Rn Villa Senior Care

Based on interview and record review, it was determined the facility failed to ensure the preparation, completeness, and accuracy of documentation or records for 3 of 4 sampled residents (#s 1, 2, and 4) whose records were reviewed. Findings include, but are not limited to:

During the survey resident records for residents 1, 2, and 4 were reviewed and were found to be missing, incomplete, or inaccurate in multiple areas, including signed physicians' orders, hospital discharge paperwork, hospice admission, outside provider notes, service plans, and RN assessments.

The need to ensure resident records were complete and accurate was discussed with Staff 1 (ED) and Staff 2 (Regional Director) on 03/27/25. They acknowledged the findings.

Refer to C260, C270, and C280.

OAR 411-054-0025 (8) Facility Administration: Records

(8) RECORDS. The facility must ensure the preparation, completeness, accuracy, and preservation of resident records.
(a) The facility must develop and implement a written policy that prohibits the falsification of records.
(b) Unless required or allowed by state or federal law, a facility shall not disclose any personally identifiable information regarding:
(A) A resident’s sexual orientation;
(B) Whether a resident is LGBTQIA2S+;
(C) A resident’s gender transition status; or (D) A resident’s human immunodeficiency virus status.
(c) The facility shall take appropriate steps to minimize the likelihood of inadvertent or accidental disclosure of information described in subsection (b) of this section to other residents, visitors or facility staff, except to the minimum extent necessary for facility staff to perform their duties. Facilities must notify residents or resident representatives if a resident is affected by a disclosure of information.
(d) Resident records must be kept for a minimum of three years after the resident is no longer in the facility.
(e) Upon closure of a facility, the licensee must provide the Department with written notification of the location of all records.
Name:

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents’ needs and preferences, provided clear instructions to staff, and/or were implemented 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 moved into the facility in 07/2023 with diagnoses including lymphedema, dysphagia (difficulty swallowing), gastroesophageal reflux disease, and obesity.

The resident’s service plan dated 02/18/25 and intermediate service plans dated 12/24/24 to 03/24/25 were reviewed, observations of the resident were made, and interviews with staff and the resident were conducted. The resident’s service plan was not reflective, did not provide clear direction to staff, and/or was not implemented in the following areas:

* Instructions to speak in an elevated clear voice on the resident’s left side due to hearing loss;
* Lymphedema and instructions for monitoring;
* Dietary needs, including mechanical soft texture, medications crushed, reflux and aspiration precautions;
* Sleep patterns and ensure head of bed remains at 30 degrees or more;
* Grooming assistance;
* Bathing assistance including role of hospice;
* Incontinent care assistance and use of barrier cream;
* Safety, including ability to use call light, frequency of safety checks, evacuation instructions;
* Instructions to staff regarding side rails;
* Life enrichment and activity preferences; and
* Preference for door to remain open.

The need to ensure service plans were reflective, provided clear direction to staff, and were implemented was discussed with Staff 1 (ED) and Staff 2 (Regional Director) on 03/27/25. They acknowledged the findings.

2. Resident 2 was admitted to the facility in 09/2021 with diagnoses including morbid obesity, insulin dependent diabetes mellitus type 2, and chronic obstructive pulmonary disease (COPD).

Observations were made of the resident's care on 03/25/25 and 03/26/25, interviews with the resident and facility staff were conducted, and the service plan dated 02/17/25 was reviewed.

Resident 2's service plan was not reflective of the resident's current needs and lacked clear instructions to staff in the following areas:

* Instructions to staff on providing care to the resident with significant vision impairment;
* Instructions on signs and symptoms of hypo- and hyperglycemia to report;
* Instructions for proper maintenance of blood sugar monitor on left upper extremity and how to monitor for malfunctions;
* Instructions to staff on blood glucose monitoring protocol when resident slept late and skipped meals;
* Oxygen equipment precautions, instructions for proper maintenance, and how to monitor for safety;
* Instructions for aspiration precautions and interventions while choking;
* How side rails were to be used and monitored for safety;
* History of dehydration;
* Non-pharmaceutical interventions for pain, including how a person expresses pain or discomfort;
* How a person expresses memory loss;
* Instructions on to whom to report skin impairments;
* Personality, including how the person copes with change or challenging situations;
* Number of staff needed to assist with emergency evacuations;
* Instructions on peri and skin care;
* Skin and wound condition monitoring;
* Use of barrier cream with toileting changes; and
* Electric wheelchair equipment precautions and instructions for proper maintenance.

The need to ensure service plans reflected residents' current needs and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 1 (ED) and Staff 2 (Regional Director) on 03/27/25 at 11:16 am. They acknowledged the findings.

3. Resident 1 moved into the facility in 06/2023 with diagnoses including left partial hip replacement due to left hip fracture and chronic atrial fibrillation.

The resident’s service plan dated 03/06/25 and intermediate service plans dated 01/29/25 to 03/22/25 were reviewed, observations of the resident were made, and interviews with staff and the resident were conducted. The resident’s service plan was not reflective or did not provide clear direction to staff in the following areas:

* Left posterior hip precautions;
* Outside providers, including home health admission;
* Safety, including ability to use call light, frequency of safety checks, evacuation instructions;
* Fall interventions; and
* Use of shower chair for bathing assistance.

The need to ensure service plans were reflective, provided clear direction to staff, and were implemented was discussed with Staff 1 (ED) and Staff 2 (Regional Director) on 03/27/25. They acknowledged the findings.

OAR 411-054-0036 (1-4) Service Plan: General

(1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan.

(2) SERVICE PLAN.
The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence.
(a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations.
(b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services.
(c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided.
(d) Changes and entries made to the service plan must be dated and initialed.
(e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed.
(f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative.
(g) The facility administrator is responsible for ensuring the implementation of services.
(h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements.

(3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN.
(a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident.
(b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences.
(c) Staff must document and date adjustments or changes as applicable.

(4) QUARTERLY SERVICE PLAN REQUIREMENTS.
(a) Service plans must be completed quarterly after the resident moves into the facility.
(b) The quarterly evaluation is the basis of the resident's quarterly service plan.
(c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained.

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to ensure residents who had a significant change of condition had their service plan updated as needed for 1 of 4 sampled residents (# 2), failed to determine what resident-specific action or intervention was needed for a resident following a short-term change of condition, communicate the determined action or intervention to staff, and document progress until the condition resolved for 2 of 4 sampled residents (#s 2 and 4) who experienced changes of condition. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 09/2021 with diagnoses including morbid obesity, insulin dependent diabetes mellitus type 2, and chronic obstructive pulmonary disease (COPD).

Resident 2's progress notes, dated 12/22/24 through 03/23/25, service plan dated 02/17/25, additional intermediate service plans, after-visit summaries to the emergency department, and significant change of condition evaluation dated 03/12/25 were reviewed.

a. The following significant change of condition lacked documentation the facility updated the service plan as needed:

* 03/12/25: significant physical and cognitive decline.

b. The following short-term changes of condition lacked documentation the facility determined what resident-specific action or intervention was needed for the resident, communicated the determined action or intervention to staff, and/or documented weekly progress until the condition resolved:

* 02/28/25: return to the facility after hospitalization related to aspiration pneumonia and influenza A from 02/20/25 through 02/28/25;
* 02/28/25: discontinued orders for glipizide 5 mg (to control blood sugar), propranolol 40 mg (to control blood pressure), and oxygen therapy;
* 02/28/25: diet texture was changed from regular to mechanical soft;
* 02/28/25: order for medications to be crushed in puree;
* 02/28/25: “[Resident] newly requires a mechanical soft diet texture and is also 1:1 feeding assistance”;
* 03/02/25: “resident on alert for loss of appetite”;
* 03/03/25: “…[resident] has had ‘little to no’ intake over the last 2 days”;
* 03/03/25: ED visit related to altered mental status; and
* 03/04/25: ED visit related to altered mental status and cough.

The need to ensure the facility had a system in place to ensure residents who had a significant change of condition had their service plan updated, and to determine what resident-specific action or intervention was needed for a resident following a short-term change of condition, communicate the determined action or intervention to staff, and document progress until the condition resolved was discussed with Staff 1 (ED) and Staff 2 (Regional Director) on 03/27/25 at 11:16 am. They acknowledged the findings.

2. Resident 4 moved into the facility in 07/2023 with diagnoses including lymphedema and cellulitis.

Progress notes and intermediate service plans dated 12/24/24 to 03/24/25 were reviewed, and the following was identified:

a. A 03/04/25 progress note indicated the resident had “tenderness with palpation on the right foot”. There was no documented evidence actions or interventions were determined, documented, and communicated to staff on each shift. There was no documented evidence of written communication regarding the change of condition for caregivers on each shift.

b. The following changes of condition lacked resident-specific instructions to staff:

* 01/23/25 – new medication (cefpodoxime);
* 01/24/25 – new medication (enalapril);
* 01/27/25 – new medication (ciprofloxacin);
* 02/08/25 – new medication (pantoprazole);
* 02/19/25 – new medications (omeprazole and aspirin); and
* 02/26/25 – new medication (furosemide).

The need to ensure resident-specific actions or interventions were determined, documented, and communicated to staff on each shift, and written communication of changes of condition were provided to caregivers on each shift was discussed with Staff 1 (ED) and Staff 2 (Regional Director) on 03/27/25. They acknowledged the findings, and no further information was provided.

OAR 411-054-0040 (1-2) Change of Condition and Monitoring

(1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift.

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to ensure the RN performed a timely assessment, developed interventions based on the condition of the resident, or updated the service plan for 2 of 4 sampled residents (#s 1 and 2) who experienced a significant change of condition. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 09/2021 with diagnoses including morbid obesity, insulin dependent diabetes mellitus type 2, and chronic obstructive pulmonary disease (COPD).

Resident 2's progress notes, dated 12/22/24 through 03/23/25, service plan dated 02/17/25, additional intermediate service plans, after-visit summaries to the emergency department, and significant change of condition evaluation dated 03/12/25 were reviewed.

Resident 2's clinical records and interviews with staff indicated the resident had experienced an overall decline in physical and cognitive status and an increase in ADL assistance.

A decline in physical and cognitive condition following hospitalization from 02/20/25 through 02/28/25 represented a significant change of condition for which a timely RN assessment was required. An RN assessment was completed on 03/12/25, ten days later. Additionally, there was no documented evidence interventions were made as a result of this assessment and service plan was updated.

The need to ensure the facility RN assessed all significant changes of condition timely and made interventions as a result of the assessment was discussed with Staff 1 (ED) and Staff 2 (Regional Director) on 03/27/25 at 11:16 am. They acknowledged the findings.

2. Resident 1 moved into the facility in 06/2023 with diagnoses including left partial hip replacement due to left hip fracture and chronic atrial fibrillation.

The resident's 12/27/24 to 03/24/25 progress notes were reviewed. The following was identified:

Resident 1 was admitted to hospice on 12/28/24, which constituted a significant change of condition that required a timely RN assessment that documented findings, resident status, and interventions made as a result of the assessment. An RN assessment was completed on 02/05/25, or 39 days after the significant change of condition occurred.

On 03/25/25 at 2:20 pm, Witness 1 (LPN Consultant) acknowledged that the RN assessment was not completed timely.

The need to ensure an RN assessment was completed timely for a significant change of condition was discussed with Staff 1 (ED) and Staff 2 (Regional Director) on 03/27/25. They acknowledged the findings.

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services

Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information.

