Gateway Living

Based on observation, record review and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:

Observation of the seven cottage kitchen areas and main food storage areas (cooks shack, dry storage and freezer room) were reviewed on 02/12/25 at 10:15 am through 1:45pm and found the following:

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

*Reach in freezer door ice and water dispensers in 620,622, 608 and 604;
* Kitchen floor in 608;
* Microwaves in 608 and 604;
* Ovens in 604 and 608;
* Interior of cabinets and/or drawers in 608,
* Interior of refrigerator in 604;

b. The following areas were in need of repair:

* Multiple cabinets or drawers in 611 and 608 with dings/chips/scratches/non smooth surfaces. Drawer in 608 broken.
* Reach in refrigerator in 604 drawer broken.
* Reach in refrigerator in house 612 at 50 degrees Fahrenheit, door not shutting/sealing appropriately;


c. Staff 3 and Staff 4 observed to reheat alternate protein sources for meals and did not check temperatures of food items to ensure at appropriate/safe temperatures prior to serving residents.

d. Multiple potentially hazardous foods (PHF) in all cottages were found open without open dates. Unlabeled and undated food items were found in multiple cottages. Staff food was found stored with resident foods in multiple cottages.

e. Staff 3 and staff 4 were observed to not sanitize thermometers prior to use nor in between use for different food items. Staff 4 was observed to use a knife for cutting up resident food then wash and rinse and put back in sharps drawer without sanitizing equipment before storage.

f. Cottage 608 had a resident requiring pureed foods. The pureed crab cake for this resident was not at the correct texture with visible varying particle sizes and not a smooth texture. The pureed food items were warmed in a microwave and the temperatures were not checked prior to plating. Surveyor checked the texture and it was grainy and not smooth with chunks. The temperature of the food product did not feel hot to the mouth and most likely was not at 135 degrees as required for service. Surveyor instructed staff of the need to reprocess the food item until smooth and consistent. Surveyor also notified staff 2(kitchen manager) who followed up with the cook to ensure correct consistency was served to the resident.
g. Majority of cottages had dirty dishes in both sinks. Multiple staff were observed to wash hands over the dishes. Staff must have a designated empty and available sink for handwashing tasks.

h. Multiple cottages had a bag of recyclable cans stored in the kitchen area and/or stored with food storage areas causing potential cross contamination concerns along with attractants for insects and pests.

i. In cottage 608 plates for residents were plated and sat uncovered for 10-15 minutes prior to being served to residents. A resident’s meal was served to their room uncovered and unprotected.

At approximately 1:15 pm surveyor reviewed items with Staff 2 (Kitchen manager/PIC) and they acknowledged the above areas. On 3/13/25 at 2:00 pm, surveyor reviewed above areas with Staff 1 (Administrator) who acknowledged the need for correction.

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

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

This Rule is not met as evidenced by:

Based on observations and interviews, 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:

Based on interview and record review, conducted during a site visit on 04/16/24, it was confirmed the facility failed to provide delegation and teaching that is documented by an RN for 3 of 3 sampled staff (#'s 6, 7, and 8). Findings include, but are not limited to:A review of delegations for insulin administration for Residents 6,7, and 8 indicated the following:· Re-evaluation was not completed within 60 days of the initial delegation and some of the documents were not completely filled out,· For Resident 7, Staff 6 (MT) had an initial delegation for insulin administration on 06/23/23 (Rescinded on 07/27/23), an initial delegation on 08/26/23 and a review on 04/05/24,· For Resident 7, Staff 8 (MT) had an initial delegation for insulin administration on 05/13/23 (Rescinded on 07/27/23), a review on 11/23/23 and 04/12/24,· For Resident 8, Staff 8 had an initial delegation for insulin administration on 11/01/23 and on 04/11/24 by a different RN,· For Resident 8, Staff 7 (MT) had an initial delegation for insulin administration on 11/01/23 and on 04/16/24 by a different RN· For Resident 6, Staff 8 had an initial delegation for insulin on 07/20/23 and on 04/12/24 by a different RNIn an interview on 04/23/24, Staff 1 (ED) stated there had been several RNs that were rotating in during that time. S/He stated they always had an RN available.The findings were reviewed with and acknowledged by Staff 1 via phone call on 04/23/24.It was determined the facility failed to provide delegation and teaching that is documented by an RN.Verbal plan of correction: The facility is working with an RN consultant and they are current with their delegations.

Based on interview and record review, conducted during a site visit on 04/16/24, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (#1). Findings include, but are not limited to:A review of Resident 2's November 2023 MAR, progress notes, and physician orders indicated the following:· Order dated 10/13/23 for Admelog Solostar U-100 Insulin Lispro 100 unit/ml (3ml) SQ pen. Inject 3-15 units by subcutaneous route TID per sliding scale. Sliding scale: <150= No Insulin; 150-199= 3 units; 200-249= 5 units; 250-299= 7 units; 300-349= 10 units; 350-400= 15 units· Progress note dated 11/27/23 indicated resident was given 9 units of Lispro instead of 3 units in error, for a CBG of 179In an interview on 04/23/24 with Staff 1 (ED), s/he stated the incident did occur and the MT was removed from administering insulin.The findings were reviewed with and acknowledged by Staff 1 on 04/23/24.It was confirmed the facility failed to carry out medication and treatment orders as prescribed.

The findings of the re-licensure survey, conducted 11/13/23 through 11/16/23, 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 first revisit to the re-licensure survey of 11/16/23, conducted 07/29/24 through 07/30/24, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, 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 11/16/23, conducted on 10/29/24, are documented in this report. It was determined the facility was in compliance with OARs 411 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 facility failed to provide effective administrative oversight to ensure quality of care and services rendered in the facility. Findings include, but are not limited to:During the re-licensure survey, conducted 11/13/23 through 11/16/23, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number and severity of citations.Refer to deficiencies in the report.

Based on observation and interview, it was determined the facility failed to treat residents with dignity and respect and provide a safe and homelike environment in multiple buildings and for two unsampled residents who required meal assistance. Findings include, but are not limited to:1. Observations from 11/13/23 to 11/16/23 of the interior of the memory care and residential care communities in buildings 611 and 612 were found to have various equipment stored in common area alcoves, including shower chairs, an oxygen tank, walkers, a wheelchair cushion, a high/low table, a toilet riser, a seated scale, and wheelchair footrests.During an interview on 11/15/23, Staff 1 (Administrator) confirmed the clutter in the alcoves precluded a safe and homelike environment for residents and would have the equipment stored elsewhere.The need to provide a safe and homelike environment for residents was discussed with Staff 1 and Staff 2 (Chief Operating Officer) on 11/15/23. They acknowledged the findings.
2. During an observation of lunch service on 11/14/23 at 12:45 pm, a caregiver was noted to stand over two residents while providing meal assistance, not providing a dignified dining experience.The need to ensure residents were treated with dignity and respect was discussed with Staff 1 (Administrator), Staff 4 (RN), Staff 7 (Care Manager), and Staff 28 (Care Manager) on 11/16/23. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to investigate injuries of unknown cause to rule out abuse or neglect, document all required areas of an investigation, and/or report to the local SPD office if abuse or neglect could not be ruled out, for 2 of 4 sampled residents (#s 2 and 6) reviewed for injuries of unknown cause. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in 09/2023 with diagnoses including dementia and seizure disorder.A review of the resident's clinical record, including progress notes, dated 09/13/23 through 11/13/23, and staff interviews identified the following:* 11/04/23: A bruise on the resident's left hand.There was no documented evidence the bruise had been investigated to rule out abuse or suspected abuse, nor evidence the local SPD was immediately notified.During an interview on 11/14/23 at 11:21 am, Staff 1 (Administrator) confirmed the bruise was not promptly investigated.The facility was directed to self-report the incident to the local SPD office. Confirmation of the reporting was received on 11/15/23 at 1:50 pm.The need to immediately investigate injuries of unknown cause to rule out abuse or suspected abuse, and to notify the local SPD if abuse could not be ruled out, was discussed with Staff 1 and Staff 2 (Chief Operating Officer) on 11/15/23. They acknowledged the findings.
2. Resident 6 moved into the MCC in 03/2021 with diagnoses including schizophrenia, dementia, and diabetes mellitus.A review of progress notes and "weekly skin/shower assessment" forms from 08/02/23 through 11/12/23 documented the following injuries:* 08/02/23: "bleeding from a skin tear" on genital area;* 08/29/23: "two dry scabs on outside of upper right arm";* 09/06/23: "two skin tears on left arm..."; and* 09/20/23: "small dried scab to Rt lateral forearm near elbow."There was no documented evidence the facility either reported the injuries to the local SPD office or the local AAA as suspected abuse or neglect or immediately investigated and documented how the facility reasonably concluded the injuries were not the result of abuse or neglect.The need to ensure the facility responded appropriately to injuries of unknown cause was reviewed with Staff 1 (Administrator), Staff 4 (RN), and Staff 7 (Care Manager) on 11/16/23. They acknowledged the findings.The facility was instructed to report the injuries to the local SPD office and confirmation of the report was received on 11/17/23.

