Holi Senior Living

Based on observation and interview, it was determined the facility failed to ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000.

Findings include, but are not limited to:

On 03/12/25 at 10:45 am, the facility kitchen was observed to need cleaning in the following areas:

* Wall behind spray hose in dishwashing area – build up of black matter;

* Exterior doors on two and three door freezers – smears/spills/drips;

* Interior of two and three door freezers – food debris on bottom shelves;

* Hood vents above cooking equipment – dusty/greasy; and

* Flooring under prep counters and ice maker – build up of black matter.

Other areas of concern included:

* Individual portioned food containers in refrigerator were not labeled or dated;

* Garbage can next to handwashing sink full and not covered when not in use;

* Colored cutting boards – worn finish, potentially uncleanable; and

* Two kitchen staff not wearing hair restraints.

The areas of concern were observed and discussed with Staff 1 (Dining Services Director) on 03/12/25. The findings were acknowledged.

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

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

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities.

Findings include, but are not limited to:

Refer to C240.

OAR 411-057-0140(2) Administration Compliance

(2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57.

This Rule is not met as evidenced by:

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 02/01/22. 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, conducted during a site visit on 01/24/24 and 01/25/24, it was confirmed the facility failed to investigate and report an injury of unknown cause for 1 of 1 sampled resident (# 6). Findings include, but are not limited to:An incident report, dated 12/14/23, indicated Resident 6 had an unwitnessed fall with injury and was unable to tell staff what had happened.During an interview on 01/25/24, Staff 1 (Executive Director) stated the incident report "was recently found in the RN's desk" and the incident should have been reported to APS.The findings of the investigation were reviewed with and acknowledged by Staff 1, Staff 2 (RN), Staff 3 (Wellness Coordinator), Staff 4 (Marketing and Sales Director), and Staff 5 (Regional Director of Operations) on 01/25/24.It was determined the facility failed to investigate and report an injury of unknown cause.Verbal plan of correction: All incidents will be reviewed by RN and ED at daily clinical meetings. Staff will be trained on 1/31/24 to complete incident reports timely. Facility was in the process of reporting the incident to APS on 01/25/23.

Based on interview and record review, conducted during a site visit on 01/24/24 and 01/25/24, it was confirmed the facility failed to ensure a resident receives regular bathing assistance for 1 of 1 sampled resident (# 4). Findings include, but are not limited to:During an interview on 01/24/24, Resident 4 s/he had to "beg for showers on scheduled shower days."Resident 4's service plan, dated 01/25/24, indicated "Staff will provide standby assist for showers twice a week."A review of the facility's "Caregiver Daily Assignment Sheet" and "Shower Review" sheets, dated 01/09/24 through 01/24/24, indicated Resident 4 had not received a shower from 01/14/24 through 01/23/24.The findings of the investigation were reviewed with and acknowledged by Staff 1, Staff 2 (RN), Staff 3 (Wellness Coordinator), Staff 4 (Marketing and Sales Director), and Staff 5 (Regional Director of Operations) on 01/25/24.It was determined the facility failed to ensure a resident receives regular bathing assistance.Verbal plan of correction: Beginning 01/31/23, facility will be including shower sheets to clinical meeting.

Based on observation, interview, and record review, conducted during a site visit on 01/24/24 and 01/25/24, it was confirmed the facility failed to follow physician orders as prescribed for 2 of 2 sampled residents (#s 3 and 5). Findings include, but are not limited to:Resident 3's MAR, dated 10/01/23 through 10/31/23, indicated the following:*Atorvastatin 40mg (heart medication) and Losartan 100mg (hypertensive) were not administered 10/01/23 through 10/04/23. Notes indicated the facility was "waiting for medication from the pharmacy;"*Amlodipine 5mg (blood pressure) was not administered 10/14/23 through 10/17/23. Notes indicated the facility was "waiting for medication from the pharmacy;" and*Donepezil 5mg (dementia) was not administered 10/27/23 through 10/30/23. Notes indicated "meds unavailable."There was no documented evidence Resident 3's Atorvastatin, Losartan, Amlodipine, or Donepezil had been discontinued by a physician for any length of time in 10/2023.During an interview on 01/25/24, Resident 5 stated s/he was supposed to receive his/her Carbidopa/Levo 25-100mg (Parkinsons medication) late, and that if s/he did not receive it on time his/her body would begin to "lock up".Physicians order for Resident 5, dated 08/16/23, indicated s/he was to receive Carbidopa/Levo 25-100mg every two hours beginning at 8:00 am.On 01/25/24, Resident 5 was observed to have his/her 10:00 am dose of Carbidopa/Levo 25-100mg administered at approximately 10:37 am.The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (Wellness Coordinator), Staff 4 (Marketing and Sales Director), and Staff 5 (Regional Director of Operations) on 01/25/24.It was determined the facility failed to follow physician orders as prescribed.

The findings of the kitchen inspection, conducted on 11/14/23, 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 revisit to the kitchen inspection of 11/14/23, conducted on 01/26/24, are documented in this report. The facility was found 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 maintained in accordance with Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:Observations of the facility kitchen, food storage areas, food preparation and food service on 11/14/23 revealed the following:* The outside of the juice machine had splatters present and was sticky to the touch; * The stand up fan was dusty; * The outside of the reach in freezer had drips visible, the handles were sticky to the touch, and the inside of the far right unit had food debris present; * A large canned food holder to the left of the stove had built up food debris on the racks; * The wall behind the large canned food holder had gouges and chipped paint present; * The industrial can opener had black matter present; * The double doors to the left of the dry storage had drips, scuffs, and brown matter present;* There were two 6.56 pound cans of pears that were very dented; * The area surrounding the dry food storage and walk in cooler had paint chipping present; * The flooring underneath the kitchen equipment had built-up black matter present; * The stand up mixer behind the kitchen door had dried, built up food matter throughout the machine; * The bread rack had food debris present; * Caulking around the hand washing sink was cracked and pulling away from the wall; * There was brown matter and drips observed on the wall where the hand washing sink was located from the automatic towel dispenser down to the floor; * The pipes under the hand washing sink had a layer of dust present; * There were two white unconnected pipes on the floor located to the left of the hand washing sink; * The lower section of the convection oven had built-up brown matter inside the lower portion of the equipment; * Inside of the right oven was in need of cleaning; * The back area of the stove, above the grill, had built up food debris present; * The fire safety inserts located in the hood above the stove had built up debris observed; * The lower shelving under the two compartment sink across from the stove had food debris present; * Cutting boards located in the kitchen and in the upstairs kitchenette had deep score marks observed; * The microwaves located in the kitchen and upstairs kitchenette had food build-up present on the inside and outside; * The upstairs kitchenette cupboards under the cereal buffet had food debris and splatters inside of them; * The food warmers located in the kitchenette had brown, built-up debris present; and * The drawers located in the upstairs kitchenette had food debris inside of them. The areas in need of cleaning and repair were reviewed with Staff 2 (Dining Services Manager) on 11/14/23. He acknowledged the findings.

Based on observation and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 240.

The findings of the Change of Ownership survey conducted 08/08/22 through 08/11/22 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, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.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 daySituations were identified where there was a failure of the facility to comply with the Departments rules that were likely to cause residents serious harm. Immediate plans of correction were requested in the following area:OAR 411-054-0025 (1): Facility Administration: Operation; andOAR 411-054-0045 (1)(f)(B): RN Delegation and Teaching.The facility put immediate plans of correction in place during the survey and the situations were abated.

The findings of the first revisit to the Change of Ownership survey of 08/11/22, conducted 02/21/23 through 02/22/23 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.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 08/11/22 conducted 05/01/23 through 05/02/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.

Based on observation, interview and record review, it was determined the licensee failed to ensure adequate administrative oversight of facility operations and supervision and training of staff, which posed a risk to the safety of residents. Findings include, but are not limited to:During the Change of Ownership survey, conducted 08/08/22 through 08/11/22, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the severity and number of citations.1. Situations were identified which constituted an immediate plan of correction to residents' health and safety in the following areas:Situations were identified where there was a failure of the facility to comply with the Departments rules that were likely to cause residents serious harm. Immediate plans of correction were requested in the following area:OAR 411-054-0025 (1): Facility Administration: Operation; andOAR 411-054-0045 (1)(f)(B): RN Delegation and Teaching.The facility put immediate plans of correction in place during the survey and the situations were abated. 2. Refer to deficiencies in the report.

Based on interview and record review, it was determined the facility failed to implement effective methods of responding to and resolving complaints. Findings include, but are not limited to:During the survey, multiple non-sampled residents expressed their concerns with the following:* Lack of structured activity program;* Call light times were long; * Food was served cold; * There was no resident forum (resident council/suggestion box); * Residents were not involved in care planning; and* There was a lack of staff on night shift. On 08/11/22, Staff 1 (ED) was interviewed about the facility's grievance resolution policy. She stated the facility had a grievance resolution policy, however, she had not yet implemented the system. She acknowledged the facility did not have a system of responding to and resolving resident complaints.

