Serenity RCF

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 09/17/24 at 11:00 am, the facility kitchen was observed to need cleaning in the following areas:

* Hood vents above stove/grill/deep fat fryer – greasy/dusty;
* Stainless steel surrounding stove/grill/deep fat fryer – significant accumulation of grease drips;
* Deep fat fryer – exterior with significant drips of grease/food debris;
* Stove/grill – front and sides had drips/spills;
* Shelf below grill – grease drips/debris;
* Lower shelf on prep counter – debris/spills/food;
* Flooring underneath equipment – build up of debris/black matter; and
* Dry storage flooring – food debris, black matter under shelving next to utility sink, sugar packets and repairs needed over the access to the crawl space which was on the floor near the utility sink.

The following areas included improper food storage:

* Food containers in refrigerator not labeled/dated/sealed securely;
* Open packages of frozen breaded food product and tater tots in upright freezer;
* Dry storage:
- Open bags of flour, rice, sugar and panko crumbs creating risk of cross contamination and/or rodent/pest infestation. (Containers with
securely sealed lids would be an appropriate option.);
- Scoop stored in bag of flour, creating a cross contamination risk; and
- Resident food items (snacks) stored in kitchen dry storage, not readily accessible to residents.

The areas of concern were observed and discussed with Staff 1 (Director of Food Service) on 09/17/24. 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 interview and record review, conducted during a site visit on 04/24/24, it was confirmed the facility failed to fully implement and update an acuity-based staffing tool (ABST) for 3 of 3 sampled residents (#1, 2 and 4). Findings include, but not limited to:A review of the facility's ABST on 04/24/24, indicated the first floor had six residents entered and the second floor had eleven residents entered for a total of 17 residents.A review of the facility census indicated the facility is home to 19 total residents. Resident 1 was admitted to the facility on 10/04/23 and his/her ABST indicated the last update was made on 11/29/23.Resident 2 was admitted to the facility on 01/16/24 and was not entered into the facility ABST.Resident 4 was admitted to the facility on 01/25/24 and was not entered into the facility ABST.In an interview on 04/24/24, Staff 1 (Med tech) confirmed there were 19 residents in the facility.In an interview on 05/03/24, Staff 4 (Administrator) stated the facility used the Oregon Department of Human Services (ODHS) ABST and had not been updated the tool regularly.The facility failed to fully implement and update an ABST.The findings were reviewed with and acknowledged by Staff 4 on 05/03/24.

The findings of the initial licensure survey, conducted 09/25/23 through 09/28/23, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day
The findings of the first re-visit of the re-licensure survey of 09/28/23, conducted 01/22/24 through 01/31/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day

The findings of the second re-visit to the re-licensure survey of 09/28/23, conducted 05/29/24 through 05/31/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.

Based on observation, interview, and record review, it was determined the facility failed to provide adequate administrative oversight of the operation of the facility and the quality of services rendered in the facility. Findings include, but are not limited to:During the re-visit survey, conducted 01/22/24 through 01/31/24, oversight to ensure resident care and services rendered in the facility was found to be ineffective. Refer to deficiencies in the report.

Based on interview and record review, it was determined the facility failed to ensure the preparation, completeness, accuracy and preservation of resident records for 1 of 1 sampled resident (#5) whose records were requested. Findings include but are not limited to:Resident 5 was admitted to the facility in 12/2023 with diagnoses including complications of diabetes mellitus and left lower extremity amputation. Resident 5's move-in evaluation and service plan were requested on 01/22/24. The facility was not able to provide the documentation. There was no service plan or behavior support plan available to staff for the resident. On 01/22/24 at 11:20 am, Staff 2 (Director of Nursing Services) verified there was no service plan or behavior support plan available to staff for the resident. The move-in evaluation was emailed on 01/22/24 at 4:01 pm. Resident 5's service plan was requested from Staff 2 on 01/23/24 at 3:39 pm. On 01/24/24 at 11:41 am, Staff 2 stated, "I am finishing [the resident's] care plan now..."The service plan was emailed on 01/24/24 at 1:22 pm. The need to ensure the preparation, completeness, accuracy and preservation of resident records was discussed with Staff 1 (ED), Staff 13 (Owner), Staff 14 (Program Director), and Staff 17 (Owner) on 01/31/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to develop and conduct ongoing quality improvement programs that evaluated services, staff performance, resident outcomes and resident satisfaction. Findings included, but are not limited to:During the re-visit survey, conducted 01/22/24 through 01/31/24, quality improvement oversight to ensure adequate resident care, services and satisfaction was found to be ineffective.During an interview on 01/31/24 at 11:00 am, Staff 1 (ED) acknowledged there was no quality improvement system to ensure adequate resident services and resident satisfaction.Refer to the deficiencies in the report.

Based on interview and record review, it was determined the facility failed to report suspected abuse to the local Seniors and People with Disabilities (SPD) office, promptly investigate all reports of abuse and suspected abuse, take measures necessary to protect residents and prevent the reoccurrence of abuse, and have documented evidence of an administrator review of investigations, for 1 of 1 sampled resident (#5) who was involved in resident to resident altercations. Findings include, but are not limited to: Resident 5 was admitted to the facility in 12/2023 with diagnoses including complications of diabetes mellitus and left lower extremity amputation. The "24 hour binder", progress notes dated 12/15/23 through 01/18/24, Resident Care Interim Service Plans dated 01/06/24 through 01/12/24, and the resident's clinical records were reviewed. The following was identified:* On 01/06/24 at 5:52 am, a progress note reflected the resident was on alert for a "verbal and physical altercation" with another resident; * On 01/06/24 at 1:09 pm, a progress note reflected the resident was using his/her power chair to run over both staff and other residents as well as threw a "[bowl] of guacamole" at another resident; * On 01/06/24 at 2:05 pm, a progress note reflected the resident threatening other residents and causing a resident to fall by "ramming" him/her into a table with an electric wheelchair; * On 01/07/24 at 2:48 pm, a progress note reflected staff heard the resident engaging in a verbal altercation which ended when Resident 5 "threw [his/her] orange juice towards another resident"; and * On 01/15/24, there was an "Occurrence Report/Investigation" partially filled out which identified another resident slapped Resident 5 on the left side of his/her face.There was no documented evidence the resident to resident altercations were immediately reported to the local SPD office.There was an Occurrence Report/Investigation that was started for the resident to resident altercation occurring on 01/15/24, however, it lacked any follow-up action or interventions to prevent reoccurrence and an Administrator's review. There was no documented evidence the altercations were promptly investigated to take measures necessary to protect residents and prevent the reoccurrence of abuse.On 01/22/24 at 2:30 pm, Staff 1 (ED) was requested to report the resident to resident altercation occurring on 01/15/24. At 4:30 pm, on the same day, Staff 1 stated he left a voice message at the local SPD office. No additional information was received.Survey called the local SPD office on 01/23/24 at 11:56 am and reported the above resident to resident altercations. The need to ensure resident to resident altercations were immediately reported to the local SPD office and investigations were conducted promptly with documentation of the Administrator's review was discussed with Staff 1 (ED), Staff 3 (RCC), Staff 13 (Owner), Staff 14 (Program Director), and Staff 17 (Owner) on 01/25/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to provide services to assist the residents in activities of daily living for 1 of 1 sampled resident (#5) and two unsampled residents who required intermittent intervention, supervision and staff support for residents who exhibit behavioral symptoms. Findings include, but are not limited to:a. Resident 5 was admitted to the facility in 12/2023 with diagnoses including complications of diabetes mellitus and lower left extremity amputation.The resident's medical records were reviewed. There was no service plan or behavior support plan available for staff to reference. Resident 5 had five documented resident to resident altercations between 01/06/24 and 01/15/24. There were two Resident Care Interim Service Plans relating to the altercations directing staff to do the following:* 01/06/24 - "Monitor resident for increased behaviors, document [verbal] as [well] as physical aggression notify community RN and MT on shift of any changes"; and* 01/11/24 - "Monitor resident for increased anxiety, changes in behavior or appetite. Encourage resident to stay away from [the other resident] and redirect them to another area away from [the other resident]. Notify community RN and MT of any changes, concerns or behaviors."Both of the Resident Care Interim Service Plans related to a resident to resident altercation that occurred on 01/06/24. There was no documented evidence of instruction to staff for the remaining four incidents, and no behavioral interventions for staff to attempt in order to negate further altercations. During an interview with Staff 15 (Universal CG) on 01/25/24 at 1:11 pm, she confirmed they "just watch the resident" relating to behaviors and use a "calm voice."b. On 01/22/24 at 11:23 am, two unsampled residents and three staff members were observed in the dining room. One of the residents was overheard to be upset and was raising his/her voice. After approximately one minute of him/her being upset, the other resident began shouting, "Hey! Shut up! You shut up now!" Staff were observed to be watching the incident. The resident who told the other resident to "shut up," got up and started walking towards the other resident, while yelling. One staff member got very close (approximately 12 inches away) to the resident standing up and told the resident repeatedly to "sit down." The resident continued to escalate until Staff 2 (Director of Nursing Services) asked the resident who was angry first to come outside with her, which s/he agreed to. Staff then walked away from the resident who was standing. S/he was observed to still be upset. There was no action observed to attempt to calm the resident down by the three staff members who remained in the dining room. The need to ensure the facility provided services to assist residents who required intermittent intervention, supervision and staff support related to exhibiting behavioral symptoms was discussed with Staff 1 (ED), Staff 3 (RCC), Staff 13 (Owner), Staff 14 (Program Director), and Staff 17 (Owner) on 01/25/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure the initial evaluation contained all required elements and the use of an assistive device was evaluated, for 1 of 1 sampled resident (#1) whose initial evaluation was reviewed. Findings include, but are not limited to:Resident 1 was admitted to the facility in 08/2023 with diagnoses including schizophrenia, anxiety disorder, post-traumatic stress disorder, Type 2 diabetes mellitus, chronic pain and multiple pressure wounds.a. Resident 1's initial move-in evaluation lacked information regarding the following elements:* Eating routine;* History of treatment and effective non-drug interventions in regards to mental health issues;* Personality, including how the person copes with change or challenging situations;* Dental status; and* Recent losses.b. A quarter-length side rail was observed on the resident's hospital bed during the survey. The rail was in the down position, securely attached to the bed and positioned up near the head of the bed where it would be adjacent to the resident's upper body when s/he was in bed. In an interview on 09/27/23, the resident stated s/he did not use the side rail and did not ask the staff to use it either. Therefore, the rail did not restrict the resident's movement and would not be considered a device with restraining qualities.Though the presence of the side rail was noted in the resident's record, the evaluations lacked documentation of how the side rail was to be used, including whether the rail restricted the resident's movement or not.The need to ensure evaluations included all required information was reviewed with Staff 1 (ED) and Staff 2 (Director of Nursing) on 09/28/23. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure the initial evaluation contained all required elements and the use of an assistive device was evaluated, for 1 of 1 sampled resident (#5) whose initial evaluation was reviewed. This is a repeat citation. Findings include, but are not limited to:Resident 5 was admitted to the facility in 12/2023 with diagnoses including complication of diabetes mellitus and a lower left extremity amputation. On 01/22/24 at 11:20 am, Staff 2 (Director of Nursing Services) confirmed the evaluation was not in the resident's medical record. a. Resident 5's initial move-in evaluation lacked information regarding the following elements:* Eating routine; * Visits to health practitioner(s), Emergency Room, hospital or Skilled Nursing Facility in the past year; * Personality, including how the person copes with change or challenging situations; and * Fluid preferences.Although the evaluation was dated on 12/12/23, there was no documented evidence of who was involved in the evaluation process. b. Resident 5 was identified on the initial evaluation as having side rails. There was no documented evidence the side rails were evaluated. On 01/23/24 at 2:27 pm, the resident's bed was observed to have a quarter-length side rail in the down position. Resident 5 stated s/he wanted them "taken off" as s/he did not use them. Though the presence of the side rail was noted in the resident's initial move-in evaluation, there was no documented evidence the side rail was evaluated for how the side rail was to be used, including whether the rail restricted the resident's movement or not.The need to ensure evaluations included all required information was reviewed with Staff 1 (ED) and Staff 13 (Owner) on 01/23/24. They acknowledged the findings.

4. Resident 1 was admitted to the facility in 08/2023 with diagnoses including schizophrenia, anxiety disorder, post-traumatic stress disorder, Type 2 diabetes mellitus, chronic pain and multiple pressure wounds. Observations of the resident, interviews with the resident and staff, and review of Resident 1's service plan, dated 09/17/23, indicated the service plan was not reflective of the resident's current care needs or did not provide clear direction to staff for providing services in the following areas:* Dental status;* Information regarding the safe use, precautions and monitoring of the resident's side rails;* Information and procedure for covering the resident's catheter bag when in his/her wheelchair;* Information regarding the resident's reluctance/resistance to going to the hospital and to medical appointments with new providers; and* Information from an Interim Service Plan (ISP) dated 09/09/23 directing staff to ensure the resident's power wheelchair was being charged while the resident was in bed and to ensure the resident had the facility phone number with him/her when leaving the facility was not added to the service plan when it was reviewed on 09/17/23.The need to ensure service plans were reflective of the residents' status and included adequate instructions for staff for providing care and services was discussed with Staff 1 (ED) and Staff 2 (Director of Nursing) on 09/28/23. They acknowledged the findings.
Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were readily available to staff, provided clear direction regarding the delivery of services, included a written description of who shall provide the services and what, when, how, and how often the services shall be provided, and was being followed for 3 of 3 sampled residents (#s 1, 2, and 3) whose service plans were reviewed. Findings include, but are not limited to: 1. During the acuity interview on 09/25/23, Staff 7 (Universal CG) reported resident service plans were kept in a binder in the main office for staff reference. However, upon inspection on 09/25/23 at 11:25 am, Resident 1, 2 and 3's service plans and behavior support plans were not in the binder. At that time, Staff 2 (Director of Nursing) acknowledged the service plans were not in the binder and said she would re-print them.2. Resident 2 moved into the facility in 08/2023 with diagnoses including hypertension and history of a cerebral vascular accident (CVA).Although the service plan was reflective of the resident's CVA affecting his/her left side, it did not address the fact that prior to the incident, s/he was left sided dominant. Per observations and interviews with Resident 2, staff interviews, and record review, the resident's 08/31/23 service plan lacked clear direction in the following areas: * Care of the resident's left hand contracture; * How blood pressures were taken;* The use of a PRN psychotropic; * Behavior triggers and interventions; * Offering a shower or a bed bath; * Grooming assistance; * Lower left leg brace; * Assistance needed for writing correspondence; and * Activity preferences. The need to ensure Resident 2's service plan provided clear direction regarding the delivery of services, and included a written description of who shall provide the services and what, when, how, and how often the services shall be provided was discussed with Staff 4 (Behavior Coordinator) on 09/27/23 and on 09/28/23 with Staff 1 (ED) and Staff 2 (Director of Nursing). They acknowledged the findings. 3. Resident 3 moved into the facility in 07/2023 with diagnoses including dementia and depression. Observations of the resident, staff interviews, and review of the service plan, dated 08/09/23, showed the service plan was not reflective of the resident's current care needs, did not provide clear direction to staff or was not followed in the following areas: * Scheduled pain medications; * Reporting changes of condition, including agitation and insomnia to the Licensed Nurse; * Staff assistance needed to eat and drink;* Preference of drinking from a straw; * Bathing options; * Changing clothes daily; * Application of make-up; * Fall history and interventions; * Behavioral and cognitive functioning; * Behavior interventions; * Ensuring the call light and personal items were within reach; and * Activity interests including being read to versus reading independently. The need to ensure Resident 3's service plan provided clear direction regarding the delivery of services, included a written description of who shall provide the services and what, when, how, and how often the services shall be provided, and was followed was discussed with Staff 4 (Behavior Coordinator) on 09/27/23 and on 09/28/23 with Staff 1 (ED) and Staff 2 (Director of Nursing). They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were readily available to staff, provided clear direction regarding the delivery of services, included a written description of who shall provide the services and what, when, how, and how often the services shall be provided, and was being followed for 2 of 2 sampled residents (#s 4 and 5) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to: a. On 01/22/24 at 11:20 am, survey attempted to locate Resident 5's service plan. Staff 2 (Director of Nursing) confirmed the resident's service plan or the behavior support plan were not in the binders and not available to staff. On 01/25/24 at 11:15 am, survey requested Resident 4's behavior support plan. Staff 3 (RCC) confirmed it was not available to staff. b. Resident 4 was admitted to the facility in 11/2023 with diagnoses including depression, diabetes mellitus, and schizophrenia. Observations of the resident, staff interviews, and review of the service plan, dated 12/13/23, showed the service plan was not reflective of the resident's current care needs, did not provide clear direction to staff, or was not followed in the following areas: * Diabetic diet; * What the resident was able to do with supervision during meal times; * Blood glucose sensor applied to the back of the resident's right arm; * What staff should monitor for relating to the blood glucose sensor and skin issues;* RN to complete all toenail trimming; * Interventions for depression; * Interventions if the resident exhibits memory issues and refuses to interact with others; and * Snack prior to going to sleep at night. The need to ensure service plans were readily available to staff, were reflective of the residents' status, and included adequate instructions for staff for providing care and services was discussed with Staff 1 (ED), Staff 13 (Owner), Staff 14 (Program Director), and Staff 17 (Owner) on 01/31/24. 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 consisted of the resident, the resident's legal representative if applicable, any person of the resident's choice, the facility administrator or designee, at least one other staff person who was familiar with or provided services to the resident, and Local APD or AAA case manager, as available, for 2 of 2 sampled residents (#s 4 and 5) whose service plans were reviewed and 2 of 2 unsampled residents who were interviewed. Findings include, but are not limited to:a. Resident 4's service plan was not signed nor was there documented evidence of a Service Planning Team in the resident's medical record. There was no documented evidence of a Service Planning Team located in Resident 5's medical record, and there was no documented evidence of a service plan or behavior support plan available to review for Service Planning Team involvement.b. During an interview on 01/23/24 at 3:10 pm, Witness 1 (Multnomah County Case Worker) confirmed he had not been invited to any care conferences and that he was the Case Worker for all 20 residents who resided in the community.c. On 01/23/24 between 3:26 pm and 4:18 pm, two unsampled residents were interviewed about their Service Planning Team. Both residents had resided at the facility greater than five months. Neither resident was aware of a time when their service plan was reviewed with them. Both residents reported they wanted Witness 1 involved on their Service Planning Team.The need to ensure service plans were developed by a Service Planning Team that consisted of the resident, the resident's legal representative if applicable, any person of the resident's choice, the facility administrator or designee, at least one other staff person who was familiar with or provided services to the resident, and Local APD or AAA case manager, as available, was discussed with Staff 1 (ED), Staff 3 (RCC), Staff 13 (Owner), Staff 14 (Program Director), and Staff 17 (Owner) on 01/25/24. They acknowledged the findings.