Based on observation, interview, and record review, it was determined the facility failed to immediately notify the local SPD office of any incident of abuse/neglect or suspected abuse/neglect for 1 of 1 sampled resident (# 8) who had reportable incidents. This is a repeat finding. Findings include, but are not limited to: Resident 8 moved into the facility in 04/2024 with diagnoses including schizoaffective disorder and multiple sclerosis.Review of the resident's service plan, dated 07/24/24, interviews with care staff on 07/29/24, and observations of the resident on 07/29/24 and 07/30/24 indicated the resident required full assistance for all ADL care, including use of a mechanical lift for transfers. The resident's service plan stated the resident had poor decision-making ability and "[Resident] has a history of engaging in unsafe sexual contact with peers." The resident's behavior plan, dated 07/24/24, stated the resident "was deemed unable to consent." The resident's 05/24/24 through 07/29/24 progress notes and incident reports were reviewed and the following was identified:* A progress note dated 05/24/24 indicated "Staff report that resident was also calling [his/her] family and telling them "They are abusing me."There was no documented evidence the facility immediately notified the local SPD office and promptly investigated the report of abuse. * A progress note dated 05/26/24 indicated that Resident 8 stated another resident stayed in his/her room the previous night and they engaged in sexual relations. There was no documented evidence the facility immediately notified the local SPD office and promptly investigated the report of abuse. * A progress note and communication report which detailed an interview with the resident, dated 05/29/24, indicated the resident reported that another resident had entered his/her bedroom the previous night and they had engaged in sexual relations. There was no documented evidence the facility immediately notified the local SPD office and promptly completed an investigation which included all required elements. * An incident report dated 06/16/24 indicated the resident had five small light green skin discolorations on his/her outer thigh. The resident stated s/he did not know how s/he got them. An investigation was completed on 06/17/24 and concluded the discolorations were consistent with care staff's hand placement on the resident's thigh when assisting the resident with ADL care. There was no documented evidence that the facility immediately notified the local SPD office. The facility was asked to report the four incidents to the local SPD office. Confirmation of the reports was provided to the survey team by 07/31/24. The need to ensure the facility immediately reported all incidents of abuse/neglect or suspected abuse/neglect was discussed with Staff 1 (Administrator) and Staff 2 (Administrative Support Specialist) on 07/30/24 at 3:30 pm. They acknowledged the findings.

2. Resident 2 was admitted to the facility in 09/2023 with diagnoses including dementia, chronic obstructive pulmonary disease, and urinary retention.A review of the resident's initial evaluation revealed the following required elements were not addressed:* Customary routines: eating and bathing;* Interests, hobbies, social, and leisure activities;* Personality: including how the person copes with change or challenging situations;* Independent activities of daily living, including: ability to manage medications and housework and laundry;* Pain: pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort;* Indicators of nursing needs, including potential for delegated nursing tasks;* Review of risk indicators, including complex medication regimen and elopement risk or history; and* Environmental factors impacting the resident's behavior, including noise, lighting, and room temperature.The need to address all required elements in the initial evaluation was discussed with Staff 1 (Administrator) and Staff 2 (Chief Operating Officer) on 11/15/23. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure move-in evaluations contained all required elements and addressed sufficient information to develop an initial service plan to meet the residents' needs for 3 of 3 sampled residents (#s 1, 2, and 4) who were recently admitted to the facility, and the most recent quarterly evaluations were relevant to the needs and conditions of the residents for 2 of 3 sampled residents (#s 5 and 6) whose quarterly evaluations were reviewed. Findings include, but are not limited to:1. Resident 4 was admitted to the facility in 11/2023 with diagnoses including paroxysmal atrial fibrillation, type 2 diabetes mellitus, chronic obstructive pulmonary disease, schizoaffective disorder, and benign prostatic hyperplasia.Review of the move-in evaluation identified the following required elements were not documented as being addressed:* Presence of depression, thought disorders, behavioral and mood problems;* History of treatment;* Effective non-drug interventions;* Personality: including how the person copes with change or challenging situations;* Ability to manage medications;* Pain: including how a person expresses pain or discomfort; and* Environmental factors that impact the resident's behavior including, but not limited to: noise, lighting, room temperature.The need to ensure the initial evaluation contained all required elements and addressed sufficient information to develop an initial service plan to meet the resident's needs was reviewed with Staff 1 (Administrator), Staff 4 (RN), and Staff 8 (Care Manager) on 11/16/23. They acknowledged the findings. No further information was provided.
5. Resident 1 was admitted to the facility in 10/2023 with diagnoses including dementia and thoracic/lumbar compression fractures.a. A review of the resident's initial evaluation revealed the following required elements were not addressed:* Customary routines: eating and bathing;* Interests and hobbies;* Personality: including how the person copes with change or challenging situations;* Independent activities of daily living, including: ability to manage housework and laundry;* Pain: including how a person expresses pain or discomfort;* Fluid preferences;* Review of risk indicators, including complex medication regimen and elopement risk or history; and* Environmental factors impacting the resident's behavior, including noise, lighting, and room temperature.b. A review of the resident's initial evaluation revealed the following areas lacked sufficient information to develop an initial service plan to meet the resident's needs:* Pain: pharmaceutical and non-pharmaceutical interventions;* Fall risk or history; and* Emergency evacuation ability.The need to address all required elements in the initial evaluation and describe the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level was discussed with Staff 1 (Administrator), Staff 4 (RN), Staff 7 (Care Manager), and Staff 28 (Care Manager) on 11/16/23. They acknowledged the findings.
4. Resident 6 moved into the facility in 03/2021 with diagnoses including dementia, schizophrenia, and personality disorder.Resident 6's current evaluation, dated 09/08/23, failed to describe the resident's physical health status, mental status, and environmental factors that help the individual function at their optimal level or address the following required elements:* Fluid preferences;* Pain, including how a person expresses pain, pharmaceutical and non-pharmaceutical interventions;* Interests, hobbies, and social and leisure activities;* Personality, including how the person copes with change;* Non-pharmaceutical interventions for personality disorder and behaviors;* Environmental factors that impact behavior, including noise, light, and room temperature; and* Accurate weight.During the survey Resident 6 was observed to remain in his/her room, expressed hip pain with movement, and was receiving pain medication per physician's order.The need to ensure quarterly evaluations included required information and described the resident's needs to help them function at their optimal level was discussed with Staff 1 (Administrator), Staff 4 (RN), and Staff 7 (Care Manager) on 11/16/23. They acknowledged the findings.
3. Resident 5 was admitted to the facility in 02/2018 with diagnoses including schizophrenia and chronic obstructive pulmonary disorder.A review of the resident's record identified his/her quarterly evaluation, dated 09/25/23, was not relevant to the current needs and conditions of the resident regarding oxygen use.The need to ensure quarterly evaluations were relevant to the needs and conditions of the residents was discussed with Staff 1 (Administrator), Staff 4 (RN), Staff 5 (LPN), Staff 7 (Care Manager), Staff 8 (Care Manager), and Staff 28 (Care Manager) on 11/16/23. They acknowledged the findings.

