Laurel Pines Retirement Lodge

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

Observations of the kitchen on 02/10/25 showed the following areas needed cleaning or repair:

a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, and grease was visible on or underneath the following throughout the kitchen and dry storage:

* Doors, walls, ceilings, and floors;
* Ceiling lights and vents;
* Wooden and stainless center island cabinets, drawers, and shelves;
* Sauce containers inside the dry storage area;
* Popcorn machine;
* Oven and stove;
* Metal and plastic shelving and racks; and
* Ware wash machine and ware wash floor drains.

b. The following areas needed repair:
* Doors throughout the kitchen had areas where the paint was worn away and/or chipped, exposing bare wood. This created an uncleanable surface;
* The wooden center island had multiple areas where the paint was worn away and/or chipped, exposing bare wood. This created an uncleanable surface;
* Ceiling light fixtures with cracks;
* Multiple areas of concrete flooring throughout the kitchen were observed with cracks; and
* A large hole in the wall of the dry storage, next to the electrical panel.

c. Multiple food items/packages/containers found in cold food storage that were not covered, properly closed/sealed and were exposed to potential contamination.

d. Multiple food items were not dated when opened and/or prepared.

On 02/10/2025, the areas in need of correction in accordance with the Food Sanitation Rules OARs 333-150-0000 was attempted to be reviewed with Staff 1 (Administrator). Staff 1 declined reviewing areas in need of correction.

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule

(1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules).

This Rule is not met as evidenced by:
Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and in good repair in accordance with the Food Sanitation Rules OARs 333-150-0000. This is a repeat citation. Findings include, but are not limited to:

Observations of the kitchen on 06/23/25 showed the following areas needed cleaning or repair:

a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, and grease was visible on or underneath the following throughout the kitchen and dry storage:

* Doors, walls, and floors;
* Metal shelving and racks; and
* Ware wash machine and ware wash floor drains.

b. The following areas needed repair:
* Doors throughout the kitchen had areas where the paint and finish were worn away and/or chipped, exposing bare wood. This created an uncleanable surface; and
* Areas of concrete flooring were observed with cracks.

On 06/23/25, the areas in need of correction in accordance with the Food Sanitation Rules OARs 333-150-0000 was reviewed with Staff 3 (Interim Administrator). She acknowledged the findings.

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule

(1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules).

This Rule is not met as evidenced by:

Based on record review and interview, it was determined the facility failed to ensure 1 of 2 sampled staff (#2) who prepared food had active food handlers certificates. Findings include, but are not limited to:

On 02/10/2025 employee records were requested and reviewed with Staff 1 (Administrator) to ensure staff had active food handler's cards on file.

Staff 2 (Dining Services Director) did not have an active Oregon food handlers card.

On 02/10/2025, Staff 1 acknowledged the need for all staff to have an active Oregon food handler card. Staff 2 was pulled from the floor until they obtained an active Oregon food handler card.

OAR 411-054-0070 (3-4) Staffing Requirements and Training – Pre-service

(3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding:

(a) A review of their written position description with their job responsibilities.

(b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings.
(A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities.
(B) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of
this rule.

(c) Abuse and reporting requirements.
(d) Fire safety and emergency procedures.

(e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease.

(A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula:
(i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease.
(ii) Policy addressing respiratory hygiene and coughing etiquette.
(iii) Standard precautions.
(iv) Hand hygiene.
(v) Use of personal protective equipment.
(vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection.
(vii) Isolating and cohorting of residents during a disease outbreak.
(viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks
under ORS 433.004 and safeguards for employees who report disease outbreaks.

(B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff.
(i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means.
(ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval.

(f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below:
(A) Effective March 31, 2024, all staff must have completed the required training.
(B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities.
(g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate.

(4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF.
(a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training.
(A) Documentation of dementia training:
(i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training.
Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training.
(ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff.
(B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training.
(C) A certificate of completion must be made available to the Department upon request.
(D) Pre-service dementia care training must include the following subject areas:
(i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms.
(ii) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses.
(iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities.
(iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to:
(I) Identify and address pain.
(II) Provide food and fluids.
(III) Prevent wandering and elopement.
(IV) Use a person-centered approach.

(b) ORIENTATION TO RESIDENT. Pre-service orientation to resident:
(A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan.
(B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable

This Rule is not met as evidenced by:
.

Based on observation and interview, 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 deficiencies in this report.

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval

(Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation.

This Rule is not met as evidenced by:

Based on interview and record review, conducted during a site visit from 07/21/2024 through 08/01/2024, it was determined the facility failed to provide modified special diets that are appropriate to residents' needs and choices for 1 of 1 sampled resident (# 6). Findings include, but are not limited to:Resident 6's service plan, dated 02/16/24, indicated s/he was to receive a diabetic diet.On 07/31/24, Resident 6 stated "Everything they serve spikes my insulin, and they will not make me special food."On 08/01/24, Staff 1 (Administrator) stated the facility did not provide diabetic specific meal plans.It was confirmed that the facility failed to provide modified special diets that are appropriate to residents' needs and choices.Findings were reviewed and acknowledged by Staff 1 (Administrator), Staff 2 (RCC), and Staff 6 (Activities Director).Verbal Plan of Correction:Staff 1 will collaborate with the RN to obtain physician orders for a diabetic diet for Resident #6. Staff 1 and the RN will work with kitchen staff to ensure that residents requiring special diets are appropriately care-planned and that their dietary needs are accommodated.