This Rule is not met as evidenced by:

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 2 and 4) whose orders were reviewed. Findings include, but are not limited to:

1. Resident 4 moved into the facility in 07/2023 with diagnoses including lymphedema.

The resident’s 03/01/25 to 03/24/25 MAR and physician orders were reviewed, and the following was identified:

The resident had an order for wound care treatment to be provided two times per day, at 10:30 am and 7:00 pm. The MAR was not filled out for the 10:30 am treatment on 03/02/25, 03/03/25, 03/04/25, and 03/09/25.

In an interview at 10:26 am on 03/26/25, Staff 6 (CG) confirmed the treatments had not been provided.

The need to ensure treatment orders were carried out as prescribed was discussed with Staff 1 (ED) and Staff 2 (Regional Director) on 03/27/25. They acknowledged the findings.

2. Resident 2 was admitted to the facility in 09/2021 with diagnoses including morbid obesity, type 2 insulin dependent diabetes mellitus, and chronic obstructive pulmonary disease (COPD).

Resident 2's current physician orders, MARs from 03/01/25 through 03/24/25 were reviewed, and interviews with facility staff and the resident were conducted.

The resident was hospitalized from 02/20/25 through 02/28/25 for influenza and aspiration pneumonia. The hospital emergency department (ED) after-visit summary, dated 02/28/25, was received by the survey team on 03/26/25 and contained the following physician orders:

* Stop taking propranolol 40 mg (for blood pressure) and glipizide 5 mg (to control blood glucose). However, according to the MAR, both medications were administered on 03/01/25 and 03/02/25;

* Implement diet recommendation of mechanical soft diet texture. Based on observation of breakfast and lunch meals on 03/25/25 and 03/26/25, Resident 2 was given a regular texture diet with food cut into pieces by staff providing 1:1 feeding. After review of the discharge orders by this surveyor on 03/26/25, Witness 1 (LPN) was notified of the diet texture order and stated the prescribed texture was scheduled to be implemented starting 03/27/25. There was no negative outcome to Resident 2. No meals were observed on 03/27/25 because Resident 2 was sent to the ED for evaluation of suspected urinary tract infection; and

* Directed staff to administer medications by crushing in puree. During the interviews with Staff 16 (MT) on 03/24/25 at 3:10 pm and with Staff 4 (MT) on 03/26/25 at 3:05 pm, both confirmed the resident was taking medications whole, one pill at a time with water.

The need to ensure physician or other legally recognized practitioner orders were carried out as prescribed was reviewed with Staff 1 (ED) and Staff 2 (Regional Director) on 03/27/25 at 1:16 pm. They acknowledged the findings.

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders

(f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order.

This Rule is not met as evidenced by:

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

Fire and life safety records dated 10/05/24 through 03/06/25 were reviewed on 03/25/25 at 10:38 am with Staff 15 (Maintenance Supervisor) and Staff 7 (Lead Enrichment). The following was identified:

Fire drill documentation did not include problems encountered, comments relating to residents who resisted or failed to participate in the drills.

During an interview on 03/25/25 at 10:45 am, Staff 15 stated he met with the Fire Marshal regarding how to best assist residents who refused to participate in fire drills. Staff 15 stated the plan was to close any fire doors as well as resident room doors who chose not to participate in the fire drill and place a blanket underneath the gap at the bottom of their door. Staff 15 stated the Fire Marshal indicated the sprinkler system should be sufficient until the fire department arrives to assist with rescue. However, there was no documented evidence of approval for this plan by the Fire Marshal.

The need to follow all OFC requirements for fire drills and documentation was discussed with Staff 1 (ED) and Staff 2 (Regional Director) on 03/27/25 at 12:45 pm. They acknowledged the findings. No additional information was provided.

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety

(1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080.

This Rule is not met as evidenced by:

Based on observation and interview, conducted during a site visit from 01/08/24 through 01/09/24, it was confirmed the facility failed to provide three daily nutritious, palatable meals for 4 of 4 sampled residents (#s 2, 6, 13 and 14). Findings include, but are not limited to:The morning and noon meals were observed on 01/08/24.During the morning meal, meals were delivered on a rolling preparation cart that was not insulated or enclosed at 8:37 am. Meals were served on Styrofoam plates with a red Cambro insulator, paper napkins and plastic cutlery. Hot and cold food were served on the same plate. The cart with residents' morning meals was observed unattended for over 15 minutes while a CG was feeding a resident. The temperature of the last meal served off the cart was taken when delivered to the resident at 9:08 am and scrambled eggs were 95 degrees.The noon meal was observed and temperature was taken of the pork served to the last resident off the cart. The pork was 103 degrees.A sample tray was ordered for the noon meal. The temperature of the pork on the sample tray was 106 degrees. The pork was cold and chewy when eaten.During separate interviews on 01/08/24 Resident 2, Resident 6, Resident 13 and Resident 14 all stated the food was consistently served cold.During an interview on 01/08/24 Staff 14 (Dietitian) stated that s/he ordered a test tray monthly as part of an audit, but did not take temperature of food given to residents. A copy of the report was requested, but was not provided. The facility failed to provide three daily nutritious, palatable meals.The findings were reviewed with and acknowledged by Staff 1 (Administrator), Staff 2 (Regional Director of Operations), Staff 3 (Assistant Administrator) and Staff 4 (RN) on 01/09/24.Facility Verbal Plan of Correction: The facility to increase number of times temperatures were taken during meal service, on steam table, and throughout service to be done by cook. Education to dietary department was to be provided. Facility would ensure food would not be plated until staff were available to deliver meals. Facility to ensure cold and hot food were served separate. Facility had dietary aides added to contract as of 01/01/24 and was recruiting for two more dietary aides.Based on observation and interview, conducted during a site visit from 01/08/24 through 01/09/24, it was confirmed the facility failed to provide three daily nutritious, palatable meals for 4 of 4 sampled residents (#s 2, 6, 13 and 14). Findings include, but are not limited to:The morning and noon meals were observed on 01/08/24.During the morning meal, meals were delivered on a rolling preparation cart that was not insulated or enclosed at 8:37 am. Meals were served on Styrofoam plates with a red Cambro insulator, paper napkins and plastic cutlery. Hot and cold food were served on the same plate. The cart with residents' morning meals was observed unattended for over 15 minutes while a CG was feeding a resident. The temperature of the last meal served off the cart was taken when delivered to the resident at 9:08 am and scrambled eggs were 95 degrees.The noon meal was observed and temperature was taken of the pork served to the last resident off the cart. The pork was 103 degrees.A sample tray was ordered for the noon meal. The temperature of the pork on the sample tray was 106 degrees. The pork was cold and chewy when eaten.During separate interviews on 01/08/24 Resident 2, Resident 6, Resident 13 and Resident 14 all stated the food was consistently served cold.During an interview on 01/08/24 Staff 14 (Dietitian) stated that s/he ordered a test tray monthly as part of an audit, but did not take temperature of food given to residents. A copy of the report was requested, but was not provided. The facility failed to provide three daily nutritious, palatable meals.The findings were reviewed with and acknowledged by Staff 1 (Administrator), Staff 2 (Regional Director of Operations), Staff 3 (Assistant Administrator) and Staff 4 (RN) on 01/09/24.Facility Verbal Plan of Correction: The facility to increase number of times temperatures were taken during meal service, on steam table, and throughout service to be done by cook. Education to dietary department was to be provided. Facility would ensure food would not be plated until staff were available to deliver meals. Facility to ensure cold and hot food were served separate. Facility had dietary aides added to contract as of 01/01/24 and was recruiting for two more dietary aides.

Based on observation, interview and record review, conducted during a site visit on 01/08/24 and 01/09/24, it was confirmed the facility failed to implement a service plan that reflects the resident's needs for 1 of 1 resident (# 9). Findings include, but are not limited to:A review of Resident 9's service plan, dated 12/08/23, indicated resident will call for assistance. Under "Environmental Factors Assistance" the service plan indicated: "Resident requires extra assistance to assure all personal items are within easy reach and may need to call for additional assistance if [s/he] needs help retrieving an item. [His/Her] hands are partially atrophied..." On 01/08/24 at 12:07 pm, Resident 9 was observed to be yelling for staff assistance from his/her room.In an interview on 01/08/24, Resident 9 stated s/he usually yells for help if s/he is unable to locate his/her call button, but staff aren't very responsive. Resident 9 attempted to locate his/her call button but was unable to find it. Compliance Specialist (CS) observed his/her call button to be located above his/her right shoulder next to his/her neck. Resident 9 stated s/he was unable to reach the call button in its current location. Resident 9 was asked if they would like their call button moved. Resident 9 stated they would like it moved to his/her chest. CS placed the call button within reach. On 01/09/24 at 12:53 pm, a caregiver was observed leaving Resident 9's room. Resident 9 was observed to be laying in bed with his/her bedside table tray table covering his/her arms. Resident 9 was asked if s/he is able to reach his/her call light and s/he said no because of the "lump". S/He could not move his/her arms because the bedside tray table was on top of them. Resident 9 was asked if the bedside table was moved out of the way would s/he be able to reach her call pendant and s/he said yes. The table was moved and s/he was able to lift his/her arm to his/her chest to press the pendant. S/He said s/he will yell if s/he needs to but people don't come sometimes. The facility failed to implement a service plan that reflects the resident's needs.The findings were reviewed with and acknowledged by Staff 1 (Administrator), Staff 2 (Regional Director of Operations), Staff 3 (Assistant Administrator) and Staff 4 (RN) on 01/09/24.Facility Verbal Plan of Correction: A new call button was just purchased for Resident 9 so s/he can press his/her arm on it, and it is used like a door bell, it will be placed on resident's side rail ASAP so Resident 9 always has access to it from his/her bed. Based on interview and record review, conducted during a site visit on 01/08/24 through 01/09/24, it was confirmed the facility failed ensure service plan was reflective of the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence for 1 of 1 sampled resident (# 2). Findings include, but are not limited to:A review of Resident 2's service plan, dated 12/04/23, indicated resident was a one-person hands-on assist with bathing. Resident preferred showers on Mondays and Thursday evenings. Showers were scheduled per service plan for Mondays and Thursdays morning.A review of facility shower schedule indicated Resident 2 was scheduled for showers on Mondays and Thursdays at 10:30 am.A review of Resident 2's shower refusal forms and resident shower/skin report forms, dated 02/01/23 - 01/09/24, indicated there were five shower refusals dated 06/22/23, 10/30/23, 12/14/23, 12/15/23 and 12/25/23, and four refusals were signed by the resident. There was one completed resident shower/skin report form dated 02/10/23 completed.A review of Resident 2's progress notes, dated 10/01/23 - 11/30/23, indicated no showers or refusals were documented. In an interview on 01/08/24, Resident 2 stated s/he has gone 32 and 45 days without showers in the last year. No one even asked during some of those times. S/He wasn't even on the shower schedule for some time. S/He can go all day without seeing someone. His/her showers were on Monday or Tuesday and Thursday or whenever they want. The last shower Resident 2 received was a week ago Saturday. S/He was offered a shower on Thursday but said no because lunch was being brought and s/he had home health coming right after.In an interview on 01/09/24, Staff 13 (Caregiver) stated Resident 2 refused his/her shower yesterday. In an interview on 01/09/24, Staff 1 (Administrator) stated Resident 2 frequently refuses showers and staff are supposed to fill out refusal forms to document refusals.The facility failed to ensure service plan was reflective of the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence.The findings were reviewed with and acknowledged by Staff 1 (Administrator), Staff 2 (Regional Director of Operations), Staff 3 (Assistant Administrator) and Staff 4 (RN) on 01/09/24.Facility Verbal Plan of Correction: The facility was to implement a system to appropriately document refusals of showers, as well as coordinating shower times consistent with resident preferences and having multiple people attempt to offer showers for residents who refuse.Based on observation, interview and record review, conducted during a site visit on 01/08/24 and 01/09/24, it was confirmed the facility failed to ensure the implementation of services for 1 of 1 sampled residents (# 14). Findings include, but are not limited to:A review of Resident 14's service plan dated 10/15/23 indicated staff are to assist with compression socks around 1:00 pm. In an interview on 01/08/24, Resident 14 stated staff did not help him/her with compression stockings. S/he should have his/her compression stockings put on daily around 1:00 pm but most people didn't know how to do it so it happened maybe once a week. S/he was also supposed to be transferred into his/her chair every day for a couple hours so s/he could get out of bed, but that also only happened once a week. Last Thursday was his/her last shower, and last use of compression stockings. S/he insisted that staff put his/her laundry away.On 01/08/24 at 1:45 pm, Resident 14 was observed to not have compression stockings on.In an interview on 01/09/24, Resident 14 stated staff did not put his/her compression stockings on at all on 01/08/24.The facility failed to ensure the implantation of services.The findings were reviewed with and acknowledged by Staff 1 (Administrator), Staff 2 (Regional Director of Operations), Staff 3 (Assistant Administrator) and Staff 4 (RN) on 01/09/24.Facility Verbal Plan of Correction: Facility was actively hiring and was to be staffed to their contract within two weeks.