2. Resident 2 was admitted to the facility in 09/2023 with diagnoses including dementia, chronic obstructive pulmonary disease, and urinary retention.The resident's current service plan, dated 08/22/23, was reviewed, observations were made, and interviews with staff were conducted. Resident 2's service plan was not reflective of the resident's needs and/or did not provide clear direction regarding the delivery of services in the following areas:* Level of assistance required for hygiene, dressing, bathing, toileting, and ambulation;* Rate of oxygen flow; and* Placement of catheter.The need to ensure service plans reflected the residents' needs and provided clear direction regarding the delivery of services was discussed with Staff 1 (Administrator) and Staff 2 (Chief Operating Officer) on 11/15/23. 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' current care needs, were implemented, and provided clear directions to staff regarding the delivery of services, and/or failed to ensure changes or entries made to the service plan were dated and initialed for 5 of 6 sampled residents (#s 1, 2, 4, 5, and 6) whose service plans were reviewed. Findings include, but are not limited to:1. Resident 4 was admitted to the facility in 11/2023 with diagnoses including paroxysmal atrial fibrillation, type 2 diabetes mellitus, chronic obstructive pulmonary disease, schizoaffective disorder, and benign prostatic hyperplasia.Interviews with the resident and staff, and review of the current service plan, dated 10/31/23, revealed Resident 4's service plan was not reflective of the resident's current needs or lacked clear instructions to staff in the following areas:* Smoking;* Self-catheterization;* Bathing and personal hygiene;* Instructions on what types of skin impairments to report and to whom;* Instructions on signs and symptoms of hypo- and hyperglycemia to report;* Instructions for bleeding precautions and interventions while on anticoagulation therapy;* Instructions on signs and symptoms of depression to report while on anti-depressant therapy; and* Oxygen equipment precautions, instructions for proper maintenance, and how to monitor for safety.The need to ensure the service plan reflected the resident's current needs and provided clear instructions to staff regarding delivery of services was reviewed with Staff 1 (Administrator), Staff 4 (RN), and Staff 8 (Care Manager) on 11/16/23. They acknowledged the findings. No further information was provided.
3. Resident 1 was admitted to the facility in 10/2023 with diagnoses including dementia and thoracic/lumbar compression fractures.The resident's current service plan, dated 10/20/23, was reviewed, observations were made, and interviews with staff were conducted. Resident 1's service plan did not provide clear direction regarding the delivery of services and/or was not implemented in the following areas:* Level of assistance required for transfers, dressing, perineal care, bathing, and grooming;* Pain management including identifying non-verbal expressions and coordination prior to providing care;* Assistive device used for oral care;* Prevention of skin breakdown, including frequency of repositioning;* Fidget device used for behaviors;* Seated upright with head of bed at 90 degree angle during meals; and* Evacuation needs in the case of an emergency.The need to ensure service plans provided clear direction and/or were implemented regarding the delivery of services was discussed with Staff 1 (Administrator), Staff 4 (RN), Staff 7 (Care Manager), and Staff 28 (Care Manager) on 11/16/23. They acknowledged the findings.
4. Resident 6 moved into the facility in 03/2021 with diagnoses including dementia, schizophrenia, and personality disorder.The resident's current service plan, dated 09/08/23, was reviewed. Observations of the resident and interviews with staff revealed Resident 6's service plan was not reflective of the resident's needs and did not provide clear direction regarding the delivery of services in the following areas:* Preferred activities, pertinent to the resident's current level of physical and cognitive functioning;* Preferred snacks and fluids;* Hygiene assistance required;* Bathing assistance and preferences;* Dressing assistance needed;* Skin integrity (including use of a full mattress on the floor, turning/repositioning every two hours);* Incontinence care;* Ambulation ability and needs;* Behaviors, including inability to wander, sexual comments; and* Evacuation needs in the case of an emergency.In an interview on 11/14/23 with Staff 7 (Care Manager), the service plan was reviewed. The need to ensure changes and entries made to the service plan were dated and initialed was discussed. Staff 7 acknowledged the 09/08/23 service plan did not include dates and initials in some areas to identify the changes.The need to ensure service plans reflected the residents' needs, provided clear direction to staff, and changes and entries were dated and initialed was discussed with Staff 1 (Administrator), Staff 4 (RN), and Staff 7 on 11/16/23. They acknowledged the findings.
5. Resident 5 was admitted to the facility in 02/2018 with diagnoses including schizophrenia and chronic obstructive pulmonary disorder.The resident's current service plan, dated 09/25/23, was reviewed, observations were made, and interviews with staff were conducted. Resident 5's service plan was not reflective and/or did not provide clear direction to staff in the following areas:* Oxygen use;* Level of assistance needed with switching from oxygen concentrator to tanks;* Interventions for oxygen compliance; and* Level of toileting assistance needed with colostomy checks and emptying.The need to ensure service plans reflected the residents' needs and provided clear direction to staff was discussed with Staff 1 (Administrator), Staff 4 (RN), Staff 5 (LPN), Staff 7 (Care Manager), and Staff 28 (Care Manager) on 11/16/23. 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 which consisted of the resident, the resident's legal representative if applicable, any person of the resident's choice, the facility administrator or designee, and at least one other staff person who was familiar with or would be providing services to the resident, as well as the case manager, for 2 of 6 sampled residents (#s 1 and 6) whose service plans were reviewed. Findings include, but are not limited to:Resident 1's and 6's most recent service plans lacked evidence that a Service Planning Team reviewed and participated in the development of the service plans.In an interview on 11/16/23, Staff 7 (Care Manager) was asked about the process for including the facility RN in development of the service plan for Resident 6 and whether the resident's case manager was notified, in advance, of the service-planning meeting. Staff 7 reported the "case manager only wanted to have a copy of the service plan once a year" and was not able to provide documentation that the facility RN or other required staff participated in the service plan development.On 11/16/23, the need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (Administrator), Staff 2 (Chief Operating Officer), and Staff 7. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to determine and document what actions or interventions were needed for residents who experienced short-term changes of condition, ensure actions or interventions were communicated to staff on each shift, document progress at least weekly until the conditions resolved, and monitor each resident consistent with his or her evaluated needs for 6 of 6 sampled residents (#s 1, 2, 3, 4, 5, and 6) who experienced changes of condition. Residents 3 and 6 experienced continued weight loss. Findings include, but are not limited to:1. Resident 3 was admitted to the facility in 07/2022 with diagnoses including acute respiratory failure.Review of clinical records, including the service plan, dated 09/19/23, progress notes from 08/01/23 through 11/13/23, and incident reports revealed the following information:a. Resident 3 experienced a severe weight loss of 25 pounds, or 10.41% of his/her total body weight, in three months, from 07/2023 through 10/2023. The weight loss constituted a significant change in condition.The resident had a physician order, dated 05/30/23, for house protein shakes with breakfast.An RN assessment dated 10/15/23 noted a new intervention for staff to save the resident's meal and offer it at another time or to offer an alternate meal if the resident refused his/her meal.Observations of the resident between 11/14/23 and 11/16/23 showed the resident ate zero percent of breakfast and lunch on both days. Staff offered a house protein shake to the resident after the meals, which the resident refused. Staff did not hold the resident's meal to offer at another time or offer alternate meals. In a 11/15/23 interview with Staff 22 (CG), when asked what instructions were in place if Resident 3 did not eat his/her meal, she stated, "We will offer him/her a health shake."On 11/15/23 the facility was asked to obtain the weight for Resident 3. The resident's weight was observed to be 199.2 pounds, an additional loss of 15.8 pounds, or 7.34% of his/her total body weight, in just over one month.The 11/15/23 observations and interview with Staff 22 were relayed to Staff 5 (LPN) on the same date.There was no documented evidence the facility monitored the resident's weight loss, noting progress at least weekly through resolution, evaluated previously implemented interventions for effectiveness, or determined if new interventions needed to be developed. The resident continue to experience weight loss.b. Review of the record showed the following short-term changes of condition were identified:* 08/26/23 - Positive for COVID-19;* 09/06/23 - New medication order: magnesium oxide 400 mg, one tablet daily (a supplement);* 09/20/23 - New medication orders: Bisacodyl 10 mg one tablet PRN if no bowel movement in three days (for constipation); haloperidol 0.25 milliliters every four hours PRN (for nausea, agitation, and hallucinations); hyoscyamine 0.125 mg one tablet every four hours PRN (for excessive secretions); Lorazepam 0.25 milliliters every four hours PRN (for anxiety, shortness of breath); and morphine 0.25 milliliters every two hours PRN (for pain and shortness of breath);* 10/04/24 - New medication order; sulfamethoxazole - trimethoprim 800 mg/160 mg (for toe infection);* 10/10/23 - Multiple new and discontinued medication orders;* 11/01/23 - New medication orders: aripiprazole 15 mg one tablet daily (for schizophrenia) and olanzapine five mg one tablet every evening (for psychotic itching).There was no documented evidence the facility determined and documented what actions or interventions were needed for each of Resident 3's short-term changes of condition, communicated interventions to staff on each shift, and monitored the resident until the each condition resolved.The need to ensure the facility had a system to determine and document what actions or interventions were needed for residents' short-term changes of condition, communicate the interventions to staff on each shift, evaluate previously implemented interventions for effectiveness or determine if new interventions needed to be developed, and monitor each change of condition until resolution was discussed with Staff 1 (Administrator) and Staff 2 (Chief Operating Officer) on 11/16/23. They acknowledged the findings.
4. Resident 2 was admitted to the facility in 09/2023 with diagnoses including dementia, chronic obstructive pulmonary disease, and urinary retention.The resident's clinical record, including progress notes, was reviewed, and interviews were conducted. The following was revealed:a. The following short-term changes of condition lacked documentation of actions or interventions needed for the resident and the communication of the determined actions or interventions to staff on all shifts:* 09/12/23: Moved into the facility;* 09/21/23: Catheter bag with blood and no urine output;* 10/01/23: Citalopram 10 mg (for depression) was not administered or available in the facility from 10/01/23 through 10/04/23;* 10/01/23: Metoprolol ER 25 mg (for hypertension) was not administered or available in the facility from 10/01/23 through 11/07/23;* 10/01/23: Olanzapine 5 mg (for schizophrenia) was not administered or available in the facility for both morning and evening doses from 10/01/23 through 10/31/23;* 10/01/23: Pulmicort 90 mcg inhaler (for shortness of breath) was not administered or available in the facility for both morning and evening doses from 10/01/23 through 10/05/23 and from 11/04/23 through 11/07/23; and* 11/11/23: Return from hospital.b. The following short-term change of condition lacked documentation of actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, and documentation of progress noted, at least weekly, through resolution:* 09/26/23: Return from hospital.The need to ensure actions or interventions for short-term changes of condition were determined, documented, and communicated to staff on each shift and the changes of condition were monitored, at least weekly, through resolution was discussed with Staff 1 (Administrator) and Staff 2 (Chief Operating Officer) on 11/15/23. They acknowledged the findings.
5. Resident 4 was admitted to the facility in 11/2023 with diagnoses including paroxysmal atrial fibrillation, type 2 diabetes mellitus, chronic obstructive pulmonary disease, schizoaffective disorder, and benign prostatic hyperplasia.Clinical records, including the service plan dated 10/31/23 and progress notes from 11/01/23 through 11/13/23, were reviewed, and interviews with facility staff and the resident were conducted.The following short-term changes of condition lacked documentation the facility determined what resident-specific action or intervention was needed for the resident, communicated the determined action or intervention to staff, monitored the resident consistent with evaluated needs, and documented weekly progress until the condition resolved:* 11/02/23: Emergency department visit related to urinary tract infection;* 11/02/23: Multiple medications including antidepressants, antipsychotics, blood-thinner, and bronchodilators were placed on hold by the facility while awaiting delivery from pharmacy;* 11/11/23: Emergency department visit related to blood in urine;* 11/11/23: New diagnosis of prostatitis (inflammation of prostate gland);* 11/12/23: Started new opioid medication for pain control as needed; and* 11/12/23: New antibiotic, one dose for prostatitis.The need to ensure the facility evaluated the resident and determined what resident-specific action or intervention was needed for the resident following a short-term change of condition, communicated the determined action or intervention to staff, monitored the resident consistent with evaluated needs, and documented progress at least weekly until the condition resolved was reviewed with Staff 1 (Administrator), Staff 4 (RN), and Staff 8 (Care Manager) on 11/16/23. They acknowledged the findings. No further information was provided.
3. Resident 1 was admitted to the facility in 10/2023 with diagnoses including dementia and thoracic/lumbar compression fractures.Resident 1's 10/20/23 through 11/12/23 progress notes and 10/20/23 through 11/01/23 Weekly Skin/Shower Assessments were reviewed, and interviews were conducted. The following was revealed:a. The following short-term changes of condition lacked documentation of actions or interventions needed for the resident and the communication of the determined actions or interventions to staff on all shifts:* 10/20/23 - Quetiapine 25 mg (for behaviors) was not administered for the morning doses on 10/24/23 and 10/25/23 or for the evening doses on 10/20/23 and 10/24/23;* 10/20/23 - Acetaminophen 160 mg/5 ml PRN (for pain) was not administered or available in the facility from 10/20/23 through 10/24/23, and a progress note, dated 10/23/23, noted Resident 1 showed "non-verbal indicators of pain...however, resident does not have any PRN medications available at this time.";* 10/20/23 - Senokot 17.2 mg daily (for constipation) was not administered or available in the facility from 10/20/23 through 10/24/23;* 10/21/23 - Aripiprazole 2 mg daily (for behaviors) was not administered or available in the facility from 10/21/23 through 10/25/23; and* 10/24/23 - Resident refused six meals since admission.b. The following short-term change of condition lacked documentation of progress noted, at least weekly, through resolution:* 10/24/23 - Multiple areas of bruising to right and left arms.The need to ensure actions or interventions for short-term changes of condition were documented and communicated to staff on each shift and the changes of condition were monitored, at least weekly, through resolution was discussed with Staff 1 (Administrator), Staff 4 (RN), Staff 7 (Care Manager), and Staff 28 (Care Manager) on 11/16/23. They acknowledged the findings.
2. Resident 6 was admitted to the facility in 03/2021 with diagnoses including dementia and schizophrenia.a. A review of the resident's clinical record, including progress notes, meal monitoring, and monthly weights obtained between 06/03/23 and 10/03/23 showed the following:* Progress note dated 09/26/23: "has been eating 25 to 100% of [his/her] meals";* Progress note dated 10/03/23: "Resident's appetite has decreased. Resident has been refusing meals ... in pain";* Progress note dated 10/05/23: "resident was yelling out in pain during last rounds";* Progress note dated 10/09/23: "appetite today has been low";* Progress note dated 10/17/23: "has been refusing more meals, 6 meals this week";* "Activities of Daily Living: Appetite Record" log, kept in a binder on the MCC unit, showed that between 11/01/23 and 11/13/23 the resident: * refused meals 13 times; * ate 25% of meals five times; * ate 75% of meals two times; and * ate 100% of meals four times.* Weight records showed the following: * 06/03/23: 140.5 pounds; * 07/03/23: 138.2 pounds; * 08/03/23: 137.4 pounds; * 09/03/23: 139.0 pounds; * 10/03/23: 134.5 pounds; * 11/03/23: no weight obtained "refused"; and * 11/15/23: 124.0 pounds - weight obtained per surveyor request.Between 06/03/23 and 10/03/23 Resident 6 showed a weight loss of 5.5 pounds, and meal monitoring between 11/01/23 and 11/13/23 showed continued poor meal intake.There was no documented evidence the facility evaluated the resident, determined actions or interventions needed and communicated them to staff, or monitored the resident weekly through resolution related to the change of condition for weight loss and pain.Between 10/03/23 and 11/15/23, Resident 6 lost an additional 10.5 pounds, or 7.5% total body weight, resulting in a severe weight loss.Resident 6 was observed to be dependent on staff to bring meals to his/her room and place the meals within reach on his/her mattress. Resident 6 was able to feed him/herself independently at lunch on 11/14/23, ate approximately 50% of his/her meal, and was able to drink fluids from a cup with a cover and spout. On 11/15/23, observations during the lunch meal showed Resident 6 kept his/her eyes closed with the plate of food on the mattress. Staff offered to remove the plate and bring it back , which the resident agreed to. Resident 6 did not eat any of the lunch meal.During an interview on 11/15/23, Staff 31 (MT) stated the resident had been having increased pain which had improved since pain medications were being provided routinely, instead of PRN, since late October. Staff 31 stated the resident continued to refuse meals at times "depending on [his/her] mood" and that staff offered snacks throughout the day. Staff 31 was not aware of any additional interventions.The need to ensure the facility determined, documented, and communicated to staff what actions were needed in response to changes of condition, and that the resident was monitored with weekly progress noted until the condition resolved, was discussed with Staff 1 (Administrator), Staff 2 (Chief Operating Officer), Staff 4 (RN), and Staff 7 (Care Manager) on 11/16/23. They acknowledged the findings.b. Resident 6's 08/02/23 through 11/13/23 facility progress notes showed the following changes of condition:* 08/02/23: "skin tear with bleeding" to genital area;* 08/11/23: perineal bleeding, "placed on AC x 72 h [alert charting for 72 hours] for continued monitoring";* 08/29/23: two dry scabs;* 09/06/23: two skin tears to left arm;* 09/20/23: dried scabs to right lateral forearm; and* 10/20/23: return from emergency department, "placed on AC x 72 h [alert charting for 72 hours] for continued monitoring."There was no documented evidence the changes were monitored at least weekly through resolution. In addition, when "alert charting" was initiated, there was no documented evidence of the monitoring.The need to ensure short-term changes of condition were monitored, with weekly progress noted until resolution, was reviewed with Staff 1 (Administrator), Staff 4 (RN), and Staff 7 (Care Manager) on 11/16/23. They acknowledged the findings.
6. Resident 5 was admitted to the facility in 02/2018 with diagnoses including schizophrenia and chronic obstructive pulmonary disorder (COPD).Resident 5's 08/01/23 through 11/13/23 progress notes, 08/01/23 through 10/24/23 Weekly Skin/Shower Assessments, and Incident Reports dated 08/04/23, 08/07/23, 08/12/23, and 11/23/23 were reviewed.The resident experienced multiple short-term changes of condition without documented evidence resident-specific instructions or interventions were developed and communicated to staff on all shifts in the following areas:* 08/02/23 - red skin around ostomy stoma;* 08/04/23 through 08/07/23 - hospitalization for COPD exacerbation and non-ST-elevation myocardial infarction (NSTEMI);* 08/07/23 - four new medications;* 08/12/23 - bruise on arm;* 10/25/23 - mood change after notification that sister passed away; and* 11/12/23 - bruise on back after fall.The need to ensure resident-specific actions or interventions were determined and implemented for residents with short-term changes of condition, communicated to staff on all shifts, and monitored to resolution was discussed with Staff 1 (Administrator), Staff 4 (RN), Staff 5 (LPN), Staff 7 (Care Manager), and Staff 28 (Care Manager) on 11/16/23. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure an RN assessed significant changes of condition and documented findings, resident status, and interventions made as a result of the assessment for 3 of 4 sampled residents (#1, 3, and 6) reviewed for significant changes. Findings include, but are not limited to:1. Resident 3 was admitted in 07/2020 with diagnoses including retention of urine.The resident's clinical record was reviewed and revealed the resident experienced a Foley catheter placement on 08/14/23.There was no documented evidence the facility RN conducted an assessment which included documentation of findings, resident status, and interventions made as a result of the assessment.During a 11/16/23 interview, Staff 5 (LPN) acknowledged it was unlikely an RN assessment had been completed for Resident 5's Foley catheter placement. No further documentation was provided.The need for an RN to conduct an assessment when a resident experienced a significant change of condition was reviewed with Staff 1 (Administrator) and Staff 2 (Chief Operating Officer) on 11/16/23. They acknowledged the findings.
3. Resident 1 was admitted to the facility in 10/2023 with diagnoses including dementia and thoracic/lumbar compression fractures.The resident's clinical record was reviewed and revealed the following:The 10/20/23 service plan indicated Resident 1 was non-verbal, legally blind, required full assist with all meals, and may become combative "usually with turning or transfers." On 11/16/23 an interview with Staff 33 (MT) confirmed Resident 1 did not verbally express pain or ask for pain medication.* On 10/25/23 an RN assessment was completed and indicated "resident appeared thirsty but did not take water when offered." The assessment did not include interventions made as a result of the assessment.* On 11/02/32 an RN assessment was conducted and documented a medication aide reported Resident 1 "is calm if we give [him/her] Tylenol before doing care. I think [s/he] must be in pain." The RN documented "will coordinate with CM [Care Manager] to arrange for possible order to pre-medicate for pain before cares." No documented evidence was provided that the intervention by the RN was communicated to staff.The need to ensure RN assessments included findings, resident status, and interventions made as the result of the assessment was discussed with Staff 1 (Administrator), Staff 4 (RN), Staff 7 (Care Manager), and Staff 28 (Care Manager) on 11/16/23. They acknowledged the findings.
2. Resident 6 moved into the facility in 03/2021 with diagnoses including dementia and schizophrenia.Progress notes documented Resident 6 had been experiencing symptoms of constipation and rectal bleeding on 10/17/23 though 10/19/23 and was sent to the emergency department on 10/19/23.On 10/20/23, Resident 6 returned to the facility and was assessed by a facility RN. The assessment did not include interventions made as a result of the assessment.The need to ensure RN assessments included findings, resident status, and interventions made as the result of the assessment was discussed with Staff 1 (Administrator), Staff 4 (RN), and Staff 7 (Care Manager). They acknowledged the findings.