Based on interview and record review conducted during a site visit on 07/31/2024 through 08/01/2024, it was determined that the facility failed to fully update and implement an acuity-based staffing tool (ABST) for 1 of 3 sampled residents (# 6). Findings include, but are not limited to:On 08/01/24, Staff 1 (Administrator) stated the facility utilized the ODHS ABST and the facility's census was 36 residents.Only 32 residents were entered into the facility's ABST. Resident 6 was not entered in the facility's ABST.It was determined the facility failed to fully update and implement an ABST.Findings were reviewed and acknowledged by Staff 1 (Administrator), Staff 2 (RCC), and Staff 6 (Activities Director) on 08/01/24.Verbal Plan of Correction:Staff 1 to audit ABST tool to assure all residents are accurately entered, ensure acuity levels were properly updated, and an accurate staffing plan was generated based on resident needs.

Based on observation and interview, conducted during a site visit from 07/21/2024 through 08/01/2024, it was determined the facility failed to keep the interior of the facility free from unpleasant odors; and keep clean all interior materials and surfaces for 1 of 1 sampled resident (# 5). Findings include, but are not limited to:The following observations were made:· Facility floors were covered with a dark sticky substance and a white substance in several sections;· Used coffee cups were found resting on a handrail in the facility hallway; and· There was damage to drywall along the baseboards in the hallways.On 07/31/24, Resident 5 stated housekeeping and CG's were not adequately assisting residents in maintaining a clean and odor-free facility.It was confirmed the facility failed to keep the interior of the facility free from unpleasant odors; and keep clean all interior materials and surfaces.Findings were reviewed and acknowledged by Staff 1 (Administrator), Staff 2 (RCC), and Staff 6 (Activities Director).Verbal Plan of Correction:Staff 1 to communicate with CG and housekeeping staff the importance of keeping the common area of the facility clean and free of odors.

The findings of the re-licensure survey conducted 02/21/23 through 02/23/23 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations. Abbreviations possibly used in this document:ADL: activities of daily 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 first re-visit to the re-licensure survey of 02/23/23, conducted 06/14/23 through 06/15/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.Abbreviations possibly used in this document:ADL: activities of daily 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 second re-visit to the re-licensure survey of 02/23/23, conducted 08/16/23 through 08/17/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

Based on observation and interview, it was determined the facility failed to ensure the kitchens were clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:The main kitchen was toured on 02/22/23, and meal preparation and dining service was observed. The following areas needed cleaning or repair:* The interior floor of the three-door freezer had dried debris and spills;* The lower portion of the range/oven was missing the front kick-plate, exposing electric and gas connection components;* A section of the wall adjacent to the warewashing machine had scraped or peeling paint;* The PVC pipes and the walls under the warewashing counter and sink had dried debris build-up;* The wooden center island had multiple areas where the paint was worn away or chipped, exposing bare wood. This created an uncleanable surface that could harbor bacteria;* The vents on the left side of the ice machine had greasy build-up and the bin in which the ice scoop was stored had paper bits and other debris in it; and* The lower cabinets of the counter that was just outside the kitchen had dried debris and spills on the exterior doors and frame.The need to ensure the kitchen was clean and in good repair was reviewed with Staff 1 (Administrator) and Staff 4 (Maintenance) on 02/23/23. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to provide a daily program of social and recreational activities based upon individual and group interests, physical, mental and psychosocial needs for the residents. Findings include, but are not limited to: Observations during the re-licensure survey, dated 02/21/23 through 02/23/23, revealed a lack of scheduled and unscheduled activities provided to residents. On 02/22/23 at 10:00 am, a group interview was conducted with six residents in attendance. During the group interview all attendees described the lack of activities taking place at the community. A review of the activity calendar for February 2023 revealed that one to two activities were listed on each day, however no start time for the activity was listed. Residents in the group interviewed stated that coloring pages were available daily, however no scheduled group activities were taking place.Failure to provide an activity program based on individual and group needs was reviewed with Staff 1 (Administrator) and Staff 2 (RN) on 02/22/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure resident move-in evaluations addressed all required elements for 2 of 2 sampled residents (#s 1 and 2) whose move-in evaluations were reviewed. Findings include, but are not limited to:1. Resident 1 moved into the facility in 02/2023. The current move-in evaluation failed to address the following required elements:* Customary routines;* Interests, hobbies, social, leisure activities;* Spiritual, cultural preferences and traditions;* Physical health status including list of diagnoses, list of medications and PRN use and vital signs if indicated by diagnosis, health problems or medications;* Mental health issues including history of treatment and effective non-drug interventions;* Personality, including how the person copes with change or challenging situations;* Nutrition habits, fluid preferences or weight if indicated;* Fall risk or history;* Complex medication regimen;* History of dehydration or unexplained weight loss or gain;* Recent losses;* Unsuccessful prior placements; and* Environmental factors which impact the resident's behavior, including, but not limited to, noise, lighting, and room temperature.The need to address all required elements on the move-in evaluation was discussed with Staff 1 (Administrator) on 02/22/23. Staff acknowledged the findings.
2. Resident 2 was admitted to the facility in 02/2023 with diagnoses including cauda equina (syndrome and neuromuscular dysfunction of the bladder).The initial evaluation dated 01/26/23 failed to address the following required elements:* Recent losses; and* Environmental factors that impact the resident's behavior including, but not limited to: noise, lighting, room temperature.The need to ensure the initial evaluation included all of the required elements was discussed with Staff 1 (Administrator) on 02/23/23. The findings were acknowledged.