Based on interview and record review conducted during a site visit from 01/08/24 through 01/09/24, it was confirmed the facility failed to assess for and monitor change in conditions for 1 of 1 sampled resident (# 8). Findings include, but are not limited to:A review Resident 8's service plan, dated 07/25/23, MAR, dated October 2023, and physician orders, and progress notes, dated 09/01/23 through 10/18/23, indicated the following:· The service plan in the area of skin monitoring directed staff to monitor residents skin for any signs of new or changing skin conditions;· Progress note, dated 10/01/23, indicated resident had an open wound on his/her "right side lower back" and wound was cleaned and a bandage applied;· Alert Charting note, dated 10/07/23, indicated "staff will continue to monitor" wound on backside;· Alert Charting note, dated 10/09/23, indicated Med tech requested RN to look at the wound;· Nurse's Note, dated 10/09/23, indicated a "Wound/Skin Assessment" entered by Staff 4 (RN) indicated an assessment of Resident 8's open wound was completed;· Progress note, dated 10/12/23 at 10:05 am, indicated resident received new orders for decubitus ulcer;· Nurse's Note, dated 10/13/23, indicated a "Change in Condition" entered by Staff 4 indicated resident had experienced a change in condition including increased difficulty swallowing medications, moving less, staying in recliner more which has led to a stage 2 pressure ulcer;· Physician orders directed treatment for wound care on lower back to be carried out two times per day was initiated on 10/13/23;· The MAR indicated wound care began in the evening of 10/13/23; and· On 10/15/23 there is no indication that wound care was completed at 10 am.In an interview on 01/09/24, Staff 4 stated Resident 8 had a chronic decubitus ulcer on his/her backside. Staff 4 stated s/he had a conversation with Resident 8's family suggesting that the ulcer was due to sleeping in his/her recliner. The facility tried different dressings until physician orders were received and then Staff 4 worked with home health on trying to get resident a different bed to help offload from the wound site.The facility failed to assess for and monitor change in conditions.The findings were reviewed with and acknowledged by Staff 1 (Administrator), Staff 2 (Regional Director of Operations), Staff 3 (Assistant Administrator) and Staff 4 (RN) on 01/09/24.Facility verbal plan of correction: The facility RN had been through courses on change of conditions. The facility had an LPN in place and staff had been monitoring and reporting skin. Skin conditions were decreasing. The facility was to have a treatment aid starting the following week.

Based on interview and record review, conducted during a site visit on 01/08/24 and 01/09/24, it was confirmed the facility failed to ensure delegation and teaching was provided and documented by a RN in accordance with the Oregon Administrative Rules (OAR) adopted by the Oregon State Board of Nursing (OSBN) in chapter 851, division 047 for 5 of 5 sampled resident (# 5, 7, 11, 13, 14) who received insulin injections by a facility unregulated assistive person (UAP). Findings include, but are not limited to: In an interview on 01/08/24, Staff 4 (RN) stated s/he had been instructed to complete delegations with each staff member having one document that contained all residents with delegated tasks by the regional RN. In an interview on 01/09/24, Witness 1 (OSBN Liaison) confirmed delegations must be completed in a one-to-one manner, one staff member to one resident for one delegated task. A review of the facility's delegation binder indicated that six med techs had been delegated to and each med tech had a single document containing six residents names that required delegated tasks regarding subcutaneous insulin injections. No documented delegations were provided for the use of a glucometer for any staff member.the facility failed to ensure delegation and teaching was provided and documented by a RN in accordance with the Oregon Administrative Rules (OAR) adopted by the Oregon State Board of Nursing (OSBN) in chapter 851, division 047.The findings were reviewed with and acknowledged by Staff 1 (Administrator), Staff 2 (Regional Director of Operations), Staff 3 (Assistant Administrator) and Staff 4 on 01/09/24.Facility Written Plan of Correction: The Registered Nurse had been in-serviced on delegation process according to OARs and was completed 01/08/24. The registered nurse was to administer all insulins until delegations were completed. Within 10 calendar days, the registered nurse was to re-delegate all med techs to be completed by 01/18/24. The Administrator or designee was to review delegations every 60 days or as needed.

See findings in C0282, C0301, C0303 and C0310.Facility Verbal Plan of correction: RN Will follow up with the provider about the orders for nebulizer and inhaler. MT training on ordering medications and corrective actions with MT if "meds not available" documented and provide training to document interventions to get meds in building by 1/15/23. Clinical meeting to re-start 1/10/23 and will review prog notes, incident reports, MAR exceptions, PRN effectiveness and 24 hour alerts and review physician orders 5 days/week.

Based on interview and record review, conducted during a site visit from 01/08/24 through 01/09/24, it was confirmed the facility failed to ensure the staff person who administers the medication must visually observe the resident take the medication for 1 of 1 sampled resident (# 4). Findings include, but are not limited to:A review of Resident 4's May 2023 MAR and progress notes indicated the following:· On 05/21/23 a progress note entered at 8:54 pm, indicated during the 3:00 pm medication pass Staff 15 (Former med tech) observed Resident 4 taking medications. When Staff 15 asked the resident what s/he was taking Resident 4 stated s/he was taking his/her morning medications, and that s/he had forgotten to take them.· MAR indicated on 05/21/23, Resident 4's scheduled 5:00 pm Risperidone (psychotropic) and Trifluoperazine (psychotropic) held due to a medication error. In an interview on 01/09/24, Staff 1 (Administrator), Staff 2 (Regional Director of Operations) and Staff 3 (Assistant Executive Director) stated Resident 4 now waited with his/her walker by the med cart when his/her medications were due. There was also a med tech training that occurred after this incident for staff to visually observe residents take medications.The facility failed to ensure the staff person who administers the medication must visually observe the resident take the medication.The findings were reviewed with and acknowledged by Staff 1, Staff 2, Staff 3 and Staff 4 (RN) on 01/09/24.Facility verbal Plan of Correction: The facility provided a staff training after the incident to observe residents take medications.

Based on interview and record review, conducted during a site visit from 01/08/24 through 01/09/24, it was confirmed the facility failed to carry out medication orders as prescribed for 1 of 1 sampled resident (# 5). Findings include, but are not limited to:A review of Resident 5's June 2023 MAR and physician orders indicated the following:· Resident to receive Lantus, 14 units as a subcutaneous injection every morning and hold for CBG less than 80;· On 06/04/23 at 9:09 am Lantus not given due to medication not in facility and facility ordered stat.In an interview on 01/09/24, Resident 5 stated s/he did not recall the facility running out of his/her insulin, "but it's possible." The facility failed to carry out medication orders as prescribed.The findings were reviewed with and acknowledged by Staff 1 (Administrator), Staff 2 (Regional Director of Operations), Staff 3 (Assistant Administrator) and Staff 4 (RN) on 01/09/24.Facility verbal plan of correction: RN will follow up with the provider about the orders for nebulizer and inhaler. MT training on ordering medications and corrective actions with MT if "meds not available" documented and provide training to document interventions to get medications in building by 01/15/24. Clinical meeting to re-start 01/10/24 and was to review progress notes, incident reports, MAR exceptions, PRN effectiveness and 24 hour alerts and review physician orders 5 days/week.Based on interview and record review, conducted during a site visit on 01/08/24 through 01/09/24, it was confirmed the facility failed to carry out medication orders as prescribed for 1 of 1 sampled resident (# 7). Findings include, but are not limited to:A review of Resident 7's 10/01/23 - 10/31/23 MAR and physician orders indicated the following:· Physician ordered Ozempic, 0.5mg, subcutaneous injection once per week for diabetes;· MAR indicated on 10/10/23 Ozempic not available;· On 10/17/23, 10/24/23 and 10/31/23, there was no indication that the Ozempic injection was administered.A review of facility Incident Report indicated Resident 7 did not receive his/her Ozempic injection on 10/31/23.In an interview on 01/09/24, Resident 4 stated s/he did not receive his/her Ozempic a while back because there were not staff delegated to give those shots.The facility failed to carry out medication orders as prescribed.The findings were reviewed with and acknowledged by Staff 1 (Administrator), Staff 2 (Regional Director of Operations), Staff 3 (Assistant Administrator) and Staff 4 (RN) on 01/09/24.Facility Verbal Plan of correction: The facility RN was to follow up with the provider about the orders for nebulizer and inhaler, MT training was to be provided on ordering medications and corrective actions to be taken with MT if "meds not available" was documented and provide training to document interventions to get medications in the building by 01/15/24. Clinical meetings were to re-start 01/10/24 and were to review progress notes, incident reports, MAR exceptions, PRN effectiveness and 24 hour alerts and review physician orders five days a week.Based on interview and record review, conducted during a site visit from 01/08/24 through 01/09/24, it was confirmed the facility failed to carry out medication orders as prescribed for 3 of 3 sampled residents (#s 9, 11, &12). Findings include, but are not limited to:A review of Resident 9's 11/01/23 - 11/30/23 MAR and physician orders indicated:· Order for Melatonin (a sleep aid) one tab by mouth at night;· MAR indicated medication not available on 11/14/23, 11/16/23, 11/17/23, 11/18/23 and 11/19/23;· Order for Albuterol HFA inhale 2 puffs by mouth every four (4) hours as needed for dyspnea/ shortness of breath;MAR indicated Albuterol not administered for 11/01/23 - 11/30/23;· Order for Iprat/Albut to inhale 3ml via nebulizer every six (6) hours as needed for wheezing or dyspnea due to asthma. Use if albuterol inhaler is ineffective;· Iprat/Albut order effective date 10/30/23 and discontinued on 11/16/23. New order for Iprat/Albut start date 11/30/23;· MAR indicated Iprat/Albut added on 11/03/23, scheduled for 8:00 am, 12:00 pm, 5:00 pm and 9:00 pm, first administration on 11/05/23 at 5:00 pm;· MAR indicated Iprat/Albut was administered 38 times by the facility after being discontinued on 11/16/23.In an interview on 01/09/24, Staff 4 (RN) stated Resident 9's physician had access to the facility's MAR system and was making changes within the system for Resident 9's medications.A review of Resident 11's 11/01/23 - 11/30/23 MAR and physician orders indicated:· Physician order for Divalproex Sodium for bipolar disorder, one (1) tablet by mouth every morning and an order for three (3) tablets by mouth revery evening;· MAR indicated morning dose of Divalproex Sodium was unavailable on 11/03/23 and evening dose unavailable on 11/14/23;· Physician order for Furosemide one (1) tablet by mouth by mouth every day for heart condition;· MAR indicated on 11/28/23 resident was out of Furosemide;· Physician order for propranolol 1 tablet by mouth twice daily for hypertension;· MAR indicated on 11/02/23 propranolol not administered being mailed from pharmacy;· Physician order for Vitamin D3, a capsule by mouth everyday;· MAR indicated on 11/12/23 Vitamin D3 not available;· Physician order for Zinc Oxide 20% ointment to be applied in a thick layer over right buttocks 2 times daily; and· MAR indicated on 11/28/23 8am dose of Zinc Oxide not administered due to not being able to locate.In an interview on 01/09/24, Resident 11 stated the facility did run out of his/her medications and sometimes s/he had trouble getting his/her PRN medications when requested.A review of Resident 12's 11/01/23 - 11/30/23 MAR and physician orders indicated the following:· Physician order for Diclofenac 1% gel to apply 4 grams topically 3 times daily;· MAR indicated Diclofenac was unavailable on 11/28/23 at 8am and 11/29/23 at 5pm;· Physician order for Losartan (high blood pressure) 100mg tab by mouth every day;· MAR indicated on 11/14/23 Losartan unavailable;· Physician order for Oxycodone 10 mg tab, 1 tablet by mouth twice daily. Scheduled dose to be given 30-60 minutes prior to wound care. May also take 1 tablet by mouth as needed for pain (4 hours between doses), last does to be given prior to sleep.· MAR indicated on 11/13/23 and 11/25/23 resident received his/her 2 scheduled doses as well as 3 PRN doses of Oxycodone; and· MAR further indicated on 11/10/23, 11/12/23, 11/13/23, 11/17/23, 11/25/23 and 11/26/23 oxycodone was administered less than 4 hours between doses. The facility failed to carry out medication orders as prescribed.The findings were reviewed with and acknowledged by Staff 1 (Administrator), Staff 2 (Regional Director of Operations), Staff 3 (Assistant Administrator) and Staff 4 (RN) on 01/09/24.Facility verbal plan of correction: RN was to follow up with the provider about the orders for nebulizer and inhaler. MT training was to occur for ordering medications and corrective actions with MT if "meds not available" documented and provide training to document interventions to get medications in building by 01/15/23. Clinical meeting to re-start 01/10/23 and will review progress notes, incident reports, MAR exceptions, PRN effectiveness and 24-hour alerts and review physician orders 5 days/week.

Based on interview and record review, conducted during a site visit on 01/08/24 and 01/09/24, it was confirmed the facility failed to keep an accurate MAR for 2 of 2 sampled residents (#s 11 and 13). Findings include, but are not limited to:In an interview on 01/09/24, Staff 6 (med tech) stated Staff 7 (med tech) had been delegated to by the facility RN during the morning medication pass on 01/09/24. Staff 6 stated s/he had been delegated for several residents during the afternoon medication pass on 01/09/24 and would receive the rest of the delegations for residents during the evening medication pass on 01/09/24. Staff 6 stated s/he had not logged out of the computer s/he was using when Staff 7 and the RN documented in the MARs for delegated tasks that morning [01/09/24].A review of Resident 11 and Resident 13s' 01/01/24 - 01/31/24 MARs indicated both residents' delegated insulin had been administered by Staff 6.In an interview on 01/09/24, Staff 4 (RN) stated s/he had forgotten to change users on the computer for medication passes when providing delegation teaching on the morning on 01/09/24.Staff 7 had documented in the MAR as Staff 6.The facility failed to keep an accurate MAR.The findings were reviewed with and acknowledged by Staff 1 (Administrator), Staff 2 (Regional Director of Operations), Staff 3 (Assistant Administrator) and Staff 4 on 01/09/24.Facility Verbal Plan of correction: The facility was to complete med tech training to include using correct staff ID's when documenting in MAR.

Based on observation, interview and record review, conducted during a site visit from 01/08/24 through 01/09/24, it was confirmed the facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident for 5 of 5 sampled residents (#s 2, 6, 10, 14 and 15). Findings include, but are not limited to:On 01/08/24 at 10:32 am, Resident 14 was observed to press his/her call light button. At 10:46 am, a staff member was observed to answer the call light and asked for assistance from another staff member to provide incontinence care. It took a total of 20 minutes and 43 seconds for two staff members to respond to the resident's call light to assist resident with incontinence care.A review of Resident 14 call light logs for 01/08/24, indicated Resident 14 used his/her call light 12 times and three of those calls took longer than 20 minutes for staff to respond to, varying from 21 minutes to 54 minutes. A review of call lights logs, dated 01/05/24 - 01/08/24, for Residents 2, 6 and 10 indicated:* Resident 2 had 11 instances of call lights over 20 minutes;* Resident 6 had nine instances of call lights over 20 minutes; and* Resident 10 had four instances of call lights over 20 minutes.In an interview on 01/08/24, Resident 2 stated s/he has gone all day without seeing a staff member.In an interview on 01/08/24, Staff 8 (med tech) stated the facility was short staffed [on 01/08/24].In an interview on 01/08/24, Resident 14 stated s/he frequently waited 30 minutes to an hour for staff to respond to his/her call light.In an interview on 01/08/24, Resident 6 stated on 11/06/23 there were only 2 caregivers working on swing shift and s/he waited 1-2 hours for staff to respond to his/her call light.In an interview on 01/08/24, Witness 2 (ODHS Contract Administrator) stated the contract required direct care staff during the day and evening shift to be 0.5 full time employees (FTE) per individual served under the contract and for night shift there needed to be 4 FTE for individuals served under the contract. In an interview on 01/09/24, Resident 15 stated the facility does not have enough staff and it has taken 2.5 hours for staff to respond to his/her call light before. S/he stated nights and weekends were really bad for staffing.In an interview on 01/09/24, Resident 10 stated on a bad day it took staff anywhere from 30 minutes to 2 hours to respond.The resident roster indicated there were 14 residents served under the contract (C wing) at the time of the site visit.A review of staff assignment sheets, dated 01/08/24 and 01/09/24, indicated the following:· On 01/08/24 during day shift there was 1 med tech and 1 caregiver assigned for A and B wing of the facility. For C wing 1 med tech and 3 caregivers were assigned;· On 01/09/24 during swing shift there was 1 med tech and 1 caregiver assigned for A and B wing of the facility. For C wing 1 med tech and 5 caregivers were assigned.The facility was staffed short of the facility contract requirements.A review of the staff schedules dated 08/01/23 through 01/31/24, indicated the facility was consistently not staffed to the contract requirements. The staff schedule for 11/06/23 indicated there were 2 caregiver and 2 med techs scheduled for swing shift.The facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident.The findings were reviewed with and acknowledged by Staff 1 (Administrator), Staff 2 (Regional Director of Operations), Staff 3 (Assistant Administrator) and Staff 4 (RN) on 01/09/24.Facility Verbal Plan of correction: Facility was actively hiring and was to be staffed to their contract within two weeks. Based on observation, interview and record review, conducted during a site visit from 01/08/24 through 01/09/24, it was confirmed the facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident for 5 of 5 sampled residents (#s 2, 6, 10, 14 and 15). Findings include, but are not limited to:On 01/08/24 at 10:32 am, Resident 14 was observed to press his/her call light button. At 10:46 am, a staff member was observed to answer the call light and asked for assistance from another staff member to provide incontinence care. It took a total of 20 minutes and 43 seconds for two staff members to respond to the resident's call light to assist resident with incontinence care.A review of Resident 14 call light logs for 01/08/24, indicated Resident 14 used his/her call light 12 times and three of those calls took longer than 20 minutes for staff to respond to, varying from 21 minutes to 54 minutes. A review of call lights logs, dated 01/05/24 - 01/08/24, for Residents 2, 6 and 10 indicated:* Resident 2 had 11 instances of call lights over 20 minutes;* Resident 6 had nine instances of call lights over 20 minutes; and* Resident 10 had four instances of call lights over 20 minutes.In an interview on 01/08/24, Resident 2 stated s/he has gone all day without seeing a staff member.In an interview on 01/08/24, Staff 8 (med tech) stated the facility was short staffed [on 01/08/24].In an interview on 01/08/24, Resident 14 stated s/he frequently waited 30 minutes to an hour for staff to respond to his/her call light.In an interview on 01/08/24, Resident 6 stated on 11/06/23 there were only 2 caregivers working on swing shift and s/he waited 1-2 hours for staff to respond to his/her call light.In an interview on 01/08/24, Witness 2 (ODHS Contract Administrator) stated the contract required direct care staff during the day and evening shift to be 0.5 full time employees (FTE) per individual served under the contract and for night shift there needed to be 4 FTE for individuals served under the contract. In an interview on 01/09/24, Resident 15 stated the facility does not have enough staff and it has taken 2.5 hours for staff to respond to his/her call light before. S/he stated nights and weekends were really bad for staffing.In an interview on 01/09/24, Resident 10 stated on a bad day it took staff anywhere from 30 minutes to 2 hours to respond.The resident roster indicated there were 14 residents served under the contract (C wing) at the time of the site visit.A review of staff assignment sheets, dated 01/08/24 and 01/09/24, indicated the following:· On 01/08/24 during day shift there was 1 med tech and 1 caregiver assigned for A and B wing of the facility. For C wing 1 med tech and 3 caregivers were assigned;· On 01/09/24 during swing shift there was 1 med tech and 1 caregiver assigned for A and B wing of the facility. For C wing 1 med tech and 5 caregivers were assigned.The facility was staffed short of the facility contract requirements.A review of the staff schedules dated 08/01/23 through 01/31/24, indicated the facility was consistently not staffed to the contract requirements. The staff schedule for 11/06/23 indicated there were 2 caregiver and 2 med techs scheduled for swing shift.The facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident.The findings were reviewed with and acknowledged by Staff 1 (Administrator), Staff 2 (Regional Director of Operations), Staff 3 (Assistant Administrator) and Staff 4 (RN) on 01/09/24.Facility Verbal Plan of correction: Facility was actively hiring and was to be staffed to their contract within two weeks. Based on observation, interview and record review, conducted during a site visit from 01/08/24 through 01/09/24, it was confirmed the facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident for 5 of 5 sampled residents (#s 2, 6, 10, 14 and 15). Findings include, but are not limited to:On 01/08/24 at 10:32 am, Resident 14 was observed to press his/her call light button. At 10:46 am, a staff member was observed to answer the call light and asked for assistance from another staff member to provide incontinence care. It took a total of 20 minutes and 43 seconds for two staff members to respond to the resident's call light to assist resident with incontinence care.A review of Resident 14 call light logs for 01/08/24, indicated Resident 14 used his/her call light 12 times and three of those calls took longer than 20 minutes for staff to respond to, varying from 21 minutes to 54 minutes. A review of call lights logs, dated 01/05/24 - 01/08/24, for Residents 2, 6 and 10 indicated:* Resident 2 had 11 instances of call lights over 20 minutes;* Resident 6 had nine instances of call lights over 20 minutes; and* Resident 10 had four instances of call lights over 20 minutes.In an interview on 01/08/24, Resident 2 stated s/he has gone all day without seeing a staff member.In an interview on 01/08/24, Staff 8 (med tech) stated the facility was short staffed [on 01/08/24].In an interview on 01/08/24, Resident 14 stated s/he frequently waited 30 minutes to an hour for staff to respond to his/her call light.In an interview on 01/08/24, Resident 6 stated on 11/06/23 there were only 2 caregivers working on swing shift and s/he waited 1-2 hours for staff to respond to his/her call light.In an interview on 01/08/24, Witness 2 (ODHS Contract Administrator) stated the contract required direct care staff during the day and evening shift to be 0.5 full time employees (FTE) per individual served under the contract and for night shift there needed to be 4 FTE for individuals served under the contract. In an interview on 01/09/24, Resident 15 stated the facility does not have enough staff and it has taken 2.5 hours for staff to respond to his/her call light before. S/he stated nights and weekends were really bad for staffing.In an interview on 01/09/24, Resident 10 stated on a bad day it took staff anywhere from 30 minutes to 2 hours to respond.The resident roster indicated there were 14 residents served under the contract (C wing) at the time of the site visit.A review of staff assignment sheets, dated 01/08/24 and 01/09/24, indicated the following:· On 01/08/24 during day shift there was 1 med tech and 1 caregiver assigned for A and B wing of the facility. For C wing 1 med tech and 3 caregivers were assigned;· On 01/09/24 during swing shift there was 1 med tech and 1 caregiver assigned for A and B wing of the facility. For C wing 1 med tech and 5 caregivers were assigned.The facility was staffed short of the facility contract requirements.A review of the staff schedules dated 08/01/23 through 01/31/24, indicated the facility was consistently not staffed to the contract requirements. The staff schedule for 11/06/23 indicated there were 2 caregiver and 2 med techs scheduled for swing shift.The facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident.The findings were reviewed with and acknowledged by Staff 1 (Administrator), Staff 2 (Regional Director of Operations), Staff 3 (Assistant Administrator) and Staff 4 (RN) on 01/09/24.Facility Verbal Plan of correction: Facility was actively hiring and was to be staffed to their contract within two weeks. Based on observation, interview and record review, conducted during a site visit from 01/08/24 through 01/09/24, it was confirmed the facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident for 5 of 5 sampled residents (#s 2, 6, 10, 14 and 15). Findings include, but are not limited to:On 01/08/24 at 10:32 am, Resident 14 was observed to press his/her call light button. At 10:46 am, a staff member was observed to answer the call light and asked for assistance from another staff member to provide incontinence care. It took a total of 20 minutes and 43 seconds for two staff members to respond to the resident's call light to assist resident with incontinence care.A review of Resident 14 call light logs for 01/08/24, indicated Resident 14 used his/her call light 12 times and three of those calls took longer than 20 minutes for staff to respond to, varying from 21 minutes to 54 minutes. A review of call lights logs, dated 01/05/24 - 01/08/24, for Residents 2, 6 and 10 indicated:* Resident 2 had 11 instances of call lights over 20 minutes;* Resident 6 had nine instances of call lights over 20 minutes; and* Resident 10 had four instances of call lights over 20 minutes.In an interview on 01/08/24, Resident 2 stated s/he has gone all day without seeing a staff member.In an interview on 01/08/24, Staff 8 (med tech) stated the facility was short staffed [on 01/08/24].In an interview on 01/08/24, Resident 14 stated s/he frequently waited 30 minutes to an hour for staff to respond to his/her call light.In an interview on 01/08/24, Resident 6 stated on 11/06/23 there were only 2 caregivers working on swing shift and s/he waited 1-2 hours for staff to respond to his/her call light.In an interview on 01/08/24, Witness 2 (ODHS Contract Administrator) stated the contract required direct care staff during the day and evening shift to be 0.5 full time employees (FTE) per individual served under the contract and for night shift there needed to be 4 FTE for individuals served under the contract. In an interview on 01/09/24, Resident 15 stated the facility does not have enough staff and it has taken 2.5 hours for staff to respond to his/her call light before. S/he stated nights and weekends were really bad for staffing.In an interview on 01/09/24, Resident 10 stated on a bad day it took staff anywhere from 30 minutes to 2 hours to respond.The resident roster indicated there were 14 residents served under the contract (C wing) at the time of the site visit.A review of staff assignment sheets, dated 01/08/24 and 01/09/24, indicated the following:· On 01/08/24 during day shift there was 1 med tech and 1 caregiver assigned for A and B wing of the facility. For C wing 1 med tech and 3 caregivers were assigned;· On 01/09/24 during swing shift there was 1 med tech and 1 caregiver assigned for A and B wing of the facility. For C wing 1 med tech and 5 caregivers were assigned.The facility was staffed short of the facility contract requirements.A review of the staff schedules dated 08/01/23 through 01/31/24, indicated the facility was consistently not staffed to the contract requirements. The staff schedule for 11/06/23 indicated there were 2 caregiver and 2 med techs scheduled for swing shift.The facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident.The findings were reviewed with and acknowledged by Staff 1 (Administrator), Staff 2 (Regional Director of Operations), Staff 3 (Assistant Administrator) and Staff 4 (RN) on 01/09/24.Facility Verbal Plan of correction: Facility was actively hiring and was to be staffed to their contract within two weeks.