Based on observation, interview and record review, it was determined the facility failed to develop and conduct ongoing quality improvement programs that evaluated services, staff performance, resident outcomes and resident satisfaction. Findings included, but are not limited to:During the survey, conducted 08/08/22 through 08/11/22, quality improvement oversight to ensure adequate resident care, services and satisfaction was found to be ineffective.On 08/10/22, Staff 1 (ED) was interviewed about the facility's quality improvement program. She stated the facility had a "Quality Improvement (QI) Program" policy, however, she had not yet implemented the QI program. She acknowledged 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 implement effective methods of infection control and to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents. Findings include, but are not limited to:1. Observations and interviews with staff were conducted to determine adherence to universal precautions for infection control.On 08/08/22 at 11:15 am, the surveyor obtained permission and observed Staff 5 (CG) and Staff 12 (CG) provide incontinent care for Resident 3. During the observation, Staff 5 failed to change gloves after removing a soiled incontinent product and wiping feces and urine from Resident 3's perineum. Staff 5 applied barrier cream to the resident's bottom and touched the resident's clean blanket and clean incontinent brief while wearing the same soiled gloves.2. On 08/09/22 at 12:20 pm, observations of the lunch meal being served in the memory care unit revealed direct care staff serving food to residents without the use of an apron or other material to act as a barrier between potentially soiled clothing and resident food. Care staff were observed holding trays of food against their clothing while distributing the meals.The need to ensure direct care staff consistently used universal precautions and used an apron while serving food was discussed with Staff 1 (ED) and Staff 2 (Director of Wellness) on 08/10/22 and 08/11/22. They acknowledged the findings.
3. During an environmental tour of the facility on 08/08/22 through 08/11/22 multiple observations were made of residents and family members who brought dining room chairs outside to the interior secured courtyard. The dining room chairs were not of sufficient weight. When the chairs were no longer in use they were not brought back into the facility.Multiple residents were observed being able to lift or pull the chairs to different locations around the courtyard. The interior courtyard had a black metal gate with openings wide enough to secure a foothold, and with the use of the dining room chairs, had the potential to aid in elopement from the secured area. During the survey, multiple residents who resided in the MCC verbalized a desire to "get out of here". Due to the design of the gate and the lack of sufficiently weighted or secured seating in the courtyard, this posed a potential risk to the health and safety of residents. The above findings were discussed with Staff 1 (ED) and Staff 18 (Maintenance Director) on 08/09/22 at 11:30 am and with Staff 15 (Director of Operations), and Staff 19 (VP of Operations) on 08/11/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure investigations of incidents were thorough and complete in order to rule out neglect for 2 of 3 sampled residents (#s 1 and 3) whose incidents were reviewed. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in 09/2014 with diagnoses including dementia.a. The resident experienced nine incidents between 05/12/22 and 08/05/22, including falls and sustaining skin injuries. While the documentation of the investigations did include sufficient evidence to rule out abuse, the investigations did not include documentation of whether current interventions were in place or other service planned directions were followed at the time of the incident in order to properly rule out neglect.b. Incident investigations did not include documentation of the Administrator review and signature.The need to ensure incident investigations included and documented a review of whether staff were following the provisions of the service plan in order to rule out neglect and include documentation of the Administrator's review was discussed with Staff 1 (ED) and Staff 2 (Director of Wellness) on 08/10/22. They acknowledged the findings. Surveyor: An, Eun-Suk2. Resident 3 was admitted to the facility in 11/2020 with diagnoses including dementia and wrist and rib fractures. Resident 3 required a wheelchair for mobility. Observations of the resident from 08/08/22 to 08/11/22 revealed the resident required staff assistance with transfers and incontinent care.a. Clinical records reviewed from 05/08/22 to 08/08/22 noted the following:* The resident's 05/11/22 service plan indicated the resident required staff assistance with bladder and bowel management four times per shift as feasible;* On 05/25/22 staff documented the resident had a fall on 05/24/22. S/he was incontinent of bowel and was wearing only socks; and* On 06/20/22 staff documented the resident had a fall. The resident reported s/he wanted to use the bathroom. There was no documented evidence the facility conducted an investigation to reasonably conclude the above incidents were not the result neglect of care for not receiving timely bladder and bowel management, which constituted abuse. b. Incident investigations did not include documentation of the Administrator review and signature.The need to investigate incidents of suspected abuse and neglect and to report the incidents to the local APD when the facility's investigation was unable to rule out abuse was discussed with Staff 1 (ED), Staff 2 (Director of Wellness) and Staff 15 (Director of Operations) on 08/09/22 and 08/10/22.

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:On 08/08/22 at 9:30 am, during the entrance conference, the surveyor requested an activity calendar for the current month. At 4:25 pm, the same day, Staff 1 (ED) stated there was no facility activity calendar. The following observations were made from 08/08/22 to 08/10/22: * There was no posted activity calendar in the RCF or MCC unit;* There was no scheduled activity program;* Residents sat out in the common area for long periods of time watching movies or other TV shows, wandered the halls, or remained in their room; and* Staff did not provide any individual or group activities to residents in the MCC unit.During a group interview on 08/09/22, multiple non-sampled residents expressed there were no scheduled activities. On 08/09/22 and 08/10/22, the failure to provide an activity program based on individual and group needs was reviewed with Staff 1, Staff 2 (Director of Wellness) and Staff 15 (Director of Operations). They acknowledged the findings.

2. Resident 2 was admitted to the facility in 01/2022 with diagnoses including dementia and psoriasis.The resident's quarterly evaluation, dated 07/04/22, was reviewed and care staff were interviewed. The evaluation was incomplete or inaccurate in the following areas: * Skin condition (injuries, psoriasis);* Weight changes; and* Falls (history and interventions).The need for quarterly evaluations to be complete and accurate was discussed with Staff 1 (ED) and Staff 2 (Director of Wellness) on 08/10/22. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure initial move-in evaluations included all required elements, for 2 of 2 sampled residents (#s 4 and 5) and that quarterly evaluations were reflective for 1 of 3 sampled residents (#2). Findings include, but are not limited to:1. Resident 4 was admitted to the facility on 07/28/22 and Resident 5 was admitted to the facility on 07/01/22. The new move-in evaluations were not signed or dated and lacked information regarding the following required elements:* Customary routines including eating and bathing preferences;* Spiritual and cultural preferences and traditions; * Mental health issues including depression, thought disorders or behavioral or mood problems including history of treatment and non-drug interventions; * Cognition, including memory, confusion and decision making;* Communication and sensory abilities including hearing,vision and speech;* Activities of daily living including toileting, bowel and bladder management, dressing, grooming, bathing, and personal hygiene;* Eating, dental status, and assistive devices;* Independent activities of daily living including ability to manage medications, use of call light and transportation;* Pain including pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort;* Skin condition;* Nutrition habits, fluid preferences, and weight if indicated;* List of treatments: type, frequency, and level of assistance needed;* History of dehydration or unexplained weight loss or gain;* Recent losses;* Unsuccessful prior placements; and* Elopement risk or history.Additionally, Resident 4's evaluation lacked the following required elements:* Personality, including how the person copes with change or challenging situations;* Mobility: ambulation, transfers, and assistive devices; * Independent activities of daily living including ability to manage medications, housework, laundry and transportation;* Review of risk indicators including fall risk or history, emergency evacuation ability;* Complex medication regimen;* Environmental factors that impact the resident's behavior including, but not limited to noise, lighting and room temperature. Additionally, Resident 5's evaluation lacked the following required elements:* List of current diagnosis;* List of medications and PRN use;* Vital signs if indicated by diagnosis, health problems or medications; and* Alcohol or drug use.The move-in evaluation and the need to complete all required components was reviewed with Staff 1 (ED), Staff 2 (Wellness Director), Staff 15 (Director of Operations), Staff 19 (VP of Operations) on 08/09/22 and 08/11/22. 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, provided clear direction to caregiving staff regarding the delivery of services, and were followed for 3 of 5 sampled residents (#s 2, 3 and 5) whose service plans were reviewed. Findings include, but are not limited to:1. Resident 3 was admitted to the facility in 11/2020 with diagnoses including dementia. Resident 3 was observed to utilize a wheel-chair for mobility and needed to be assisted for food intake during the breakfast and lunch meal.Observations of the resident, interviews with staff, review of the current 05/11/22 service plan and clinical records during the survey, revealed Resident 3's service plan was not reflective of the resident's status and did not provide specific directions to staff, and was not followed in the following areas:* Use of air mattress;* Denture care status;* Weight changes including plans;* Oral care status;* Skin status; and* Activity status.The need to ensure the service plan provided clear instruction to staff, was reflective of the resident's needs and was followed was discussed with Staff 1 (ED), Staff 2 (Director of Wellness) and Staff 15 (Director of Operation) on 08/09/22 and 08/10/22. They acknowledged the findings.
2. Resident 2 moved into the facility in 01/2022 with diagnoses including dementia. The most recent service plan available to staff, dated 01/01/22, was not followed or lacked clear instruction for staff in the following areas: * Obtain daily blood pressure;* Use of a knee brace;* The preference to keep room door locked;* Activity needs and preferences;* History of falls and current fall interventions; and* Skin conditions and treatment.The need to ensure the most current service plans were available to staff, reflective of resident needs and included clear direction to staff was discussed with Staff 1 (ED) and Staff 2 (Director of Wellness) on 08/10/22. They acknowledged the findings.
3. Resident 5 was admitted to the facility in 07/2022. The resident's current service plan, dated 08/03/22, temporary service plans (TSP), observations of the resident's apartment and interviews with staff were completed during the survey.a. The following care areas were not followed:* Weekly skin checks;* Weekly hydration monitoring for dehydration;* Daily blood pressure checks and PRN hypertension medication;* Two hour skin checks while wearing prosthetics;* Staff to order and administer PRN pain medications;* Weekly weights;* Apartment floor to be free of clutter;* Nursing needs including delegated tasks;* Use of "shrinker" on right amputation;* Daily HHPT exercises; and* Two-person transfers.A TSP was written on 07/26/22 to remind the resident to wear prosthetics after dinner and take them off prior to bed and to assist the resident with exercises. The information was added to the TAR and multiple staff had initialed the TAR, which indicated the treatment had been done. Observations during the survey from 08/08/22 through 08/11/22 showed the resident's prosthetics were placed at bedside. The resident was not observed to wear the prosthetics or "shrinker" during the survey. During an interview on 08/10/22, Staff 10 (MT), confirmed she doesn't assist with exercises, use of prosthetics or skin monitoring. During an interview on 08/10/22, Staff 12 (CG), reported "[s/he] doesn't wear the prosthetics, I don't give him reminders to put them on or help [him/her] do it. I don't help [him/her] with exercises."During an interview on 08/11/22, Staff 1 (ED), reported "I don't think I have ever seen [him/her] wear them [prosthetics]."b. The following care areas were not reflective and failed to provide clear direction to staff:* Urinal use and type of assistance needed; and* Incontinent care completed in bed.The need to ensure the service plan provided clear instructions, were reflective of the resident's needs and were followed was discussed with Staff 1 (ED), Staff 15 (Director of Operations), Staff 19 (VP of Operations) on 08/11/22. They acknowledged the findings.


Based on observation, interview and record review, it was determined the facility failed to ensure service plans were updated after a significant change of condition, were reflective of residents' needs, provided clear direction to caregiving staff regarding the delivery of services and were followed for 1 of 4 sampled residents (#8) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:Resident 8 was admitted to the facility in 11/2022 with diagnoses including dementia. Resident 8 was observed to utilize a wheel-chair for mobility, required 1-2 person assist for transfers, ambulation, bed mobility and needed assistance for food intake during breakfast and lunch meals from 02/21/23 through 02/22/23.Observations of the resident, interviews with staff, review of the current 01/07/23 service plan, temporary service plans and the clinical record revealed Resident 8's service plan was not updated after a significant change of condition, was not reflective of the resident's status, failed to provide specific directions to staff, and was not followed in the following areas:* Skin status, including treatments and intervention to float heels;* 1:1 meal assistance;* Weight loss intervention to provide preferred foods when meals were refused;* Hospice provided bathing;* One-to-two person assist with mobility, including ambulation, transfers and bed mobility; * Recent falls; * Toileting status;* Emergency evacuation status; and* Activity status.The need to ensure the service plans were updated following a significant change of condition, provided clear instruction to staff, were reflective of the resident's needs and was followed was discussed with Staff 2 (ED), Staff 8 (Wellness Coordinator) and Staff 22 (Director of Wellness, RN) on 02/22/23. 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 5 of 5 sampled residents (#s 1, 2, 3, 4 and 5). Findings include, but are not limited to:Resident 1, 2, 3, 4 and 5's current service plans were reviewed during the survey. The service plans lacked evidence the residents or their legal representative's participated in the development of the service plans and that a Service Planning Team was used to develop the service plan. The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (ED), Staff 2 (Director of Wellness) and Staff 3 (Resident Care Coordinator) on 08/11/22. They acknowledged the findings.

2. Resident 3 was admitted to the facility in 11/2020 with diagnoses including dementia and wrist and rib fractures. Resident 3 required a wheelchair for mobility. Observations of the resident from 08/08/22 to 08/11/22 revealed the resident required staff assistance with transfers and incontinent care.a. Resident 3's clinical record dated 05/08/22 through 08/08/22 were reviewed during the survey and revealed the following:* The resident's 05/11/22 service plan indicated the resident required staff assistance with bowel and bladder management four times per shift as feasible; * On 05/25/22 staff documented the resident had a fall on 05/24/22. S/he was incontinent of bowel and was wearing only socks; and* On 06/20/22 staff documented the resident had a fall. Staff further documented the resident wanted to use the bathroom.There was no documented evidence the facility thoroughly reviewed the incidents to determine if service planned interventions were followed in the area of bowel and bladder management and evaluated for effectiveness or new interventions determined and communicated to staff.On 08/09/22 and 08/10/22, the above findings were reviewed with Staff 1 (ED), Staff 2 (Director of Wellness) and Staff 15 (Director of Operations). They acknowledged findings.b. Clinical records reviewed from 05/08/22 to 08/08/22 and staff interview noted the following:* 05/04/22 - Returned from the hospital;* 05//18/22 - "blister/diaper rash on the hip"; and* 06/08/22 - Small red area on coccyx.There was no documented evidence that the resident's short-term changes of condition were consistently monitored, at least weekly, to resolution. On 08/09/22 and 08/10/22, the above findings were reviewed with Staff 1 (ED), Staff 2 (Director of Wellness) and Staff 15 (Director of Operations). They acknowledged findings.
Based on observation, interview and record review, it was determined the facility failed to ensure residents who experienced changes of condition were evaluated, necessary actions/interventions were determined, documented, and communicated to staff, and the residents' conditions, including the effectiveness of interventions, were monitored weekly through resolution for 4 of 5 sampled residents (#s 1, 2, 3 and 5) who had documented changes of condition. Resident 1 had repeated falls with injuries. Findings include, but are not limited to: 1. Resident 1 was admitted to the memory care unit in 09/2021 with diagnoses including encephalopathy and dementia. During the survey, s/he was identified as having a history of and recent falls.Observations of Resident 1 throughout the survey confirmed the resident was often unsteady on his/her feet, had poor safety awareness and was dependent on staff for most ADLs. Clinical records, including the service plan, temporary service plans (TSP's), incident reports and investigations, provider notes and charting notes were reviewed. The clinical record provided the following information:a. Resident 1 experienced nine falls between 05/12/22 and 08/05/22 as follows:* 05/12/22 in common area;* 05/16/22 in common area resulting in skin tear and bruising;* 05/18/22 in common area resulting in pain and bruising;* 05/21/22 in outside courtyard resulting in abrasion;* 05/25/22 in common area;* 06/09/22 in room, bruising and swollen lip observed the following day;* 07/07/22 in common area;* 07/13/22 in common area, skin tears to head, bruising visible several days later; and* 08/04/22 in common area.The records documented information on the falls, how the injuries occurred, treatment provided and that the resident was placed on alert monitoring. Incident investigations provided, from 05/12/22 through 08/05/22, were reviewed and documented new fall interventions including: * 05/16/22 staff to assist [the resident] when looking to sit down;* 05/18/22 guide resident to a chair to sit, re-direct to an activity and ensure resident is wearing non-skid socks or shoes;* 05/21/22 staff to assist resident when outside for walks, re-direct back inside when outside for walks; and*07/07/22 present the resident with an activity to keep occupied, re-direct as feasible, keep dining room chairs pushed in.While the follow-up investigations included documentation of new interventions identified to prevent further falls/injury, the record did not include documented evidence the new interventions were communicated to staff and there was no evidence the interventions were implemented and monitored for effectiveness. The failure of the facility to ensure interventions were communicated to staff, added to the service plan, were implemented and monitored for effectiveness to prevent future falls or injuries placed the resident at risk and the resident continued to experience falls and/or injuries. b. Resident 1 sustained multiple skin injuries (as listed above) and included the following:* 05/26/22 sustained redness and bruising to nose while ambulating in common area; * 06/20/22 hit chin on a shelf, bruising to chin; * 06/27/22 hit head on handrail, sustained a cut to the head; * 08/05/22 bleeding to head, bruising visible two days later.The skin injuries represented short term changes of condition. The injuries were identified and documented in the alert monitoring charting notes by medication technicians. While the facility licensed nurse discontinued the alert monitoring of the skin injuries and noted the status of the injury at the time of ending the alert monitoring, there was no documented evidence interventions were developed if needed and staff was monitoring the skin issues, at least weekly, until the injury was resolved. The monitoring process and need to ensure interventions related to changes of condition were communicated to staff and the conditions were monitored at least weekly until resolved was discussed with Staff 1 (ED) and Staff 2 (Director of Wellness) on 08/10/22. They acknowledged the findings. 2. Resident 2 was admitted to the memory care unit in 01/2022 with diagnoses including dementia and chronic kidney disease.Clinical records, including the service plan, dated 01/01/22, temporary service plans (TSP's), provider visit notes and charting notes were reviewed. The clinical record provided the following information:Resident 2 had the following skin injuries identified during the review period from 05/09/22 through 08/01/22:* 05/19/22 abrasions to left knee and head, skin tear to right hand;* 05/21/22 bruising to left eye;* 06/17/22 skin rash to neck, forehead and top of head;* 06/25/22 bruise to right hand; and* 07/22/22 open area on neck with drainage.Resident 2's skin injuries represented short term changes of condition. The clinical record revealed the following:The skin injuries were identified and documented in the alert monitoring charting notes by medication technicians.While the facility licensed nurse discontinued the alert monitoring of the skin injuries and noted the status of the injury at the time of ending the alert monitoring, there was no documented evidence the injuries were evaluated at onset, interventions developed, if needed, and the skin issues were being monitored, at least weekly, until the injuries were resolved. The need to ensure changes of condition were evaluated at onset, interventions developed as needed and monitored, at least weekly, until resolved was discussed with Staff 1 (ED) and Staff 2 (Director of Wellness) on 08/10/22. They acknowledged the findings.
3. Resident 5 was admitted to the facility in 07/2022 with diagnosis of diabetes, CVA (cerebrovascular accident) and hypertension. a. Review of the clinical record, including progress notes indicated the following short-term changes of condition were not monitored through resolution and monitoring instructions were not communicated to staff:* On 07/03/22, missed insulin dose at 2:00 pm;* On 07/16/22, ER visit 07/16/22 and return to facility on 07/17/22 with diagnosis of hyperglycemia;* On 07/28/22, vomiting and elevated BP 188/81 at 9:14 am, PRN Clonidine was given and BP rechecked at 12:20 pm. Blood pressure (BP) remained elevated at 166/75. No further BP monitoring was completed. b. Resident 5's new move-in evaluation dated 07/01/22 and physician orders indicated the following evaluated care needs that required monitoring:* Dehydration monitoring, related to diabetes;* Weekly skin monitoring; and* Blood pressure monitoring due to history of CVA and hypertension.There was no documented evidence the facility monitored the resident per evaluated care needs. c. A review of the current service plan, dated 08/03/22, temporary service plans (TSP's) and progress notes from 07/02/22 through 08/08/22 noted the following service planned fall risk interventions:* Two-person transfers;* Monitor every two hours; * Provide verbal cues during transfers; * Keep apartment free of clutter on the floor; and* Home health PT. On 07/16/22, staff documented the resident had a witnessed fall in his/her apartment. There was a TSP written for staff to monitor for latent injuries and bruises, however; the facility failed to review the service planned interventions for effectiveness and new interventions determined and communicated to staff.On 08/05/22, staff documented the resident had an unwitnessed fall in his/her apartment. There was no documented evidence the service planned fall interventions were reviewed for effectiveness and there was no documented evidence monitoring instructions were communicated to staff.Resident 5 was alert and oriented and able to explain how both falls occurred.The need to ensure the facility monitored service planned fall interventions for effectiveness, monitor and document on the resident's condition until resolved and communicate changes of condition to staff was discussed with Staff 1 (ED), Staff 15 (Director of Operations), Staff 19 (VP of Operations) on 08/11/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure the RN performed an assessment, interventions developed based on the condition of the resident and updated the service plan for 2 of 2 sampled residents (#s 2 and 3) who experienced a significant change of condition in weight status. Resident 3 continued to have weight loss. Findings include, but are not limited to:1. Resident 3 was admitted to the facility in 11/2020 with diagnoses including dementia. Observations of the resident on 08/08/22 and 08/09/22 revealed the resident required hands-on assistance to eat meal and nectar thickened liquids to drink. Resident 3's weight record was reviewed during the survey and revealed the following:* 04/2022 - 137. 2 pounds;* 05/2022 - 127.1 pounds; and* 08/2022 - 116.3 pounds.From 04/2022 to 05/2022, Resident 3 had weight loss of 10.1 pounds or 7.36 % of his/her body weight, which represented a significant change of condition.Weights documented after 05/2022 revealed the resident experienced another significant weight loss of 8.49 % in three months from 05/2022 to 08/2022. There were no weights recorded in 06/2022 and 07/2022 to review.There was no documented evidence the RN completed an assessment of the resident's condition which included that the weight loss had been evaluated, actions or interventions had been determined to address the weight loss.During the survey on 08/09/22 the following was observed:* From 9:05 am to 9:40 am, the resident was not observed in common area or in the dining room, the resident was in his/her bed;* At 10:25 am, Staff 5 (CG) was observed in Resident 5's room to assist the resident with fluid intake. Staff 5 stated s/he complained of being thirsty and offered a cup of thickened orange juice;* At 12:00 pm, the resident was in the dining room for lunch. S/he was holding a sandwich and s/he ate the sandwich independently with staff cueing. The resident consumed 80 % of lunch. The failure to complete a RN assessment at the time of the significant weight loss and failure to initiate interventions resulted in further weight loss.On 08/09/22 and 08/10/22, the above findings and lack of an RN assessment was shared with Staff 1 (ED), Staff 2 (Director of Wellness) and Staff 15 (Director of Operations). They acknowledged the findings.
2. Resident 2 was admitted to the facility in 01/2022 with diagnoses including dementia. a. Observations of the resident from 08/08/22 to 08/10/22 revealed the resident required hands-on assistance to eat meals. Direct care staff reported the resident ate well with staff assistance and the resident would be unable to eat unless staff assisted. The resident was observed to be able to drink his/her thickened liquids with minimal assistance from staff. Resident 2's weight record was reviewed during the survey and revealed the following:* 03/2022 - 156.5 pounds;* 04/2022 - 160.7 pounds; * 05/2022 - 174.7 pounds; and* 08/2022 - 178.4 pounds.From 03/2022 to 08/2022, Resident 2 had weight gain of 21.9 pounds or 13.09 % of his/her body weight, which represented a significant change of condition.There were no weights recorded on 06/2022 or 07/2022. On 07/28/22, the facility RN instructed staff to "please take weight monthly" to determine weight changes. The next weight was obtained on 08/04/22 of 178.4 pounds. There was no documented evidence the RN completed an assessment of the resident's condition, which included whether the weight gain had been evaluated and any actions or interventions determined to address the weight gain.b. On 07/22/22, charting notes documented the resident had an open wound on his/her neck and a family member cleaned and placed a dressing on the wound. The wound was described as having drainage and a "hole" was visible. Direct care staff documented cleaning and dressing the wound daily from 07/22/22 through 08/01/22. On 07/28/22, the resident was seen by the facility RN and the assessment described the wound and provided instruction for staff to leave the wound open, monitor and allow it to heal. The RN assessment, conducted on 07/28/22, was not completed timely for the open wound which represented a significant change of condition.The need to ensure changes of condition were evaluated and referred to the RN, on a timely basis, for assessment and interventions was discussed with Staff 1 (ED) and Staff 2 (Director of Wellness) on 08/10/22. They acknowledged the findings.