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 included a written description of who shall provide the services, and what, when, how, and how often the services shall be provided for 3 of 4 sampled residents (#s 1, 2 and 4) whose service plans were reviewed. Findings include, but are not limited to:1. Resident 4 was admitted to the facility in 01/2020 with diagnoses which included hypertension and diabetes mellitus. Observations and an interview with the resident, interviews with staff, and review of the resident's clinical record during the survey revealed s/he required staff assistance for several ADL care needs and was on hospice services.Resident 4's current service plan, dated 03/20/23, was not reflective, did not provide clear direction regarding the delivery of services, or failed to consistently include a written description of who shall provide the services, and what, when, how, and how often the services shall be provided in the following areas: * Bathing assistance;* Dressing assistance;* Toileting assistance;* Mobility/transfer assistance; and * Personal hygiene and grooming. The need to ensure the service plan was reflective of Resident 4's current needs, provided clear direction to staff, and included a written description of who shall provide the services, and what, when, how, and how often the services shall be provided was discussed with Staff 1 (Administrator) on 02/22/23 at 1:50 pm. Staff 1 acknowledged the service plan was not reflective in several areas and needed to be updated. No further information was provided.
2. Resident 1 was admitted to the facility in 02/2023 with diagnoses including chronic obstructive pulmonary disease and diabetes mellitus.Resident 1 was observed to utilize a wheelchair for mobility.Observations of the resident, interviews with staff, review of the current 02/10/23 service plan and clinical records during the survey revealed Resident 1's service plan was not reflective of his/her status and did not provide clear direction to staff regarding the delivery of services in the following areas:* Use of oxygen including flow setting;* Oral care status;* Use of a sleep apnea machine;* Type of bathing preferences;* Hospice service status including when and what to report or to whom to report;* Transfer status, 1-person versus 2-person assistance; and* Pet care.The need to ensure the service plan provided clear instructions to staff and was reflective of the resident's needs was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 02/22/23. They acknowledged the findings.
3. Resident 2 was admitted to the facility 02/2023 with diagnoses including cauda equina (syndrome and neuromuscular dysfunction of the bladder).Resident 2's service plan dated 02/11/23 and ISP's (Interim Service Plans) were reviewed, observations were made and interviews with the resident and caregiving staff revealed the following information:The service plan was completed 02/11/23 - five days after the resident moved into the facility - and was not readily available to staff at the time the survey team entered the facility. An interview with Staff 3 (RCC) on 02/23/23 at 8:35 am revealed that she was uncertain as to why there was a delay in completing the service plan and having it readily available to staff. The following areas of the service plan were not reflective of the resident's needs or lacked clear direction regarding the provision of services: * Frequency of incontinence care;* Behavioral issues and interventions for staff to attempt; * Oxygen use; and * Smoking status. The need for the facility to ensure service plans were reflective of the resident's needs as identified in the evaluation, were completed before a resident moved in and were readily available to staff was discussed with Staff 1 (Administrator) on 02/23/23. The findings were acknowledged.


Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and provided clear instruction for staff for 1 of 3 sampled residents (# 5) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:Resident 5 was admitted to the facility on 03/09/23 with diagnoses including recent stroke. The resident's 06/04/23 service plan and temporary service plans were reviewed during the survey.The service plan was not reflective and failed to provide clear instruction to staff in the following areas:* Diet including order for thin liquids;* Mobility including transfer assistance;* History of drug use; and * Behaviors.The need to ensure service plans were reflective and provided clear instruction to staff was discussed with Staff 1 (Administrator and Staff 2 (RN) on 06/15/23. They acknowledged the findings.
1. Resident 5 had their service plan reviewed and updated to include all care needs for proper delivery of service. All others service plans will be reviewed for accuracy as well. 2. Service plan team to discuss/review plans of care to ensure they are thorough and up to date upon admission, quarterly, and as needed with changes of condition. 3. The service plans will be reviewed for resident care needs and accuracy of care instructions monthly4. RN and/or designee will audit/monitor service plans to ensure they are reflective of care needs have clear instructions.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that included the resident, the resident's legal representative if applicable, any person of the resident's choice, the Administrator or designee, and at least one other staff person who was familiar with or who was going to provide services to the resident for 4 of 4 sampled residents (#s 1, 2, 3 and 4). Findings include, but are not limited to:Resident 1, 2, 3 and 4's current service plans were reviewed during the survey. The service plans lacked evidence 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 (Administrator) and Staff 2 (RN) on 02/23/23. They acknowledged the findings.

