bruise on [his/her] right inner thigh." There was no documented evidence the injury of unknown cause had been investigated to rule out abuse or had been reported to the local SPD office.The facility was directed to self-report the injury of unknown cause to the local SPD office on 7/21/21. Confirmation the injury was reported was provided prior to exit.The need to ensure injuries of unknown cause were immediately investigated to rule out abuse and reported as appropriate, was discussed with Staff 1 (Executive Director) on 7/21/21. She acknowledged the findings.
Based on interview and record review, it was determined the facility failed to conduct investigations for injuries of unknown cause to rule-out abuse, or report the injuries as suspected abuse to the local Seniors and People with Disabilities (SPD) office for 1 of 1 sampled resident (#5) who had documented injuries of unknown cause. This is a repeat citation. Findings include, but are not limited to: Resident 5 was admitted to the facility in July 2017 with diagnoses including edema and cellulitis. Progress notes indicated that on 10/7/21 there was a quarter sized bruise found on the resident's right forearm. There was no documented evidence the facility had conducted an immediate investigation to reasonably conclude the bruise of unknown cause was not the result of abuse. In an interview on 10/20/21 with Staff 1 (ED) and Staff 3 (Regional RN), they confirmed that there was no documented evidence of an investigation and the facility did not report to the local SPD office. On 10/21/21, the need to conduct investigations related to injuries of unknown cause to rule-out abuse or report the injuries as suspected abuse to the local SPD office was discussed with Staff 1. She acknowledged the findings. Staff 1 reported the incident to the local SPD office per surveyor request.
1. Prognote of bruising was documented and investigated in an incident report. Due to lack of documentation we were unable to rule out abuse and neglect. The bruise was reported to APS on that day2. RN, RCC and ED will review 24/72 hr report which will show prognotes entries to insure any incident including injuries of unknown cause have an incident report and are investigated. RN/ED will rule out abuse and Neglect. MedTech training on Incident Report 11/2/2021-11/4/2021. RN, RCC, and ED will review all incidents to assess for abuse and neglect. 3. RN, RCC and ED will check 24 hour report daily to assure any needed incident reports were filled out.4. RN and ED will check incident reports for abuse and neglect.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and in good repair and that food was stored in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:The kitchen was toured on 7/19/21 with Staff 16 (Dietary Aide/Cook) and Staff 17 (Dietary Aide/Cook) at 9:10 am. The following was observed: 1. Multiple open items in the refrigerators were undated. 2. Food spills, splatters, debris, grease, dirt and black and gray matter was observed on or underneath the following:* Interior and exterior of cabinets, drawers, shelves and window sills;* Floors throughout the kitchen, with increased build-up in corners and under dish area;* Pipes and drain under dish area;* Food delivery cart;* Refrigerators and freezers in kitchen;* Freezers in kitchen;* Floors and shelves in dry storage rooms;* Interior of microwave;* Stand mixer;* Top and front of ice machine;* Can opener;* Silverware storage containers;* Light fixtures;* Stove hood; * Hand washing sink; and* Air conditioner vent adjacent to food prep area. 3. The following areas were observed to be in need of repair:* A crack was noted in flooring next to the dishwasher;* An oblong, approximately two inch hole in the flooring was observed adjacent to the ice machine;* Triple sink was reported to be out of order and water was observed to be turned off;* Caulking in dish area was cracked with build-up of black matter;* Shelves in refrigerator had chipped vinyl;* Ice machine missing lower vent cover;* Wall by dishwashing sink had patched, spackled areas that had not been painted;* Cabinets across from dish area had chipped paint;* Counter by stand mixer had approximately 4 by 2 inch area of counter with missing laminate;* Bottom panels of cabinet drawers under food prep area had chipped paint; and * Laminate on cabinets in coffee area in dining room was peeling. The improperly stored food and the areas in need of cleaning and repair were observed and discussed with Staff 1 (Executive Director), Staff 16 and Staff 17 on 7/19/21. They acknowledged the findings. Undated foods were observed to be appropriately dated or disposed of following the discussion. Staff 17 reported the stove hood was scheduled to be cleaned on 7/22/21.
Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and in good repair and that food was stored in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to:The kitchen was toured on 10/19/21 with Staff 1 (ED) and Staff 5 (Dietary Manager). The following was observed: 1. Food spills, splatters, debris, and dirt was observed on, inside, or underneath the following:* Refrigerators and freezers in kitchen;* Refrigerators and freezers in storage rooms;* Floors and shelves in dry storage rooms;* Shelves above the stove; and* Light fixtures.2. The following areas were observed to be in need of repair:* Triple wash sink faucet;* Caulking in dish area was cracked with build-up of black matter;* Shelves in refrigerators had chipped vinyl;* Counter by stand mixer and prep area missing; and * Laminate and paint on cabinets in coffee area in the dining room was peeling. 3. Dry food packages were being stored on the floors and not on racks in the dry food storage rooms. On 10/19/21 and 10/20/21, the need to ensure foods are stored correctly and areas in need of cleaning and repair were discussed with Staff 1 and Staff 5. They acknowledged the findings.
1. Kitchen staff spend the first day cleaning up all refrigerators and freezers, floors and shelves, shelving above stove and light fixtures. Maintenance manager repaired caulking in dish area and ordered new shelves for refrigerators2. Kitchen manager will audit her cleaning 5 days a week, ED will do a once a week walk through to ensure cleaning and repair/upkeep is being completed. Maintenance manager will buy and repair the missing counter by the stand mixer and prep area. ED will contact plumber for faucet fixture, and get a date to come in complete work. Maintenance manager will repair laminate and paint the cabinets in coffee area. Kitchen staff will use a pallet to place boxes from sysco on in the storage area until food can be put away. 3. Kitchen manager will check 5 days a week, Maintenance Manager will check once a week and complete repair with in a week, ED will over view once a week4. Kitchen Manager, Mantiance Manager, and ED

2. Resident 3 was admitted in 2020. S/he was alert, oriented and a reliable historian.During an interview on 7/19/21 at 11:15 am, Resident 3 said that his/her spouse was now helping him/her with showers because staff had not provided the assistance agreed upon. The resident further added that his/her spouse was out of town and s/he had not received a shower for several weeks. S/he also stated s/he had not refused any bathing assistance that was offered. The current service plan was updated on 7/12/21 to reflect that the spouse would assist the resident with showers. Staff were to "assist as needed." Prior to 7/12/21, staff were to provide bathing assistance. Caregiver ADL task sheets, reviewed from 6/1/21 - 7/12/21, revealed the resident received three showers (6/7/21, 6/11/21 and 7/2/21) during that time frame (50 days). The bathing schedule was reviewed with Staff 10 (CG) on 7/21/21. The schedule indicated that Resident 3 was to be assisted with a shower twice a week (Monday and Friday) on evening shift. Staff 10 was unaware that the spouse was now assisting the resident with showers. The complaint of lack of showers and the lack of documented evidence that those services were provided was shared with Staff 1 (Executive Director) on 7/20/21 at 1:00 pm. She acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to provide assistance with activities of daily living for 2 of 3 sampled residents (#s 2 and 3). Findings include, but are not limited to:1. Resident 2 was admitted to the facility in March of 2021 with diagnoses which included quadriplegia. S/he was alert, oriented and a reliable historian.Observations of Resident 2 during the survey revealed s/he was dependent on staff for all ADL care including meal assistance, required two person assist for positioning and bed mobility, and had an open area on his/her left heel and left buttock. S/he was unable to use the facility call system and used voice command to call the facility phone when in need of assistance. The service plan, dated 7/14/21, indicated the following:* Resident 2 needed "frequent checks and reposition resident frequently in bed/chair with 2 person assistance ..."; * S/he needed full assist for all ADL cares to include dressing, grooming and hygiene; and* "Use the sliding draw sheet to turn and reposition every two hours while in bed." During an interview on 7/20/21, Staff 8 (CG) said Resident 2 needed two person assist with bed mobility and transfers using a Hoyer lift and total assist with all ADL's including meals and drinks.On 7/19/21 at 10:45 am, Resident 2 was observed laying in bed, unclothed and covered with a blanket. Resident reported s/he wanted to get dressed and had not been turned since approximately 8:00 am. At 11:35 am a CG entered the room to provide care.On 7/20/21 at 11:00 am the resident reported not receiving breakfast until approximately 10:45 am after telling a CG s/he had not eaten. Additionally, the resident reported the staff had not brushed his/her teeth in over a week.During an interview on 7/20/21 at 