2. Resident 7's July and August MARs were reviewed, included an order to obtain CBG's twice monthly, and notify the physician for CBG readings above 300.In an interview on 08/10/22, Staff 9 (MT) stated the facility LPN provided instruction, initially, on how to obtain and record the CBG but there were no written instructions available for how to obtain the resident's CBG's for staff to refer to when performing the task.The need to have written instructions available for staff to follow when performing a taught task was reviewed with Staff 1 (ED) and Staff 2 (Director of Wellness) on 08/10/22. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure the teaching, delegation and supervision of special tasks of nursing care was completed in accordance with the Oregon State Board of Nursing (OSBN) Division 47 Rules, for 2 of 2 sampled residents (#s 5 and 7) who were being assisted with insulin injections or CBG readings by unlicensed facility staff. Resident 5 was at risk for harm related to potential medical complications from the lack of an RN assessment of the resident's condition, unlicensed staff training and supervision to ensure safety and accuracy of insulin administration. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility with diagnoses including diabetes and bilateral below the knee amputation. Review of Resident 5's clinical record and staff interviews identified the following:* Blood sugars were documented on the MAR ranging from 102 to 377;* The resident would take his/her own CBG's, inform the MT who would then advise the resident on how much insulin, including any additional sliding scale dose that was needed; * The resident would then administer their own insulin injection; and* The MT's would then initial on the MAR that they had administered the insulin, including documentation of the sliding scale dose administered. A review of the 07/01/22 through 08/08/22 MAR indicated Staff 7 (MT), Staff 10 (MT), Staff 14 (MT), Staff 20 (MT) and Staff 21 (MT) initialed the MAR for insulin administration. There was no documented evidence an RN delegation had been completed which included the following:* RN assessment to determine Resident 5's condition was stable and predictable;* Determination of frequency resident should be reassessed, including rationale; * Rationale why the task could be safely delegated;* Skills, abilities and willingness of unlicensed staff to complete the task;* Unlicensed staff were taught the task was client specific and not transferable;* Determination of frequency the unlicensed staff should be supervised and re-evaluated, including rationale; and* Written instructions available including risks, side effects, response, risk factors, and whom to report the same;* RN takes responsibility for delegating task and ensures supervision will occur for as long as RN was supervising performance.In an interview on 08/09/22, Staff 2 (Wellness Director) explained the resident and his/her spouse received teaching and education at another facility prior to moving in. She further stated she was unaware that CBG's and advising on sliding scale insulin dose was a delegated or taught task. Staff 2 confirmed there were no unlicensed staff that had been delegated nor had there been an assessment of the resident's condition. A review of the 07/01/22 through 08/08/22 MAR indicated 31 occasions where the sliding scale insulin dose was incorrectly documented.On 08/09/22, Staff 10 (MT) stated she documented insulin administration on the MAR and was confused on how to document the sliding scale dose.A review of the progress notes dated 07/02/22 through 08/08/22 indicated the following:* On 07/16/22, Resident 5 went to the ER and returned with a diagnosis of hyperglycemia and a recommendation to increase daily scheduled insulin dose; and * On 07/28/22 the MAR indicated Resident 5's CBG was 123 at 5:00 pm and should have been administered 0 units sliding scale dose however, the MAR indicated the resident was administered 6 units. Later in the evening on 07/28/22, Resident 5 called for assistance due to vomiting.The lack of an RN assessment of the resident's condition, lack of unlicensed staff delegation and supervision to ensure safety and accuracy of insulin administration put Resident 5 at risk for harm related to potential medical complications and an ER visit.On 08/09/22, the need to ensure all staff who administered insulin injections or performed delegated, taught tasks were appropriately delegated and supervised in accordance with OSBN Administrative Rules was discussed with Staff 1 (ED) and Staff 2. They acknowledged the above findings. The Surveyor requested an immediate plan to ensure insulin was administered by licensed or delegated staff in accordance with OSBN Division 47 Rules.On 08/09/22 at 4:25 pm, a plan to address the delegation issue was submitted and the situation was abated.