2. Resident 4 was admitted to the facility in 01/2020 and had a history of falls.Resident 4's clinical record and progress notes, reviewed from 12/01/22 through 02/21/23, revealed the following:a. The resident fell on 12/09/22. Review of the record revealed no documented evidence the facility consistently monitored and documented on the progress of the resident's condition at least weekly until resolved. b. On 12/14/22, Resident 4 was placed on alert charting for Covid. Although alert monitoring was initiated, there was no documented monitoring of resident's condition until resolution.c. On 01/04/23, staff documented that Resident 4 had a decrease in appetite. The facility initiated short-term monitoring the same day. However, no monitoring until resolution was documented for the short-term change in condition.On 02/22/23 at 3:15 pm, Staff 1 (Administrator) reported she reviewed the resident's record and concluded the short-term changes in condition had not been monitored until resolved. No further information was provided.
Based on observation, interview and record review, it was determined the facility failed to determine and document what action or intervention was needed for a resident in response to a short-term change of condition and document on the progress of the condition at least weekly until resolved, for 2 of 4 sampled residents (#s 3 and 4) who experienced multiple changes of condition. Findings include, but are not limited to:1. Resident 3 was admitted to the facility in 2019 with diagnoses including type 2 diabetes mellitus with nephropathy, right below knee amputation and chronic anticoagulation.The resident's current service plan, dated 11/18/22, noted the resident sustained frequent minor injuries including bruises and skin tears. Interviews with staff and observations of the resident indicated the resident was fairly independent, ambulatory in a wheelchair, active and enjoyed rearranging things in his/her room. Staff and the resident acknowledged s/he frequently bumped into or grazed against things that resulted in bruises and skin tears.Review of progress notes from 11/21/22 through 02/17/23, the current service plan, Temporary Service plans (TSPs) and facility Incident Reports indicated Resident 3 experienced the following changes of condition:* 11/21/22: skin tear on left hand;* 11/28/22: reopened skin tear on right hand;* 12/08/22: tested positive for COVID 19 and experienced symptoms;* 12/18/22: placed on "Alert Charting" for agitated behavior;* 01/11/23: wound to right knee;* 01/14/23: open sore in perineal area;* 01/16/23: bruise to right eye;* 01/23/23: bruise to left eye;* 01/24/23: skin tear left ankle;* 02/02/23: fell out of wheel chair while out in the community and sustained a skin tear to the right hand;* 02/08/23: bruises on right thigh and left inner knee;* 02/09/23: skin tear on right hand;* 02/09/23: left eyelid swollen; and* 02/19/23: scraped right finger.The facility failed to consistently determine and document what action or intervention was needed following these short term changes of condition, and failed to document on the progress of the condition at least weekly and document that the condition was resolved.The need to ensure changes of condition were monitored until resolved was reviewed with Staff 1 (Administrator) and Staff 2 (RN) on 02/22/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to develop interventions, communicate the interventions to staff on each shift, and monitor the conditions with progress noted at least weekly for 1 of 3 sampled residents (# 5) who experienced changes of condition. This is a repeat citation. Findings include, but are not limited to:Resident 1 was admitted to the facility in 03/09/23 with diagnoses including a recent stroke. The resident's progress notes, dated 04/03/23 through 06/14/23 and temporary service plans (TSP's) were reviewed and revealed the following: * 04/24/23 - Behaviors including suicidal ideation;* 05/20/23 - Rash on left forearm; and* 06/04/23 - Behaviors including aggression and self-harm.There was no documented evidence the facility developed interventions, communicated the interventions to staff on each shift, and monitored the conditions with progress noted at least weekly through resolution for each of Resident's 5's short-term changes of condition.The need to ensure short-term changes of condition were evaluated to determine and document what action or intervention was needed for the resident, the determined action or intervention be communicated to staff on each shift, and monitored with progress noted at least weekly through resolution was discussed with Staff 1 (Administrator), and Staff 2 (RN) on 06/15/23. They acknowledged the findings.
1.Resident 1's Change of condition and progress note's have been reviewed. 2. Will review with/educate staff regarding: change of condition, need for interventions, temporary service plans and weekly progress notes including the importance of charting until the issue has been resolved/ closed out. Staff conducting shift to shift reporting.3. A weekly review of alert/change of condition charting will be completed to be sure the documentation is present.4. RCC and/ or designee will ensure ongoing compliance.

Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules, for 1 of 1 sampled resident (#1) who received insulin injections by unlicensed facility staff. Findings include, but are not limited to:According to OSBN Division 47 Administrative Rules, delegation means an RN authorizes an unlicensed person to perform tasks of nursing care and indicates the authorization in writing. The delegation process includes nursing assessment of the client in a specific situation, evaluation of the ability of the unlicensed persons, teaching the task and observing the staff demonstrate the task.During the acuity interview on 02/21/23, Resident 1 was identified to be administered insulin injections by non-licensed staff.Resident 1's MARs, reviewed from 02/13/23 through 02/22/23, revealed the resident received Novolog (insulin to treat diabetes) three times daily and Lantus (insulin to treat diabetes) once daily. The insulin had been given by Staff 7 (MT), Staff 8 (MT) and Staff 12 (MT) on multiple occasions.Interviews with staff, and review of delegation records and the 02/13/23 - 02/22/23 MAR, revealed the following:* RN assessment, 02/07/23, indicated that Resident 1's diabetes condition was stable and predictable. There was no documented evidence as to how the RN determined the resident's condition was stable and predictable;* There was no documentation of the rationale for the frequency for reassessing the resident's condition based on the resident's needs;* There was no documentation of the rationale for deciding the task could be safely delegated to unlicensed persons; and* There was no documentation of the rationale for the frequency for supervising and reevaluating the unlicensed person based on the unlicensed person's skills and abilities.On 02/22/23, the need to ensure all staff who administered insulin injections were appropriately delegated and supervised in accordance with OSBN Administrative Rules was discussed with Staff 1 (Administrator) and Staff 2 (RN). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed, for 2 of 4 sampled residents (#s 1 and 2) whose orders were reviewed. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in 2023 with diagnoses including diabetes mellitus and chronic obstructive pulmonary disease.a. Resident 1 had a physician's order, dated 02/10/23, to administer insulin aspart (NOVOLOG) 3 units three times with meals.The resident's 02/01/23 through 02/22/23 MAR showed the resident received insulin lispro 3 units, not insulin aspart as prescribed.b. Resident 1 had a physician's order, dated 02/10/23, to administer 5 L/minute of oxygen continuously.The resident's 02/01/23 through 02/22/23 MAR showed there was no indication the oxygen treatment order was transcribed to the MAR or TAR and carried out as ordered.c. Resident 1 had a physician's order, dated 02/10/23, to administer methadone 2.5 mg two times daily for one week (7 days) then one time daily for one week.The resident's 02/01/23 through 02/22/23 MAR showed the resident received the medication two times daily for 9 days, not 7 days as prescribed.d. Resident 1 had a physician's order, dated 02/10/23, to administer Lantus (insulin to treat diabetes) 33 units nightly.The resident's 02/01/23 through 02/22/23 MAR showed the medication was not administered on 02/16/23 and staff documented "withheld per DR/RN orders". There was no physician order or facility RN order to hold the medication.e. Resident 1 had a physician's order, dated 02/10/23, to administer methadone 2.5 mg two times daily for one week (7 days).The Controlled Substance Drug Disposition logs indicated 7.5 mg of methadone was dispositioned on 02/14/23 to administer, not 2.5 mg as prescribed.f. Resident 1 had a physician's order, dated 02/10/23, to administer chlorpromazine 50 mg 4 times daily. The resident's 02/01/23 through 02/22/23 MAR showed the medication was not administered on 31 occasions due to "waiting on pharmacy delivery."g. Resident 1 had a physician's order, dated 02/10/23, to apply hydrocortisone 0.5 % cream two times daily. The resident's 02/01/23 through 02/22/23 MAR showed the medication was not applied on seven occasions due to "waiting on pharmacy delivery."The need to ensure physician's orders were carried out as prescribed was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 02/22/23. They acknowledged the findings.
2. Resident 2 was admitted to the facility in 02/2023 with diagnoses including cauda equina (syndrome and neuromuscular dysfunction of the bladder). The resident's 02/01/2023 through 02/21/23 MARs and physician's orders were reviewed and revealed the following orders were not followed: * Budesonide (an inhaler) 0.5 mg inhale 2 puffs twice daily was not administered on 14 occasions because the facility was "waiting on pharmacy delivery;" and* Mineral oil liquid (a laxative) 15 ml once daily was not administered on 12 occasions because the facility was "waiting on pharmacy delivery."The need to ensure the facility followed physician orders was discussed with Staff 1 (Administrator) on 02/23/23. The findings were acknowledged.

2. Resident 1 was admitted to the facility in 2023 with diagnoses including diabetes mellitus and chronic obstructive pulmonary disease.a. There was no reason for use for multiple scheduled medications.b. The MAR indicated Resident 1 was prescribed the following PRN medications:* Ipratropium-albuteral nebulizer 4 times daily for shortness of breath as needed;* Morphine 20 mg every hour as needed for shortness of breath; and* Ipratropium-albuteral nebulizer and Morphine, both to be administered to treat shortness of breath.The MAR lacked resident-specific parameters and instructions for unlicensed staff as to when to administer the medications. c. The MAR indicated Resident 1 was prescribed to check CBG (to check blood sugar level) and to administer insulin administration three times daily. There was no clear parameters when to hold insulin injection or when to report to the doctor.d. The MAR included orders to administer clonazepam, chlorpromazine and haloperidol as needed for "anxiety/agitation or nausea."The MAR lacked resident-specific parameters and instructions for unlicensed staff as to when to administer those medications or which one should be given first. Those medications were not administered during the review period.e. The MAR indicated Resident 1 was prescribed chlorpromazine (a medication to treat mental illness) 4 times daily. Staff documented on the MAR 33 occasions between 02/13/23 and 02/22/23 where the medication was not administered as ordered because either they were waiting on the pharmacy delivery or it was withheld per doctor's order. However, during this same time period, staff documented on three occasions the medication was administered.The need to ensure accurate documentation of the MAR and to provide clear parameters when a resident was prescribed more than one PRN medication for the same condition was reviewed with Staff 1 (Administrator) and Staff 2 (RN) on 02/22/23. They acknowledged the lack of parameters in the MAR.
Based on interview and record review, it was determined the facility failed to maintain an accurate medication administration record (MAR) of all medications that were ordered by a legally-recognized prescriber and administered by the facility, for 3 of 4 sampled residents (#s 1, 2 and 3) whose MARs were reviewed. Findings include, but are not limited to:Resident 1, 2 and 3's 02/01/23 through 02/20/23 MARs were reviewed during the survey. The following inaccuracies were identified:1. Resident 3 was admitted to the facility in 2019 with diagnoses including type 2 diabetes mellitus with nephropathy, right below knee amputation and chronic anticoagulation.The MAR indicated Resident was prescribed the following PRN medications:* Tylenol (for pain) and Norco (for moderate to severe pain); and* Albuteral puffer and ipratropium-albuteral nebulizer - both to be administered to treat wheezing or shortness of breath.The MAR lacked resident-specific parameters and instructions for unlicensed staff as to when to administer the medications. The need to ensure there were clear parameters when a resident was prescribed more than one PRN medication for the same condition, and that the MAR indicated when a resident could self-direct a PRN medication, was reviewed with Staff 1 (Administrator) and Staff 3 (RCC) on 02/23/23. They acknowledged the lack of parameters in the MAR.
3. Resident 2 was admitted to the facility in 02/2023 with diagnoses including cauda equina syndrome, neuromuscular dysfunction of bladder and COPD. Resident 2's MARs dated 02/06/23 through 02/21/23 were reviewed and the following was noted:a. Multiple medications lacked a reason for use.b. Resident 2 was prescribed bisacodyl, lactulose and magnesium citrate for constipation. There were no parameters listed on the MAR for the PRN bowel medications. Interviews with Resident 2 and Staff 8 (MT) on 02/22/23 confirmed that Resident 2 was able to self-direct which PRN bowel medication s/he wanted. The need to ensure accurate documentation of the MAR and to provide clear parameters when a resident was prescribed more than one PRN medication for the same condition was reviewed with Staff 1 (Administrator) on 02/23/23. The findings were acknowledged.