11:44 am, Staff 10 (CG) stated she had repositioned Resident 2 at 6:15 am that morning and then again at 10:30 am. Staff 10 confirmed the resident had not been turned and repositioned for over four hours. Review of ADL records from 5/1/21 through 7/19/21 revealed multiple blanks, indicating tasks were not completed for the following: * "Grooming assistance Q [every] shift [including brushing teeth]";* "Meals given";* "All care provided Q shift"; and* "Safety checks: turn and reposition every two hours. Complete range of motion with arms and legs. Ask if [s/he] needs anything like drinks, using phone, TV, hungry, snacks."The above findings were shared with Staff 1 (Executive Director), Staff 2 (RN) and Staff 3 (Regional RN) on 7/21/21. They acknowledged the findings and reported a meeting had been held with all care staff regarding Resident 2's care requirements.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction regarding the delivery of services and were followed for 3 of 3 sampled residents (#s 1, 2 and 3) whose service plans were reviewed. Findings include, but are not limited to:1. Resident 3 was admitted to the facility in 12/2020. During the entrance conference acuity interview on 7/19/21, staff said Resident 3 needed assistance with ADLs, had fallen multiple times and had several skin injuries. Observations and interviews with Resident 3 on 7/19/21, and an interview with a CG on 7/20/21 revealed s/he required staff assistance for several ADL care needs, used a urinal, had specific clothing preferences, ate all meals in his/her apartment, and had a history of falls.Resident 3's service plan, dated 5/26/21, was not reflective in the following areas:* Meal service preference;* Use and care of urinal;* Clothing preferences;* Frequency of visual observations to prevent falls; and* Specific direction to staff when bathing assistance would be needed. The need to ensure the service plan was reflective of Resident 3's current needs and provided clear direction to staff was discussed with Staff 1 (Executive Director), Staff 2 (RN) and Staff 3 (Regional RN) on 7/21/21. They acknowledged the findings.
2. Review of Residents 2's service plan dated 7/14/21 revealed it was not reflective of the resident's current status, lacked clear direction to staff and/or was not followed in the following areas:* Supra pubic catheter care instructions;* Colostomy care and instructions;* Hobbies, interests past and present with instructions; * C-PAP machine use nightly lacked instructions for staff on use and care of equipment;* Meal and fluid assistance including the use of a straw for all liquids;* Compression stockings; * Compression gloves; * Cognitive status;* Ability to communicate and make decisions;* Inability to use facility call system; * Turning and repositioning every two hours;* Range of motion every shift; * Side rails, including instructions for safety with use;* Seat belt in wheel chair with instructions; * Cat and care of cat; * Wounds to left buttock and left heel with instructions to check dressing every shift; and*PT and OT outpatient services.The need to ensure service plans were reflective, provided clear instructions to staff and/or was followed was discussed on 7/21/21 with Staff 1 (Executive Director), Staff 2 (RN) and Staff 3 (Regional RN). The staff acknowledged the findings.
3. Review of Resident 1's 6/1/21 service plan revealed it was not reflective of the resident's status and did not provide clear direction to staff related to the following: * Instructions for catheter care;* Wound on right hip; and * Hospital bed. The need to ensure service plans were reflective of the resident's status and provided clear instruction to staff was discussed with Staff 1 (Executive Director), Staff 2 (RN) and Staff 3 (Regional RN) on 7/21/21. They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of the residents' current needs and provided clear direction to staff for 2 of 3 sampled residents (#s 4 and 5) whose service plans were reviewed. This is a repeat citation. Findings include but are not limited to:1. Resident 4 was admitted to the facility in 09/2019 with diagnoses including diabetes and peripheral vascular disease.Observations and interviews with Resident 4 made during the survey and review of Resident 4's current and temporary service plans and progress notes dated 09/19/21 through 10/19/21 indicated the following:Resident 4's current service plan indicated the resident had a wound on the lower extremity which was treated with a wound VAC treatment (Vacuum-assisted closure of a wound).On 10/19/21, Resident 4 was observed in his/her apartment with bandages on the lower extremity and the resident stated the wound only required dressing changes and no longer required the wound VAC.Progress notes stated the wound VAC was discontinued 09/24/21.During an interview on 10/19/21 Staff 3 (Regional RN) confirmed the service plan did not reflect the discontinuation of the wound VAC treatment.The need to ensure service plans were reflective of the resident's current needs and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 3 on 10/19/21. They acknowledged the findings.