Based on observation, interview and record review, it was determined the facility failed to coordinate on-site health services with outside providers and ensure outside service providers left written information in the facility that addressed the on-site service being provided, for 2 of 4 sampled residents (#s 3 and 5) who received outside services. Findings include, but are not limited to:1. Resident 5 was admitted to the facility in 07/2022 with diagnoses of bilateral below the knee amputation and diabetes. a. The record indicated Resident 5 began receiving HH PT services on 07/07/22. The HH PT service provider had consistently left written information regarding the service provided and the following recommendations:* On 07/07/22, "needs caregiver assist for all transfers and assist with maintaining hygiene and skin checks";* On 07/13/22, "please provide assistance with hygiene and skin checks and caregiver assist with all mobility tasks at this time"; * On 07/20/22, "remind pt [patient] to wear "shrinker" on RBK (right below knee) amputation, do [his/her] exercises and to call CG to assist with transfers";* On 07/21/22, "please monitor for any increase in [his/her] pain and neuropathy"; and* On 08/01/22, "continue to assist [name] with transfers and home exercise program. Please monitor skin for bruise, wounds."There was no documented evidence the facility implemented the above recommendations. b. 07/16/22 ER visit noted a diagnosis of hyperglycemia. Review of the after visit summary indicated the following recommendations were made:* Increase existing Lantus insulin from 25 units to 30 units;* New medication, PRN Hydrocodone every four hours;* New medication, Protonix 40 mg tablet, once daily; and* Follow up with "PCP" [primary care provider] within two days. The ER after visit summary was reviewed and signed by three facility staff, however there was no documented evidence the facility followed up to ensure the medication recommendations were implemented and follow up appointment with PCP was scheduled. The need to ensure the facility had a system for coordinating on-site services with outside providers was discussed with Staff 1 (ED), Staff 15 (Director of Operations) and Staff 19 (VP of Operations) on 08/11/22. They acknowledged the findings.
2. Resident 3 was admitted to the facility in 11/2020 with diagnoses including dementia. Resident 3's clinical record, dated 05/08/22 through 08/08/22, was reviewed during the survey and revealed the following:* 05/06/22 a hospital discharge report, indicated not to use a straw for fluid intake; and* 06/02/22 a hospice visit note indicated frequent oral care was to be provided to the resident.Observations of the resident on 08/08/22 revealed the resident was provided thickened liquids with a straw.There was no documented evidence the recommendations were communicated to staff or implemented. 3. A pharmacy audit was conducted on 05/11/22 through 05/13/22 of multiple non-sampled residents and recommendations were made. There was no documented evidence the recommendations were communicated to staff or implemented.On 08/09/22 and 08/10/22, the need to ensure on-going coordination of care was discussed with Staff 1 (ED), Staff 2 (Director of Wellness) and Staff 15 (Director of Operations). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure a safe medication administration system was in place for all residents and failed to ensure adequate professional oversight of the medication and treatment administration systems. Findings include, but are not limited to:1. During the survey, conducted 08/08/22 through 08/11/22, administrative oversight of the medication and treatment administration system was found to be ineffective based on deficiencies in the following areas:* C 282: RN Delegation and Teaching;* C 302: Tracking Control Substances;* C 303: Medication and Treatment Orders;* C 310: Medication Administration; * C 315: Treatment Administration; and* C 325: Self-Administration of medications.The need to ensure the facility had a safe medication administration system and the overall medication and treatment administration system was reviewed with Staff 1 (ED), Staff 2 (Director of Wellness) and Staff 15 (Operation of Director) on 08/09/22 and 08/10/22. They acknowledged the findings.
2. Resident 5 was admitted to the facility in 07/2022 with diagnoses of diabetes, hypertension and pain. a. A review of the progress notes dated 07/02/22 through 08/08/22 identified the following:On 07/15/22, Staff 2 (Director of Wellness) received a verbal phone order to "hold Clonidine (for hypertension) PRN, every 6 hours when SBP (systolic blood pressure) was over 155 and PRN Bismuth every 6 hours (for indigestion), due to possible drug interaction with Clopidogrel (blood thinner)" until the physician completed a medication review. The PRN Bismuth and PRN Clonidine were held from 07/16/22 through 07/22/22. The medication review had not been completed, the facility failed to follow up with the physician and the medications were placed back on the MAR, resulting in the medications being available to administer to the resident. On 07/28/22, the PRN Clonidine was administered. b. A review of Resident 5's signed physician orders upon move-in indicated the resident was prescribed Oxycodone PRN, every eight hours for pain. The Oxycodone was transcribed onto the July and August 2022 MAR. During observation and interview on 08/08/22 with Staff 7 (MT) there was no PRN Oxycodone in the medication cart and there was no page for the Oxycodone in the narcotic disposition log for Resident 5. Staff 7 stated she "doesn't believe [she] had ever administered Oxycodone to the resident" and "believed the facility never received the Oxycodone from the pharmacy." The need to ensure the facility had a safe medication administration system was reviewed with Staff 1 (ED), Staff 2, Staff 15 (Director of Operations) and Staff 19 (VP of Operations) on 08/11/22. They acknowledged the findings.

2. Resident 1 was admitted in 09/2021 and had diagnoses including dementia and anxiety.Resident 2 had a physician's order for Lorazepam 0.5 mg, one tablet PRN for severe anxiety.The Controlled Substance Disposition Log revealed the Lorazepam was administered on 08/01/22, however, the MAR (reviewed from 08/01/22 through 08/08/22) lacked documentation that the resident received the medication. The inconsistency between the MAR and Controlled Substance Disposition log was reviewed with Staff 1 (ED) and Staff 2 (Director of Wellness) on 08/10/22. They reviewed the documentation and acknowledged the discrepancies.
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 3 sampled residents (#s 1 and 4) whose MARs and Controlled Substance Drug Disposition logs were reviewed for accuracy. Findings include, but are not limited to:1. Resident 4 was admitted in 2022 and had diagnoses which included hip replacement.Resident 4 had an order for oxycodone, one - two tablets (5 - 10 mg) every four hours PRN pain (1 tab for pain 1-5 and 2 tabs for pain 6 - 10).Resident 4's Controlled Substance Disposition Logs and MARs, reviewed from 8/1/22- 8/10/22, revealed two occasions when staff signed on the drug disposition log that the oxycodone was given. However, the MAR lacked documentation that the resident received the medication. Inconsistencies between the MARs and Controlled Substance Disposition logs were reviewed with Staff 1 (ED) and Staff 2 (Director of Wellness) on 08/11/22. They reviewed the documentation and acknowledged the discrepancies.

