Markham House

Based on observation, interview and record review, it was determined the facility failed to ensure the kitchen was clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-0000. Findings include, but are not limited to:

On 08/06/25 from 11:10 am until 12:20 pm, observations of the facility's kitchen identified the following:

a. Food spills, splatters, debris, dirt, and/or black matter was observed on or underneath the following:
* Walls throughout the kitchen;
* Interior and exterior of the cabinets in the dining service area; and
* Interior of the microwave.

b. Food Storage: multiple items in dry storage were opened and not dated.

c. Food Service: alcohol wipes were not available to staff for sanitizing the probe thermometer after use.

d. Cleaning and Repair
* The Hobart mixer was not covered when not it use;
* There was a build-up of ice along the black pipe on the right hand ceiling of the walk-in freezer;
* There was a chip in the corner of the wall by the Hobart mixer;
* There was a worn area on the exit door with exposed wood, rendering the surface uncleanable; and
* There were two cracked ceiling light covers above the stove and one cracked ceiling light cover in the dry storage area.

e. Infection Control and Cleanliness:
* Beard restraints were not available for staff use;
* Tables in the dining area were set with cutlery with food surface contact areas exposed to potential contamination; and
* Tables in the dining area were set with drinking glasses not stored in an inverted position.

The kitchen was toured, and the above areas were discussed with Staff 1 (ED) and Staff 2 (Culinary Services Director) on 08/06/25 at 12:20 pm. The findings were acknowledged.

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

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

This Rule is not met as evidenced by:
Based on observation and interview it was determined the facility failed to ensure the kitchen was clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-0000. This is a repeat citation. Findings include, but are not limited to:

On 10/21/25, from 10:15 am until 10:35 am, observations of the facility's kitchen identified the following:

a. Food spills and splatters were observed on the walls surrounding the stove and on the walls throughout the kitchen;

b. Food Storage: multiple items in dry storage were opened and not dated.

The kitchen was toured, and the above areas were discussed with Staff 1 (ED) on 10/21/25 at 10:35 am. The findings were acknowledged.

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

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

This Rule is not met as evidenced by:

Based on observation, interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include but are not limited to:

Refer to C240.

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval

(Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation.

This Rule is not met as evidenced by:

The findings of the change of ownership survey, conducted 08/05/24 through 08/07/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations. Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day
The findings of the first re-visit to the change of ownership survey of 08/07/2024, conducted 12/17/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations. Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day


The findings of the second re-visit to the re-licensure survey of 08/07/24, conducted on 02/27/25, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, and OARs 411 Division 004 Home and Community Based Services Regulations.

Based on observation, interview, and record review, it was determined the facility failed to provide 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 08/05/24 through 08/07/24, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the scope, severity, and number of citations.Refer to deficiencies in the report.

Based on observation and interview, it was determined the facility failed to ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: On 08/05/24 at 10:15 am, the following areas were observed in the kitchen:* The ceiling vents and sprinklers had a layer of dust;* The floor underneath the dishwasher had an uneven surface, cracks and water damage;* The dishwasher digital thermometer indicated that the rinse cycle temperature reached between 150 F and 170 F, not 180 F as indicated on the dishwasher data plate.* Two staff did not restrain their hair. The findings were discussed with Staff 1 (Resident Care Manager) and Staff 2 (Chef) on 08/07/24. The findings were acknowledged.
Based on observation and interview, it was determined the facility failed to ensure the kitchen was maintained and food was stored in accordance with the Food Sanitation Rules OARs 333-150-0000. This is a repeat citation. Findings include, but are not limited to: On 12/17/24, the following areas were observed in the kitchen:* The flooring below the dish machine was damaged and pulling up.* The hand washing sink faucet was damaged and basin was soiled and had debris.* There were multiple undated, unlabeled, or uncovered food items in the walk in refrigerator and the deli-refrigerator. * Butter, a potentially hazard food, was left un-refrigerated on the dining room tables. The areas in need of repair and the food storage concerns were discussed with Staff 2 (Culinary Services Director) and Staff 18 (ED). They acknowledged the findings.