2. Review of Residents 5's service plan dated 8/9/21 revealed it was not reflective of the resident's current status and/or lacked clear direction to staff in the following areas:* Bathing assistance;* Toileting assistance;* Dressing assistance; and* Hospice/palliative care.On 10/21/21, the need to ensure service plans were reflective and provided clear instructions to staff was discussed with Staff 1 (ED). She acknowledged the findings.


1. RN D/Ced wound vac from reisdent 4 Service Plan, once a week. RN D/Ced palliative care from resident 5 SP. RN and RCC once a week will go though 5 SP to update information on bathing, toileting and dressing.2. Wellness Director will review the serivce plans for details at 90 day review. ED will review service plans with resident at service plan meeting3. Upon move in, first 30 days, 90 day review and change of conditions.4. RN and ED

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that consisted of the resident, the resident's legal representative if applicable, any person of the residents choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services, for 2 of 3 sampled residents (#s 2 and 3) whose service plans were reviewed. Findings include, but are not limited to:Resident 2 and 3's most recent service plans lacked documentation that a Service Planning Team reviewed and participated in the development of the service plans.The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (Executive Director), Staff 2 (RN) and Staff 3 (Regional RN) on 7/21/21. They acknowledged the findings.

3. Resident 3 was admitted in 12/2020.Resident 3's clinical record and charting notes, reviewed from 4/1/21 through 7/19/21, revealed the following:a. Resident 3 fell 17 times between 4/9/21 and 7/18/21. The facility failed to complete investigations for five of the 17 falls and failed to investigate the circumstances for each fall to determine if service-planned interventions were implemented, were effective or if new interventions were needed. b. During an interview on 7/19/21, Resident 3 was observed to have several wounds on his/her knees and shins. S/he stated the wounds were caused during recent falls.Progress notes and incident investigations revealed Resident 3 sustained multiple skin tears/injuries to his/her bilateral knees, shins and forehead during falls on 5/15/21, 6/8/21 and 7/2/21.According to the current service plan, the resident "has ongoing issues with wounds and/or skin tears requiring wound care assistance." The plan indicated the licensed nurse would complete a "Weekly Skin Evaluation Form." The clinical record lacked evidence the wounds had been evaluated and monitored, the facility RN informed per facility policy, wounds assessed and noted on a facility Weekly Skin Evaluation form, and treatment initiated and performed.During interviews with Staff 2 (RN) and Staff 3 (Regional RN ) on 7/20/21 at 11:45 am, Staff 3 said that according to the facility's "Skin Condition Evaluation and Monitoring" policy, skin injuries would be assessed weekly by the licensed nurse and documentation of those assessments would be noted on a "Skin Evaluation" form. Both reviewed the record and confirmed that there were no Skin Evaluation forms completed, no on-going monitoring, and no documentation of wound care. Staff 2 (RN) stated she would assess the wounds that day.On 7/21/21, Staff 2 provided her assessment of the wounds to the surveyor. Staff 2 had provided wound care, notified the physician, and requested orders for daily wound care until healed. The above information was discussed with Staff 1 (Executive Director), Staff 2 (RN) and Staff 3 (Regional RN) on 7/21/21. They acknowledged the findings. No further information was provided.
Based on observation, interview and record review, it was determined the facility failed to ensure short-term changes of condition were identified, evaluated, RN notified per facility policy, were monitored at least weekly to resolution and actions or interventions were determined, documented and communicated to staff for 3 of 3 sampled residents (#s 1, 2 and 3). Findings include, but are not limited to:1. Resident 2 was admitted to the facility in 3/2021 with diagnosis including quadriplegia and chronic pain syndrome.Resident 2's record was reviewed for changes of condition and monitoring from 4/17/21 through 7/19/21 and revealed the following:* 4/17/21: Accident/incident in wheel chair which resulted in emergency services assistance for possible leg injury; * 4/26/21: Three missed medications with monitoring for increased pain;* 4/30/21 and 5/18/21: Increase in two different pain medication dosages; * 6/2/21: Left heel and top of left great toe redness and/or wounds;* 6/2/21: Coccyx wound (ongoing); and* 7/12/21: Wounds to right and left buttocks.There was no documented evidence the resident's changes of condition were monitored weekly to resolution. The failure to monitor changes of condition weekly to resolution was reviewed with Staff 1 (Executive Director), Staff 2 (RN) and Staff 3 (Regional RN) on 7/21/21. They acknowledged the findings.
2. Resident 1 was admitted to the facility in July 2019 with diagnoses including dementia. Review of Resident 1's 4/1/21 through 7/19/21 facility record revealed the following: *A progress note dated 4/19/21 indicated the resident experienced "possible seizure activity...shaking, loss of vision...loss of consciousness." There was no documented evidence the facility referred the resident to the facility nurse for assessment.*Resident 1 was re-admitted to the facility from the hospital on 5/29/21 with a wound on his/her right hip. There was no documented evidence the facility monitored the wound at least weekly to resolution. * A progress note dated 6/9/21 revealed the resident had a bruise on his/her inner thigh. There was no documented evidence the facility monitored the bruise at least weekly through resolution. * Hospice bath aide notes dated 6/21/21, 6/25/21, 6/28/21 and 7/1/21 stated the resident had a rash on his/her "bottom". There was no documented evidence the facility determined what actions or interventions were needed for the resident or monitored the rash at least weekly through resolution. The failure of the facility to ensure that residents who experienced changes of condition necessitating assessment were appropriately referred to the RN, that actions and interventions were developed as appropriate and that residents were monitored at least weekly through resolution of changes was discussed with Staff 1 (Executive Director), Staff 2 (RN) and Staff 3 (Regional RN) on 7/21/21. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure facility RN assessment based on resident condition and facility policy for 2 of 3 sampled residents (#s 2 and 3) reviewed for skin wounds. Findings include, but are not limited to:1. Resident 3 was admitted to the facility in 2020 and had a history of skin wounds to his/her lower extremities. On 7/19/21, Resident 3 was observed to have several wounds on his/her knees and shins. S/he stated the wounds were caused during recent falls.During interviews with Staff 2 (RN) and Staff 3 (Regional RN) on 7/20/21, Staff 3 said that according the facility's "Skin Condition Evaluation and Monitoring" policy, skin injuries would be assessed weekly by the licensed nurse and documentation of those assessments would be noted on a "Skin Evaluation" form. Both reviewed the record and confirmed that no assessments of the wounds had been completed. Staff 2 (RN) stated she would assess the wounds that day.On 7/21/21, Staff 2 provided her assessment of the wounds to the surveyor. Staff 2 had provided wound care, notified the physician, and requested orders for daily wound care until healed. The above information was discussed with Staff 1 (Executive Director), Staff 2 (RN) and Staff 3 (Regional RN) on 7/21/21. They acknowledged the findings. No further information was provided.Refer to C 270, example 3.
2. Resident 2 was admitted to the facility in 3/2021 with diagnoses which included quadriplegia.Observations, staff interviews and record review during the survey revealed the resident had developed wounds on the left buttock and left heel.There was no documented facility RN assessment. Staff 2 (RN) was interviewed on 7/20/21 at 2:30 pm. She reported she was unable to find documentation of RN assessments completed for the wounds to the left buttock and left heel. The above information was discussed with Staff 1 (Executive Director) and Staff 3 (Regional RN) on 7/21/21. They acknowledged the findings. No further information was provided.