Based on interview and record review, conducted during a site visit on 01/08/24 and 01/09/24, it was confirmed the facility failed to verify direct care staff have demonstrated satisfactory performance in any duty they are assigned for 2 of 3 (#'s 8 and 9) sampled staff. Findings include, but are not limited to the following:A review of Resident 1's MAR and progress notes for January 2023 indicated the following:· Resident moved into facility on 01/24/23.· From 01/24/23 through 01/31/23 Resident 1 was scheduled for four administrations per day of Insulin Lispro Solution on a sliding scale.· Of the 30 administrations, residents blood sugar was within range to administer insulin six times.· Resident 1 had five had instances of moderate hypoglycemia when blood sugars were under 70.· Progress notes indicated three instances in which resident was monitored for low blood sugar and offered snacks to raise his/her blood sugar.A review of facility binder containing diabetic resident assessments and hyperglycemia and hypoglycemia protocols indicated moderate hypoglycemic occurs when CBGs 70 or less. The protocol is to administer 4oz of juice or 5 packets of sugar dissolved in 4-6oz of water. Blood sugars to be checked every 15-30 minutes and if resident is still hypoglycemic to contact PCP. In an interview on 01/08/24, Staff 5 (Med tech) stated if resident blood sugars are low, s/he has to document, offer orange juice and a snack to bring blood sugars back to normal, wait 15 to 30 minutes and recheck CBG's. Blood sugar under 70 is considered low. Each resident's chart indicated what signs and symptoms the resident exhibits when hyper/hypoglycemic. S/he further stated s/he could contact the nurse for guidance as well.In an interview on 01/09/24, Staff 6 (Med tech) stated s/he was given a pamphlet to study for signs and symptoms of hyperglycemia and hypoglycemia. If staff were concerned about a resident the nurse was available to call. Below 70 is considered hypoglycemic.A review of staff demonstrated competencies for Staff 7 (Med tech), Staff 8 (Caregiver), and Staff 9 (Former med tech) was completed, and 2 of 3 staff did not have demonstrated competencies.In an interview on 01/09/24, Staff 1 (Administrator) and Staff 2 (Regional Director of Operations) stated it was staffs' responsibility to return their demonstrated competency checklists when the checklists were completed.The facility failed to verify direct care staff have demonstrated satisfactory performance in any duty they are assigned.The findings were reviewed with and acknowledged by Staff 1, Staff 2, Staff 3 (Assistant Administrator) and Staff 4 (RN) on 01/09/24.Facility Verbal Plan of correction: Facility was to audit current staff competencies by 01/23/24. New hires' competencies were to be done by the trainer and with the direct supervisor, with a final check done by Assistant Executive Director. The new system was created 01/09/24 and was being put into place.

Based on observation and interview, conducted during a site visit on 01/08/24 and 01/09/24, it was confirmed the facility failed to take measures to prevent the entry of rodents, flies, mosquitoes and other insects. Findings include, but are not limited to:During the site visit flies were observed throughout the interior of the facility. On 01/08/24 a staff member was observed to exit and re-enter through a side door. Upon reentry the door did not latch, swinging open and left unattended, allowing for the entry of insects. In an interview with Staff 1 (Administrator) and Staff 2 (Regional Director of Operations) stated the flies started a couple of weeks ago and staff have been unable to determine the source.The facility failed to take measures to prevent the entry of rodents, flies and mosquitoes and other insects. The findings were reviewed with and acknowledged by Staff 1, Staff 2, Staff 3 (Assistant Administrator) and Staff 4 (RN) on 01/09/24.Facility Verbal Plan of correction: The facility had residents who collect soda bottles or food at bedside. The facility hired a housekeeper. Education would be provided to residents and staff to bag up bottles and on not propping doors open by 1/30/23.

Based on observation and interview, conducted during a site visit on 01/08/24 and 01/09/24, it was confirmed the facility failed to keep the interior of the facility free from unpleasant odors and clean and in good repair. Findings include, but are not limited to:Throughout the site visit, strong and pervasive odors were observed in C-wing, and were strongest near room 31. The floors in the dining room were observed to have 1-2 inch gaps between the planks, and carpeting throughout the facility was observed to have large dark stains.On 01/08/24 between 11:00 am and 11:20 am, the restrooms near rooms 13 and 15 were observed to have brown spots and smears on the toilets and inside of the toilet bowls.In an interview on 01/09/24, Staff 1 (Administrator) stated a housekeeper was just hired as of 01/08/24 and there was a maintenance worker making repairs in some of the resident rooms.The facility failed to keep the interior of the facility free from unpleasant odors and clean and in good repair.The findings were reviewed with and acknowledged by Staff 1, Staff 2 (Regional Director of Operations), Staff 3 (Assistant Administrator) and Staff 4 (RN) on 01/09/24.Verbal Plan of Correction: Maintenance was working on repairs. New housekeeper hired yesterday 01/08/24 and s/he would do carpet shampooing by the end of the week. If housekeeper was unable, will request from maintenance. Staff would clean resident wheelchairs 1x/week. Executive Director to do daily rounding 5 days/week and would document to ensure resident rooms with odors were being cleaned.

The findings of the kitchen inspection, conducted 09/20/23, 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.

The findings of the first revisit to the kitchen inspection of 09/20/23, conducted 11/08/23, 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 and interview, it was determined the facility failed to ensure the kitchen was clean, in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:On 09/20/23 the facility kitchen was observed to need cleaning in the following areas:a. Food spills, splatters, debris, dust, dirt, and black matter was observed on, inside, around or underneath the following: * Upper and lower shelves throughout the kitchen;* Gas range hood;* Black serving cart in between convection oven and three door freezer; and* Ice scoop bucket.b. Inside the walk-in refrigerator there were three dessert cups with gelatin and whipped cream and two cans of sliced pineapple uncovered and lacking proper labeling. The need to ensure the kitchen was clean, in accordance with the Food Sanitation Rules OAR 333-150-000, was discussed with Staff 1 (ED) and Staff 2 (Dining Services Director) on 09/20/23. They acknowledged the findings.

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 02/07/2023. 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 include the resident in the service planning team. Findings include the following:During an unannounced site visit on 02/07/2023 Compliance Specialist (CS) reviewed service plans for Resident #1-#3 (R1-R3). One service plan states resident refused to sign until they could meet with their case manager and the other two service plans did not have resident signatures or reasons for resident not signing. In an interview with Resident #3 (R3) it was stated that the facility had not gone over their care plan with them in over 6 months and the last time they went over it, they believe it was an old care plan.