2. Resident 1 moved into the facility in 07/2024 with diagnoses including type II diabetes without complication.The resident's 07/02/24 service plan was reviewed, observations were made, and interviews with caregivers were conducted during the survey.a. The 07/02/24 service plan, which was available to staff, was not updated within 30-days of move-in to reflect changes in skin and ADLs status.b. In addition, Resident 1's service plan was not reflective, did not provide clear direction to staff and/or was not implemented in the following areas:* Customary routines;* Oral health status;* Personal hygiene status;* Repositioning/bed mobility status;* Use of side rails;* Ability to use call system;* Bowel management;* Transfer status including using mechanical lift; and* Pain status.The need to ensure service plans were reflective of the resident's needs, provided clear direction to staff and implemented was discussed with Staff 1 (Resident Care Manager) and Witness 1 (Consultant RN) on 08/06/24 and 08/07/24. The findings were acknowledged.
Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were updated at 30-days after move-in, at least quarterly, reflective of residents' needs, were readily available to staff, and provided clear direction regarding the delivery of services for 2 of 4 sampled residents (#s 1 and 3) whose service plans were reviewed. Findings include, but are not limited to:1. Resident 3 was admitted to the facility in 11/2021 with diagnoses including cognitive impairment and dementia.Observations of the resident, interviews with staff, and review of the resident's record, were completed during the survey.a. The current service plan available to staff, dated 02/05/24, had not been updated quarterly, was not reflective of the resident's current care needs or did not provide clear direction to staff in the following area:* weight change status.b. Review of the resident's record noted a significant change of condition on 06/24/24 related to weight loss. There was no documented evidence the service plan had been reviewed and updated as needed.The need to ensure resident service plans were updated at least quarterly, available to staff, reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (Resident Care Manager) and Staff 4 (Business Office Manager) on 08/07/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure changes of condition had determined and documented resident specific actions or interventions, were communicated to staff, and/or were monitored weekly through resolution for 3 of 4 sampled residents (#s 1, 2 and 3) who experienced changes of condition. Resident 1 developed unstageable pressure sores. Findings include, but are not limited to: Resident 1 moved into the facility in 07/2024 with diagnoses including, type II diabetes mellitus without complications, aftercare following surgical amputation and acquired absence of left foot.a. During the acuity interview on 08/05/24, the resident was identified to have a pressure sore in the coccyx area and received hospice services.The 07/01/24 initial evaluation indicated "no skin concerns needing treatment or monitoring." During an interview on 08/06/24, Witness 1 (RN Consultant) reported the resident admitted with a pressure sore on the coccyx area.The resident's current service plan, updated 07/02/24, hospice visit notes, dated 07/09/24 through 07/31/24, progress notes dated 07/03/24 through 08/04/24 and "Skin Issues (minor) LN[licensed nurse] Tracking and Weekly Progress note" were reviewed. Staff were interviewed.Staff documented the following in the resident's progress notes:* 07/05/24 - "Barrier cream applied to 1 cm x 2 cm redness to coccyx."; and* 07/10/24 - " ...another bed sore starting."The skin issues tracking and weekly progress note showed the following:* 07/03/24 - 3 cm x 1 cm. stage II;* 07/10/24 - hospice changed dressing; and* 07/17/24 - dressing intact. No complaint of pain.There was no documented evidence the facility evaluated the resident condition, document the changes and updated the service plan when the facility identified the pressure sores. Additionally, there was no documented evidence the facility monitored the pressure sores at least weekly. Further review of the skin tracking and weekly progress notes showed the following:* 07/24/24 - worsening wound bed. Unstageable; and* 07/31/24 - no changes to wound bed.Hospice visit notes showed the following:* 07/24/24 - "Worsening coccyx wound stage I, now unstageable."During the survey, between 08/05/24 and 08/07/24, Resident 1 was observed in bed at all times and required staff assistance with bed mobility.There was no documented evidence the facility completed a full evaluation to determine the resident's condition, monitored the resident's change in skin condition, or re-evaluated the resident when the new pressure sore was identified. In addition, there was no documented evidence the facility developed interventions