Based on interview and record review, it was determined the facility failed to maintain an accurate treatment record of all treatments ordered by a legally-recognized practitioner and administered by the facility, for 1 of 1 sampled resident (#3) for whom the facility provided PRN wound care. Findings include, but are not limited to:Resident 3 was admitted to the facility in 2019 with diagnoses including type 2 diabetes mellitus with nephropathy, right below knee amputation and chronic anticoagulation. The resident's current service plan, dated 11/18/22, noted the resident sustained frequent minor injuries including bruises and skin tears. Interviews with staff and observations of the resident indicated the resident was fairly independent, ambulatory in a wheelchair, active and enjoyed rearranging things in his/her room. Staff and the resident acknowledged s/he frequently bumped into or grazed against things that resulted in bruises and skin tears.Review of Resident 3's progress notes from 11/21/22 to 02/21/23 indicated facility staff documented on several occasions that they provided basic wound care for the resident, either because they observed one of the resident's dressings had become soiled or fallen off, or the resident requested a new dressing.Resident 3's MAR lacked documentation of a physician's order to provide basic wound care including the type of treatment, instructions for PRN treatments and the date and time the treatment was administered.The need to ensure the facility obtained orders for PRN treatments and the administration of the treatments was documented on the resident's MAR was reviewed with Staff 1 (Administrator) and Staff 2 (RN) on 02/22/23. They acknowledged the lack of orders and documentation.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 sampled newly-hired direct care staff (#s 7, 12 and 13) completed all required training within 30 days of hire. Findings include, but are not limited to:Staff training records were reviewed on 02/23/23. Staff 7 (MT/CG) hired 04/19/22, Staff 12 (MT/CG) hired 07/06/22 and Staff 13 (CG) hired 09/07/22, failed to have documented evidence of competency demonstrated in all assigned job duties prior to working independently with residents in the following areas:* Role of service plans in providing individualized care;* Providing assistance with ADLs;* Changes associated with normal aging;* Identification, documentation and reporting of changes of condition;* Conditions that require assessment, treatment, observation and reporting;* General food safety, serving and sanitation; and * First Aid and abdominal thrust training.The requirement to demonstrate competency in all assigned job duties prior to working independently with residents was reviewed with Staff 1 (Administrator) on 02/23/23. No additional information was provided.
Based on interview and record review, it was determined the facility failed to ensure 1 of 1 caregiving staff (#9) demonstrated competence in all job duties within 30 days of hire, and 2 of 3 caregiving staff (#s 7 and 12) completed First Aid certification and abdominal thrust training. This is a repeat citation. Findings include, but are not limited to:Training records were reviewed on 06/15/23.There was no documented evidence Staff 9 (MT), hired 01/17/23, had demonstrated competency in all required areas and within 30 days of hire including:* Role of service plans in providing individualized care;* Providing assistance with ADL's;* Changes associated with normal aging;* Identification, documentation and reporting of changes of condition;* Conditions that require assessment, treatment and observation and reporting; and* General food safety, serving and sanitation.Additionally, there was no documented evidence Staff 7 (CG) and Staff 12 (MT) had completed First Aid certification and abdominal thrust training.The need to ensure staff had demonstrated competence in all job duties within 30 days of hire, and completed First Aid certification and abdominal thrust training was reviewed with Staff 1 (Administrator) on 06/15/23 at 1:00 pm. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to have documented evidence that 12 hours of annual in-service training, including six hours related to the care of the dementia resident, was completed for 2 of 2 long-term staff (#s 3 and 14) whose training records were reviewed. Findings include, but are not limited to:Staff 3 (RCC) was hired 11/2017 and Staff 14 (CG) was hired 03/2015. a. Staff 3 failed to have documented evidence of completing 12 hours of annual in-service training including six hours of annual in-service training related to the care of the dementia resident, between 11/2021 and 11/2022.b. Staff 14 failed to have documented evidence of completing 12 hours of annual in-service training on topics related to the provision of care in a CBC setting, between 03/2021 and 03/2022.The need to ensure staff completed required annual in-service training, based on anniversary dates of hire, was reviewed with Staff 1 (Administrator) on 02/23/23 at 11:40 am. She acknowledged the findings. No further information was provided.