Based on interview and record review, it was determined the facility failed to coordinate care with outside providers in order to ensure the continuity of care for 1 of 2 sampled residents (#1) who received services from an outside provider. Findings include, but are not limited to:Resident 1 was admitted to the facility in July 2019 with diagnoses including dementia. During the acuity interview on 7/19/21, Resident 1 was identified as receiving outside services related to hospice. Outside provider notes left by the hospice bath aide on 6/21/21, 6/25/21, 6/28/21 and 7/1/21 documented the resident had a rash on his/her "bottom".There was no documented evidence the notes left by the bath aide had been reviewed by the facility or that this information had been communicated to staff. The need to ensure on-going coordination of care was maintained and documented was discussed with Staff 1 (Executive Director), Staff 2 (RN) and Staff 3 (Regional RN) on 7/20/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 1 of 1 sampled resident (#2) whose MARs and Controlled Substance Disposition logs were reviewed for accuracy. Findings include, but are not limited to:Resident 2's physician orders and 7/1/21 through 7/19/21 MAR and controlled substance disposition logs were review and revealed the following: Resident 2 had 5/18/21 physician orders for Dilaudid 1 mg every six hours for a pain scale of five to seven, and Dilaudid 2 mg every six hours for a pain scale of eight to ten.Resident 2's 7/1/21 through 7/19/21 Controlled Substance Disposition log and MAR showed the following: * There were 53 doses of Dilaudid signed as given on the disposition log but only 42 doses signed as administered on the MAR; and* On 7/11/21 the disposition log showed 2 mg of Dilaudid was given but the MAR showed 1 mg was administered. On 7/21/21 the requirement to have a system in place for accurately tracking controlled substances administered by the facility was discussed with Staff 1 (Executive Director), Staff 2 (RN) and Staff 3 (Regional RN). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure residents' MARs were accurate and provided clear instruction and parameters for administration of PRN medications for 2 of 3 sampled residents (#s 1 and 2) whose MARs were reviewed. Findings include, but are not limited to:1. Resident 2's 7/1/21 through 7/19/21 MARS were reviewed and revealed the following:* PRN bowel care medications (Docusate Sodium and GlycoLax Powder) lacked clear instruction to staff regarding the order of administration; and * PRN Clonidine HCL, ordered for dysreflexia (a syndrome in which there is a sudden onset of excessively high blood pressure) lacked information on what symptoms to monitor for and when and who to notify of dysreflexia symptoms.The need to ensure MARs were accurate, included clear parameters and instruction to staff for medication administration and follow up was discussed with Staff 1 (Executive Director), Staff 2 (RN) and Staff 3 (Regional RN) on 7/21/20. They acknowledged the findings.
2. Review of Resident 1's 6/7/21 physician orders and 7/1/21 through 7/19/21 MARs and progress notes revealed the following: Resident 1 had a signed physician order dated 6/7/21 for prn wound care to his/her right hip. The order was not transcribed onto the MAR. A 7/7/21 progress note indicated staff had completed wound care to the resident's right hip. The wound care treatment was not documented on the MAR. The need to ensure MARs were accurate and included all medications and treatments that were ordered by a prescriber was discussed with Staff 1 (Executive Director), Staff 2 (RN) and Staff 3 (Regional RN) on 7/20/21. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure supportive devices with potentially restraining qualities were assessed, included a thorough review by an RN, PT or OT prior to use, documented less restrictive alternatives prior to use, and provided instruction to caregivers on the correct use of and precautions for the device for 1 of 1 sampled resident (#2) who had side rails on their bed and a seat belt in their wheel chair. Findings include, but are not limited to:Resident 2 was admitted to the facility in 3/2021.During the acuity interview it was reported that Resident 2 had side rails on their bed and a seat belt in their wheel chair. On 7/19/21 the resident's bed was observed to have two quarter length side rails in the up position and a seat belt in the wheel chair. There was no documented evidence the devices with restraining qualities had been assessed by an RN, PT or OT including documentation of less restrictive alternatives prior to use, nor was there evidence the service plan had identified the use of and precautions related to the devices.The lack of assessment and instructions provided for use of supportive devices with potentially restraining qualities was discussed with Staff 1 (Executive Director), Staff 2 (RN) and Staff 3 (Regional RN) on 7/21/21. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to have sufficient number of caregivers to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to: During the entrance conference on 7/19/21 and observations thrroughout the survey, the following was identified: * The facility had 33 residents;* Six residents needed two-person assist with transfers or care; * Three additional residents were identified as requiring heavy care;* One resident required meal assistance; * Three residents had catheters; and * One resident had an ostomy. The staffing plan provided by the facility was as follows: * Day and Evening shifts: two CGs and one MT; and* Night shift: one MT and one CG. Observation and an interview with Staff 10 (CG) on 7/19/21 at 9:10 am, she reported she was the only CG on duty. Additionally, she stated there were many days she did not feel she could adequately perform her job duties due to lack of staff. Review of the facility staffing schedule from 7/1/21 through 7/19/21 and time clock records for the respective days revealed the facility did not meet their posted staffing plan on multiple days as follows: * On 4/9/21: One staff is documented to have worked the noc shift;* 4/10/21: Swing shift was short one staff;* 4/19/21: Day shift was short one staff; * 4/1/21, 4/5/21, 4/13/21 and 4/15/21: Day shift was short one staff for 1.5-2 hours at the beginning of the shift; and * 4/3/21, 4/7/21 and 4/11/21: The swing shift was short one staff for up to five hours.The need to ensure the facility had a sufficient number of caregivers to meet the 24-hour scheduled and unscheduled needs of each resident was discussed with Staff 1 (Executive Director), Staff 2 (RN) and Staff 3 (Regional RN) on 7/21/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 1 of 2 newly hired caregiving staff (#7) demonstrated satisfactory performance in all required areas within 30 days of hire. Findings include, but are not limited to:Training records were reviewed with Staff 4 (Business Office Manager) on 7/21/21 and revealed the following:* There was no documented evidence Staff 7 (CG), hired 6/12/21, had demonstrated competency in all required areas within 30 days of hire including:* Providing assistance with ADL's. The need to ensure newly hired staff completed required training within 30 days of hire was reviewed with Staff 1 (Executive Director) on 7/21/21. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted and documented every other month, and fire and life safety instruction was provided to staff on alternate months. Findings include, but are not limited to:On 7/19/21, fire drill and fire/life safety training records for the previous six months were requested.Review of the documentation provided identified the following: * One fire drill had been completed during the six-month time frame reviewed; and * Fire and life safety instruction was not consistently provided to staff on alternate months. The requirements regarding fire drills and fire/life safety instruction for staff was reviewed with Staff 1 (Executive Director) on 7/20/21 at 3:10 pm. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure residents received fire and life safety training within 24 hours of admission and annually. Findings include, but are not limited to:Fire and life safety records were requested during the survey. The following deficiencies were identified:* There was no documentation of fire and life safety training provided to residents within 24 hours of move-in; and * Annual fire and life safety training was not provided to residents.The need to ensure residents received fire and life safety training within 24 hours of admission and re-instructed, at least annually, was discussed with Staff 1 (Executive Director) on 7/20/21 at 3:10 pm. She acknowledged the findings. No further information was provided.

Based on observation, interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include but are not limited to:Refer to C 156, C 231, C 240, C 260 and C 513.

Based on observation and interview, it was determined the facility failed to ensure the environment was kept clean and in good repair. Findings include, but are not limited to:Observations of the facility on 7/19/21 revealed the following:* Multiple doors throughout the facility had scrapes and gouged areas;* Hand rails had scrapes exposing bare wood surfaces;* Several walls throughout facility had scrapes and/or gouges. The A-hall seating area wall had a hole approximately 2 x 4 inches in size which was covered with tape; * The staff laundry room had dirt, dust, debris and detergent on the floors and shelves; * The resident laundry room linoleum floor had two areas that were split and cracked. The laminate on the top and corners of the cabinet doors was peeling off. There was dirt, dust and debris on the floor; and* A freezer in the resident laundry room was leaking water onto the floor. The surveyor toured the environment with Staff 1 (Executive Director) on 7/19/21. She acknowledged the above areas needed to be cleaned and repaired.
Based on observation and interview, it was determined the facility failed to ensure the environment was kept clean and in good repair. This is a repeat citation. Findings include, but are not limited to:Observations of the facility during the survey revealed the following:* Multiple doors throughout the facility had stained, discolored, scraped, gouged and chipped areas;* Multiple door frames and door sealing materials showed areas of warping and/or were not securely attached; and* The resident laundry room linoleum floor had two areas that were split and cracked. The surveyor toured the environment with Staff 1 (Executive Director) on 10/20/21. She acknowledged the above areas needed to be cleaned and repaired.
1. ED called company replacing floor and was able to schedule a time for company to replace flooring in resident laundry room. Doors were counted and ordered for replacement. Stain was purchased to re-stain other doors that do not need replacing. Paint for door frame was purchased and door frames are being repaired. Exit doors weather striping has been purchased for repair. Maintenance manager will have all doors stained by 11/6/2021, all doors replace by 11/19/2021. All door frames will be fixed by 11/19/2021. Exit doors will be repaired by 11/24/2021. Flooring will be completed 11/6/2021.2. Mantiance Manager has a schedule to complete each door and door frame once a quarter, each week ED will audit doors and door frames, confirm if repair needs to be done as soon as possiable or i can wait until scheduled repair. 3. repair will be completed once a quarter and audit completed once a week4. Mantiance Manager and ED

Based on observation and interview, it was determined the facility failed to ensure all exit doors were equipped with an alarming device or other acceptable system to provide security and to alert staff when residents exited the building. Findings include, but are not limited to:Observations on 7/19/21 showed that all exit doors 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 an alarming device or other acceptable system was discussed with Staff 1 (Executive Director). She acknowledged the findings.