Based on interview and observation it was confirmed that the facility failed to establish and maintain infection prevention and control protocols. Findings include the following:During an unannounced site visit on 02/07/2023 Compliance Specialist (CS) rang the front doorbell to gain entry into the facility. There were not any signs on the front door indicating directions for screening in or for COVID-19 symptoms. Front desk staff did not provide any directions for screening nor did CS observe any location for staff or visitors to screen in. CS observed multiple staff throughout the facility with their masks below their noses or worn at their chin including in resident care areas.In an interview with Staff #1 (S1) it was stated that there was a screening area but had to request screening documents from the front desk in order for CS to screen in at the screening station.

Based on interview and record review it was confirmed that the facility failed to ensure medication and treatment orders were carried out as prescribed. Findings include the following:During an unannounced site visit on 02/07/2023 Compliance Specialist (CS) reviewed Medication Administration Records (MARs) for Resident #1 and Resident #3 (R1 & R3) for December 2022 to current as well as progress notes. CS found instances of medication not available, scheduled medications not able to be given due to being too close to last administration and an alert charting for receiving the wrong resident ' s medications.In separate interviews with R1 and R3 the following was stated:· That the facility is administering medications late.· The facility is giving the wrong medications or not giving medications at all.

Based on record review, interview and observation it was confirmed that the facility failed to have sufficient staff to meet the scheduled and unscheduled needs of the residents. Findings include the following:During an unannounced site visit on 02/07/2023 Compliance Specialist (CS) reviewed facility call light logs for Resident #1-#3 (R1-R3) for 02/03-02/05/2023 which revealed instances of multiple calls over 15 minutes on all three residents call light reports, with eight calls exceeding 30 minutes.In an interview with Staff #1 (S1) it was stated that the facility expectation for call light response is five minutes or less.CS observed the swing shift come on and day shift leave, one staff member from swing called off and another would be coming in late. CS observed staff rearrange their schedule to try to ensure there was enough coverage for both sections of the facility. The posted staffing plan stated for day and swing shift there will be two med techs, one to two caregivers for A/B wing and six to seven caregivers for C wing and on NOC shift there will be one med tech, one caregiver for A/B wing and four caregivers for C wing. The facility was not staffed at that for swing shift on 02/07/2023.

Based on interview and record review it was confirmed that the facility failed to have a training program that includes methods to determine competency of direct care staff through evaluation, observation or written testing. Findings include the following:During an unannounced site visit on 02/07/2023 Compliance Specialist reviewed demonstrated competencies for Staff #3-#5 (S3-S5) which revealed one staff had a correctly and thoroughly completed competency checklist. One staff member had completed their checklist over three months past their hire date with no staff signature and the third staffs record revealed no completion dates on the checklist.In an interview with Resident #3 (R3) it was stated that new care staff were passing medications without proper training.Findings we shared with Staff #1 who acknowledged findings.

The findings of the kitchen inspection, conducted on 08/11/22, 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 first re-visit to the kitchen inspection of 08/11/22, conducted 11/04/22, are documented in this report. The facility was found to be 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, interview, and record review, it was determined the facility failed to ensure food was prepared in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:Observations of the kitchen, including food storage areas, food preparation, and food service, on 08/11/22 revealed:* A package of meat was thawing in a two-compartment sink without being in a container with cold water running over it;* The drain under the two-compartment sink located in the food preparation section of the kitchen had dark brown matter in it;* Although food temperatures were taken and the food tested within the correct range, staff were not using alcohol wipes to wipe the probe thermometer after use;* The steam table and cold storage container located in the food serving area had what appeared to be old food debris on top of the lids and on food contact surfaces;* The grill, stove top, and both ovens were in need of deep cleaning;* The warewasher had debris on the top and was in need of cleaning;* The warewasher used chemicals to sanitize, but testing strips did not work for the machine;* The toaster was sticky to the touch;* The standing mixer had dried-on food debris on it; and* The fan in the walk-in refrigerator had a thick layer of dust on it.The kitchen was toured with Staff 2 (Cook) on 08/11/22 at approximately 12:45 pm. The areas in need of cleaning were discussed with Staff 1 (ED) on 08/11/22 at approximately 1:00 pm. Both Staff 1 and Staff 2 acknowledged the findings.

The findings of the re-licensure survey conducted 11/15/21 through 11/18/21 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 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 11/18/21, conducted 02/22/22 through 02/24/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 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 day

The findings of the second re-visit to the re-licensure survey of 11/18/21, conducted 05/18/22 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 interview and record review, it was determined the facility failed to implement effective methods of responding to and resolving resident complaints. Findings include, but are not limited to:1. A review of Resident Council minutes dated 09/23/21 and 10/21/2021 revealed the following resident concerns:* "The kitchen needs to let us know about changes in the menu ahead of time. Not when caregivers take orders to residents ...";* "Too much frozen food, instant, high sodium foods";* "Would like some fresh fruit on snack tray ...";* "Clothes are coming up missing again ...";* "Too much instant/frozen food still. Too much processed food";* "Trouble getting help...seemed like hours...also meals late or not [delivered] frequently";* "Caregivers on phone in my room is becoming an issue";* "Shower curtain in shower rooms, need non-slip tiles in all bathrooms";* "Patio/deck doors need to be locked at night. All [three] of them are left open..";* "How does the financial situation of the company affect residents ...is there a problem that has led to the changes in the care and services?":* "Survey residents";* "Caregivers should always answer the call buttons within [five] minutes";* "Security, especially at night...smoking area is not safe at night"; and* "Does anyone know CPR?";There was no documented evidence the concerns identified during the meetings had been addressed, responded to or resolved.2. The survey team conducted resident interviews with multiple alert and oriented facility residents between 11/15/21 and 11/18/21. Some residents voiced concerns regarding the facility including equipment failure, dissatisfaction with call light responses, staffing and lack response from the Administrator regarding concerns. In an interview on 11/18/21, Staff 1 (Executive Director) stated she had not yet reviewed the Resident Council meeting notes from 10/21/21. The facility had no documented evidence showing follow-up to residents' concerns. She acknowledged the need to improve the facility's method for responding to and resolving resident complaints and concerns.The need to implement effective methods of responding to and resolving resident complaints was discussed with Staff 1, Staff 5 (Resident Care Coordinator), and Staff 6 (Resident Care Director) on 11/18/21. They acknowledged the findings.

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 included, but are not limited to:During the survey, conducted 11/15/21 through 11/18/21, quality improvement oversight to ensure adequate resident care, services and satisfaction was found to be ineffective.In an interview on 11/18/21, Staff 1 (Executive Director) confirmed the facility did not have a quality improvement plan in place.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, resident outcomes and resident satisfaction. This is a repeat citation. Findings included, but are not limited to:During the survey, conducted 02/22/22 through 02/24/22, quality improvement oversight to ensure adequate resident care, services and satisfaction was found to be ineffective.In an interview on 02/24/22, Staff 1 (Executive Director) acknowledged the facility did not have a quality improvement plan in place.Refer to the deficiencies in the report.

Based on interview and record review, it was determined the facility failed to ensure reasonable precautions were exercised against any condition that could threaten the health, safety, or welfare of residents. Findings include, but are not limited to:Five residents resided on C-Hall during the survey.In individual interviews on 11/15/21 and 11/18/21 with residents on C-Hall, they expressed concern that call lights were not answered in a timely manner, often exceeding 30 minutes. One resident stated that during the evening shift on 11/17/21, s/he waited over an hour for staff to answer his/her call light. S/he said s/he felt "neglected" as his/her incontinence brief was "soaked". S/he added that "this happens frequently ...It's affecting my quality of life." S/he said s/he reported the incident to Staff 6 (Resident Care Director). Review of the call log for the resident revealed s/he pressed the call button at 8:55 pm. It took 1 hour and 30 minutes before staff "resolved" or responded to the call. Call light response logs, for the time period of 11/01/21 through 11/18/21, were reviewed. The following was revealed:* Residents on C-Hall called 691 times for assistance; and * 228 of the 691 calls exceeded 15 minutes (33% of the time), with 70 of those calls exceeding 30 minutes. The above information was discussed with Staff 6 (Resident Care Director) on 11/18/21 at 2:55 pm. He was aware of the incident that occurred on 11/17/21. He added he was in process of his investigation of why it took so long for staff to respond to the resident's call light. The surveyor reviewed the call log with Staff 6. He said staff should be answering calls within 10 minutes. He acknowledged that response times were too long. He stated that he did not routinely audit the call logs/response times and was unaware of the numerous call times exceeding 15 minutes. The need to ensure call lights were answered in a timely manner was discussed with Staff 1 (Executive Director) on 11/18/21 at 3:10 pm. She reviewed the call logs and acknowledged the findings. She stated the system would be reviewed, audits performed and changes made to ensure calls were answered timely.

Based on interview and record review, it was determined the facility failed to ensure reasonable precautions were exercised against any condition that could threaten the health, safety, or welfare of residents. This is a repeat citation. Findings include, but are not limited to:During the survey conducted 2/22-2/24/22 five residents resided on the C-Hall. During the survey, call light response logs, for the time period of 02/01/22 through 02/23/22, were reviewed. The following was revealed:* Residents on C-Hall called 853 times for assistance; and * 362 of the 853 calls exceeded 15 minutes (42.4 % of the time), with 158 of those calls exceeding 30 minutes. In an interview on 02/24/22, Staff 9 (MT) and Staff 11 (CG) explained the call system used in the facility. Staff 9 reported that when a resident activated a call pendant, the call signal activated the medication technician computers (used in C-Hall). The call signal was audible as well as visual. The other medication technician computer (used in Halls A and B), however, did not receive the call signal. Staff 9 stated the MTs would use walkie talkies to communicate with staff if they saw a call had gone unanswered for an extended period. Staff 11 reported caregivers received call notifications on an "ipod" they would carry with them. The ipod did not have an audible tone. Caregivers were required to look at the ipod "every seven minutes" to check if a call pendant had been activated. Care givers also would carry walkie talkies to communicate with other staff to respond to call notifications.The need to ensure call lights were answered in a timely manner was discussed with Staff 1 (Executive Director) on 02/23/21. She reviewed the call logs and acknowledged the findings. She stated the system would be reviewed, audits performed by Staff 17 (Business Office Manager) and changes made to ensure calls were answered timely.

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 OAR 333-150-000. Findings include, but are not limited to:On 11/15/21 at 9:45 am, the facility kitchen was observed to need cleaning and repair in the following areas:a. Food spills, splatters, debris, dirt and black matter was observed on or underneath the following:* Wall, pipes and drain under dish machine;* Caulking behind dish machine;* Floor perimeter and tile edge in dish machine area; and * Knobs of ovens.b. The following areas needed repair:* Doors, frames and jambs were scraped and gouged; and * Walls in the dish machine area had several scraped areas.The areas that required cleaning and repair were observed and discussed on 11/15/21 with Staff 3 (Dining Services Director) and discussed with Staff 1 (Executive Director) on 11/16/21. The findings were acknowledged.

2. Resident 1 moved into the facility in 07/2021. The new move-in evaluation failed to address the following elements:* Personality, including how a person copes with change or challenging situations; and* Environmental factors that impact the resident's behavior including noise, lighting and room temperature.The need to ensure move-in evaluations included all required elements was discussed with with Staff 2 (RN) and Staff 5 (Resident Care Coordinator) on 11/17/21, and with Staff 1 (Executive Director) on 11/18/21. The findings were acknowledged.
Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 2 of 2 sampled resident (#s 1 and 3) and failed to complete 30-day evaluations for 1 of 2 sampled resident (#3). Findings include, but are not limited to:1. Resident 3 was admitted to the facility in 08/2021.The move-in evaluation failed to address the following:* Environmental factors that impact a resident's behavior including noise, lighting and room temperature. There was no documented evidence Resident 3's initial evaluation was updated and modified as needed during the 30 days following the resident's move into the facility. The failure to address all required areas in the move-in evaluation and to update or modify the evaluation within 30 days after move-in was discussed with Staff 2 (RN) on 11/17/21 and with Staff 1 (Executive Director), Staff 5 (Resident Care Coordinator) and Staff 6 (Resident Care Director) on 11/18/21. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and provided clear direction regarding the delivery of services for 2 of 4 sampled residents (#s 1 and 3) whose service plans were reviewed. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in 2021 with diagnoses including insulin dependent diabetes, a history of falls, skin breakdown and a urinary catheter. Review of Resident 1's clinical record, interviews with care staff and observations during the survey revealed s/he had a ½ siderail on the left side of the bed. Additionally, the resident needed assistance with ADL care, including emptying his/her catheter bag, but often refused the help.Resident 1's service plan, dated 11/10/21, revealed it was not reflective of the resident's needs and lacked clear direction regarding the delivery of services in the following areas:* Siderail use, including correct use and precautions related to the use of the device; and * Interventions when s/he refused care. The need to ensure the service plan was reflective of Resident 1's current care needs and provided clear direction to staff was discussed with Staff 2 (RN) and Staff 5 (Resident Care Coordinator) on 11/17/21, and with Staff 1 (Executive Director) on 11/18/21. The findings were acknowledged.
2. Resident 3 was admitted to the facility in 2021 with diagnoses including cerebrovascular accident. Observations of the resident and interviews with staff were conducted throughout the survey. The resident's 11/11/21 service plan, temporary service plans, and 8/4/21 through 11/15/21 progress notes were reviewed.The resident's current service plan was not reflective of the resident's needs and preferences and did not offer clear instruction for the staff in the following areas:* Mobility - regarding the resident's use of manual wheelchair, electric wheelchair and walker;* Sleeping routine-regarding the resident's preference to sleep in his/her electric wheelchair frequently; and* Siderail use-including associated risks. The need to ensure service plans were reflective of the resident's current needs and status and provided clear instruction to staff was discussed with Staff 1 (Executive Director), Staff 5 (Resident Care Coordinator), and Staff 6 (Resident Care Director) on 11/18/21. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' care needs and provided clear direction to staff regarding the delivery of service 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 in 2021 with diagnoses including chronic peripheral venous insufficiency and urinary tract infection.Observations of the resident, interviews with staff and review of the service plan and clinical records during the survey, from 02/22/22 thru 02/24/22, showed the service plan was not reflective of the resident's current care needs and failed to provide clear direction in the following:* Use of oxygen including setting;* Toileting status including use of a bedpan;* Transfer status;* Use of glasses; and* Use of side rails.On 02/24/22, service plans were discussed with Staff 1 (Executive Director) and Staff 16 (RN/Resident Care Director). They acknowledged the service plan was not reflective of the resident's status and lacked clear instructions.
1). Resident #5 returned to the community the evening of 02.21.2022 following a lengthy hospital stay related to COVID which resulted in a terminal condition. The resident's service plan was under review at the time of the re-survey.2). All resident service plans are currently under review to assure accuracy and personalization. Temporary service plans are available for use to notify all staff of changes as those changes occur. 3). Resident service plans are reviewed and revised quarterly and more often if needed.4). Compliance is assured by the Resident Care Coordinator, the SNC Program Director and the Excutive Director.

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 3 of 4 sampled residents (#s 1, 2 and 3). Findings include, but are not limited to:Resident 1, 2 and 3'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 (Executive Director), Staff 5 (Resident Care Coordinator) and Staff 6 (Resident Care Director) on 11/18/21. They acknowledged the findings.

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 2 of 3 sampled residents (#s 5 and 6). This is a repeat citation. Findings include, but are not limited to:Resident 5 and 6's most recent 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 (Executive Director) and Staff 16 (RN/Resident Care Director) on 02/23/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure short term changes of condition were monitored until resolution for 2 of 4 sampled residents (#s 1 and 2) who experienced short-term changes of condition. Findings include, but are not limited to:1. Resident 1 was admitted in 2021 and had diagnoses which included a urinary catheter, history of urinary tract infections (UTIs), falls and skin injuries.Resident 1's clinical record and charting notes, reviewed from 08/01/21 through 11/15/21, revealed the following:a. On 09/02/21, a MT charted in progress notes that the resident "shows signs of possible UTI." No further information, including documented monitoring until resolution, was noted. b. On 09/13/21, the resident sustained a "deep cut between [his/her] fourth toe and little toe on [his/her] left leg." Documentation indicated the facility treated the injury and initiated short-term change monitoring. However, no monitoring until resolution was documented for the change in condition.c. A progress note, dated 09/30/21, indicated the resident "hurt [his/her] foot on door, was bleeding ..." Although treatment was provided, there was no specific information about the wound or monitoring until resolution. d. On 10/06/21, staff noted that the resident had a small abrasion on top of the fourth toe on his/her right foot. The record revealed no documented monitoring of the wound at least weekly until resolved. In an interview on 11/17/21 at 4:30 pm, Staff 2 (RN) and Staff 5 (Resident Care Coordinator) stated they were unable to find documentation that the short-term changes in condition were monitored until resolved. The need to ensure the facility monitored short term changes of condition with weekly progress noted until resolution was reviewed with Staff 1 (Executive Director) on 11/18/21. She acknowledged the findings. 2. Resident 2 moved into the facility in 2019. His/her clinical record and charting notes, reviewed from 08/01/21 through 11/15/21, revealed the following:* On 08/15/21, the resident was "throwing up on this shift with diarrhea." Documentation indicated the facility initiated short-term change monitoring. However, no monitoring until resolution was documented.* On 09/30/21, staff reported that the resident had a "pale or lighter pigmented skin on [his/her] left inner thigh." Documentation indicated "care staff will continue to monitor." There was no documented on-going monitoring of the resident's skin condition until either resolved or it was determined that monitoring was no longer needed. In an interview on 11/18/21 at 8:20 am, Staff 6 (Resident Care Director) stated he was unable to find documentation that the conditions were monitored until resolved. The need to ensure the facility monitored short term changes of condition with weekly progress noted until resolution was reviewed with Staff 1 (Executive Director) on 11/18/21. She acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure residents were assessed by a facility RN in accordance with their conditions, findings documented, and interventions developed and implemented as a result of the assessment for 1 of 2 sampled residents (#1), who experienced a significant change of condition. Findings include, but are not limited to:Resident 4 was admitted to the facility in 2011 with diagnoses including cerebral palsy. The resident was receiving hospice services at the time of survey. The resident's 08/01/21 through 11/15/21 progress notes, 02/2021 through 11/2021 weight records, 09/14/21 service plan, multiple temporary service plans, 11/01/21 through 11/18/21 MAR and 11/04/21 evaluation were reviewed and revealed the following:The facility weight records noted the following:* 08/18/21-138.3 pounds.* 09/2021-no weight listed;* 10/13/21-121.8 pounds;* 10/14/21-130 pounds; and* 11/14/21-120.2 pounds.. Between 8/2020 and 11/2021 Resident 4 lost 18.1 pounds in three months or 13.8% of his/her body weight constituting a severe weight loss. There was no documented evidence the facility RN completed an assessment including findings, resident status, and interventions made as a result of the assessment. Observations of the resident during lunch on 11/17/21 and 11/18/21 showed the resident was able to partially feed him/herself. Staff would then assist him/her with the resident consuming 80% of the meal on 11/17/21 and 100% on 11/18/21. In an 11/18/21 interview with Staff 2 (RN), she confirmed she did not complete a thorough RN assessment regarding Resident 4's severe weight loss.The failure to ensure an RN assessment was completed for significant changes of condition was discussed with Staff 1 (Executive Director), Staff 5 (Resident Care Coordinator), and Staff 6 (Resident Services Director) on 11/18/21. They acknowledged the findings.

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 11/15/21, Resident 1 was identified to be administered insulin injections by non-licensed staff.Resident 1's MARs, reviewed from 11/01/21 through 11/15/21, revealed insulin had been given by Staff 9, 14 and 15 (MTs) on multiple occasions.Delegations for Staff 9 (MT) completed 09/16/21, Staff 14 (MT) completed 09/15/21, and Staff 15 (MT) completed 10/21/21, lacked documentation in the following areas:* A current nursing assessment and condition of the client;* The skills, ability and willingness of the unlicensed person;* That the unlicensed person was competent to safely perform the task of nursing care; and * That the RN took responsibility for delegating the task to the unlicensed person, and ensured that supervision would occur for as long as the RN was supervising the performance of the delegated task. The need to ensure staff who administered insulin injections was delegated in accordance with OSBN Division 47 Rules was discussed with Staff 2 (RN) on 11/17/21 at 4:00 pm. Staff 2 acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure a safe medication system ensuring adequate professional oversight. Findings include, but are not limited to:1. Refer to C 303 and C 310.
2. In interviews on 02/22/22 and 02/23/22, Staff 2 (RN) stated the facility had a special needs contract which covered one area of the facility. The RN was providing oversight of the clinical needs primarily for the residents in the contracted section of the facility. There was no other licensed nurse providing services at the facility. An interview with Staff 9 (MT) revealed the facility had a triple check system for medication orders and administration of medications. The MT who received orders from the physician would be the "first check" and was responsible for faxing the orders to the pharmacy. The MT who was on duty for the next shift would be the "second check" and the RCC would be the "third check". Staff 9 verified there was currently a vacancy in the RCC position and the "second check" was not being completed consistently. Furthermore, the medication orders were being forwarded to the RN, however, this system was not effective in producing a "third check".The need to have a medication administration system that was receiving professional oversight was discussed with Staff 1 (Executive Director) and Staff 16 (RN/Resident Care Manager) on 02/24/22. They acknowledged the findings.