Based on interview and record review, it was determined the facility failed to ensure fire and life safety instruction was provided to staff on alternating months. Findings include, but are not limited to:On 02/22/23, fire drill and fire/life safety training records for the previous six months were requested.Review of the documentation provided identified the following: * No fire and life safety instruction was provided to staff. On 02/23/23 at 8:45 am, Staff 1 (Administrator) informed the survey team that fire and life safety instruction had not been provided to staff per the rule. The requirements regarding fire and life safety instruction were reviewed with Staff 1. She acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure fire and life safety instruction was provided to staff on alternating months. This is a repeat citation. Findings include, but are not limited to:On 06/15/23, fire drill and fire/life safety training records from the alleged compliance date of 04/24/23 were requested.Review of the documentation provided identified the following: * No fire and life safety instruction was provided to staff. On 06/15/23 at 1:00 pm, Staff 1 (Administrator) informed the survey team that fire and life safety instruction had not been provided to staff per the rule. The requirements regarding fire and life safety instruction were reviewed with Staff 1. She acknowledged the findings.
1. A fire and life safety training session will be completed with staff.2. Fire and Life Safety education will be completed and documented every other month alternating with fire drills. 3. Fire and life safety trainings will be audited each month for completeness4. Maintenance and/or desingee will ensure this is done and documented.

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:* Documentation of fire and life safety training provided to residents within 24 hours of move in; and * Documentation of annual fire and life safety training 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 (Administrator) on 02/23/23 at 9:45 am. She acknowledged the findings. No further information was provided.
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. This is a repeat citation. Findings include, but are not limited to:Fire and life safety records were requested during the survey. The following deficiencies were identified:* Documentation of fire and life safety training provided to residents within 24 hours of move in; and * Documentation of annual fire and life safety training 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 (Administrator) on 06/15/23 at 1:00 pm. She acknowledged the findings. No further information was provided.
1. Facility will audit current resident records for Fire and Life Safety training completion. Training will be provided where lacking.2. Fire and Life Safety Training will be done with all residents at quarterly care conferences and documented that is was reviewed. All new residents will have fire and life safety training complete with documentation within 24 hours of moving in.3. Quarterly audits to be completed to ensure all residents have received fire and life safety trainings upon move in and annually.4. Maintenance and/or Designee will ensure fire and life safety training with the residents is done .

Based on observation, interview and record review, it was determined the facility failed to ensure its relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to C 260, C 270, C 372, C 420, C 422 and C 513.

Based on observation and interview, it was determined the facility failed to ensure the facility exterior was free of litter. Findings include, but are not limited to:The exterior of the building was toured on 02/21/23. Cigarette butts, trash and debris littered both smoking areas and the front entrance.The exterior was toured with Staff 1 (Administrator) on 02/21/23 at 3:50 pm. She acknowledged the findings.