4. During lunch service in building 612 on 11/14/23, at 12:30 pm, while wearing gloves, Staff 12 (CG) was observed to remove a dirty plate from the dining room table and place it on a kitchenette counter. Without removing gloves and performing hand hygiene, she then picked up two clean plates of food and served them to residents.The need to ensure staff followed infection prevention and control practices during meal times was reviewed with Staff 1 (Administrator) and Staff 2 (Chief Operating Officer) on 11/15/23. They acknowledged the findings.
Based on observation and interview, it was determined the facility failed to establish and maintain effective infection prevention and control protocols for 1 of 2 sampled residents (# 1) observed during incontinence care and for multiple non-sampled residents observed during meal service. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in 10/2023 with diagnoses including dementia and thoracic/lumbar compression fractures.Observations of Resident 1 during the survey revealed s/he was dependent on two staff for all incontinence care and needed assistance with incontinence care while in bed.On 11/14/23, at 1:40 pm, the surveyor obtained permission and observed two caregivers providing incontinence care for Resident 1. Both caregivers failed to change gloves after removing a soiled incontinence brief and then wiping Resident 1's perineum. The soiled incontinence brief was initially tossed on the floor beside the bed prior to retrieving a trash can. The caregivers proceeded to touch the resident's clean incontinence brief, the resident's lower legs and both sides of the resident's body, bed linens, the resident's fall mat, and the bed control. Both caregivers doffed their gloves, and one caregiver removed the incontinence garbage from the resident's room. Both caregivers performed hand hygiene following the disposal of the resident's garbage.Following care, the surveyor reviewed the observations with regard to maintaining effective infection prevention and control while providing incontinence care. The caregivers verbalized understanding and indicated they would return to the resident's room and clean his/her bed control.2. On 11/14/23, at 12:35 pm, a caregiver was observed providing meal assistance to two non-sampled residents. The caregiver provided meal assistance to one resident with her left hand and held the food container with her right hand. The caregiver turned around and provided meal assistance to the second resident with her right hand and held the food container with her left hand. The surveyor observed the caregiver rub the second resident's arm and shoulder with both hands and then return to providing meal assistance to both residents with the same process. The caregiver did not change her gloves or perform hand hygiene prior to resuming meal assistance to both residents.3. During meal observations at lunch time on 11/13/23 and 11/14/23, in multiple buildings, direct care staff were observed serving and/or providing meal assistance to residents seated in the dining room. The direct care staff, who also provided ADL cares such as bathing, toileting, and incontinence care to residents prior to the meal service, did not wear aprons or other protective barriers over their clothing during the meal service.The need to ensure staff followed infection prevention practices during meal times and incontinence care was reviewed with Staff 1 (Administrator) on 11/16/23. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure a safe medication system and adequate professional oversight. Findings include, but are not limited to:The facility failed to ensure a safe medication and treatment system, and administrative oversight was found to be ineffective based on deficiencies in the following areas:C 303: Systems: Treatment Orders;C 304: Systems: Medication and Treatment Review; andC 310: Systems: Medication Administration.Failure to ensure a safe medication system and adequate professional oversight of the system was reviewed with Staff 1 (Administrator) and Staff 2 (Chief Operating Officer) on 11/16/23. They acknowledged the findings.

2. Resident 2 was admitted to the facility in 09/2023 with diagnoses including including dementia, chronic obstructive pulmonary disease, and urinary retention.Resident 2's 10/01/23 through 11/13/23 MARs, corresponding progress notes, and current physician's orders were reviewed.Records revealed the following medications were not given as prescribed on the following dates, with documentation stating the facility was awaiting delivery of supplies:* Citalopram 10 mg (for depression) - 10/01/23 through 10/04/23;* Metoprolol ER 25 mg (for hypertension) - 10/01/23 through 11/07/23;* Olanzapine 5 mg (for schizophrenia) for both morning and evening doses - 10/01/23 through 10/31/23; and* Pulmicort 90 mcg inhaler (for shortness of breath) - 10/01/23 through 10/05/23 and from 11/04/23 through 11/07/23.During an interview on 11/14/23 at 11:15 am, Staff 7 (Care Manager) confirmed the medications were not administered during those time frames.The need to ensure physician orders are carried out as prescribed was discussed with Staff 1 (Administrator) and Staff 2 (Chief Operating Officer) on 11/15/23. They acknowledged the findings.
4. Resident 5 moved into the facility in 02/2018 with diagnoses including schizophrenia and chronic obstructive pulmonary disorder.Resident 5's current physician orders and 10/01/23 through 11/13/23 MARs were reviewed. The following orders were not administered as prescribed:* Combivent Respimat inhaler 4gm - use first for shortness of breath, then try albuterol inhaler; and* Albuterol 90 microgram inhaler - use 2nd for shortness of breath if Combivent inhaler not effective.On 10/07/23 and 10/21/23 albuterol was administered without first using Combivent Respimat.The need to ensure all medications were administered as prescribed by the physician was discussed with Staff 1 (Administrator), Staff 4 (RN), Staff 5 (LPN), Staff 7 (Care Manager), and Staff 28 (Care Manager) on 11/16/23. They acknowledged the findings.
5. Resident 4 was admitted to the facility in 11/2023 with diagnoses including paroxysmal atrial fibrillation, type 2 diabetes mellitus, chronic obstructive pulmonary disease, schizoaffective disorder, and benign prostatic hyperplasia.Resident 4's current physician orders and 11/01/23 through 11/13/23 MAR were reviewed. Interviews with facility staff and the resident were conducted.a. Resident 4 was observed to have continuously administered oxygen via nasal cannula, and the service plan noted the resident was to have "Oxygen 2-3LPM via nasal cannula at all times." There was no documented evidence the facility had a written, signed physician or other legally recognized practitioner order documented in the resident's facility record for the oxygen therapy being administered to the resident.b. Hydrocodone/APAP 5/325mg was ordered to be administered every 6 hours as needed for pain. Medication was administered every 5 hours 12 minutes on 11/13/23.c. Medications prescribed at time of admission were placed on hold by the facility because they were awaiting delivery from the pharmacy, including the following:* Cephalexin 250mg (for recurrent urinary tract infection);* Dorzolomide/Timolol solution 2-0.5% (eye drops);* Eliquis 5mg (for atrial fibrillation);* Increzza 40mg (for schizophrenia);* Prednisolone solution 1% (eye drops);* Sertraline 50mg (for depression);* Spiriva 18mcg inhaler (for chronic obstructive pulmonary disease);* Albuterol 90mcg inhaler (as needed for chronic obstructive pulmonary disease);* Maalox/Mylanta (as needed for gastrointestinal upset); and* Artane 2mg (as needed for involuntary movements)There was no documented evidence the facility had written, signed physician or other legally recognized practitioner orders documented in the resident's facility record to hold these medications.The need to ensure 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 and physician orders were carried out as prescribed was reviewed with Staff 1 (Administrator), Staff 4 (RN), and Staff 8 (Care Manager) on 11/16/23. They acknowledged the findings. No further information was provided.
3. Resident 1 was admitted to the facility in 10/2023 with diagnoses including dementia and thoracic/lumbar compression fractures.Resident 1's current physician orders, signed on 10/20/23 and 10/31/23, and 10/01/23 through 11/13/23 MARs were reviewed.a. The following orders were not administered as prescribed:* Aripiprazole 1 mg daily (for behaviors) - not given on 10/21/23 through 10/25/23;* Quetiapine 25 mg twice a day (for behaviors) - 9 am dose not given on 10/24/23 and held with no order on 10/25/23. The 5 pm dose was not given on 10/20/23 and held with no order on 10/24/23.b. Resident 1's discharge physician orders from the hospital, dated 10/20/23, indicated a general/regular texture diet.On 11/16/23, an interview with Staff 28 (Care Manager) confirmed the hospital physician orders were not being followed, and Resident 1 was given a pureed diet.The need to ensure all medications were administered as prescribed by the physician was discussed with Staff 1 (Administrator), Staff 4 (RN), Staff 7 (Care Manager), and Staff 28 (Care Manager) on 11/16/23. They acknowledged the findings.
Based on observation, interview, and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 5 of 6 sampled residents (#s 1, 2, 4, 5, and 6) whose orders were reviewed. Resident 6 experienced rectal bleeding and emergency care, potentially as a result of not receiving bowel care medications as prescribed. Findings include, but are not limited to:1. A review of Resident 6's clinical record, including progress notes, physician's orders, and the 10/01/23 through 11/13/23 MARs showed the following:Physician's orders, signed 09/12/23, prescribed the following bowel care medications:* "MOM - give 30 mL daily as needed for constipation day 2 no BM [bowel movement] and/or per Nursing directions";* "Suppository - Insert rectally once daily as needed for constipation day 3 no BM and/or per Nursing direction"; and* "Enema - Insert one enema daily as needed for constipation day 4 no BM and/or per Nursing direction."The Milk of Magnesia (MOM) and Enema orders had not been transcribed onto the 10/2023 or 11/2023 MAR.* Progress notes dated 10/17/23 documented "PRN glycerin supp [given at 8:56 PM] for bowel care." On 10/19/23 staff documented "PRN glycerin suppos given at 10:52 AM for day 8 no BM. Nursing is aware."* On 10/19/23 at 4:43 pm, Resident 6 was transported to the emergency department due to "moderate rectal bright red blood bleeding."* Review of the progress notes, dated 10/20/23, and the emergency department discharge summary showed the resident was diagnosed with "constipation" and received an enema resulting in a bowel movement. The resident then returned to the facility.The facility failed to transcribe the medication orders to the MAR, resulting in staff not administering medication for constipation. Resident 6 did not receive bowel medications as ordered on days 2, 3, and 4 of not having a bowel movement, resulting in rectal bleeding and an emergency department visit for treatment of constipation.The need to ensure physician's orders were carried out as prescribed was discussed with Staff 1 (Administrator), Staff 4 (RN), and Staff 7 (Care Manager). They acknowledged the medications were not administered as ordered to treat the resident's constipation.