to ensure the pressure sore did not get worse. The facility's failure to evaluate the resident's skin condition and to determine actions or interventions, document and communicate the actions or interventions with staff on all shifts, and to monitor interventions for effectiveness created a risk of harm to the resident as s/he developed unstageable pressure sores.b. Resident 1's progress note, dated 07/03/24 through 08/04/24 and the MAR, dated 07/0124 through 08/06/24 showed the following:* 07/03/24 - "on alert for new move in."; and* 07/23/24 - on antibiotic for cellulitis.There was no documented evidence the changes of condition in skin and initiation of antibiotic were monitored through resolution.The need to ensure changes in residents' skin was evaluated, actions or interventions were determined, documented, communicated to staff on all shifts, and implemented, ensure interventions were monitored for effectiveness and the changes of condition were monitored through resolution was discussed with Staff 1 (RCM) and Staff 4 (Business Office Manager) on 08/07/24. They acknowledged the findings.
3. Resident 2 moved into the facility in 07/2024 with diagnoses including dementia and syncope.The resident's current service plan dated 07/09/24, and progress notes dated 07/16/24 through 08/05/24 were reviewed. The following short-term changes of condition lacked documentation of resident-specific actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts and progress noted at least weekly through resolution:* 07/20/24: Return from the hospital due to elevated blood pressure. The need to ensure resident-specific actions or interventions for short term changes of condition were determined, documented, communicated to staff on each shift and the changes of condition were monitored, at least weekly, through resolution was discussed with Staff 1 (Resident Care Manager). She acknowledged the findings.
2. Resident 3 was admitted to the facility in 11/2021 with diagnoses which included cognitive impairment and dementia.Observations of the resident, interviews with staff and Resident 3, and review of the resident's medical chart were conducted during the survey. Resident 3's record revealed the following weights: *05/10/24: 152.4 lbs.; *06/24/24: 139.6 lbs.;*07/05/24: 139.6 lbs.; *08/03/24: 137.2 lbs.; and*08/05/24: 135.2 lbs.Between 05/10/24 and 06/24/24 Resident 3 lost 12.8 lbs or 8.4% of his/her body weight representing a significant change of condition. An RN assessment was completed for Resident 3's weight loss on 06/24/24, however there was no documented evidence actions/interventions were developed, communicated to staff nor was the change monitored weekly through resolution. At the time of the survey, 08/05/24 the resident weighed 135.2 lbs. On 08/05/24 at 2:45 pm, in an interview with the resident, s/he stated they ate breakfast and lunch in their room. S/he also stated the food at the facility was good. It was observed the resident had a kitchenette in unit including a refrigerator and microwave to contain and prepare snacks.On 08/05/24 at 2:30 pm, in an interview with Staff 7 (CG/MT) and Staff 12 (CG), they stated Resident 3 was able to eat and choose meals independently. The need to ensure the facility had a process for determining what actions or interventions were needed for a resident and providing written instructions to staff following a change of condition was reviewed with Staff 1 (Resident Care Manager) and Staff 4 (Business Office Manager) on 08/07/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure an RN completed an assessment that documented findings, resident status, and interventions made as a result of the assessment for 1 of 4 sampled residents (# 1), who experienced significant changes of condition in skin. Findings include, but are not limited to:Resident 1 moved into the facility in 07/2024 with diagnoses including, type II diabetes mellitus without complications, aftercare following surgical amputation and acquired absence of left foot.During the acuity interview on 08/05/24, the resident was identified to have a pressure sore on the coccyx area.During the interview on 08/06/24, Witness 1 (RN Consultant) reported the resident admitted with the pressure sore on the coccyx area.The resident's current service plan, updated 07/02/24, was reviewed. There was no specific interventions for the pressure sore provided to staff to follow.Hospice visit notes, dated 07/09/24 through 07/31/24, progress notes dated 07/03/24 through 08/04/24 and "Skin Issues (minor) LN [Licensed Nurse] Tracking and Weekly Progress note" were reviewed. Staff were interviewed.Staff documented the following in the resident's progress notes:* 07/10/24 - " ...another bed sore starting."The skin issues tracking and weekly progress note showed the following:* 07/10/24 - hospice changed dressing;* 07/17/24 - dressing intact. No complaint of pain;* 07/24/24 - worsening wound bed. