Barbur Vista Residential Care

The findings of the re-licensure survey conducted 03/25/24 through 03/27/24 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations. Abbreviations possibly used in this document:ADL: activities of daily 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 03/27/24, conducted 08/13/24 through 08/14/24, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.Abbreviations possibly used in this document:ADL: activities of daily 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 revisit to the re-licensure survey of 03/27/24, conducted 10/10/24, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Based on observation and interview, it was determined the facility failed to ensure a resident's right to receive services in a manner that protected privacy and dignity for 1 of 1 unsampled resident who received ADL care. Findings include, but are not limited to:An observation conducted at 12:12 pm on 03/26/24 revealed the following:Staff 9 (CG) entered Room 1 and stated to the unsampled resident that it was time to go to lunch. Staff 9 then stated, "You're wet. I need to change you." He proceeded to provide incontinent care for the unsampled resident while the door to the resident's room was open and the care provided was in view of the hallway.The need to ensure residents had the right to receive services in a manner that protected privacy and dignity was discussed with Staff 1 (Executive Director) and Staff 2 (RN) on 03/27/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure resident service plans were reflective of resident needs, were readily available to staff, and provided clear direction to staff regarding the delivery of services for 3 of 4 sampled residents (#s 1, 2, and 4) whose service plans were reviewed. Findings include, but are not limited to:1. Resident 4 was admitted to the facility in 01/2024 with diagnoses that included ataxic gait and chronic pain. The service plan available to staff was dated 01/09/24.Resident 4 was out of the facility between 01/20/24 and 3/11/24. The resident returned to the facility with several changes including:* Smoker;* Fall risk;* Safety checks two times per shift;* Pain in right shoulder, neck; and* Non-pharmalogical interventions for pain: rest, ice pack, PRN medication.A review of the resident's clinical record showed the most current service plan was dated 03/11/24. The service plan was not available to direct care staff for review. The need to ensure service plans were available to care staff was discussed with Staff 1 (ED), Staff 2 (RN), and Staff 3 (Resident Care Director) on 03/27/24. They acknowledged the findings.
2. Resident 2 was admitted to the facility in 10/2023 with diagnoses including Parkinson's Disease. The resident's current service plan dated 01/25/24 and temporary service plans were reviewed, interviews were conducted, and observations were made. The service plan was not reflective of the resident's needs and preferences in the following areas:* Supportive devices including use of four-wheeled walker and wheelchair;* Ambulation status;* Transfer status;* Evacuation assistance;* Activities;* Use of glasses/vision status;* Grooming assistance; and* Toileting assistance.The need to ensure service plans were reflective of residents' needs and preferences was discussed with Staff 1 (Executive Director) and Staff 2 (RN) on 03/27/24. They acknowledged the findings.3. Resident 1 was admitted to the facility in 08/2023 with diagnoses including Lewy body dementia. The resident's current service plan dated 02/23/24 and temporary service plans were reviewed, interviews were conducted, and observations were made. The service plan was not reflective of the resident's needs and preferences in the following areas:* Communication status; * Fall history; and* Use of a catheter.The need to ensure service plans reflected residents' needs and preferences was discussed with Staff 1 (Executive Director) and Staff 2 (RN) on 03/27/24. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to establish and maintain infection prevention and control protocols to provide a safe, sanitary, and comfortable environment for multiple sampled and unsampled residents during ADL care and meal service. Findings include, but are not limited to:Observations made from 03/25/24 to 03/26/24 revealed the following:1. Observations of lunch service on 03/25/24 and 03/26/24 revealed multiple universal caregivers served food and provided direct feeding to residents without donning a protective barrier over potentially contaminated clothing.2. Staff 9 (CG) and Staff 15 (CG) were observed at 12:00 pm on 03/26/24. Staff 15 entered Room 8 wearing single use gloves, assisted the resident with transferring, then exited the room. She did not remove the gloves or perform hand hygiene after leaving the room. Staff 9 and Staff 15 entered Room 4 wearing single use gloves and assisted the resident with repositioning in bed. They exited the room, doffed the single use gloves, and donned clean gloves without performing hand hygiene. They both began serving residents and carrying food from the kitchen pass to dining room tables.3. Staff 9 was observed providing incontinent care to an unsampled resident at 12:12 pm on 03/26/24. He entered the room wearing single use gloves and began assisting the resident with a brief change. He changed the soiled briefs and pants, then donned cleaned briefs and pants without removing soiled gloves and performing hand hygiene first. He then exited the room wearing the soiled gloves, removed them in the dining room, and donned new gloves without performing hand hygiene. He then began serving food to residents in the dining room.4. Staff 11 (CG) was observed walking out of a resident's room with incontinent trash at 12:39 pm on 03/26/24. She disposed of the trash, doffed soiled gloves, and walked into another resident's room without performing hand hygiene.The need to establish and maintain infection prevention and control protocols to provide a safe, sanitary, and comfortable environment was discussed with Staff 1 (Executive Director) and Staff 2 (RN) on 03/27/24. They acknowledged the findings.
Based on observation and interview, it was determined the facility failed to maintain effective infection prevention and control protocols to provide a safe, sanitary and comfortable environment for multiple sampled and unsampled residents. This is a repeat citation. Findings include, but are not limited to:Observations made from 08/13/24 to 08/14/24 revealed the following:a. Observations of lunch service on 08/13/24 revealed multiple universal caregivers served food to residents without donning a protective barrier over potentially contaminated clothing, and delivered meals to unsampled residents in their rooms without covering the food to prevent potential contamination.b. Staff 18 (CG) was observed walking out of a resident's room with incontinent trash and single use gloves at 2:22 pm on 08/14/24. She was observed touching multiple surfaces with the soiled gloves. She disposed of the trash, doffed soiled gloves, and walked into another resident's room and assisting the resident with transferring without performing hand hygiene. The need to maintain effective infection prevention and control protocols was discussed with Staff 17 (Owner) at 9:15 am on 08/14/24. He acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to carry out treatment orders as prescribed for 1 of 1 sampled resident (#2) who had diet orders. Findings include, but are not limited to:Resident 2 was admitted to the facility in 10/2023 with diagnoses including Parkinson's disease and was identified during the acuity interview as receiving hospice services. The resident's service plan dated 01/25/24, temporary service plans, and physician orders dated 10/25/23 and 02/27/24 were reviewed, observations were made, and interviews were conducted. The following was identified:a. The resident had a physician order for a pureed diet. The International Dysphagia Diet Standardization Initiative (IDDSI) described a pureed diet as a Level 5 diet. It must not contain lumps, and must not be sticky. At 1:00 pm on 03/25/24 and 12:23 pm on 03/26/24, staff were observed to feed the resident. The texture of the food was sticky as evidenced by large portions clinging to the spoon and had visible lumps in it. b. The resident had a physician order for "[s]tart Thick-It [a product which thickens liquids] - follow package directions until the liquid drink is nectar thick in consistency." Observations made on 03/25/24 and 03/26/24 revealed staff provided the resident with non-thickened ice water from the kitchen tap on multiple occasions. No staff were observed thickening the resident's liquids as instructed on the order.The need to ensure treatment orders were carried out as prescribed was discussed with Staff 1 (Executive Director) and Staff 2 (RN) on 03/27/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and contained reasons for use, for 3 of 4 sampled residents (#s 1, 2, and 3) whose medications were reviewed. Findings include, but are not limited to:1. Resident 3's 03/01/24 through 03/25/24 MAR was reviewed and identified 12 medications that lacked a reason for use. In an interview on 03/26/24, Staff 6 (MT) stated she did not know why the pharmacy sent the prescriptions over without a reason for use. In an interview with Staff 1 (ED) on 03/27/24, discussed that facility RN can also add reasons for use to MAR.The need to ensure accurate MARs included reasons for use was discussed with Staff 1, Staff 2 (RN), and Staff 3 (Residential Care Director) on 03/27/24. They acknowledged the findings.
2. Resident 1 was admitted to the facility in 08/2023 with diagnoses including Lewy body dementia. The resident's 03/01/24 to 03/25/24 MARs and physician orders dated 03/19/24 were reviewed. Eight medications lacked a reason for use.The need to ensure an accurate MAR that included minimum requirements was discussed with Staff 1 (Executive Director) on 03/27/24. She acknowledged the findings.3. Resident 2 was admitted to the facility in 10/2023 with diagnoses including Parkinson's disease. The residents 03/01/24 to 03/25/24 MAR and physicians orders dated 12/29/23 were reviewed. Six medications lacked a reason for use.The need to ensure an accurate MAR that included minimum requirements was discussed with Staff 1 (Executive Director) and Staff 2 (RN) on 03/27/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 sampled staff (#s 6 and 14) completed 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care setting, including six hours on dementia care and the annual infection control training. Findings include, but are not limited to:Staff training records were reviewed on 03/26/24. Staff 6 (MT), hired 11/20/20, and Staff 14 (CG), hired 11/16/21, lacked documentation of completing annual infection control training and six hours of annual dementia care in-service training in the most recent calendar year. In an interview on 03/26/24, Staff 1 (ED) stated Staff 6 and Staff 14 had attended monthly staff meetings with training topics but acknowledged all the annual training had not been completed.On 03/26/24, the need to ensure all direct care staff completed 12 hours of annual required training, including six hours on dementia care and annual infection control training, was discussed with Staff 1. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to conduct fire drills according to the Oregon Fire Code. Findings include, but are not limited to:Fire drill records dated 10/2023 to 03/2024 were reviewed with Staff 1 (Executive Director) at 1:37 pm on 03/26/24. There was no documented evidence the facility was completing the following:* Conducting unannounced fire drills every other month; and* Keeping a written record of the number of occupants evacuated, time to evacuate, and problems encountered relating to residents who resisted or failed to participate in fire drills.During the record review, Staff 1 stated the facility was conducting fire drills every three months, and they were not evacuating any residents during the drills.The need to ensure the facility conducted fire drills according to Oregon Fire Code was discussed with Staff 1 on 03/27/24. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure annual reinstruction of fire and life safety procedures to residents according to Oregon Fire Code. Findings include, but are not limited to:During an interview at 1:44 pm on 03/26/24, Staff 1 (Executive Director) stated the facility had not developed a system to complete annual reinstruction to residents regarding the facility's fire and life safety procedures. Therefore, there was no documentation to review.The need to ensure documentation of annual reinstruction of the facility's fire and life safety procedures to residents was discussed with Staff 1 on 03/27/24. She acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure annual re-instruction of fire and life safety procedures to residents according to Oregon Fire Code. This is a repeat citation. Findings include, but are not limited to:On 08/13/24 at 2:08 pm, Staff 16 (Office Manager) stated there was a system discussed for the annual re-instruction of fire and life safety procedures to residents, but there was no documentation that a system had been implemented. On 08/14/24 at 11:06 am, Staff 17 (Owner) and Staff 3 (Residential Care Director) confirmed the lack of documentation of annual re-instruction of fire and life safety procedures to residents. The need to ensure documentation of annual re-instruction of the facility's fire and life safety procedures to residents was discussed with Staff 17 and Staff 3 on 08/14/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure the relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to C295, C422, C513, and C530.

Based on observation and interview, it was determined the facility failed to ensure locked storage for chemicals, and other toxic materials. Findings include, but are not limited to:The facility was toured at 10:15 am on 3/25/24. Observations revealed bleach and other chemical cleaners in unlocked storage in the following areas:* Cottage 'A' laundry room; and* Cottage 'B' basement kitchenette under the sink.The need to ensure locked storage for chemicals and other toxic materials was discussed with Staff 1 (Executive Director) on 03/27/24. She acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure the interior was maintained in clean and good repair and free from unpleasant odors. Findings include, but are not limited to:The interiors of Cottage 'A' and Cottage 'B' were toured at 10:15 am on 03/25/24. The following was identified:1. Facility-wide, there was a buildup of dust, dirt, splashes, stains, and black scuffs on the walls, doors, door frames, ceiling fans, vents, ledges, and baseboards.2. In Cottage 'A,' the following was observed:* An unpleasant odor in the hall near Rooms 3 and 4 that did not dissipate;* The couch in the activities area was badly stained;* A wood arm chair in the activities area had a broken arm;* A lounge chair outside of Room 6 was badly stained;* The baseboards in the laundry room and the door frame in the shower room across from the laundry room were warped with water damage;* The carpet in the hall of the laundry room had large stains; and* The bottom ledge in the shower room across from the laundry room was peeling away from the floor.3. In Cottage 'B,' the following was observed:* The main entrance door was rusted on the inside and the outside;* The interior door frame of the main entrance door was chipped on both sides on the bottom;* The laundry room had a strong mildew odor that did not dissipate;* The bathmat in the basement shower room was worn with black matter around the edges;* The shower rod in the basement shower room was rusted;* There was an inch-wide crack between the basement shower room floor and the hall floor; and* There was an unpleasant odor in the hall outside of Room 12 in the basement that did not dissipate during the survey.The need to ensure the facility was maintained clean and in good repair and free from unpleasant odors was discussed with Staff 1 (Executive Director) on 03/27/24. She acknowledged the findings.
Based on observation and interview, it was determined the facility failed to ensure the interior was maintained in clean and good repair and free from unpleasant odors. This is a repeat citation. Findings include, but are not limited to:The facility was toured on 08/13/24 at 9:45 am. The following was identified:1. Facility-wide, there was a buildup of dust, dirt, splashes, stains, and black scuffs on the walls, doors, door frames, vents, ledges, and baseboards.2. In Cottage 'A,' the following was observed:* The couch in the activities area was stained and torn;* The baseboards in the laundry room and the door frame in the shower room across from the laundry room were warped with water damage; and* The carpet throughout the building was stained.3. In Cottage 'B,' the following was observed:* The main entrance door was rusted on the inside and the outside;* The interior door frame of the main entrance door was chipped on both sides on the bottom; * The white couch in the sun room had stains on the front, seat, and arms; and* There was an unpleasant odor in the hall outside of Room 12 in the basement that did not dissipate during the survey.The building was toured with Staff 17 (Owner) and the areas needing cleaning and repair as well the area with unpleasant odors were reviewed. He acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure soiled linens and soiled clothing were washed with a minimum rinse temperature of 140 degrees Fahrenheit or a chemical disinfectant. Findings include, but are not limited to:The facility's March temperature logs were reviewed at 2:00 pm on 03/26/24. The logs indicated the facility washing machines rinse temperatures ranged from 115 to 118 degrees Fahrenheit. During an interview at 2:14 pm on 03/26/24, Staff 16 (Office Manager) confirmed the facility was not using a detergent that contained disinfectant for soiled laundry.The need to ensure a minimum rinse temperature of 140 degrees Fahrenheit or use of a chemical disinfectant for soiled linen and clothing was discussed with Staff 1 (Executive Director) on 03/27/24. She acknowledged the findings.
Based on observation and interview, it was determined the facility failed to ensure washers for soiled laundry had a minimum rinse temperature of 140 degrees Fahrenheit unless a chemical disinfectant was used. This is a repeat citation. Findings include, but are not limited to:Observations of the Cottage B laundry room and janitorial closet were made at 11:54 am on 08/13/24. The washing machine did not have a temperature gauge to ensure a rinse temperature of 140 degrees Fahrenheit. There was no disinfectant observed in either the laundry room or the closet.During an interview at 11:55 am on 08/13/24, Staff 18 (CG) stated she used one detergent for all laundry. The detergent did not contain a disinfectant. During an interview at 12:05 pm on 08/13/24, Staff 13 also confirmed she used one detergent for all laundry that did not contain a disinfectant.The need to ensure to ensure washers for soiled laundry had a minimum rinse temperature of 140 degrees Fahrenheit unless a chemical disinfectant was used was discussed with Staff 17 (Owner) at 9:43 am on 08/14/24. He acknowledged the findings.

The findings of the kitchen inspection, conducted 01/30/23, 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 OARs 333-150-0000.
The findings of the first revisit to the kitchen inspection of 01/30/23, conducted 05/18/23, 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 OARs 333-150-0000.



The findings of the second revisit to the kitchen inspection of 01/30/23, conducted 07/06/23, 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 OARs 333-150-0000.


The findings of the third revisit to the kitchen inspection of 01/30/23, conducted 09/15/23, 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 food was prepared, and the kitchen was maintained, in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:Observations of the facility main kitchen in Building A, service kitchen in Building B, food storage areas, food preparation, and food service on 01/30/23 revealed:*Building A: - The garbage in the food prep area had no lid; - Interior and behind the ovens had a buildup of grease and debris; - Interior of the freezer and refrigerator has spills and splatters; - A dish rack was stored on the floor; - The prep area back-splash had spills and splatters; and - Multiple bins had scoops with handles in the food.*Building B: - Multiple drawer interiors had spills, splatters, and debris; - Multiple cupboards were damaged, creating and uncleanable surface and had spills, splatters, and debris; and - The dishwasher was removed and staff were hand washing dishes without sanitizing them. The facility began transporting dishes to Building A for sanitation.The kitchens were toured with Staff 2 (Head Chef). She acknowledged the areas in need of cleaning.The areas in need of cleaning and repair were reviewed with Staff 1 (Executive Director). She acknowledged the findings.
Based on observation and interview, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to:Observations of the facility's main kitchen in Building A, service kitchen in Building B and food storage areas on 05/18/23 revealed:Building A: * Interior of the ovens had a buildup of grease and debris;* A dish rack was stored on the floor;* The prep area backsplash had spills and splatters; and* Walls, flooring, pipes and electrical outlets around the sink had spills and splatters.Building B:* Multiple drawer interiors and exteriors had spills, splatters and debris; * Multiple drawers and cupboards were damaged with particle board exposed creating uncleanable surfaces; * Cupboard door below sink was broken; and * Multiple cupboards had spills, splatters, garbage and debris.The areas in need of cleaning and repair were observed and reviewed with Staff 1 (Executive Director) on 05/18/23. She acknowledged the findings.
Building A:- Interior of the ovens has been cleaned and ad to daily cleaning schedule . ED will perform a weekly check to ensure tasks are completed.-Extra Dish rack was removed . -the perp area backsplash was cleaned and ad to daily cleaning schedule.ED will perform a weekly check to ensure tasks are completed.-Wall, flooring, pipes and electical outlet, aroung sink area was cleaned and ad to dailt cleaning schedule, ED will perform a weekly check to ensure tasks are completed. Bulding B:-There is a cleaning plan in place with daily chores for the employees to complete. The ED will perform a weekly check to ensure tasks are completed.-The broken cabinets were taken out, and we covered the unusable cabinets with plastic sheets until our remodeling was finished in three to six months.-All dishes will be washed in the cottage A. While we are waitting for our remodeling to be finished in three to six months.


Based on observation and interview, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to:Observations of the facility's main kitchen in Building A, service kitchen in Building B and food storage areas on 07/06/23 revealed:Building A: * The bottom left corner of the dishwashing sink was leaking water.Building B:* Some cupboards with exposed particle board had been repaired. However, the majority still had exposed particle board rendering the surfaces uncleanable and the material used to cover the broken cupboards was a rough, uncleanable plywood; * The cupboard door below sink was broken; * Multiple cupboard interiors had spills, splatters, garbage and debris;* The gap between floor and stove had black matter buildup, dust, and food debris;* The space between the sink and the countertop had black matter buildup; and* The counter and backsplash behind the sink had a half-inch gap.The areas in need of cleaning and repair were observed and reviewed with Staff 1 (Executive Director) on 07/07/23. She acknowledged the findings. Cottage A- The left-bottom corner of the sink used for washing dishes is repaired. Cottage B:-The damaged cabinets were removed, and we painted and covered them with plywood until our renovation project was complete, which took three to six months.-There is a cleaning schedule for staff to follow. To make sure chores are finished, the ED will conduct a weekly check.-The space between the floor and the stove was cleaned, and the cover was replaced. -New caulking was applied between the countertop and backsplash as well as the sink and countertop.

Based on observation and interview, it was determined the facility failed to ensure the kitchen inspection survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to C 240.

Based on observation and interview, it was determined the facility failed to ensure the kitchen inspection survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include, but are not limited to:Refer to C 240.

Based on interview, observation and record review, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents. Findings include, but are not limited to:During the unannounced site visit on 5/28/21 at 2:37 am and again on 6/3/21 during day shift, multiple Oregon Department of Human Services infection control guidelines, which were established to protect the facility staff and residents from the spread of COVID-19 and made available to all facilities, were not being followed by the facility. Deficiencies that were identified included, but were not limited to:On 5/28/21, Compliance Specialists (CS) were not screened in at any time during their visit and Staff #3 was observed with his/her mask down upon entering the facility. On 6/3/21, staff were not wearing eye protection and the facility was under an Executive Order for confirmed or suspected COVID. Review of screening logs on 5/28/21 reveal not all staff were screened in prior to working. On 6/3/21, the above findings were discussed with Staff #1-2, who were in agreement.

Based on interview and record review, it was confirmed the facility failed to give medications as prescribed. Findings include: During onsite visit on 6/3/21, Compliance Specialist (CS) reviewed 06/2021 Medication Administration Records (MAR) for Resident #1-3 and found multiple instances where medications were not given as prescribed. MAR documentation noted some medications were not given due to medication not being available. The above findings were discussed with Staff #1-2, who were in agreement.

Based on interview, observations, and record review, it was confirmed the facility failed to ensure adequate staffing to meet residents scheduled and unscheduled needs. Findings include: During onsite visit on 5/28/21 at 2:37 am Compliance Specialist (CS) observed Cottage B to have 1 CG onsite and Cottage A to have 1 CG and 1 MT onsite. During onsite visit on 6/3/21 at 10:00 am the facility had 1 CG in Cottage B, 1 CG in Cottage A, and a MT who was passing medications in both cottages, along with a MT in training. Resident #1's room was not clean, the bathroom toilet was dirty and there were piles of laundry sitting in the corner. Review of Facility Posted Staffing plan indicated that there should be 2 MT and 2 CG in each cottage during NOC shift and 2 MT and 4 CG during day shift. Review of Staff Schedules and Timecards for random days between 04/2021 and 06/03/2021 reveal there are multiple days when the posted staffing plan is not followed. There also appears to be times when there is only 1 direct care staff in Cottage A and 1 direct care staff in Cottage B (2 direct care staff). Staff schedules show staff scheduled prior to times they were employed at the facility. Review of Activities Calendar shows there should be activities 7 days a week. There is no acuity report to be reviewed. Resident #1's Service Plan indicated the facility is responsible to clean the residents room and do his/her laundry. During separate interviews on 05/20/21, 5/28/21, and 6/3/21 with Staff #1-9, Resident #1 and Resident #3 and Witness #1-3 the following was stated: There are sometimes no staff members in cottage B. Staff members sleep on couches or chairs when working in the middle of the night. I am here a lot during NOC shift, but I sometimes sleep. The call light was pulled but no one answered, there was no one in the cottage to assist residents. There is no acuity report. We are working on getting Service Plans current. I am experimenting with staffing schedules. Service Plans are not all up to date. There are two person transfers in Cottage A and Cottage B. There was no activities staff for a few months. Activities scheduled when the activities staff are not here should be done by the caregiving staff. Direct caregivers are responsible for doing housekeeping, laundry, plating and cleaning up the dishes after meals, as well as all caregiving tasks. I couldn't find all of the staff schedules, so I tried to recreate them when you asked. The above findings indicate the facility is not basing staffing on resident acuity or service plans and is not meeting residents needs. This information was reviewed with Staff #1 and #2, who were in agreement.

Based on interview, observation and record review, it was confirmed the facility failed to ensure equipment was in good repair. Findings include: During onsite visit on 6/3/21, Compliance Specialist (CS) observed the following: *Cottage A's common area toilet did not flush. *Cottage A's laundry room had a washer or dryer that was nonfunctioning and had the front door removed. *Cottage B call light in the common area upstairs bathroom immediately turned off when pulled and let go. *Cottage B call light in the common area downstairs bathroom immediately turned off when pulled and let go. *Cottage B call lights for both upstairs and downstairs common area bathrooms alert to another area if the cord was continuously pulled. CS asked to review Maintenance Logs, and they were not filled out and there was no clear system in place to ensure maintenance staff gets alerted to and resolves maintenance issues found in the building. The above findings were discussed with Staff #1 and Staff #2, who were in agreement.

The findings of the re-licensure survey conducted 2/22/21 through 2/24/20 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 cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day
The findings of the first re-visit to the re-licensure survey of 2/24/21, conducted 6/21/21 through 6/22/21, 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 cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day



The findings of the second re-visit to the re-licensure survey of 2/24/21, conducted 9/8/21, 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 observations and interviews, it was determined the facility failed to implement effective methods of infection control and to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents. Failure to implement recommendations placed residents at risk for exposure to the COVID-19 virus. Findings include, but are not limited to:1. Observations were made during the survey to determine adherence to universal precautions for infection control.On 2/24/21 at 10:00 am, the surveyor observed Staff 6 (CG) and Staff 13 (CG) provide incontinent care to Resident 1. During the observation, Staff 6 and Staff 13 failed to change gloves after removing a soiled incontinent product and wiping urine from Resident 1's perineum. Staff 6 and Staff 13 touched the resident's clean blanket and clean incontinent brief while wearing the same soiled gloves.The need to ensure staff consistently used universal precaution was discussed with Staff 1 (Interim Administrator) on 2/24/21 at 11:45 am. She acknowledged the findings.2. Between the dates of 2/22/21 and 2/24/21, Oregon Department of Human Services infection control guidelines, which were established to protect the facility staff and residents from the spread of COVID-19 and made available to all facilities, were not being followed by the facility. Deficiencies that were identified included, but were not limited to:* Staff entering the facility without being screened by dedicated staff;* Staff observed using safety glasses, not properly wearing face shields, touching PPE without practicing hand hygiene and removing PPE in close contact with other staff;* Eye protection in the PPE storage area was not stored in the designated area;* Breakroom lacking instructions and supplies for staff to manage PPE, instructions to social distance, and instructions to disinfect the area after use, including shared microwaves and tables;* Need for increased access to alcohol-based hand sanitizer throughout the facility;* Elevator lacking instructions and supplies for staff or residents to ensure hand hygiene before touching the button and instruction to maintain 6-foot social distancing within elevators;* Shared water fountain with no clear instructions to clean/disinfect; and * The facility failed to perform frequent disinfecting in high touch areas and did not ensure proper contact time of the disinfectant product when performing cleaning in high touch areas.On 2/22/21 and 2/23/21, the following guidance was provided to Staff 1 (Interim Administrator), Staff 2 (RN Consultant) and Staff 3 (Resident Care Coordinator):* Ensure all visitors and staff are screened by dedicated staff prior to entering the facility. Ensure staff are not screening themselves;* Educate staff on the importance of wearing PPE properly while in the facility;* Educate staff on the need to practice hand hygiene every time they touch or adjust their PPE;* Educate staff on the need to practice social distancing when not using PPE such as during lunch breaks;* Educate staff on proper storing of disinfected reusable eye protection;* Monitor staff and provide feedback and instructions for the correct use of PPE;* Ensure all shared equipment (e.g. microwave, tablets) was disinfected between uses;* Provide increased access to alcohol-based hand sanitizer throughout the facility;* Provide instructions to include how many people could ride together on the elevator and where to stand when 2 or more people rode;* Provide instruction and alcohol-based hand sanitizer to perform hand hygiene prior to touching elevator buttons; and* Schedule staff to perform frequent disinfecting in high touch areas and educate staff for the contact time to ensure proper disinfecting.The need to implement infection control guidance to help minimize resident's exposure to COVID-19 was reviewed with Staff 1, Staff 2 and Staff 3 during the survey. They indicated the guidance would be implemented.