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:1. Observations of the facility on 02/22/23 revealed the following:* Rooms 102, 107, 109, 112, 114, 117, 118, 124 and 125 had scraped doors and/or jambs;* The common bathroom adjacent to the television room had scraped paint on door and frame, and the ceiling fan cover was loose;* Doors to the activity room, janitor's closet, laundry room, and medication room had gouged door edges and/or scraped jambs;* The shower room, near Room 122, had multiple dirty linens on the floor, gouges and scrapes on several walls and door edge/frame, an approximate 8 x 2 inch hole in the wall above the tile floor base near the door, black matter on the wall near the shower stall, and an accumulation of dust/debris on the light fixture;* The shower room across from Room 123 had scraped and peeling wall paint, dirty linens on the floor, dust/debris on the light fixture, and gouges/scrapes in the door;* Exit doors/frames at the end of several halls had scraped/gouged edges, scraped paint on frame, or doors did not close all the way leaving a gap between the door frame and edge;* The shower room, across from Room 109, had a scraped door, and accumulation of dust/debris on the light fixture, and black matter in the caulking around the shower; and * The bathtub room, near Room 108, had an accumulation of dust/debris on the light fixture, and several scraped areas on walls.The surveyor toured the environment with Staff 1 (Administrator) on 02/22/23 at 3:50 pm. She acknowledged the above areas needed to be cleaned and repaired.
2. Resident 3's room was toured during the survey. The following areas needed repair:* The corners of the walls next to the resident's closet and the wall dividing the room were damaged, exposing metal screen underneath the damaged plaster;* One wall of the resident's bathroom was gouged, exposing bare plaster;* The footboard of the resident's bed was damaged; and* There was a piece of 1" x 8" wood attached to the baseboard of one wall where the resident reported s/he had damaged the wall with his/her power wheelchair. There was also a screw protruding from the wood.The areas in Resident 3's room needing repair were discussed with Staff 1 (Administrator) and Staff 4 (Maintenance) on 02/23/23. They acknowledged the areas needing repair.
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:1. Observations of the facility on 06/14/23 revealed the following:* Rooms 102, 107, 109, 112, 114, 117, 118, 124 and 125 had scraped jambs;* Doors to the activity room, janitor's closet, laundry room, and medication room had gouged door edges and/or scraped jambs;* The shower room, near Room 122, had multiple dirty linens on the floor, black matter on the wall near the shower stall, and an accumulation of dust/debris on the light fixture;* The shower room across from Room 123 had scraped and peeling wall paint, dirty linens on the floor, and dust/debris on the light fixture;* Exit doors/frames at the end of several halls had scraped/gouged edges, scraped paint on frame, missing door handle end caps, or doors did not close all the way leaving a gap between the door frame and edge;* The shower room, across from Room 109, had an accumulation of dust/debris on the light fixture;* The bathtub room, near Room 108, had an accumulation of dust/debris on the light fixture, and several scraped areas on walls;* Bathroom faucet in Room 123 was not secure; and* Grab bar and toilet seat were not secure in Room 114.2. Resident 3's room was toured during the survey. The following areas needed repair:* The corners of the walls next to the resident's closet and the wall dividing the room were damaged, exposing metal screen underneath the damaged plaster;* One wall of the resident's bathroom was gouged, exposing bare plaster;* Multiple surface cracks throughout tile floor;* Bathroom door had scrapes; and * Pervasive odor outside of room.The surveyor toured the environment with Staff 1 (Administrator) and Staff 4 (Maintenance) on 06/14/23 at 3:50 pm. They acknowledged the above areas needed to be cleaned and repaired.

1. Rooms 102,107,109,112,114,117,118,124 and 125 doors and jambs are being painted. Common bathroom walls, door and frame are being painted and Celiling Fan cover that was loose has been fixed.Activity room door, Janitors closet, laundry room and med room doors are being fixed where it has gouges. Shower room near 122 has been cleaned. Gouges and scrapes on walls and door frames and hole are being fixed as well as the fan being cleaned. Shower rooms across from 123 is being painted and has been cleaned. The fan is also being cleaned. Exit doors and frames are being painted and replaced as needed. Shower room across from 109 is being painted and cleaned as well as the light fixture being cleaned. Bathtub room has been dusted and cleaned. Resident 3-Patch holes in wall and paint walls and doors. Bed is being replaced for resident as well.2. Staff education on use of maintenance log for needed upkeep items/repairs to facility interior. Maintenance log to be reviewed at daily stand-up meeting for facility repair needs.3. Weekly rounds of common areas and resident rooms to be done to monitor for any upkeep/maintenance needs with repairs as needed. 4. Maintenance and Administrator and/or designee will ensure repair and maintenance is done.

Based on observation and interview, it was determined the facility failed to ensure hot water temperatures in residents' units and common shower rooms were maintained within a range of 110 - 120 degrees Fahrenheit. Findings include, but are not limited to:On 01/22/23 at 4:50 pm, water temperatures measured with the two surveyors' thermometers in rooms 110, 117, 125, 128, and the shower room near room 109 were 128.0, 132.0, 134.8, 131.0 and 122.4 degrees F, respectively. At 5:20 pm the same day, the surveyor and Staff 1 (Administrator) measured water temperatures using the surveyor's thermometer in occupied units throughout the building. Water temperatures tested at the bathroom sinks exceeded 120 degrees F. The need to ensure water temperatures were monitored and maintained within a range of 110 - 120 degrees F was discussed with Staff 1 (Administrator). She acknowledged the findings. She stated she would inform maintenance staff to check/adjust water heaters.

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes. This report reflects the findings of the complaint investigation conducted 8/25/2022. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified: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

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, but is not limited to:In an interview on 8/25/2022, Staff #1 (S1) stated that the facility uses the ODHS ABST and was still learning the system. S1 has started the process of inputting residents' data but it is not completed. Facility ABST system viewed with S1 on 8/25/2022 with CS. S1 had difficulty getting into and navigating the system. Resident names only were in the system. Hours for entire facility showed 0.00. On 8/25/2022, these findings were reviewed and acknowledged with S1. Facility Plan of Correction:Facility administrator reported at time of visit that s/he would start to work on completing entries for all residents ' times and frequencies, and ABST would be completed within 14 days.

Based on interview and observations it was confirmed that the facility failed to keep equipment necessary for the health and safety and comfort of resident in good repair. Findings include, but is not limited to. In an interview on 8/25/2022, Staff #1 (S1) stated that due to a prior fire the facility laundry area was damaged and has not been in working condition. S1 with 1-2 staff members collects and takes all laundry to a local laundrymat at least 2 times weekly to complete laundry for all residents.During an unannounced site visit on 8/25/2022, the Compliance Specialist observed contractors delivering and installing washing machines in the newly finished laundry area.On 8/25/2022, these findings were reviewed with and acknowledged by S1.Facility Plan of Correction:Administrator reported that contractors communicated that laundry machines would be set up and ready for use by the ending (end) of the day on 8/25/2022.