2. Resident 1 was admitted to the facility in 08/2023 with diagnoses including schizophrenia, anxiety disorder, post-traumatic stress disorder, Type 2 diabetes mellitus, chronic pain and multiple pressure wounds.Review of progress notes between 08/18/23 to 09/25/23, Interim Service Plans (ISPs), and interviews with staff indicated the resident experienced multiple changes of condition, including the following:* Admission to the facility;* Two non-injury falls from his/her power wheelchair while out alone in the community;* Snorting an unknown substance;* An episode of nausea and vomiting;* Treatment with an antibiotic for a urinary tract infection; and* Multiple medication changes.Though the facility communicated to staff in ISPs what actions or interventions were needed for the resident in response to each of these changes of condition, the facility failed to actively monitor the resident per the instructions, and the facility failed to document when the resident's condition was considered resolved and monitoring could be discontinued.The need to ensure staff monitored the resident effectively and documented on the status of the resident at least weekly until the change of condition was considered resolved was discussed with Staff 1 (ED) and Staff 2 (Director of Nursing) on 09/28/23. They acknowledged the findings.
Based on observation, interview, and record review, it was determined the facility failed to ensure residents with changes of condition were evaluated to determine what actions or interventions were needed, the actions or interventions were communicated to staff on each shift, and there was documentation at least weekly through resolution for 2 of 2 sampled residents (#s 1 and 3) who were reviewed for changes of condition. Findings include, but are not limited to:1. Resident 3 moved into the facility in 07/2023 with diagnoses including dementia and depression. Staff were interviewed. Resident 3's progress notes, dated 07/10/23 through 09/25/23, and the clinical record was reviewed. The following changes of condition were identified: * 07/19/23 - suicide ideation; * 07/31/23 - increased confusion; * 08/08/23 - skin irritation on the "left butt cheek"; * 08/15/23 - return from the hospital with a diagnosis of a urinary tract infection and a new antibiotic; * 08/21/23 - "voicing experiences outside of reality"; * 08/23/23 - "potential sore on the left butt"; * 08/24/23 - Unwitnessed fall; and * Multiple progress noted entries of the resident exhibiting anxiety. On 09/27/23, Staff 1 (ED) reported there were no skin issues observed but he did not document his findings.Resident 3 was observed to call out frequently. Staff attempted interventions, but they were either ineffective or only worked for a short period of time. Other residents were observed to be irritated by the resident, telling him/her to "shut up."There was no documented evidence the facility evaluated Resident 3 for the changes of condition to determine resident-specific actions or interventions, communicated the actions or interventions to staff on each shift, or documented weekly progress through resolution.The need to ensure residents with changes of condition were evaluated to determine what actions or interventions were needed, the actions or interventions were communicated to staff on each shift, and there was documentation at least weekly through resolution was discussed with Staff 1 (ED) and Staff 2 (Director of Nursing Services) on 09/28/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure changes of condition had determined and documentation of what action or intervention was needed for the resident, the actions or interventions were communicated to staff on each shift, and there was documentation at least weekly through resolution for 1 of 2 sampled residents (#5) who were reviewed for changes of condition. This is a repeat citation. Findings include, but are not limited to:Resident 5 was admitted to the facility in 12/2023 with diagnoses including complication of diabetes mellitus and a lower left extremity amputation. Resident 5's progress notes, dated 12/15/23 through 01/22/24, and clinical records were reviewed. The following changes of condition were identified: * 12/18/23 - Return from the hospital relating to catheter issues; * 12/24/23 - Return from the hospital; * 01/06/24 - Three resident to resident altercations in one day; * 01/07/24 - A resident to resident altercation and return from the hospital; and * 01/15/24 - A resident to resident altercation. There was no documented evidence the facility determined and documented what resident-specific actions or interventions were needed, communicated the actions or interventions to staff on each shift, or documented weekly progress through resolution. The need to ensure residents with changes of condition had determined and documented needed actions or interventions, the actions or interventions were communicated to staff on each shift, and there was documentation at least weekly through resolution was discussed with Staff 1 (ED), Staff 3 (RCC), Staff 13 (Owner), Staff 14 (Program Director), and Staff 17 (Owner) on 01/25/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to coordinate care with outside providers in order to ensure the continuity of care, for 1 of 1 sampled resident (#5) who received on and off site health services. Findings include, but are not limited to:Resident 5 was admitted to the facility in 12/2023 with diagnoses including complications of diabetes mellitus and lower left extremity amputation. The resident's clinical record, progress notes dated 12/15/23 through 01/18/24, and Resident Care Interim Service Plans dated 01/06/24 through 01/12/24 were reviewed. The following recommendations were made by on and off site health services: * On 01/04/24, HH OT recommended staff to cue the resident to "turn head to look to the right, lock speed at slow setting, keep bathroom light on at night, put reflective duct tape around the floor to help patient see edges." On 01/23/24 at 2:27 pm, there was no evidence of reflective duct tape in the resident's apartment. The resident was observed in a manual wheelchair during survey. * On 01/09/24, the resident's physician directed staff to contact the resident's guardian and call 911 if Resident 5 was at risk of harming others. There was no documented evidence these recommendations were communicated with staff in an effort to coordinate care. The need to ensure on-going coordination of care was discussed with Staff 1 (ED), Staff 3 (RCC), Staff 13 (Owner), Staff 14 (Program Director), and Staff 17 (Owner) on 01/25/24. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment which included protocols to prevent the development and transmission of communicable diseases, and failed to comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19. Findings include, but are not limited to:During the revisit survey, conducted 01/22/24 through 01/25/24, the facility had several residents with confirmed COVID-19.a. Per Oregon Health Authority Summary of Long-Term Care Facility Infection Control Policies for COVID-19 and Other Respiratory Pathogens, facilities were required to:* "Maintain necessary levels of PPE [Personal Protective Equipment] to respond to communicable disease cases or outbreak";* "Staff caring for residents with suspect or confirmed COVID-19 are required to wear a fit-tested N 95 respirator, eye protection, gown, and gloves"; and * "Signage must be placed immediately outside of resident rooms to alert about transmission-based precautions and protocols". Observations and interviews with staff revealed the facility did not have fit-tested N 95 respirators, gowns, or eye protection available to staff providing care to those residents with COVID-19. In addition, there was no signage placed immediately outside of resident rooms to alert about transmission-based precautions and protocols.In an interview with Staff 1 (ED) who was also identified as the Infection Control Specialist, and Staff 3 (RCC) on 01/25/24 at 10:45 am, they confirmed the facility did not have a supply of the necessary PPE for staff who provided care to residents with COVID-19, and acknowledged the lack of signage alerting about transmission based precautions and protocols. Staff 1 stated he would immediately contact a supply company to obtain the required PPE and post signage outside resident rooms. b. Observations of staff during the survey revealed multiple instances where staff failed to wear a mask, or face masks were not consistently worn properly exposing their noses and mouths.During the survey, the survey team requested staff don face masks and/or ensured masks covered their mouths and noses to comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19. The need to ensure the facility implemented and maintained infection prevention and control protocols to provide a safe, sanitary, and comfortable environment which included protocols to prevent the development and transmission of communicable diseases was reviewed with Staff 1, Staff 3, Staff 13 (Owner), Staff 14 (Program Director) and Staff 17 (Owner) during the exit conference on 