2. Resident 6 was admitted to the facility in 03/2021 with high blood pressure, congestive heart failure and asthma.a. Resident 6 had a physician's order, dated 03/11/21, to administer Furosemide (for high blood pressure) 60 mg two times daily. The resident's 08/01/22 through 08/09/22 MAR revealed staff documented 40 mg of the medication was administered to the resident, not 60 mg as prescribed.b. Resident 6 had a physician's order, dated 03/11/21, to administer lactose, 300 units with meal, for digestion, Symbicort inhaler for asthma two times daily and Systane ultra-solution eye drops daily.The resident's 08/01/22 through 08/09/22 MAR revealed there was no indication those orders were transcribed to the MAR.c. Resident 6 had a physician's order, dated 03/11/21, to administer Famotidine, 40 mg with dinner, for indigestion.The resident's 08/01/22 through 08/09/22 MAR revealed staff documented 40 mg of the medication was administered at 8:00 am in the morning, not with dinner as prescribed.d. The resident's 08/01/22 through 08/09/22 MAR revealed staff documented Calcium 500 mg was administered two times daily and Breo Elli 100-25 mcg inhaler (for chronic obstructive pulmonary disease) daily was administered to the resident. There was no signed physician order to administer those medications.On 08/11/22, the physician orders and the MARs were reviewed with Staff 1 (ED) and Staff 15 (Director of Operations). They acknowledged the findings.
3. Resident 1 was admitted to the facility in 09/2021 with diagnoses including dementia and anxiety.Resident 1 had physician's orders to administer Lorazepam 0.5 mg, every eight hours, PRN for severe anxiety and Risperdone 0.5 mg, three times daily, PRN for physical aggression. Parameters prescribed by the physician included to administer the Risperidone "if not improved with use of PRN Lorazepam first". The 07/01/22 through 08/08/22 MARs revealed the resident was administered the Risperdone on 07/21/22, however, the Lorazepam had not been administered first and deemed ineffective, as the order instructed.The need to ensure medications were administered as ordered, including following parameters, was reviewed with Staff 1 (ED) and Staff 2 (Director of Wellness) on 08/10/22. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to carry out orders as prescribed for 3 of 6 sampled residents (#s 1, 5 and 6) whose orders and MAR/TAR's were reviewed. Resident 5 was not administered blood pressure medications as prescribed which put the resident at risk. Findings include, but are not limited to:1. Resident 5 was admitted to the facility in 07/2022 with diagnoses including diabetes, stroke and hypertension. Resident 5's current signed physician orders and 07/01/22 through 08/08/22 MAR/TAR's were reviewed during the survey.a. The following was ordered by the physician: * Hydration monitoring every day and notify MD weekly, every Friday for signs and symptoms of dehydration;* Weekly skin audits every Tuesday during showers;* Weekly weights; and* Two hour skin checks when wearing prosthetics.There was no documented evidence the above orders were carried out as prescribed. b. The following medications were not carried out as prescribed:* Carvedilol tablet 6.25 mg, give 1 tablet by mouth 2 times per day with meals and hold for SBP (systolic blood pressure) less than 100 and HR (heart rate) less than 55. The MAR's indicated the resident was administered the medication at 8:00 am and 8:00 pm. The 8:00 pm dose was not given with meals and there was no documentation the SBP and HR were taken prior to administering the medication. * PRN Clonidine (for hypertension) every six hours, as needed, when SBP was over 155. The MARs and progress notes reviewed had some recorded blood pressure readings, intermittently, related to alert charting instructions. Resident 5's blood pressure was documented over the SBP of 155 on the following dates:* 07/02/22 (173/72);* 07/05/22 (166/84);* 07/09/22 (173/79); * 07/16/22 (165/69);* 07/28/22 (188/81); and* 08/05/22 (159/68). On 07/16/22, a progress note at 10:21 pm documented "systolic [blood pressure] number was very high of 165/69. Will recheck in 15 minutes. 183/80 complains of severe numbness and tingling in fingers and does not feel like [him/her] self. The PRN Clonidine was not administered. The resident was sent to the hospital at 11:36 pm.On 07/28/22 at 9:14 am, a progress note documented the resident's BP was elevated 188/81. The PRN Clonidine was administered. The resident's BP was rechecked at 12:20 pm and was recorded as 166/75. There was no further BP taken at the 6th hour to determine if the SBP was still over 155 which would require another dose of the PRN Clonidine. The failure to monitor Resident 5's SBP and administer the PRN Clonidine when systolic blood pressure was elevated above 155, as prescribed, put the resident at serious risk of potential harm. The need to ensure orders were carried out as prescribed was discussed with Staff 1 (ED), Staff 15 (Director of Operations) and Staff 19 (VP of Operations). They acknowledged the deficiencies.
Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 1 of 4 sampled residents (# 11) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 11 was admitted to the facility in 04/2021 with diagnoses including presenile dementia.Resident 11's MAR dated 02/01/23 through 02/21/23 and corresponding progress notes were reviewed and revealed the following:* Resident 11 had a prescriber's order to provide 237 mL of Vanilla Ensure three times a day with meals as a nutritional supplement; and* The resident's MAR was blank from 02/01/23 through the 8:00 am administration of Ensure on 02/07/23.On 02/22/23 at 3:10 pm, the surveyor and Staff 10 (MT) observed and checked the resident's MAR. Staff 10 was unable to confirm whether the supplement had been administered as prescribed.The need to ensure orders were carried out as prescribed was discussed with Staff 2 (ED), Staff 22 (Director of Wellness/RN), Staff 8 (Wellness Coordinator) and Staff 33 (Consultant) on 02/22/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included clear parameters for administration of prescribed medications for 3 of 5 sampled residents (#s 1, 3 and 5) whose MARs were reviewed. Findings include, but are not limited to:1. Resident 3 was admitted to the facility in 11/2020 with diagnoses including dementia.Review of the 08/01/22 through 08/08/22 MARs noted the following as needed medication:* Tylenol 325 mg tablet, take 2 tablets every 4- 6 hours as needed for pain or fever.There were no resident-specific parameters regarding whether to administer the medication in 4 hours frame verses a 6 hour time frame. The resident did not receive the medication.On 08/09/22 and 08/10/22, the above findings were reviewed with Staff 1 (ED), Staff 2 (Director of Wellness) and Staff 15 (Director of Operations). They acknowledged the findings
2. Resident 1 was admitted to the facility in 09/2021 with diagnoses including dementia and anxiety.Review of the physician's order, dated 03/15/22, and the 08/01/22 through 08/08/22 MAR noted the following discrepancy:* The resident had a physician's order for Lorazepam 0.5 mg by mouth every 8 hours PRN for severe anxiety;* Physician's order for Risperdone 0.5 mg by mouth three times daily as needed for physical aggression, paranoid delusional behavior. It included instructions to administer the Risperdone if agitation was not improved with the administration of Lorazepam first;* 08/01/22 MAR stated to give Risperdone 0.5 mg by mouth three times daily as needed for agitation.The resident-specific parameters were not transcribed as ordered for the Risperdone. In addition, the parameters did not provide clear instruction to staff regarding which medication to administer when the resident displayed either agitation, anxiety or aggression. The resident had received the Risperdone on 08/01/22.The need to ensure clear parameters were reviewed and provided for PRN medications was discussed with Staff 1 (ED) and Staff 2 (Director of Wellness) on 08/10/22. They acknowledged the findings
3. Resident 5 was admitted to the facility in 07/2022 with a diagnosis of diabetes.A review of the MAR/TAR from 07/01/22 - 08/08/22 identified the following deficiencies:* There were blanks on the MAR for Tylenol and Gabapentin on 07/06/22 at 2:00 pm; and* Documentation of the sliding scale dosage administered was inaccurately recorded on 31 occasions. The need to ensure accurate MAR/TAR's were kept was discussed with Staff 1 (ED), Staff 15 (Director of Operations), and Staff 19 (VP of Operations). They acknowledged the deficiencies.
Based on interview and record review, it was determined the facility failed to ensure resident specific parameters and instructions for insulin were followed for 1 of 4 sampled resident (# 13) whose MARs were reviewed. This is a repeat citation. Findings include, but are not limited to:Resident 13 moved into the facility on 01/06/23 with diagnoses which included Diabetes and Alzheimer's disease. Physician orders and MARs for Resident 13, reviewed from 02/01/23 - 02/21/23, revealed the following:* A physician's order for Novolog (insulin) 100 units/ml to be injected three times a day with meals; and* The MAR included "HOLD IF CBG IS <200." On the following days Novolog was given even though the CBG was less than 200:* 02/09/23 - 5 pm CBG 145;* 02/10/23 - 12 pm CBG 69;* 02/11/23 - 8 am CBG 111;* 02/11/23 - 5 pm CBG 161;* 02/12/23 - 5 pm CBG 185;* 02/16/23 - 5 pm CBG 160;* 02/19/23 - 5 pm CBG 191; and* 02/21/23 - 8 am CBG 158.There was no documented negative outcome to Resident 13.The need to ensure resident specific parameters were followed was reviewed with Staff 2 (ED) 02/22/23 at 11:00 am. She reviewed the MARs with the surveyor and acknowledged the findings. She stated the MTs would receive additional training on medication administration and documentation. No further information was provided.

3. Observations of Resident 3 during the survey and review of his/her records between 06/08/22 and 08/08/22 indicated that facility staff administered treatments, including barrier cream, on bottom area for redness.The facility failed to document on Resident 3's TAR that the treatment was administered.The need to ensure all treatments administered by the facility were documented on the TAR was discussed with Staff 1 (ED) and Staff 2 (Director of Wellness) on 08/10/22. Staff acknowledged treatments administered by the facility were not being documented on resident TARs.
Based on interview and record review, it was determined the facility failed to keep an accurate treatment record of all treatments ordered by a legally-recognized practitioner and administered by the facility, for 3 of 4 sampled residents (#s 1, 2 and 3) whose TARs were reviewed. Findings include, but are not limited to:1. Resident 1's records indicated that between 05/10/22 and 08/08/22, facility staff administered treatments, including first aid and wound care, for the following conditions:* A cut to the forearm;* A wound to the elbow;* A skin tear to the wrist;* A cut to the top of the head; and* Skin tears to the forehead.2. Resident 2's records indicated that between 05/19/22 and 08/08/22, facility staff administered treatments, including wound care, for the following conditions:* A skin tear to the hand;* An abrasion to the knee; * A dry, flaky rash to the top of head, neck and forehead; and* An open and draining wound to the neck.The facility failed to document any of the treatments it administered on Resident 1 or Resident 2's TARs.The need to ensure all treatments administered by the facility were documented on the TAR was discussed with Staff 1 (ED) and Staff 2 (Director of Wellness) on 08/10/22. Staff 2 acknowledged treatments administered by the facility were not being documented on resident TARs.