Based on interview and record review, it was determined the facility failed to ensure a registered pharmacist or registered nurse reviewed all medications and treatments administered by the facility to residents at least every 90 days for 5 of 6 residents (#s 1, 2, 4, 5, and 6) whose medication and treatment orders were reviewed. Findings include, but are not limited to:In an interview on 11/16/23, Staff 1 (Administrator) confirmed the facility lacked documented evidence medications and treatments administered by the facility to Residents 1, 2, 4, 5, and 6 had been reviewed by a registered pharmacist or RN at least every 90 days.The need to ensure a registered pharmacist or RN reviewed medications and treatments administered by the facility to residents at least every 90 days was discussed with Staff 1 and Staff 2 (Chief Operating Officer) on 11/16/23. They acknowledged the findings.

4. Resident 3 was admitted to the facility in 07/2022 with diagnoses including respiratory failure. The resident's 10/01/23 through 11/13/23 MARs and physician's orders were reviewed and identified the following:* Bisacodyl 10 mg suppository, insert one PRN if no bowel movement in three days (for constipation);* Fleet glycerin suppository, insert one PRN to be used on third day of no bowel movement per nursing direction (for constipation);* Senna 8.6 mg, take two tablets every day PRN (for constipation);* Oxygen titrate from two liters per minute to four liters per minute PRN (for shortness of breath);* Combivent Respimat, inhale contents of one vial via nebulizer every four hours (for wheezing or shortness of breath);* Morphine 0.5 mg, every two hours PRN (for pain or shortness of breath); and* Lidocaine two percent glydo gel, apply topically twice daily PRN (for pain).The PRN medications for bowel care, shortness of breath, and pain lacked resident-specific parameters for the sequential order of use.The requirement for MARs to be accurate, including resident-specific parameters for PRN medications, was discussed with Staff 1 (Administrator) and Staff 2 (Chief Operating Officer) on 11/16/23. They acknowledged the findings.
2. Resident 2 was admitted to the facility in 09/2023 with diagnoses including including chronic obstructive pulmonary disease.The resident's 10/01/23 through 11/13/23 MARs and physician's orders were reviewed. The following PRN medications for shortness of breath lacked resident- specific parameters or instructions to direct non-licensed staff on which medication should be administered and in what order:* Albuterol HFA inhaler;* Ipratropium/albuterol nebulizer; and* Morphine.During an interview on 11/14/23, Staff 7 (Care Manager) confirmed the electronic MAR system did not have parameters listed for staff on which medication should be administered and in what order.The need to ensure the resident's MAR was accurate and included resident-specific parameters and instructions for PRN medications was reviewed with Staff 1 (Administrator) and Staff 2 (Chief Operating Officer) on 11/15/23. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure residents' MARs were accurate and included resident-specific parameters and instructions for PRN medications for 5 of 6 sampled residents (#s 2, 3, 4, 5, and 6) whose MARs were reviewed. Findings include, but are not limited to:1. Resident 4 was admitted to the facility in 11/2023 with diagnoses including paroxysmal atrial fibrillation, type 2 diabetes mellitus, chronic obstructive pulmonary disease, schizoaffective disorder, and benign prostatic hyperplasia.Resident 4's 11/01/23 through 11/13/23 MAR and physician orders were reviewed and revealed the following:a. The following medications lacked specific instructions:* Dorzolamide/Timolol solution 2-0.5% (eye drops); and* Prednisolone solution 1% (eye drops).b. The following PRN medications lacked resident-specific parameters, including sequential order of use: * Acetaminophen 500mg (for pain);* Hydrocodone/APAP 5/325mg (for pain); and* Naproxen 500mg (for pain).The need to ensure MARs were accurate, contained medication-specific instructions, and provided resident-specific parameters and instructions for PRN medications was reviewed with Staff 1 (Administrator), Staff 4 (RN), and Staff 8 (Care Manager) on 11/16/23. They acknowledged the findings. No further information was provided.
5. Resident 6 was admitted to the facility in 11/2023 with diagnoses including dementia.Resident 4's 10/01/23 through 11/13/23 MARs and physician's orders, signed 09/12/23, were reviewed and revealed the following:The following PRN medications and treatments lacked resident-specific parameters, including sequential order of use: * A&D ointment as needed to affected areas (hands, feet, areas of dry skin);* House lotion: apply house lotion generously to lower arms, legs daily as needed;* House barrier cream: apply house barrier cream as needed for skin breakdown to affected areas (coccyx, peri); and* Inzo barrier cream 4 oz: apply topically to affected areas as needed for skin breakdown (buttocks).The need to ensure MARs provided resident-specific parameters and instructions for PRN medications was reviewed with Staff 1 (Administrator), Staff 4 (RN), and Staff 7 (Care Manager) on 11/16/23. They acknowledged the findings.
3. Resident 3 was admitted to the facility in 02/2018 with diagnoses including schizophrenia and chronic obstructive pulmonary disorder.Review of the resident's 10/01/23 through 11/13/23 MARs identified the following:* Three PRN inhalers had conflicting parameters regarding administration; and* Monthly vitals lacked notification parameters.The need to ensure MARs were accurate and included clear parameters for PRN medications which the facility was responsible for administering, so that non-licensed staff were not required to use their own discretion, was discussed with Staff 1 (Administrator), Staff 4 (RN), Staff 5 (LPN), Staff 7 (Care Manager), and Staff 28 (Care Manager) on 11/16/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure an Acuity-Based Staffing Tool (ABST) assessment was completed for 2 of 7 sampled residents (#s 2 and 7), and 4 unsampled residents, whose ABST data was reviewed. Findings include, but are not limited to:Review of ABST records and interviews with staff noted ABST entries were not completed at move-in for Residents 2 and 7 and for four unsampled residents.In an interview on 11/15/23, Staff 1 (Administrator) confirmed the ABST was not updated following the admission of several residents.The need to ensure an ABST assessment was completed for each resident before the resident moved into the facility and was used to develop the facility's staffing plan was discussed with Staff 1 on 11/16/23. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 sampled staff (#s 15 and 16) completed all required elements of annual infectious disease prevention training. Findings include, but are not limited to:Annual training records were reviewed on 11/16/23 with Staff 3 (Administrative Support Specialist).There was no documented evidence Staff 16 (MT), hired 06/13/97, or Staff 15 (MT), hired 08/25/21, completed all required elements of the annual infectious disease prevention training.The need for all employees to complete all required elements of infectious disease prevention training annually was discussed with Staff 1 (Administrator), Staff 4 (RN), Staff 5 (LPN), Staff 7 (Care Manager), and Staff 28 (Care Manager) on 11/16/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to provide fire and life safety instruction to staff on alternating months, conduct fire drills consistently every other month, and to document all required elements for fire drills in accordance with Oregon Fire Code (OFC) requirements. Findings include, but are not limited to:The facility provided documentation of one fire drill in the last six months, which occurred on 06/30/23. Fire drills were not consistently conducted every other month, and written fire drill documentation did not include all the required elements.There was no documented evidence staff were provided fire and life safety instruction on alternating months.During an interview on 11/14/23, Staff 1 (Administrator) confirmed the fire drills had not occurred since 06/30/23 and fire and life safety instruction to staff had not occurred over the last six months.The need to provide fire and life safety instruction to staff on alternate months, to consistently conduct fire drills every other month, and to document all required elements for fire drills as required by the OFC was discussed with Staff 1 and Staff 2 (Chief Operating Officer) on 11/14/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure residents were instructed in fire and life safety procedures within 24 hours of admission and re-instructed, at least annually, as required by the Oregon Fire Code (OFC). Findings include, but are not limited to:Fire and life safety records were reviewed on 11/14/23 at 2:30 pm.There was no documented evidence residents were provided fire and life safety procedure training within 24 hours of admission to the facility or were being re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire.The need for residents to be instructed in fire and life safety procedures within 24 hours of admission and at least annually thereafter, per the OFC, was discussed with Staff 1 (Administrator) and Staff 2 (Chief Operating Officer) on 11/14/23. They 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 C231, C555 and Z142.