01/25/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to have a system for tracking controlled substances, for 1 of 1 sampled resident (#1) who was administered PRN narcotic medications. Findings include, but are not limited to:Resident 1 was admitted to the facility in 08/2023 with diagnoses including schizophrenia, anxiety disorder, post-traumatic stress disorder, type 2 diabetes mellitus, chronic pain and multiple pressure wounds.The resident was prescribed the following PRN narcotic medications:* Hydromorphone 4mg tablet - 1 tablet three times per day as needed for pain; and* Diazepam 2mg tablet- 1 tablet three times per day as needed for muscle spasms.Review of Resident 1's 09/01/23 through 09/25/23 MAR and the Controlled Substance Disposition Record revealed the following discrepancies:a. PRN hydromorphone:* The medication was signed out on the Controlled Substance Disposition Record but not documented as having been administered on 09/02/23 twice, 09/09/23, 09/13/23 twice, 09/14/23 twice, 09/19/23 and 09/22/23; and* The medication was documented as having been administered on the MAR but was not documented in the Controlled Substance Disposition Record on 09/06/23, 09/07/23 three times, 09/08/23 and 09/13/23.b. PRN diazepam:* The medication was signed out on the Controlled Substance Disposition Record but not documented as having been administered on 09/04/23, 09/13/23, 09/14/23, 09/16/23, 09/17/23 and 09/19/23; and* The medication was documented as having been administered on the MAR but was not documented in the Controlled Substance Disposition Record on 09/04/23, and 09/16/23.The need to ensure the facility had an effective system for tracking controlled substances was reviewed with Staff 1 (ED) and Staff 2 (Director of Nursing) on 09/28/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 2 of 3 sampled residents (#s 2 and 3) whose orders were reviewed. Findings include, but are not limited to:1. Resident 2 moved into the facility in 08/2023 with diagnoses including protein calorie malnutrition. The resident's current physician orders and MARs dated from 09/01/23 through 09/25/23 were reviewed. The following medications were not administered per physician's orders: * Famotidine (for acid reflux) on 09/14/23; and * Ferrous sulfate, multi-vitamin with minerals, vitamin B-12, vitamin C, vitamin D (all supplements) from 09/03/23 through 09/10/23. The "Pass Notes" on the MAR reflected the medications were "unavailable" to the facility and "awaiting med delivery." The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (ED) and Staff 2 (Director of Nursing Services) on 09/28/23. They acknowledged the findings.2. Resident 3 moved into the facility in 07/2023 with diagnoses including Type 2 diabetes mellitus. The resident's current physician orders and MARs dated from 09/01/23 through 09/25/23 were reviewed and the following was identified: Resident 3 had an order for sliding scale Novolog (insulin). The parameters instructed staff to administer one unit for CBGs of 150 - 200, and administer two units for CBGs of 201 - 250. Documentation showed the resident's CBG reading on 09/24/23 was 222 and the facility administered one unit of Novolog. The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (ED) and Staff 2 (Director of Nursing Services) on 09/28/23. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed, and written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record for all medications and treatments the facility was responsible to administer for 2 of 2 sampled residents (#s 4 and 5) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to:1. Resident 4 was admitted to the facility in 11/2023 with diagnoses including diabetes mellitus.The resident's MAR dated 01/01/24 through 01/22/24, physician's orders, and the resident's 12/13/23 service plan were reviewed. a. The following medications and treatments were not carried out as prescribed:* There was a signed order for the Resident 4's CBGs to be checked upon waking, before meals, and before bedtime dated 12/06/23. There was no documented evidence the facility was checking Resident 4's CBGs upon waking and prior to bedtime.* The facility was directed to administer amlodipine (for hypertension) once a day after taking the resident's blood pressure and pulse with parameters to hold the medication for systolic blood pressure less than 95 and/or pulse less than 55. There was no documentation the blood pressure or pulse was taken on 01/14/24 and 01/16/24 prior to administering the medication. * Resident 4 had an order for PRN Glutose 15 gel (for low CBGs) with directions to administer it if the CBGs were less than 70. On 01/14/24, documentation showed a CBG reading of 56 at 8:00 am. There was no documented evidence the Glutose 15 gel was administered. * The resident had an order for sliding scale Novolog (for diabetes) to be administered three times a day before meals based on CBGs. There was no documented evidence the facility obtained the resident's CBGs to know how many units of insulin the resident needed and no documentation on the amount of insulin administered on: - 01/17/24 at 8:00 am, 12:00 pm, and 5:00 pm; and - 01/19/24 at 12:00 pm. * There was a signed order on Resident 4's "After Visit Summary" for the facility to provide a "Diabetic Diet." There was no documented evidence the facility was providing the physician ordered diet and the service plan reflected "low cholesterol, minced and moist diet," with no information relating to being on a diabetic diet.b. The facility did not have signed physician or other legally recognized practitioner orders in Resident 4's medical record for the following medications: * Glutose 15 gel (for diabetes), PRN; and * Diclofenac gel (for pain), PRN. The need to ensure physician orders were carried out as prescribed and written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record for all medications and treatments the facility was responsible to administer was reviewed with Staff 1 (ED), Staff 3 (RCC), Staff 13 (Owner), Staff 14 (Program Director), and Staff 17 (Owner) on 01/25/24. They acknowledged the findings.2. Resident 5 was admitted to the facility in 12/2023 with diagnoses including complication of diabetes mellitus. The resident's MAR dated 01/01/24 through 01/22/24 and physician's orders were reviewed. a. The following medications and treatments were not carried out as prescribed:* The physician's order for hydrochlorothiazide (for chronic heart failure) specified for the facility to administer the medication "every day with lunch." The facility was administering the medication at 7:00 am. * Resident 5 had a physician's order to "check blood glucose levels four times daily." There was no documented evidence the facility was checking the resident's CBGs. b. The facility did not have signed physician or other legally recognized practitioner orders in Resident 5's medical record for the following medications: * Clotrimazole cream (for odorous/redness); * Refresh liquid gel drops (for eye irritation); * Zinc oxide ointment (for odorous/redness); and * Nystatin (for yeast rash) PRN. The need to ensure physician orders were carried out as prescribed and written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record for all medications and treatments the facility was responsible to administer was reviewed with Staff 1 (ED), Staff 3 (RCC), Staff 13 (Owner), Staff 14 (Program Director), and Staff 17 (Owner) on 01/25/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to notify the physician when a resident refused to consent to orders for 1 of 1 sampled resident (#5) who had documented medication and/or treatment refusals. Findings include, but are not limited to:Resident 5 was admitted to the facility in 12/2023 with diagnoses including complications of diabetes mellitus and lower left extremity amputation. A review of the resident's 01/01/24 through 01/22/24 MAR, physician's orders, and progress notes dated 12/15/23 through 01/18/24, revealed the resident refused the following medications on multiple occasions:* Hydrochlorothiazide (for chronic heart failure); * Insulin glargine solution (for diabetes); * Losartan (for hypertension); * Metformin (for diabetes); * Nifedipine (for hypertension); and * Nystatin (for rash/redness). Although there was a progress note dated 01/21/24 indicating the physician only wanted to be notified weekly, there was no documented evidence of the order nor was there evidence the physician was being notified weekly of the resident's refusals. The need to notify the physician of resident medication and/or treatment refusals was discussed with Staff 1 (ED), Staff 3 (RCC), Staff 13 (Owner), Staff 14 (Program Director), and Staff 17 (Owner) on 01/25/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure resident MARs were accurate and included resident specific parameters and instructions for PRN medications, for 2 of 3 sampled residents (#s 2 and 3) whose MARs were reviewed. Findings include, but are not limited to:1. Resident 2 moved into the facility in 08/2023 with diagnoses including hypertension, protein calorie malnutrition, and Type 2 diabetes mellitus. The resident's current physician orders and MARs dated from 09/01/23 through 09/25/23 were reviewed and revealed the following: a. The resident had physician orders for amlodipine, carvedilol, and hydralazine (all to treat hypertension). The parameters directed staff to "hold for systolic (top number) of greater than 100 or heart rate greater than 55." There was no documentation of blood pressure readings. On 09/26/23 at 3:10 pm, Staff 7 (Universal CG) reported that Resident 2 took his/her own blood pressure and reported the numbers to staff. On 09/27/23 at 1:17 pm, the resident confirmed s/he did take his/her blood pressure from his/her "Smartwatch," and confirmed the blood pressure readings were not documented. b. On 09/09/23, staff documented Resident 2 received ferrous sulfate, multi-vitamin with minerals, vitamin B-12, vitamin C, vitamin D (all supplements) on the MAR. But in the "Exceptions" section located on the MAR, the medications were documented as not being available to administer. c. The resident had three PRN medications for pain. There were no parameters for staff to direct them on which to administer first or if the resident could self direct his/her medications. d. On 09/05/23, staff documented they administered fluticasone (for allergies) nasal spray twice at 6:09 pm, once per nostril. The parameters were to "inhale 1 spray in each nostril every 24 hours as needed." e. The physician's order directed staff to hold the 25 units of prescribed admelog solostar (insulin) if the resident's CBGs were less than 100. On 09/11/23 at 4:00 pm Resident 2's CBG was recorded as 99 and the staff documented he administered the insulin. On 09/28/23 at 10:20 am, Staff 1 (ED), confirmed he held the insulin on 09/11/23, but documented it incorrectly. The need to ensure MARs were accurate and included resident specific parameters for PRN medications was discussed with Staff 1 and Staff 2 (Director of Nursing Services) on 09/28/23. They acknowledged the findings. 2. Resident 3 moved into the facility in 07/2023 with diagnoses including Type 2 diabetes mellitus. The resident's current physician orders and MARs dated from 09/01/23 through 09/25/23 were reviewed and revealed the following: Resident 3 had a physician's order for staff to inject 12 units of Novolog (insulin) every morning. The documentation showed the resident receiving two units on 09/21/23, zero units on 09/22/23, and two units on 09/23/23. The resident had a physician's order for staff to inject 15 units of Novolog (insulin) twice a day. Documentation showed the following: * 09/20/23 - 1 unit administered at 12:00 pm and 4 units administered at 5:00 pm; * 09/21/23 - 4 units administered at 12:00 pm and 2 units administered at 5:00 pm; * 09/22/23 - 3 units administered at 12:00 pm and 4 units administered at 5:00 pm; and* 09/23/23 - 3 units administered at 12:00 pm and 1 units administered at 5:00 pm. On 09/28/23 at 10:20 am, Staff 2 (Director on Nursing Services) confirmed the resident had received 12 units of insulin in the morning and 15 units of insulin at 12:00 pm and 5:00 pm, per physician's orders on the above mentioned days. She confirmed it was her who administered Resident 3's correct amount of insulin from 09/20/23 through 09/23/23, but did not document it correctly. The need to ensure MARs were accurate and included resident specific parameters for PRN medications was discussed with Staff 1 (ED) and Staff 2 on 09/28/23. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure resident MARs were accurate and included resident specific parameters and instructions for PRN medications, for 2 of 2 sampled residents (#s 4 and 5) whose MARs were reviewed. This is a repeat citation. Findings include, but are not limited to:1. Resident 4 admitted to the facility in 11/2023 with diagnoses including pain.The resident's MAR dated 01/01/24 through 01/22/24 and physician's orders were reviewed and the following was identified: * The resident had a physician's order for PRN oxycodone (for pain) 5 mgs directing staff to administer "1/2 to 1 tablet (2.5 - 5 mg) by mouth." The parameters for the medication did not provide specific direction to unlicensed staff on which dosage to administer. * Resident 4 had a PRN for Glutose gel (for low CBGs) with direction to staff to repeat in 15 minutes "if blood glucose [is] greater than 70." The instructions should have been to re-administer the Glutose gel in 15 minutes for CBGs lower than 70.The need to ensure MARs were accurate and included resident specific parameters for PRN medications was discussed with Staff 1 (ED), Staff 3 (RCC), Staff 13 (Owner), Staff 14 (Program Director), and Staff 17 (Owner) on 01/25/24. They acknowledged the findings.2. Resident 5 was admitted to the facility in 12/2023 with diagnoses including complications of diabetes mellitus.The resident's MAR dated 01/01/24 through 01/22/24, physician's orders, and progress notes dated 12/15/23 through 01/18/24 were reviewed and the following was identified: * Refresh liquid gel drops (for eye irritation) had the parameters for unlicensed staff to administer "4 - 5 drops in right eye." Additionally, the MAR reflected the time of administration for 12:00 am. * Staff were directed to apply nystatin "topically to affected area two or three times daily". There was no reason for use and no indication of where the "affected area" was. The parameters for the Refresh liquid gel drops and the nystatin did not provide specific direction to unlicensed staff on which dosage to administer. * On 01/18/24, there was a progress note reflecting a late entry for 01/17/24 stating the resident refused "all of [his/her] medications including morning insulin." There were initials on the 9:00 am insulin indicating it was administered. The need to ensure MARs were accurate and included resident specific parameters for PRN medications was discussed with Staff 1 (ED), Staff 3 (RCC), Staff 13 (Owner), Staff 14 (Program Director), and Staff 17 (Owner) on 01/25/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure a thorough RN, PT, or OT assessment was completed prior to the use of a supportive device with restraining qualities, failed to document other less restrictive alternatives were evaluated prior to the use of the device, and failed to instruct caregivers on the correct use and precautions related to the use of the device for 2 of 2 sampled residents (#s 2 and 3) who used side rails. Findings include, but are not limited to:Resident 2 and Resident 3 were observed to have bi-lateral, half length side rails that were in the raised position attached to their beds. Although both residents did have a "Supportive Device Assessment," neither were signed so it was unknown if an RN, PT, or OT conducted the assessment. Also, there was no documentation if less restrictive alternatives were evaluated prior to the use of the device or if the resident specifically requested the side rails. During an interview with Staff 12 (CG) on 09/27/23 at 9:57 am, it was confirmed she did not check the residents' side rails or know what to do if the side rails were loose or in disrepair. The need to ensure a thorough RN, PT, or OT assessment was completed prior to the use of a supportive device with restraining qualities, which included documentation other less restrictive alternatives were evaluated prior to the use of the device, and staff were instructed on the correct use and precautions related to the use of the device was discussed with Staff 1 (ED) and Staff 2 (Director of Nursing Services) on 09/28/23. They acknowledged the findings.
Based on observation, interview, and record review, it was determined the facility failed to ensure a thorough RN, PT, or OT assessment was completed prior to the use of a supportive device with restraining qualities, failed to document other less restrictive alternatives were evaluated prior to the use of the device, and failed to instruct caregivers on the correct use and precautions related to the use of the device for 1 of 1 sampled resident (#4) who used side rails. This is a repeat citation. Findings include, but are not limited to:Resident 4 was observed to have bi-lateral, half length side rails that were in the raised position attached to the bed. Although the resident had a "Supportive Device Assessment," it was not signed so it was unknown if an RN, PT, or OT conducted the assessment. Also, there was no documentation if less restrictive alternatives were evaluated prior to the use of the device or if the resident specifically requested the side rails. During an interview with Staff 15 (Universal CG) on 01/25/24 at 1:11 pm, it was confirmed she did not check the residents' side rails for looseness or disrepair. The need to ensure a thorough RN, PT, or OT assessment was completed prior to the use of a supportive device with restraining qualities, which included documentation other less restrictive alternatives were evaluated prior to the use of the device, and staff were instructed on the correct use and precautions related to the use of the device was discussed with Staff 1 (ED), Staff 3 (RCC), Staff 13 (Owner), Staff 14 (Program Director), and Staff 17 (Owner) on 01/25/24. They acknowledged the findings.