2. Resident 5 moved into the facility in 2021 with diagnoses including deep vein thrombosis (a blood clot in a deep vein) and hypertension.a. Resident 5 had a physician's order, dated 12/03/21, to administer Carvedilol 6.25 mg for hypertension two times daily.Resident 5's 02/01/22 through 02/20/22 MAR revealed staff documented 25 mg of the medication was administered to the resident, not 6.25 mg.b. Resident 5 had a physician's order, dated 12/03/21, to administer Eliquis 2.5 mg two times daily.Resident 5's 02/01/22 through 02/20/22 MAR revealed staff documented 5.0 mg of the medication was administered, not 2.5 mg.c. Resident 5 had a physician's order, dated 12/03/21, to administer Gabapentin 100 mg at night daily.Resident 5's 02/01/22 through 02/20/22 MAR revealed staff documented 300 mg of the medication two times daily was administered, not 100 mg of the medication daily.d. Resident 5 had returned to the facility on 02/21/22 with a new order of Eliquis to administer 5.0 mg two times daily.Resident 5's 02/21/22 through 02/22/22 MAR revealed staff documented 2.5 mg of the medication was administered, not 5.0 mg.e. Resident 5 had returned to the facility on 02/21/22 with a new order of Gabapentin to administer 300 mg two times daily.Resident 5's 02/21/22 through 02/22/22 MAR revealed staff documented 100 mg of the medication two times daily was administered, not 300 mg.On 02/24/22, the physician orders and the MARs were reviewed with Staff 1 (Executive Director) and Staff 16 (RN/Resident Care Director). They acknowledged the findings.Surveyor: Gill, Lauren K.3. Resident 7's current physician's orders, dated 02/18/22, and MARs, dated 02/01/22 through 02/22/22, revealed the following medications were not given to the resident as ordered:a. Aspirin 81 mg, one time daily;* Levothyroxine 50 mg, one time daily;* Mirtazapine 15 mg, one time daily; and* Pantoprazole 40 mg, one time daily.b. Staff documented on the MAR Omeprazole and Trazadone was administered to the resident without a written order in the record.In an interview with Staff 9 (MT) at 1:15 pm on 02/23/22, s/he verified the current orders were not followed as prescribed and verified the lack of written orders.The need to ensure facility staff carried out all orders as prescribed was discussed with Staff 1 (Executive Director) and Staff 16 (RN/Resident Care Director) on 02/24/22. They acknowledged the findings. A request for order clarification and signed, written orders was sent to the physician on 02/23/22.
Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 3 of 3 sampled residents (#s 5, 6 and 7) whose orders were reviewed. Findings include, but are not limited to:1. Resident 6 was admitted in 2020 with diagnoses including schizophrenia and neurocognitive disorder.Resident 6 had physician's orders to titrate Clozapine for schizophrenia. The orders from 02/02/22 through 02/22/22 were reviewed.Resident 6's MARs, reviewed from 02/01/22 - 02/22/22, revealed the following orders were not followed:* On 02/08/22 and 02/09/22: orders were for 50 mg of Clozapine and staff administered 125 mg; * On 02/11/22 and 02/12/22: orders were for 75 mg of Clozapine and staff administered 125 mg; * On 02/13/22, 02/14/22, and 02/15/22: orders were for 100 mg of Clozapine and staff administered 125 mg; and* On 02/20/22: orders were for 125 mg of Clozapine and staff administered 100 mg.The need to ensure physician orders were followed as prescribed was reviewed with Staff 1 (Executive Director) and Staff 16 (RN/Resident Care Director) during the survey. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was maintained for all facility administered medications, including resident specific administration instructions and parameters for PRN medications for 2 of 4 sampled residents (#s 1 and 2) whose orders were reviewed. Findings include, but are not limited to:1. Resident 1 moved into the facility in 2021.Resident 1's MARs, reviewed from 11/01/21 - 11/15/21, revealed the following inaccuracies:* The MAR lacked parameters for PRN bowel medications bisacodyl suppository, Fleet enema, Milk of Magnesia and Miralax powder, regarding the sequential order of use;* PRN bisacodyl suppository and PRN Fleet enema lacked administration frequency;* Staff were instructed to apply hydrocortisone cream to rash area twice a day, and nystatin cream to red skin areas twice a day. The MAR lacked specific information indicating where the creams were to be applied; and * On 11/06/21, staff failed to document that medications were not administered because the resident was out of the facility. On 11/18/21, the need for the facility to ensure MARs were accurate and provided clear instruction to unlicensed staff was discussed Staff 2 (RN) and Staff 5 (Resident Care Coordinator) on 11/17/21, and with Staff 1 (Executive Director) on 11/18/21. The findings were acknowledged. 2. Resident 2 moved into the facility in 2019 with diagnoses which included anxiety and a history of skin breakdown. Review of Resident 2's MAR, dated 11/01/21 to 11/15/21, indicated the following deficiencies:* The resident had an order for Coloplast Brava powder to be applied under the arm twice a day for yeast infection. The MAR lacked the name of the medication; and * S/he had an order for Buspirone 10 mg one tablet three times a day PRN anxiety. The MAR failed to note the frequency and also instructed staff to give one "swab orally" versus one "tablet" as ordered.On 11/16/21, the need to maintain an accurate MAR for all medications administered by the facility was discussed with Staff 6 (Resident Care Director). He reviewed the MAR and acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was maintained for all facility administered medications, including resident specific administration instructions and parameters for PRN medications for 1 of 3 sampled residents (#5) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to:Resident 5 moved into the facility in 2021.Resident 5's MARs, reviewed from 02/01/22 - 02/22/22, revealed the following inaccuracies:* PRN bisacodyl suppository lacked administration frequency;* Staff documented they administered multiple medications to the resident on 02/09/22, 02/07/22, 02/08/22, 02/10/22, 02/11/22, 02/13/22, 02/15/22 and 02/16/22 when the resident was at the hospital, not in the facility; and* The MAR revealed to administer "Medication Order" 2 tablets orally as needed for constipation. The MAR lacked specific information indicating what medication was to be administered.On 02/24/22, the need to maintain an accurate MAR for all medications administered by the facility and to ensure MARs were accurate and provided clear instruction to unlicensed staff was discussed with Staff 1 (Executive Director) and Staff 16 (RN/Resident Care Director). The findings were acknowledged.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly-hired direct care staff (#s 12, 13 and 15) completed all required pre-service orientation including pre-service dementia training prior to beginning their job responsibilities. Findings include, but are not limited to:Training records were reviewed on 11/17/21.Staff 12, 13 and 15 (CGs), hired on 09/07/21, 09/07/21 and 08/30/21 respectively, lacked documented evidence of completing all required elements for pre-service orientation including pre-service dementia training prior to assuming job duties.The need to ensure required pre-service orientation was completed prior to newly hired direct care staff beginning their job responsibilities was reviewed with Staff 1 (Executive Director), Staff 5 (Resident Care Coordinator) and Staff 6 (Resident Care Director) on 11/18/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 12, 13 and 15) had documented demonstration of competency in all required areas within 30 days of hire. Findings include, but are not limited to:Review of staff training records on 11/17/21 revealed Staff 12, 13 and 15 (CGs), hired on 09/07/21, 09/07/21 and 08/30/21 respectively, lacked the following documentation of demonstrated competencies within 30 days of hire:* Role of service plans in providing individualized care;* Providing assistance with ADLs;* Changes associated with normal aging;* Identification, documentation and reporting of changes of condition;* Conditions that require assessment, treatment, observation and reporting;* General food safety, serving and sanitation; and * First aid and abdominal thrust.The need to ensure all newly hired staff demonstrated competency in all required training topics within 30 days of hire was discussed with Staff 1 (Executive Director), Staff 5 (Resident Care Coordinator) and Staff 6 (Resident Services Director) on 11/18/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 long-term staff (#s 10 and 11) completed 12 hours of annual in-service training including 6 hours of training in dementia care. Findings include, but are not limited to: Annual in-service training records were reviewed on 11/17/21. Staff 10 (CG/Med Tech) and Staff 11 (CG) lacked documentation of a minimum of 12 hours annual in-service training, which included six hours of dementia care training.The need to ensure long term staff had 12 hours of annual in-service training, including six hours of dementia care training, was discussed with Staff 1 (Executive Director), Staff 5 (Resident Care Coordinator) and Staff 6 (Resident Care Manager) on 4/21/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to conduct unannounced fire drills every other month at different times of the day, evening and night shifts, failed to include required components on fire drill records, and failed ensure fire and life safety instruction was provided to staff on alternate months. Findings include, but are not limited to:Fire and life safety records, reviewed between 05/2021 - 10/2021, revealed the following:* One fire drill had been completed during the six-month time frame reviewed; * Fire drill records lacked the following components:- Escape route used; - Number of occupants evacuated; 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 11/16/21 at 2:45 pm. She acknowledged the findings. No further information was provided.

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements were being met. Findings include, but are not limited to:Fire and life safety records were requested during the survey. The following deficiencies were identified:* Documentation that fire and life safety training was provided to residents within 24 hours of move-in; * Documentation that annual fire and life safety training was provided to residents, including all required training topics; and * Alternate exit routes were used during fire drills.The need to ensure residents received fire and life safety training within 24 hours of admission, were re-instructed at least annually, and alternate exit routes were used during fire drills was discussed with Staff 1 (Executive Director) on 11/16/21 at 2:45 pm. She acknowledged the findings. No further information was provided.

Based on interview and record review, it was determined the facility failed to have an emergency preparedness plan that included analysis and response to emergency hazards in event of a prolonged power failure, and failed to conduct a drill of the emergency preparedness plan at least twice a year. Findings include, but are not limited to:During individual interviews with residents on 11/15/21 and 11/18/21, they expressed concern that the facility did not have an emergency plan in the event of a power outage. In an interview with Staff 1 (Executive Director) on 11/18/21 at 11:30 am, the survey team requested:* The facility's emergency preparedness plan in the event of a prolonged power outage; and* Documentation of facility emergency preparedness drills. Staff 1 reviewed the facility's Emergency Preparedness binder and reported the following:* The plan/steps staff were to follow for utility outage was blank; and* The facility had not conducted emergency preparedness drills.The need to ensure the facility developed an emergency preparedness plan that included analysis and response to emergency hazards in event of a prolonged power failure, and to conduct a drill of the emergency preparedness plan at least twice a year was reviewed with Staff 1. She acknowledged the findings.

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 160, C 260, C 262, C 310 and C 513.

Based on observation and interview, it was determined the facility failed to ensure the environment was clean, maintained in good repair, and free from unpleasant odors. Findings include, but are not limited to:Observations of the facility on 11/15/21 through 11/18/21 revealed the following areas were in need of cleaning and/or repair:* The handrail between Resident Rooms 25 and 26 had a patch of rough exposed wood and was not a cleanable surface; * Multiple walls, doors and door frames throughout the facility and pillars in the dining area were gouged, scrapped and chipped; * There was extensive damage to the wall outside of Resident Room 5 as well as interior walls, bathroom door, door frame and bathroom walls;* Window sills throughout the facility were in need of cleaning;* Cabinets in the dining area were in need of cleaning with dust on the outer surfaces and food particles and other debris on the shelves;* The carpet throughout the facility was stained in multiple areas;* There was a pervasive unpleasant odor of urine in the hall near Resident Room 30 throughout the day on 11/18/21; and * Resident Room 15 had scrapes and gouges in the bathroom door and frame, a black stained area was visible on the carpet next to the bed, and the room had a strong urine odor.The need to ensure the environment was clean, in good repair and free from unpleasant odors was discussed with Staff 1 (Executive Director), Staff 5 (Resident Care Coordinator) and Staff 6 (Resident Care Director) on 11/18/21. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure the environment was clean, maintained in good repair, and free from unpleasant odors. This is a repeat citation. Findings include, but are not limited to:Observations of the facility on 02/22/22 and 02/23/22 revealed the following areas were in need of cleaning and/or repair:* There was extensive damage in Resident Room 5 to the bathroom door frame;* The carpet throughout the facility was stained in multiple areas; and * Resident Room 15 had scrapes and gouges in the bathroom door and frame, a black stained area was visible on the carpet next to the bed, and the room had a strong urine odor.The need to ensure the environment was clean, in good repair and free from unpleasant odors was discussed with Staff 1 (Executive Director) and Staff 18 (Maintenance Director) on 02/24/22. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure exit doors were equipped with an alarming device or other acceptable system to alert staff when residents exited the building. Findings include, but are not limited to:Observations during the survey revealed exit doors in the facility lacked alarms or other acceptable systems to alert staff when residents exited. In an interview on 11/15/21, Staff 1 (Executive Director) confirmed the facility lacked an alarming device or other acceptable system to alert staff when all residents exited the building. The need to ensure exit doors were equipped with an alarming device or other acceptable system to alert staff when residents exited the building was discussed with Staff 1, Staff 5 (Resident Care Coordinator) and Staff 6 (Resident Care Director) on 11/18/21. They acknowledged the findings.