Based on observation and interview, it was determined the facility failed to ensure the grounds were free of litter and refuse, and the exterior pathways were made of hard, smooth material and maintained in good repair. Findings include, but are not limited to:Observations of the facility exterior on 11/13/23 and 11/14/23 identified the following:* Mattresses and broken furniture were stacked behind the maintenance shed; * A bag of garbage was left near the front door of building 610 and building 632 on 11/13 and 11/14;* The sidewalk near the employee smoking area behind building 611 was uneven and had drop-offs; and* The pathway leading to the gate behind building 611 was rocky.These findings were reviewed with Staff 24 (Facilities Maintenance Specialist) on 11/15/23 and Staff 1 (Administrator) on 11/16/23. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure all interior materials and surfaces were kept clean and in good repair. Findings include, but are not limited to:The facility was comprised of 11 individual buildings, seven of which either housed residents (buildings 604, 608, 610, 611, 612, and 622) or were slated to house residents within the next month (building 620). The interior of these seven buildings was toured by various surveyors during the survey. The following areas were found to need cleaning or repair:Building 608:* Gouges on door frame to room 8;* Black streaks on door frames to rooms 1, 3, and 10;* Hole in wall behind door handle in bathroom across from room 5;* Carpet stains in room 8;* Brown stains on arms and seat of green fabric chair in common area; and* Clear coat peeling across top surface of two end tables in common area.Building 611:* Dings on the wall in sitting area of medication cart alcove;* Hole in the door of room 5;* Dings on wall/baseboard by room 1;* Threshold on both showers missing, leaving yellowish glue stains; and* A rolling shower chair, walker, a seated scale, a high/low table, and wheelchair footrests stored in alcove.Building 612:* Ripped chair near MT station;* Gouges on multiple door frames throughout building;* Recliner, shower chair, oxygen tanks, four wheeled walker, toilet riser, and fan stored in alcove; and* Plant stand had containers with decaying herbs.Findings were reviewed with Staff 1 (Administrator) and Staff 2 (Chief Operating Officer) on 11/15/23, with Staff 24 (Facilities Maintenance Specialist) on 11/15/23, and again with Staff 1 on 11/16/23. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure a time schedule for resident use of laundry facilities was provided. Findings include, but are not limited to:The facility laundry room for the residential care community, building 611, was toured with Staff 29 (CG) on 11/14/23. Observation of the laundry room identified the door was locked. Staff 29 stated that the door was always locked. Staff 34 (CG) also confirmed they were locking the door now.On 11/15/23 during an interview with a non-sampled resident s/he reported the laundry room door had recently been locked and now the only time s/he could access the laundry room was "when a particular caregiver is working and she will let me in." The resident was not aware of a schedule of when s/he had access to the laundry room.On 11/16/123 an interview with Staff 1 (Administrator) confirmed there was no time schedule of when residents had access to the laundry facilities in building 611.The need to ensure a time schedule for resident use of laundry facilities was discussed with Staff 1, Staff 4 (RN), Staff 7 (Care Manager) and Staff 28 (Care Manager). They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure all exit doors were equipped with an alarming device or other acceptable system to provide security and to alert staff when residents exited the building and ensure a call system that connects resident units to the care staff. Findings include, but are not limited to:a. Observations in building 610 (memory care) from 11/13/23 through 11/15/23 revealed an exit door to the exterior courtyard failed to have an alarm or other acceptable system to alert staff when residents exited the building. One of the courtyard doors had an audible alarm which was not operable over the course of the survey.b. Observations of resident units in building 610 and interviews with Staff 32 (MT) revealed the facility had a call system that included a cord with a button attached for the resident to use to alert staff. Resident units 4, 5, and 8 did not have a cord attached to the wall outlets for the residents to use. Room 10 had a cord attached; however, the call system was not activated when the button was pushed.On 11/16/23, the need to ensure exit doors were equipped with an audible alarm or other acceptable system to alert staff and the need to ensure residents had a system to connect resident units to care staff was discussed with Staff 1 (Administrator) and Staff 25 (Facilities Maintenance Specialist). They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to provide a call system that connected resident units to the care staff. This is a repeat citation. Findings include, but are not limited to:Building 610 was toured on 07/30/24 at 11:04 am. Staff 34 (CG) was asked to demonstrate the call system from resident rooms 4, 5, 8, and 10. Units 4 and 8 did not have a cord attached to the call system outlet. The call system in Room 10 was not activated when the button was pushed.On 07/30/24 the need to ensure residents had a system to connect resident units to care staff was discussed with Staff 1 (Administrator). She 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 C150, C200, C231, C295, C361, C374, C420, C422, C510, C513, C530, and C555.

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:Refer to C231 and C555.

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 C252, C260, C262, C270, C280, C300, C303, C304, and C310.