Based on record review and interview, it was determined the facility failed to implement an acuity-based staffing tool (ABST) to determine appropriate staffing levels for the facility. Findings include, but are not limited to:In an interview on 09/27/23, Staff 1 (ED) reported the facility had not implemented an ABST to determine appropriate staffing levels for the facility because staffing levels were specified in the special needs contract governing the facility.The need to implement an ABST was discussed and Staff 1 stated he would adopt and use the Department's ABST.

Based on interview and record review, it was determined the facility failed to update an acuity-based staffing tool (ABST) before a resident moves in to the facility and no less than quarterly, based on the evaluated care needs for 2 of 2 sampled residents (#s 4 and 5) and multiple unsampled residents. This is a repeat citation. Findings include, but are not limited to:On 01/25/24, the ABST was reviewed with Staff 1 (ED). The following was identified:* Resident 4's ABST information was inputted 16 days after admission;* Resident 5's ABST information was inputted 40 days after admission; * Ten residents had not been updated at least quarterly; and* There was one resident who was not entered in the ABST. The need to ensure the facility updated the ABST before a resident moves in to the facility and no less than quarterly was discussed with Staff 1 (ED), Staff 3 (RCC), Staff 13 (Owner), Staff 14 (Program Director), and Staff 17 (Owner) on 01/25/24. They acknowledged the findings.