Based on observation, interview and record review, it was determined the facility failed to provide a social and recreational activity program based upon individual and group interests, physical, mental and psychosocial needs of the residents. Findings include, but are not limited to:The facility consisted of two separate buildings, Cottage A and Cottage B, and posted the same activity calendar in each cottage. According to the activity calendar and observation, it was revealed on 6/21/21 and 6/22/21: * There were no scheduled activities after 4:15 pm on any day of the week;* Funny Pictures, scheduled for 6/21/21 at 10:30 am, Brain training at 11:00 am and Exercise at 2:00 p.m., was not observed to occur; and* Current Events, scheduled for 6/22/21 at 10:30 am and Tai Chi with Michelle at 11:00 am, was not observed to occur;* Most residents remained in their rooms, watching Television or resting;* No television or music was observed to be on in the common/activity area; and* Staff did not attempt to provide any individualized or group activities. During interviews on 6/21/21 and 6/22/21, Staff 18 (CG), an unsampled resident and Witness 1 (family member) stated the following:* Activities in recent weeks have been minimal;* Activity calendar was not posted in Cottage B;* An activity program as outlined on the Activity calendar was not consistently being followed; * The life enrichment staff person, who was responsible for the activity program, was identified as being on vacation for the next week; and* When the life enrichment staff person was not at the facility caregiving staff did not know who was responsible for ensuring an activity program was being provided.On 6/22/21, the failure to provide an activity program based on individual and group needs was reviewed with Staff 15 (ED). She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 2 of 2 sampled residents (#s 1 and 3) whose MARs and Controlled Substance Disposition logs were reviewed. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in February 2020. Resident 1 had signed physician orders for PRN oxycodone 5 mg as needed for pain. Resident 1's Controlled Substance Disposition logs and MARS were reviewed from 1/1/21 - 2/23/21. The following deficiencies were identified:* A 1/18/21 dose of oxycodone was documented as being removed from storage on the disposition log but was not documented as being administered on the MAR; and* A 2/10/21 dose of oxycodone was documented as being removed from storage on the disposition log but was not documented as being administered on the MAR. On 2/24/21, the need to ensure the narcotic disposition log and MAR were maintained and reflective for all controlled substances was discussed with Staff 1 (Interim Administrator). She acknowledged the findings.2. Resident 3 was admitted to the facility in June 2019. Resident 3 had signed physician orders for PRN oxycodone as needed for pain. Resident 3's Controlled Substance Disposition logs and MARS were reviewed from 2/1/21 to 2/23/21. The following deficiencies were identified:* There were discrepancies on 15 of 23 days the resident was administered PRN oxycodone in February. Of the 33 times staff documented in the Controlled Substance Disposition log that an oxycodone was unlocked and should have been administered, documentation on the MAR indicated it was only administered 14 times.* On 2/3/21 and 2/15/21, the number of oxycodone pills documented as administered on the MAR exceeded the number of pills documented as unlocked on the disposition log.The need to ensure the narcotic disposition log and MAR were maintained and reflective for all controlled substances was discussed with Staff 2 (RN Consultant) on 2/23/21 and with Staff 1 (Interim Administrator) on 2/24/21. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 1 of 1 sampled residents (# 5) whose MARs and Controlled Substance Disposition logs were reviewed. This is a repeat citation. Findings include, but are not limited to:Resident 5 was admitted to the facility in June 2021. The resident's clinical record directed staff to administer hydrocodone/Acetaminophen 5-325 mg three times daily as needed for pain.Resident 5's Controlled Substance Disposition logs and MARS were reviewed from 6/11/21 - 6/21/21. The following deficiencies were identified:* Three occasions, 6/18/21, 6/19/21 and 6/20/21 dose of hydrocodone/Acetaminophen was documented as being removed from storage on the disposition log but was not documented as being administered on the MAR.Inconsistencies between the MAR and Controlled Substance Disposition logs were reviewed on 6/22/21 with Staff 15 (ED). She reviewed the records and acknowledged the discrepancies.

2. Resident 3 moved into the facility in 6/2019 with diagnoses including bowel and bladder incontinence, and impaired functional mobility with left side neglect.a. Resident 3 had a physician's order, dated 7/8/20, to administer Eliquis 2.5 mg (anticoagulant medication used to treat and prevent blood clots) twice daily for ventricular dysfunction.Resident 3's 2/1/21 through 2/23/21 MAR revealed this order was not transcribed to the MAR.b. Resident 3 had a physician's order, dated 7/8/20, to administer finasteride 5 mg (to treat enlarged prostate) daily, with recommendations to wear gloves when administering it.Resident 3's 2/1/21 through 2/23/21 MAR revealed the recommendation of how to administer the medication was not transcribed to the MAR for staff to follow.c. Resident 3 had a physician's order, dated 7/8/20, to administer antacid-simeth 400-400-40 mg 30 ml, every four hours as needed for indigestion.Resident 3's 2/1/21 through 2/23/21 MAR revealed this order was not transcribed to the MAR.d. Resident 3 had a physician's order, dated 7/8/20, to administer Senna 8.6 mg twice daily for constipation.Resident 3's 2/1/21 through 2/23/21 MAR indicated the medication was being administered once daily to the resident, not two times a day as prescribed.e. Resident 3's 2/1/21 through 2/23/21 MAR indicated Resident 3 was being administered Lasix (diuretic medication to treat fluid retention) 60 mg daily.There was no signed physician order for the Lasix medication administration in the resident's record. f. Resident 3's 2/1/21 through 2/23/21 MAR indicated Resident 3 was being administered tamsulosin HCL 0.4 mg (to treat enlarged prostate) for benign prostatic hyperplasia.There was no signed physician order for tamsulosin HCL 0.4 mg medication administration in the resident's record. g. Resident 3's 2/1/21 through 2/23/21 MAR indicated Resident 3 was being provided wound care on the left arm daily.There was no signed physician order for daily wound care in the resident's record.On 2/24/19 at 9:40 am, the physician orders and current MARs were reviewed with Staff 2 (RN consultant). She acknowledged the findings and no further information was provided.
Based on interview and record review, it was determined the facility failed to ensure written, signed physician orders were documented in the resident's facility record for all medications and treatments the facility was responsible to administer, for 2 of 2 sampled residents (#s 1 and 3) whose orders were reviewed. Findings include, but are not limited to:Resident 1 and 3's records were reviewed during the survey. The following deficiencies were identified:1. The most recent signed physician orders in Resident 1's record for wound care was dated 9/11/20 and instructed the facility to provide wound care to the resident's toes daily until healed.Review of the MARs from 1/1/21 through 2/23/21 indicated the following discrepancies:* Though the MAR indicated wound care was being provided daily, the instructions on the MAR directed staff to provide wound care every other day. The date of the order documented on the MAR was 11/4/20.In an interview on 2/23/21, Staff 8 (Universal Worker) confirmed wound care was being provided daily and acknowledged the instructions on the MAR were not consistent with the most recent orders in Resident 1's record. She stated there may have been a newer order but was not able to provide any such document.In an interview on 2/23/21, Staff 2 (RN Consultant) acknowledged the discrepancy between the order in the record and what was written on the MAR. She was unable to locate a written, signed order for the every-other-day treatment. The surveyor asked Staff 2 to evaluate the status of the wounds, determine the most appropriate wound regimen and obtain a written order from the physician.The need to ensure written, signed physician orders were documented in the resident's record for all treatments being provided by the facility was discussed with Staff 1 (Interim Administrator) on 2/24/21. She acknowledged the discrepancy with the orders and the MAR.

Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused to consent to orders for 1 of 1 sampled resident (#4) who had documented treatment refusals. Findings include, but are not limited to:Resident 4 was admitted to the facility in 2017 with diagnoses including contracture, unspecified joint.Resident 4's 2/1/21 through 2/23/21 MARs were reviewed during the survey. Staff documented the resident refused physician-ordered, two times daily eye drops, on multiple occasions.There was no documented evidence the facility notified the physician of the refusals.On 2/23/21 and 2/24/21, the refusals were reviewed with Staff 1 (Interim Administrator) and Staff 2 (RN Consultant). They acknowledged the findings. No further information was provided.
Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused to consent to orders for 1 of 1 sampled resident (#4) who had documented treatment refusals. This is a repeat citation. Findings include, but are not limited to:Resident 4's 6/1/21 through 6/21/21 MAR was reviewed during the survey. * The physician ordered refresh optive sensitive eye drops was refused 25 times.On 6/17/21 the following medications were noted as refused: *Aspirin 81 mg;* Baclofen 5 mg;* Beneprotein powder 227 gm;* Culturelle digest 10 billion cells capsule; * Digoxin 125 mcg;* Diltiazem 60 mg;* Eliquis 2.5 mg;* Famotidine 20 mg;* Gabapentin 250 mg/5 ml;* Metroprolol tartate 25 mg; and * Benlafaxine HVL 50 mg. There was no documented evidence the physician was notified of the refusal and/or received clarification from the physician on how often s/he wanted to be notified of subsequent refusals.On 6/22/21, the need to ensure the physician/practitioner was notified of refusals was reviewed with Staff 15 (ED). She acknowledged the findings.

2. Resident 6, who had Alzheimer's dementia, MARs were reviewed for 6/1/21 through 6/21/21 and the following was revealed: * Missing reasons for multiple medications;* Routine twice a day order for an antipsychotic medication with orders to "hold for sedation" was noted. Signs and symptoms of sedation was not identified on the MAR. The medication was held per family member's request earlier in the month due to sedation; and* Orders to wait 1/2 hour prior to giving a PRN Trazadone (an extra dose) following the routine administration of the medication for insomnia was not transcribed to the MAR. Signs and symptoms of the resident's insomnia was not included on the MAR.The failure to ensure an accurate MAR was discussed with Staff 15 (ED) on 6/22/21. Staff 15 acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure residents' MARs provided clear instruction and parameters for administration for 2 of 3 sampled residents (#s 5 and 6) whose MARs were reviewed. Findings include, but are not limited to:1. Resident 5 was admitted to the facility in June 2021 with diagnoses including diabetes.The resident's 6/11/21 through 6/21/21 MARs and physician orders were reviewed and revealed the following:* The resident received scheduled insulin three times each day. There were no parameters for holding the insulin administration for low blood sugar levels; and* There was no direction for staff when to notify the physician of high and low blood sugars.The need to ensure MARs included clear parameters and direction to staff for medication administration was discussed with Staff 15 (ED). The staff acknowledged the findings.

Based on interview and record review, it was determined the facility failed to verify and document that 3 of 3 newly-hired direct care staff (#s 10, 11 and 12) demonstrated satisfactory performance in any duty they are assigned within the first 30 days of hire. Findings include, but are not limited to:Staff training records were reviewed on 2/24/21 at 8:40 am with Staff 4 (Office Manager). Staff 10 (MT) was hired 11/10/20, Staff 11 (CG) was hired 11/11/20 and Staff 12 (CG) was hired 1/4/21. The following deficiencies with the training requirements were identified:* Though the duties of the MT position included caregiving skills and abilities, the facility had not evaluated Staff 10's competency in the caregiving areas.* There was no documented evidence the facility evaluated Staff 11's competency in the caregiving areas.* Staff 12 was not determined to be competent in all the caregiving areas within 30 days of hire.The requirements for evaluating and documenting caregiver competency within 30 days of hire was reviewed with Staff 1 (Interim Administrator) and Staff 4 on 2/24/21. They acknowledged the findings and said they would address the deficiencies.
Based on interview and record review, it was determined the facility failed to verify and document that 2 of 2 newly-hired direct care staff (#s 13 and 14) demonstrated satisfactory performance in any duty they are assigned within the first 30 days of hire. This is a repeat citation. Findings include, but are not limited to:Staff training records were reviewed on 6/22/21 at 12:35 pm with Staff 15 (ED). Staff 13 (MT) was hired 5/18/21 and Staff 14 (CG) was hired 5/14/21. The following deficiencies with the training requirements were identified:* There was no documented evidence the facility evaluated Staff 13 and Staff 14's competency in conditions that require assessment, treatment, observation and reporting; and general food safety, serving and sanitation.The requirements for evaluating and documenting caregiver competency within 30 days of hire was reviewed with Staff 15 on 6/22/21. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted in accordance with Oregon Fire Code and fire and life safety instruction to staff was provided on alternate months. Findings include, but are not limited to:Review of fire and life safety records on 2/23/21, for September 2020 through February 2021, identified the following deficiencies:* Fire drills were not being conducted and recorded every other month; and* Fire and life safety instruction to staff was not being conducted and recorded on alternate months.In an interview on 2/23/21, Staff 1 (Interim Administrator) acknowledged not having any records for fire drills or fire and life safety instruction for months prior to February 2021.On 2/24/21, the need to ensure fire drills and fire and life safety instruction were completed on alternate months was discussed with Staff 1 (Administrator). She acknowledged the findings.
Based on interview and record review, it was determined the facility failed to provide documentation that fire drills included all required components. This is a repeat citation. Findings include, but are not limited to: Review of fire and life safety records on 6/21/21, for May 2021 through June 2021, identified the following required components that were not documented:*Escape route used;*Problems encountered, comments relating to residents who resisted or failed to participate in the drills;*Evacuation time-period needed; and*Number of occupants evacuatedOn 6/22/21, the need to ensure documentation of fire drills included all required components was discussed with Staff 15 (ED). She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to provide evidence that alternating evacuation routes were used during fire drills, resident evacuation capability was met, and residents received fire and life safety training upon admission and annually. Findings include, but are not limited to:Review of Fire and Life Safety Records on 2/23/21, for September 2020 through February 2021, identified the facility lacked documented evidence of the following: * Alternate exit routes were used during fire drills;* The evacuation capability of the residents, because residents were not being required to relocate during fire drills;* Fire and life safety training for residents upon admission and at least annually that included general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire; and * A written record of fire safety training, including content of the training sessions and the residents attending. On 2/24/21, the need to ensure alternate exit routes are used during fire drills, residents were being relocated during drills and fire and life safety instruction was provided to residents upon admission and at least annually was discussed with Staff 1 (Interim Administrator). She acknowledged the findings.
Based on interview and record review, it was determined the facility failed to provide evidence that alternating evacuation routes were used during fire drills. This is a repeat citation. Findings include, but are not limited to:Review of Fire and Life Safety Records on 6/21/21, for May 2021 through June 2021, identified the facility lacked documented evidence of the following: * Alternate exit routes were used during fire drills.On 6/22/21, the need to ensure alternate exit routes are used during fire drills was discussed with Staff 15 (ED). She acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure its relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to C 302, C 305, C 372, C 420 and C 422.