Based on interview and record review, it was determined the facility failed to ensure a resident who self administered a subcutaneous medication monthly and a resident who had daily insulin injections were evaluated initially and at least quarterly to assure the ability to self administer medications for 2 of 2 sampled resident (#s 4 and 5). Findings include, but are not limited to:1. Resident 4 was admitted to the facility in July 2022 with diagnoses including arthropathic psoriasis. A review of Resident 4' clinical information revealed the following:* Resident 4 was self-administering his/her Taltz subcutaneous solution for psoriasis;* There was no documented evidence a complete evaluation of the residents' ability to self administer Taltz subcutaneous solution for psoriasis was completed; and* There was no documented evidence the facility obtained a written physician order authorizing the resident to self-administer the Taltz subcutaneous solution for psoriasis. In an interview on 08/08/22 at 2:00 pm, Staff 2 (Director of Wellness) confirmed she was aware the resident required an order to self-administer her/his injection and had not yet completed an evaluation of the resident's ability to self administer medications. The need to complete evaluations of a resident's ability to self administer medications initially and at least quarterly was discussed with Staff 1 (ED) and Staff 2 on 08/11/22. They acknowledged the findings.
2. Resident 5 was admitted to the facility in 07/2022 with diagnosis including diabetes.A review of Resident 5's clinical record identified the following:* Resident 5 was self-administering his/her scheduled insulin, including taking CBG's prior to administering sliding scale dose;* There was no documented evidence a complete evaluation of the residents' ability to self administer insulin was completed; and* There was no documented evidence the facility obtained a written physician order authorizing the resident to self-administer the insulin. During an interview with Staff 2 (Director of Wellness) on 08/08/22 at 2:00 PM, she confirmed there wasn't a physician order that authorized the resident to self-administer insulin.The need to complete evaluations of a resident's ability to self administer medications and have a signed, written doctor's order for the resident to self-administer medications was discussed with Staff 1 (ED), Staff 15 (Director of Operations), and Staff 19 (VP of Operations) on 08/11/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure an assessment by a PT, OT or RN was completed for assistive devices with potentially restraining qualities for 2 of 2 sampled residents (#s 4 and 5) who had a supportive device. Findings include, but are not limited to:1. Resident 4 was admitted to the facility in 07/2022 with diagnoses including hip replacement.During the entrance conference on 08/08/22, Resident 4 was not identified as having bilateral siderails on his/her bed. An order for a hospital bed with side rails was in Resident 4's chart.Observations of the resident and the resident's room showed the siderails were on the bed and in the up position. The side rails were not in Resident 4's current service plan. Review of Resident 4's record revealed there was no documented evidence an assessment of the siderails had been completed by an RN, PT or OT.In an interview on 08/09/22 at 11:35 am, Staff 2 (Director of Wellness) stated no assessment had been completed for Resident 4's siderails.The lack of an assessment for the resident's siderails was discussed with Staff 1 (ED) and Staff 2 on 08/11/22. They acknowledged the findings.
2. Resident 5 was admitted to the facility in 07/2022 with diagnoses including bilateral below the knee amputation. During the entrance conference on 08/08/22, Resident 5 was identified as having bilateral siderails on his/her bed. Observations of the resident and the resident's room on 08/09/22 showed ¼ length bilateral siderails were installed at the head of the hospital bed and were in the up position while the resident was laying in the bed. The side rails appeared intact and in good repair. During an interview with the resident on 08/09/22, s/he reported the preference to use the siderails for self transferring while using a slideboard and pulling him/herself across the slideboard. The resident further reported s/he used them to assist the caregivers during care that was completed in bed. Review of Resident 5's record revealed there was no documented evidence an assessment of the siderails had been completed by an RN, PT or OT.In an interview on 08/09/22 at 2:00 pm, Staff 2 (Director of Wellness) stated there was no assessment completed for Resident 5's siderails.The need to ensure the supportive devices with potentially restraining qualities were assessed by an RN, PT or OT was discussed with Staff 1 (ED), Staff 15 (Director of Operations), and Staff 19 (VP of Operations) on 08/11/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to have sufficient number of caregivers to meet the 24-hour scheduled and unscheduled needs of each resident during the night shift. Findings include, but are not limited to:1. During the entrance conference and acuity interview on 08/08/22 the following was identified: * The facility consisted of two floors with resident rooms located on the first floor, in two separate units, for memory care residents and second floor for assisted living residents; * The facility had 50 residents; * One resident on the first floor required two-person assistance with transfers; and* One resident on the second floor required two-person assistance with transfers.2. The facility's staffing plan for 08/2022 was as follows: * During the night shift, there was one caregiver assigned to the second floor and on multiple days, there were no staff assigned to the second floor.3. On 08/08/22, at 9:30 am, at the entrance conference, the surveyor requested the facility staffing tool used to determine the number of caregiving staff needed to provide scheduled and unscheduled needs of the residents. Staff 1 (ED) stated she was aware of the requirement to have an acuity-based staffing tool, but the facility had not implemented it.4. During the group interview, conducted on 08/09/22 at 11:00 am, multiple alert and oriented non-sampled residents stated the following:* Residents had made complaints to management related to delayed call light response times, especially on the night shift.5. On 08/10/22, the survey team requested the call response logs from Staff 1. She stated she was not able to generate the call response logs. 6. During an interview on 08/10/11, Witness 1 stated several residents "on the assisted living unit expressed concern with the lack of staff available on the night shift", long wait times when a call light was initiated and a lack of any activity staff. Witness 1 verified they had previously expressed these concerns to Staff 1.The failure to ensure adequate staff to meet the scheduled and unscheduled needs of the residents was shared with Staff 1 and Staff 2 (Wellness Director) on 08/09/22 and 08/10/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) that met the regulation for 5 of 5 sampled residents (#s 1, 2, 3, 4 and 5) whose records were reviewed. Findings include, but are not limited to:There was no documented evidence the facility was using an ABST which would determine a staffing plan reflective to meet the 24-hour scheduled and unscheduled needs of residents.On 08/08/22, Staff 1 (ED) reported the facility had not implemented an ABST.The need to implement an ABST was discussed with Staff 1 and Staff 2 (Wellness Director). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure pre-service orientation in all required topics was completed and documented for 4 of 4 sampled staff (#s 3, 4, 5 and 6). Findings include, but are not limited to:Facility training records were reviewed on 08/08/22 and 08/09/22.Staff 3 (CG) hired 06/2022, Staff 4 (MT) hired 05/2022, Staff 5 (CG) hired 06/2022 and Staff 6 (Housekeeper) hired 06/2022, lacked documented evidence of completing the following required elements of the pre-service orientation:* Staff 3, 5 and 6 lacked documentation of resident rights and values of CBC care; and* Staff 3, 4, 5 and 6 lacked evidence of standard precautions for infection control. The need for new staff to complete the required pre-service orientation training before working with residents was reviewed with Staff 1 (ED) on 08/09/22. No additional information was received.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 sampled newly-hired direct care staff (#s 3, 4 and 5) had demonstrated competency in all assigned job duties within 30 days of hire. Findings include, but are not limited to:Staff training records were reviewed on 08/08/22 and 08/09/22. There was no documented evidence Staff 3 (CG), Staff 4 (MT), and Staff 5 (CG), hired 06/17/22, 05/13/22, and 06/17/22, respectively, demonstrated competency in all assigned job duties within 30 days of hire in the following areas:* Role of service plans in providing individualized care:* Providing assistance with ADLS;* Changes associated with normal aging;* Identification, documentation, and reporting of changes of condition; and* Conditions that require assessment, treatment, observation, and reporting.The need to ensure newly-hired direct care staff demonstrated competency in all assigned job duties within 30 days of hire was discussed with Staff 1 (ED) on 08/09/22. No further documentation was provided.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 sampled newly-hired direct care staff (#s 26 and 28) had verification of demonstrated competency in all assigned job duties within 30 days of hire. This is a repeat citation. Findings include, but are not limited to:Staff training records were reviewed on 02/21/23. 1. There was no documented evidence Staff 26 (MT), hired 12/27/22, demonstrated competency in the topic of changes associated with normal aging.2. There was no documented evidence Staff 28 (MT), hired 01/10/23, had demonstrated satisfactory performance in all assigned duties, including:* The role of service plans in providing individualized resident care;* Providing assistance with the activities of daily living;* Changes associated with normal aging;* Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition;* Conditions that require assessment, treatment, observation and reporting; and* General food safety, serving and sanitation.There was no documented evidence the facility had observed and evaluated Staff 28's ability to perform safe medication and treatment administration, unsupervised. The surveyor requested the facility remove Staff 28 from medication and treatment administration until demonstrated competency was documented in all assigned job duties. The facility expressed compliance with the request.The need to ensure newly-hired direct care staff had verification of demonstrated competency in all assigned job duties within 30 days of hire was discussed with Staff 2 (ED) and Staff 31 (Business Office Manager) on 02/21/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure fire and life safety instruction to staff was provided on alternate months and that documentation reflected all required fire drill components. Findings include, but are not limited to:On 08/09/22, fire drill and fire and life safety records were reviewed from February 2022 through July 2022. The following deficiencies were identified:1. There was no documented evidence the facility was providing fire and life safety training on alternating months for staff; and2. The evacuation/drill documentation did not contain information on:* The escape route used;* Evidence of alternate escape routes used;* Residents who resisted or failed to participate in the drills;* Evacuation time period needed; and* The number of occupants evacuated. The need to meet all requirements for fire drills and fire and life safety instruction was reviewed with Staff 1 (ED) on 08/09/22. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure fire and life safety instruction to staff was provided on alternate months and that documentation reflected all required fire drill components. This is a repeat citation. Findings include, but are not limited to: On 02/21/23, fire drill and fire and life safety records were reviewed from 11/2022 through 02/2023. The following were identified:1. There was no documented evidence the facility provided fire and life safety training on alternating months of the fire drills for staff. 2. Written fire drill records did not include information on:* Location of simulated fire origin;* The escape route used;* Problems encountered and comments relating to residents who resisted or failed to participate in the drills;* Evacuation time period needed; and * Number of occupants evacuated.3. Staff did not evacuate or relocate residents during all fire drills.4. The fire alarm system was not activated during each fire drill.The need to ensure staff received fire and life safety instruction on alternate months and the requirements regarding fire drills were discussed with Staff 2 (ED) and Staff 18 (Director of Maintenance) on 02/21/23 at 2:40 pm. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements for residents were met. Findings include, but are not limited to:Fire drill records from 02/2022 through 07/2022 were reviewed on 08/09/22 with Staff 1 (ED). The facility lacked documentation of the following required elements:* Evidence residents were being instructed on fire and life safety procedures, including designated meeting places inside or outside of the building in the event of an actual fire, within 24 hours of admission.The need to have documented evidence of all fire and life safety training components was discussed with Staff 1 (ED) 08/09/22. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure their relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to C260, C303, C372 and C420.