Based on record review and interview, it was determined the facility failed to conduct and record fire drills every other month according to the Oregon Fire Code (OFC) and failed to provide fire and life safety instruction to staff on alternate months. Findings include, but are not limited to:In an interview on 09/27/23, Staff 1 (ED) stated the facility had not been conducting fire drills and had not been providing fire and life safety training to staff on alternate months.The need to ensure fire drills and fire and life safety training was provided and documented as required was discussed. Staff 1 acknowledged the deficiencies.

Based on observation, interview, and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to C 252, C 260, C 270, C 303, C 310, C 340, C 361, and C 530.

Based on observation and interview, it was determined the facility failed to provide a lockable storage space (e.g., drawer, cabinet or closet) for the safekeeping of a resident's small valuable items and funds. Findings include, but are not limited to:During the environmental inspection of multiple occupied and unoccupied resident apartments on 09/25/23, a lockable metal security safe box was observed sitting on the shelf in the closet of each unit. Residents reported they used the security box to store valuables.The safe box was not mounted or secured to the shelf, so it was not an effective means for safekeeping a resident's valuables. The need to ensure the facility provided a lockable storage space that was secure was discussed with Staff 1 (ED) on 09/27/23. He acknowledged the safe boxes needed to be secured.

Based on observation and interview, it was determined the facility failed to ensure washers had a minimum rinse temperature of 140 degrees Fahrenheit (F) unless a chemical disinfectant is used when washing soiled linens and clothing. Findings include, but are not limited to:In an interview on 09/26/23, Staff 12 (CG) explained the process for laundering soiled linens and clothing. She did not mention the use of a disinfectant. When the disinfectant was shown to Staff 12, she stated she had not been instructed to use the product.The need to ensure a chemical disinfectant was used when washing soiled laundry was discussed with Staff 1 (ED) on 09/27/23. He acknowledged the finding and said he would immediately review the laundry process with all staff.
Based on observation and interview, it was determined the facility failed to ensure washers had a minimum rinse temperature of 140 degrees Fahrenheit (F) unless a chemical disinfectant was used when washing soiled linens and clothing. This is a repeat citation. Findings include, but are not limited to:On 01/23/24 at 3:06 pm, Staff 16 (Universal CG) reported she rinsed the soiled items then washed them. When asked if she added anything to the washing machine, she reported only using the laundry detergent.In an interview with Staff 11 (Universal CG) on 01/23/24 at 3:09 pm, it was reported she rinsed the soiled items out and washed them twice. This interview took place in the laundry room. Survey opened the cabinet where the disinfectant for clothing and the bleach for linens were both stored. Staff 11 confirmed she used bleach if the sheets had been soiled and stated she didn't use anything but laundry detergent if it was clothing that was soiled. The need to ensure a chemical disinfectant was used when washing soiled laundry was discussed with Staff 1 (ED) and Staff 13 (Owner) on 01/23/24. The acknowledged the findings.