Based on observation and interview, it was determined the facility failed to ensure all exterior pathways were smooth and maintained in good repair and the grounds were free of litter. Findings include, but are not limited to:On 2/22/21 a tour of the facility's two cottages, including exterior courtyards and pathways, identified the following deficiencies:* Drop offs greater than two inches along cement walkways, uneven patio bricks, and gaps between the cement sidewalk and brick patio at the lower level patio of cottage B which created tripping hazards; and* Refuse and litter was found at or near the lower level patio of cottage B.On 2/23/21, a tour of environment was conducted with Staff 1 (Administrator). She acknowledged the finding.

Based on observation and interview, it was determined the facility failed to ensure the environment was clean and maintained in good repair. Findings include, but are not limited to:On 2/23/21, the following was observed:* The lower part of room 9's door in cottage A had scuffs and scratches; and* Building ventilation covers and filters in Cottages A and B were covered with dust and lint.On 2/23/21, Staff 1 (Interim Administrator) and the surveyor toured the facility and the above areas were identified. She acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure covers, grates, or screens of wall heaters and associated heating elements did not exceed 120 degrees Fahrenheit (F) when installed in locations that were subject to incidental contact by individuals. Findings include, but are not limited to:On 2/23/21, a fireplace was observed in the common area of cottage B. The fireplace was located where residents could come into incidental contact with it. The metal surface surrounding the fireplace, measured with the surveyor's thermometer, was above 120 degrees F.On 2/23/21, the need to ensure the surfaces around the fireplace did not exceed 120 degrees F was discussed with Staff 1 (Interim Administrator). She acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure hot water temperatures in residents' units and common bathrooms were maintained within a range of 110 to 120 degrees Fahrenheit (F). Findings include, but are not limited to:A tour of cottages A and B was conducted on 2/23/21. The hot water temperature in the community shower/bathroom on the lower level of cottage B was measured at 98 degrees F. Repeated testing on 2/23/21 and 2/24/21 revealed the water temperature was still between 97 - 98 degrees F.On 2/23/21, hot water temperatures were discussed with Staff 1 (Interim Administrator). She acknowledged the temperatures were not being maintained within a range of 110 - 120 degrees F.

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 provide security and to alert staff when residents exited the building. Findings include, but are not limited to:During the survey, some of the exit doors in cottages A and B failed to have a working alarm or other acceptable system to alert staff when residents left the building.On 2/23/21, the lack of alarms on all exit doors was discussed with Staff 1 (Interim Administrator). She acknowledged the findings.

Based on interview and record review it was confirmed that the facility failed to provide background checks on employees prior to employment. Findings include the following:During an unannounced site visit on 01/28/2021 Compliance Specialist (CS) reviewed 4 staff files. 1 of 4 staff members was missing a background check. Facility was unable to provide a completed background check for staff.In an interview with Witness #4 (W4) it was stated that the facility is not completing background checks properly before employment or when staff change positions.

Based on interview and observation it was confirmed that the facility failed to exercise reasonable precautions against any condition that may threaten the health, safety, or welfare of the residents. Findings include the following:During an unannounced site visit on 01/28/2021 Compliance Specialist (CS) observed several staff wearing safety glasses and staff wearing no eye protection throughout the facility. CS also observed staff with masks under their noses and staff not wearing eye protection or masks in rooms with multiple other staff members.In an interview with Witness #1 (W1) it was stated that staff are not wearing masks and staff aren ' t following COVID-19 prevention practices. In an interview with Staff #1 (S1) it was confirmed that they had not been wearing their PPE correctly while CS was onsite.Based on interview, observation and document review it was confirmed that the facility failed to exercise reasonable precautions against any condition that may threaten the health, safety, or welfare of the residents. Findings include the following:During an unannounced site visit on 01/28/2021 Compliance Specialist (CS) observed several staff wearing safety glasses and staff wearing no eye protection throughout the facility. CS also observed staff with masks under their noses and staff not wearing eye protection or masks in rooms with multiple other staff members.In an interview with Witness #1 (W1) it was stated that staff are not wearing masks and staff aren ' t following COVID-19 prevention practices. In an interview with Staff #1 (S1) it was confirmed that they had not been wearing their PPE correctly while CS was onsite.A review of staff schedules during the time of facility COVID outbreak in November 2020 revealed that staff were being shared between cottages.Facility failed to provide documentation for which staff tested positive for COVID-19 and when.Based on interview, observation and document review it was confirmed that the facility failed to exercise reasonable precautions against any condition that may threaten the health, safety, or welfare of the residents. Findings include the following:During an unannounced site visit on 01/28/2021 Compliance Specialist (CS) observed several staff wearing safety glasses and staff wearing no eye protection throughout the facility. CS also observed staff with masks under their noses and staff not wearing eye protection or masks in rooms with multiple other staff members.In an interview with Witness #1 (W1) it was stated that staff are not wearing masks and staff aren ' t following COVID-19 prevention practices. In an interview with Staff #1 (S1) it was confirmed that they had not been wearing their PPE correctly while CS was onsite.A review of staff schedules during the time of facility COVID outbreak in November 2020 revealed that staff were being shared between cottages.

Based on interview and record review it was confirmed that the facility failed to report any suspected abuse to the local APS office. Findings include the following:During an unannounced site visit on 01/28/2021 Compliance Specialist (CS) reviewed facility Observation/Incident Reports for October, November, December 2020 and January 2021 document review revealed multiple instances of unwitnessed injury falls as well as injuries of unknown cause for residents considered to be unreliable narrators, where the facility failed to complete an internal investigation and provide any follow-up or report to APS.In an interview with Staff #1, Staff #6 and Staff #12 (S1, S6 and S12) it was confirmed that staff were unaware of when an incident needed to be reported and thus had not been reporting to APS.

Based on interview, observation and record review it was confirmed that the administrator failed to ensure adequate professional oversight of the medication administration system . Findings include the following:During an unannounced site visit on 01/28/2021 Compliance Specialist (CS) reviewed Narcotic logs for both Cottage A and B as well as November and December 2020 and January 2021 Medication Administration Records (MARs) for Residents #1-9 (R1-R9) and found multiple instances of medications unavailable. A review of the narcotics logs revealed R6 was has a prescription for medication A that is not to be administered within 3 hours of medication B. A review of 3 months of MARs revealed 27 instances of medication A administered within 3 hours of medication B. CS also found instances of narcotics being administered for reason X, but prescribed for Y. CS found narcotic count to be off for Resident #1 (R1) where 2 doses appear to be missing and unaccounted for on R1 MAR for time period reviewed.CS completed narcotics counts with medication aides in both Cottage A and Cottage B. Staff #8 (S8) stated that a liquid narcotic read 62ml, narcotics log was recorded at 60.5ml. CS observed liquid to read halfway between 60 and 65ml, approx. 62.5ml.In separate interviews with S8 and Staff #6 (S6) it was stated that there was no policy when the pharmacy ships liquid narcotics over the fill amount and that they do not have a way to track or account for excess liquid narcotics.

Based on interview, observation and record review it was confirmed that the facility failed to administer medications per physician orders. Findings include the following:During an unannounced site visit on 01/28/2021 Compliance Specialist (CS) reviewed Narcotic logs for both Cottage A and B as well as November and December 2020 and January 2021 Medication Administration Records (MARs) for Residents #1-9 (R1-R9) and found multiple instances of medications unavailable. A review of the narcotics logs revealed R6 was has a prescription for medication A that is not to be administered within 3 hours of medication B. A review of 3 months of MARs revealed 27 instances of medication A administered within 3 hours of medication B. CS also found instances of narcotics being administered for reason X, but prescribed for Y. CS found narcotic count to be off for Resident #1 (R1) where 2 doses appear to be missing and unaccounted for on R1 MAR for time period reviewed.CS completed narcotics counts with medication aides in both Cottage A and Cottage B. Staff #8 (S8) stated that a liquid narcotic read 62ml, narcotics log was recorded at 60.5. CS observed liquid to read halfway between 60 and 65ml, approx. 62.5ml.In separate interviews with S8 and Staff #6 (S6) it was stated that there was no policy when the pharmacy ships liquid narcotics over the fill amount and that they do not have a way to track or account for excess liquid narcotics.Based on interview, observation and record review it was confirmed that the facility failed to carry out medication orders as prescribed. Findings include the following:During an unannounced site visit on 01/28/2021 Compliance Specialist (CS) reviewed Narcotic logs for both Cottage A and B as well as November and December 2020 and January 2021 Medication Administration Records (MARs) for Residents #1-9 (R1-R9) and found multiple instances of medications unavailable. A review of the narcotics logs revealed R6 was has a prescription for medication A that is not to be administered within 3 hours of medication B. A review of 3 months of MARs revealed 27 instances of medication A administered within 3 hours of medication B. CS also found instances of narcotics being administered for reason X, but prescribed for Y. CS found narcotic count to be off for Resident #1 (R1) where 2 doses appear to be missing and unaccounted for on R1 MAR for time period reviewed.CS completed narcotics counts with medication aides in both Cottage A and Cottage B. Staff #8 (S8) stated that a liquid narcotic read 62ml, narcotics log was recorded at 60.5. CS observed liquid to read halfway between 60 and 65ml, approx. 62.5ml.In separate interviews with S8 and Staff #6 (S6) it was stated that there was no policy when the pharmacy ships liquid narcotics over the fill amount and that they do not have a way to track or account for excess liquid narcotics.Based on interview, observation and record review it was confirmed that the facility failed to administer medications per physician orders. Findings include the following:During an unannounced site visit on 01/28/2021 Compliance Specialist (CS) reviewed Narcotic logs for both Cottage A and B as well as November and December 2020 and January 2021 Medication Administration Records (MARs) for Residents #1-9 (R1-R9) and found multiple instances of medications unavailable. A review of the narcotics logs revealed R6 was has a prescription for medication A that is not to be administered within 3 hours of medication B. A review of 3 months of MARs revealed 27 instances of medication A administered within 3 hours of medication B. CS also found instances of narcotics being administered for reason X, but prescribed for Y. CS found narcotic count to be off for Resident #1 (R1) where 2 doses appear to be missing and unaccounted for on R1 MAR for time period reviewed.CS completed narcotics counts with medication aides in both Cottage A and Cottage B. Staff #8 (S8) stated that a liquid narcotic read 62ml, narcotics log was recorded at 60.5ml. CS observed liquid to read halfway between 60 and 65ml, approx. 62.5ml.In separate interviews with S8 and Staff #6 (S6) it was stated that there was no policy when the pharmacy ships liquid narcotics over the fill amount and that they do not have a way to track or account for excess liquid narcotics.Based on interview, observation and record review it was confirmed that the facility failed to administer medications per physician orders. Findings include the following:During an unannounced site visit on 01/28/2021 Compliance Specialist (CS) reviewed Narcotic logs for both Cottage A and B as well as November and December 2020 and January 2021 Medication Administration Records (MARs) for Residents #1-9 (R1-R9) and found multiple instances of medications unavailable. A review of the narcotics logs revealed R6 was has a prescription for medication A that is not to be administered within 3 hours of medication B. A review of 3 months of MARs revealed 27 instances of medication A administered within 3 hours of medication B. CS also found instances of narcotics being administered for reason X, but prescribed for Y. CS found narcotic count to be off for Resident #1 (R1) where 2 doses appear to be missing and unaccounted for on R1 MAR for time period reviewed.CS completed narcotics counts with medication aides in both Cottage A and Cottage B. Staff #8 (S8) stated that a liquid narcotic read 62ml, narcotics log was recorded at 60.5ml. CS observed liquid to read halfway between 60 and 65ml, approx. 62.5ml.In separate interviews with S8 and Staff #6 (S6) it was stated that there was no policy when the pharmacy ships liquid narcotics over the fill amount and that they do not have a way to track or account for excess liquid narcotics.

Based on interview and record review it was confirmed that the facility failed to have sufficient staff to meet the scheduled and unscheduled needs of the residents.A review of sampled residents service plans, Medication Administration Records (MARs), progress notes and incident reports for November and December 2020 and January 2021 revealed residents that are found with injuries of unknown cause, staff causing falls due to improperly transferring resident, residents experiencing multiple unwitnessed falls. Compliance Specialist (CS) also found instances of residents being found soiled through their clothing and bedding as well as residents not receiving toileting assistance due to facility not staffing to meet resident needs/preferences.In an interview with Witness #3 (W3) it was stated that the facility did not have enough staff to meet the care needs as listed in the resident service plans.

Based on interview and record review it was confirmed that the facility failed to provide staff training. Findings include the following:During an unannounced site visit on 01/28/2021 Compliance Specialist (CS) reviewed training documents and demonstrated competencies for 4 staff members. 2 of 4 staff members demonstrated competencies and or checklists were not completed within 30 days and their pre-service trainings were not completed prior to service.In an interview with Staff #2 (S2) it was stated that they had been working to ensure that staff files were complete, but at least one of the requested staff members file was a mess. In an interview with Witness #4 (W4) it was stated that staff are working without the appropriate training.