Based on observation and interview, it was determined the facility failed to ensure courtyard pathway edges did not have drop-offs and the facility grounds were kept orderly and free from refuse. Findings include, but are not limited to:1. Observations of the exterior of the facility and interior courtyard on 08/08/22 showed drop-offs along pathway edges in the interior courtyard in excess of 3 inches in multiple areas.2. An exterior corridor between the buildings had discarded and broken furniture, mobility devices and broken office chairs. The need to ensure pathways in the resident courtyard did not have drop-offs and the exterior of the facility was kept free of refuse was discussed with Staff 1 (ED) and Staff 18 (Maintenance Director) on 08/09/22 at 11:30 am. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure the interior environment was kept clean and in good repair. Findings include, but are not limited to:A tour of the facility was conducted on 08/08/22 through 08/11/22. The facility was comprised of an RCF upstairs and an endorsed memory care downstairs. The MCC units were split into two separate units that were titled MC1 (Memory Care One) and MC2 (Memory Care Two).a. MC1 required cleaning and repair in the following areas:* Multiple recliners in common areas were torn, rendering the surface uncleanable;* Toilet riser in the common use bathroom was rusted, rendering the surface uncleanable;* Gouges and peeling paint on common use bathroom door, room 128, 134, 135, and 139;* Splintered and peeling paint on handrail between rooms 124 and 126, and near rooms 129, 135, 138, 141 and 145;* Multiple wall corners in the dining room and hallway corridors were gouged with exposed sheetrock and metal underneath; and* Wall gouged and peeling paint (underneath handrail) between fire door and room 135 and around the air return vent (near med room).b. MC2 required cleaning and repair in the following areas:* Multiple recliners in common areas were torn, rendering the surface uncleanable;* Splintered and peeling paint on handrail near room 156;* Wall gouged with peeling paint approximately 10 feet above couch and drink station in the dining room;* Multiple wall corners in the dining room, hallway corridors and the wall (with windows) behind the dining room tables were gouged with peeling paint and exposed sheetrock underneath;* Wall gouged with peeling paint (underneath handrail) near electrical panel labeled 1A and 1B, rooms 102, 106, 115 and 123; and* Multiple resident room doors had gouged and peeling paint.c. RCF (upstairs) required cleaning and repair in the following areas:* Splintered handrail near room 207; and* Gouged doors on rooms 203, 207, 208 and 234.The above areas were toured and discussed with Staff 1 (ED) and Staff 18 (Maintenance Director) on 08/09/22 at 11:30 am. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure washing machines had a minimum rinse temperature of 140 degrees Fahrenheit or used a chemical disinfectant when washing soiled linens and soiled clothing. Findings include, but are not limited to:The facility laundry room was observed on 08/08/22 with Staff 18 (Maintenance Director). The washing machines were a residential type with no indicator for the water temperature. The detergent the facility used did not include a disinfecting agent. The need to ensure soiled laundry was properly disinfected was discussed with Staff 1 (ED) and Staff 18 on 08/09/22 at 11:30 am. They 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 when installed in locations that were subject to incidental contact by individuals. Findings include, but are not limited to:During a tour of the facility with Staff 1 (ED) and Staff 18 (Maintenance Director) on 08/09/22, the following observations were made: * Wall heaters with surface temperatures of 136 - 158 degrees Fahrenheit, were installed under the paper towel dispensers between the sink and toilet in common use bathrooms where residents could potentially come into incidental contact. Staff 1 and Staff 18 acknowledged the need to ensure wall heater covers did not exceed 120 degrees Fahrenheit. Staff 18 stated the wall heater knobs would be removed which would disable the use of the wall heaters. On 08/11/22, a random check of the common use bathrooms identified the wall heaters were inoperable.

Based on observation and interview, it was determined the facility failed to ensure exit door alarms were functioning to alert staff when residents exited the RCF. Findings include, but are not limited to:The facility was toured on 08/09/22 with Staff 1 (ED) and Staff 18 (Maintenance Director) and the following was identified:* There were two exit doors in the MCC units that opened into the secured courtyard. The doors had alarms installed but the alarms had been manually disabled and the doors were locked.The need to ensure the facility had operable exit door alarms was discussed with Staff 1 and Staff 18. They acknowledged the findings and Staff 18 activated the door alarms during the facility tour. Refer to Z 168.

Based on interview and record review, it was determined the facility failed to ensure residents who lived in the facility were provided a key to their units per their evaluated needs. Findings include, but are not limited to:Review of records for Residents 1, 2, and 3 revealed no documented evidence the residents had been evaluated for the ability to manage keys to their rooms.On 08/09/22 at 12:25 pm, in an interview with Staff 2 (Wellness Director/LPN), she confirmed there was no documented evidence the residents' ability to manage keys was evaluated and serviced plan if the residents were not able to manage their keys.On 08/09/22 and 08/10/22, the need to ensure all residents were evaluated for the ability to manage keys to their units and provided keys, based on those evaluations, was discussed with Staff 1 (ED) and Staff 2. They acknowledged the findings.

Based on observation and interview, the facility failed to ensure residents who lived in the facility had the freedom and support to have access to food at any time. Findings include, but are not limited to:Observations of the RCF between 08/08/22 and 08/11/22 showed no snacks were provided to residents and two large glass drink dispensers in the RCF dining area were not filled with any beverages for the resident's consumption. The residents did not have refrigerators or kitchenettes in their rooms.In an interview on 08/09/22, an unsampled resident stated sometimes the facility provided snacks if they were requested by residents but sometimes there were none available. The need to ensure all residents had access to food at any time was discussed with Staff 1 (ED), Staff 2 (Director of Wellness) and Staff 15 (Director of Operations) on 08/11/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C 150, C 154, C 156, C 160, C 231, C 242, C 360, C 361, C 370, C 372, C 420, C 422, C 510, C 513, C 530, C 540 and C 555.

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C372 and C420.

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C 252, C 260, C 262, C 270, C 280, C 282, C 290, C 300, C 302, C303, C 310, C 315, C 325 and C 340.

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C260 and C303.

3. Resident 3 resided on the memory care unit. The current service plan and temporary service plans were reviewed during survey and lacked an individualized nutrition and hydration plan based on his/her needs.Observations performed during the survey at meal times revealed the resident required hands-on assistance to eat meals, was provided regular texture foods and nectar thickened liquids to drink. The resident ate some of his/her meals with staff assistance. The resident was not observed to be provided with snacks or fluids between the morning and noon meals, during observations on 08/08/22 and 08/09/22.The resident had experienced a significant weight decline over the past five months and was dependent on staff to meet nutrition and hydration needs. The service plan did not address hydration needs and lacked information on interventions to monitor weight loss.The lack of an individualized nutritional plan was discussed with Staff 1 (ED) and Staff 2 (Wellness Director) on 08/10/22. They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to ensure individualized nutritional plans for each resident were developed and included in service plans for 3 of 3 sampled residents (#s 1, 2 and 3). Findings include, but are not limited to:1. Resident 1 resided on the memory care unit and had been identified, in the entrance conference interview, to require meal assistance. The current service plan and temporary service plans were reviewed during survey and lacked an individualized nutrition and hydration plan based on his/her needs.Observations performed during the survey at meal times revealed the resident required frequent cueing and hands-on assistance to eat meals. The resident was able to eat most of his/her meals with staff assistance. During observations on 08/08/22 and 08/10/22, the resident was not provided with snacks or fluids between the morning and noon meals.The resident had experienced slow weight decline over the past six months and was dependent on staff to meet nutrition and hydration needs. The service plan did not address hydration needs and lacked information on interventions to monitor weight changes.2. Resident 2 resided on the memory care unit and had been identified, in the entrance conference interview, to require meal assistance. The current service plan and temporary service plans were reviewed during survey and lacked an individualized nutrition and hydration plan based on his/her needs.Observations performed during the survey at meal times revealed the resident required hands-on assistance to eat meals, was provided regular textured foods and was able to use a cup to drink nectar thickened liquids independently. The resident ate most of his/her meals with staff assistance. During observations on 08/08/22 and 08/09/22, the resident was not provided with snacks or fluids between the morning and noon meals.The resident had experienced significant weight increase over the past five months and was dependent on staff to meet nutrition and hydration needs. The service plan did not address hydration needs, the provider recommendation to provide a mechanical soft diet and lacked information on interventions to monitor the weight increase.The lack of an individualized nutritional plan was discussed with Staff 1 (ED) and Staff 2 (Wellness Director) on 08/10/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to evaluate and develop individualized activity plans for 3 of 3 sampled residents (#s 1, 2 and 3) whose service plans were reviewed. Findings include, but are not limited to:Residents 1, 2 and 3's service plans offered some information relating to the resident's past interests; however, the facility had not thoroughly evaluated the resident's:* Current interests; * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and * Identification of activities for behavioral interventions. Observations of the residents from 08/08/22 through 08/10/22 revealed the lack of activity programs that included the residents in one to one or group interaction.There was no specific activity plan which detailed what, when, how and how often staff should offer and assist the residents with individualized activities.The lack of an activity evaluation and individualized activity plan was discussed with Staff 1 (ED) and Staff 2 (Wellness Director) on 08/10/22. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to provide access to a secured outdoor space and walkways which allowed residents to enter and return without staff assistance, except when indicated by OAR 411-057-0170(5)(e). Findings include, but are not limited to:The RCF included an endorsed memory care unit on the main level that was split into two units titled Memory Care One (MC1) and Memory Care Two (MC2). Observations during the survey between 08/08/22 through 08/11/22 of MC1 and MC2, showed the doors to the interior courtyard were locked and did not allow residents to exit and return without staff assistance.On 08/09/22, Staff 18 (Maintenance Director) was able to disengage the keypad lock to the MC2 door that lead to the courtyard, however, was unable to disengage the lock to the MC1 courtyard door.During a tour of the building on 08/09/22 at 11:30 am, Staff 1 (ED) and Staff 18 acknowledged the courtyard doors were locked.

Based on observation and interview, it was determined the facility failed to have a written facility policy which detailed when doors to the outdoor recreation area may be locked during nighttime hours or during severe weather. Findings include, but are not limited to:The RCF included an endorsed memory care unit on the main level that was split into two units titled Memory Care One (MC1) and Memory Care Two (MC2). During the survey, the doors to the MCC unit interior courtyard were observed to be locked during daylight hours with sunny and warm weather on 08/08/22 and 08/09/22. On 08/09/22, Staff 1 (ED) confirmed the facility did not have a written policy for when the courtyard doors would be locked. On 08/09/22 at 11:30 am, Staff 1 and Staff 18 acknowledged the above findings.