Based on interview and record review, it was determined the facility failed to ensure an individualized nutritional plan for each resident was developed and documented in residents' service plans for 2 of 2 sampled residents (#s 2 and 6) whose nutrition and hydration plans were reviewed. Findings include, but are not limited to:Service plans for Residents 2 and 6 were reviewed during survey.Resident 2's service plan included some food preferences, but lacked individualized hydration information and staff instructions related to meeting resident-specific nutrition and hydration needs.Resident 6's "eating/nutrition" plan identified the resident at "moderate risk" for nutrition and instructed staff to offer snacks and encourage fluids, but did not include information on the resident's food and drink preferences. The plan included information that the resident "will refuse meals at times," but did not provide direction to staff on what to do if the resident refused meals.The need to develop individualized nutritional plans addressing residents' nutrition and hydration preferences and needs was discussed with Staff 1 (Administrator) and Staff 2 (Chief Operating Officer) on 11/15/23 and 11/16/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to evaluate and develop individualized activity plans for 2 of 2 sampled residents (#s 2 and 6) whose activity plans were reviewed and failed to consistently provide meaningful activities for all residents which promoted or helped sustain physical and emotional well-being. Findings include, but are not limited to:a. Records for Residents 2 and 6 were reviewed during the survey. There was no documented evidence an activity evaluation had been completed and the service plans individualized to reflect one or more of the following required components:* Current abilities and skills;* Emotional/social needs and patterns;* Physical abilities and limitations;* Adaptations necessary for the resident to participate; and* Identification of activities for behavioral interventions.There was no specific activity plan which detailed what, when, how, and how often staff should offer and assist each resident with individualized activities.Resident 6's individualized activity plan was not reflective of his/her activity preferences and needs.b. Observations and interviews during survey indicated the residents were dependent on staff to initiate activities. In the two memory care houses (buildings 610 and 612) there were 10 to 15 residents observed throughout the day watching television, sleeping in chairs, staring, sitting at the dining table, or walking around the common areas.The posted activity calendar was as follows:Monday, 11/13/23:* Morning greeting and visits;* 10:00 am - tell me your story;* 2:00 pm - bingo; and* 2:30 pm - 3:00 pm - emotional.Tuesday: 11/14/23:* Morning greeting and visits;* 10:00 am - coloring;* 2:30 pm - Church (for all houses); and* 2:30 - 3:00 pm - creative minds.The November 2023 schedule was reviewed and did not include any physical activities that enhanced or maintained a resident's ability to ambulate or move, nor did it include any outdoor activities.On 11/13/23, Staff 31 (MT) reported that activities were held in the "activity room" next to building 612. She reported that during evenings when there were no scheduled activities, staff would turn the television on for the residents to watch or there were coloring supplies available on the unit to offer residents.On 11/14/23, Staff 35 (Activities Assistant) reported the caregivers were responsible for engaging residents prior to 10 am during the "morning greeting and visits."On 11/15/23 and 11/16/23, the need to evaluate and develop individualized activity plans which included all required components and was reflective of activity preferences and needs for each memory care resident, as well as the need to ensure meaningful activities that promote or help sustain the physical and emotional well-being of residents, were person-centered, and were available during residents' waking hours, was discussed with Staff 1 (Administrator) and Staff 2 (Chief Operating Officer). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to evaluate and include in the service plan behavioral symptoms that negatively impacted the resident or others in the community for 1 of 1 sampled memory care residents (#6) with documented behaviors. Findings include, but are not limited to:Resident 6 moved into the memory care unit of the facility in 03/2021 with diagnoses including dementia.Resident 6's record documented behaviors including, but not limited to, sexually inappropriate behaviors towards staff and other residents, including touching, grabbing, and sexual comments.The resident's service plan, dated 09/08/23, did not include the behaviors and lacked direction to staff for minimizing the negative impact of the behaviors.On 11/16/23 the need to evaluate and include behavioral symptoms on the resident's service plan was discussed with Staff 1 (Administrator), Staff 4 (RN), and Staff 7 (Care Manager). They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure outdoor furniture was of sufficient weight, stability, and design to prevent resident injury or aid in elopement. Findings include, but are not limited to:The outdoor secured courtyard was toured on 11/15/23 at 9:52 am. The following was observed:* Multiple wheelchairs;* Multiple walkers;* Dining and patio chairs;* Bicycles; and* A patio table.Residents had free access to the secured courtyard. The above mentioned outdoor furniture was easily movable, thus not of sufficient weight to prevent injury or aid in elopement.The need for furniture which was of sufficient weight and not easily moveable to prevent potential elopement was discussed with Staff 1 (Administrator) and Staff 2 (Chief Operating Officer) on 11/15/23 and Staff 25 (Facilities Maintenance Specialist) on 11/16/23. They acknowledged the findings.

The findings of the kitchen inspection, conducted 01/10/23, 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 1/10/23, conducted 4/14/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation, interview and record review, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with the Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:On 01/10/23 at 09:40 am, food storage, prep and service areas were toured with designated Person In Charge (PIC) Staff 2 (Head Cook). Kitchen areas in cottages 610, 611, and 612 were observed to need cleaning and repairs in the following areas:* Kitchen cabinet exteriors throughout all kitchens had multiple spills, smears, splatters, and sticky surfaces. Majority of kitchen cabinet exterior surfaces were also worn and damaged, and one drawer in cottage 611 had two holes. Maintenance Manager contacted Staff 2 and was told that work to refurbish all cabinets will be handled internally and was scheduled to start on 01/23/23;* Kitchen cabinet interiors in all kitchens were found dirty with sticky black residue;* A utensil storage drawer in cottage 611 was damaged; * Door hinges inside kitchen cabinets and under sinks in all kitchens were covered with grease, dust, and dirt, presenting risk for cross-contamination of clean kitchenware stored in cabinets;* The floor in cottage 611 had food debris, dirt, and unidentified yellow powdery substance spilled in the corner; * Two drawers under the oven in cottage 610 had brown liquid spills;* Corner of swinging door to kitchen in cottage 611 was covered with cloth and masking tape. Staff 2 was unsure of reason for this mitigation or repair; * Microwave interiors, doors and handles in cottages 610 and 612 had food debris and splashes;* Exterior of water dispensers in all reach in refrigerators were dirty and covered with white residue. Staff 2 was unaware of schedule for replacing water filters; * Interior of dishwasher in cottage 610 was dirty and covered with white residue;* Rack for clean dishes in cottage 612 was dirty; * Coffeemaker in cottage 611 was stained and dirty with splatters;* Toaster in cottage 612 was dirty and covered with food residue;* Exterior of refrigerator in cottage 612 had missing or broken control buttons; * Interior of stove exhaust hoods in cottages 610, 611 and 612 was covered with grease and layered with dust; * A gap in wall was noted under the sink where garbage disposal outlet pipe went through wall in cottage 612; * Cutting boards in all kitchens were found heavily scored and/or stained; * Ceiling vents in all kitchen areas were dirty and covered with dust; and* Electrical outlets were covered with dust/dirt/debris. On 01/10/23 at 10:10 am, the storage house that included a dry storage area with shelving, standard kitchen sink, a walk-in cooler and reach-in refrigerator was toured and observed to need cleaning and repairs in the following areas:a. Walk-in cooler:* Area under metal shelves had pooled liquid; * Surface of door near outside door handle was dirty; * Two circulating fans were covered with dust and dirt, blowing dust throughout cooler. Portion of dust collected on pipes on ceiling; and* Multiple metal shelves with peeling paint and rust. b. Reach-in refrigerator:* Circulation fan in reach-in refrigerator was covered with dust; * Interior door frame was dirty; and* Racks had areas of dirt and rust. There were portions of racks that had protective coating peeled off or missing.c. Dry storage area with shelving and kitchen sink:* Plastic cover of ceiling light fixture was cracked; * Air conditioning ceiling vent was covered with dust; * Light switches on wall next to shelf were covered with blue masking tape; * Cooking vessels were stored under sink next to cleaning products; * Surface of storage drawers had chipped and peeling paint; * Wall by reach in refrigerator was dirty; and* Wood shelving and drawers were found with damage and dust/dirt/debris accumulation.On 01/10/23 at 10:35 am, the dry storage room was toured and observed to need cleaning and repairs in the following areas:* Shelving cracked, damaged and worn with rough and soiled surfaces; * Broom was stored directly on the floor; * Gaps in wall around air conditioner wall unit, allowing outside air/contaminants and potential pests to enter through gap; * Air conditioner wall unit vent was covered with dust; and* Dust and cobwebs found in corners and edges.On 01/10/23 at 10:45 am, a room with four upright freezers was toured and observed to need cleaning and repairs in the following areas:* Molding of door frame inside room was removed, exposing underlying wall construction; * Ceiling vent covered with dust; * All four freezers had substantial build-up of frost; * Vegetable freezer had a spill on an interior door shelf; and* Gap in ceiling noted around yellow vertical pipe. On 01/10/23 at 11:55 am, kitchen staff was observed not following proper hygienic practices:* One kitchen staff was observed not using gloves properly by loading food onto cart, entering door access code while transporting food, and plating food at destination while using same pair of single-use gloves. On 01/10/23 at 09:40 am, the following improper food handling practices were observed:* Yogurt stored in the reach-in refrigerators in cottage 610 was found not dated when opened;* Milk and butter in the reach-in refrigerators in cottage 612 were found not dated when opened; * Unidentified liquid was stored in a disposable coffee cup in the reach-in refrigerator in cottage 611; * Open/damaged container of breadcrumbs found on storage shelf; and* Two coffee jars had scoops placed inside.On 01/10/23 at 11:55 am, the following improper food service practices were observed:* A caregiver transported an uncovered plates of food from the kitchen to multiple residents rooms; * Hot food item (enchiladas) was at a temperature of 130 degrees F prior to serving; and * Cold food item (flan) was found at 50 degrees F during service.Also, kitchen in cottage 611 did not have test strips for checking sanitizers available. Staff 2 said that she had strips available in the storage house. Kitchen in cottage 612 sanitizer strips were noted open to air resting in cook cart. Staff 2 acknowledged they should not be stored that way. Administration had no fixed cleaning schedule.The findings were discussed with Staff 1 (Administrator), Staff 2 (Head Cook), and Staff 3 (Assistant Administrator) on 01/10/23 at 12:40. Staff 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 240.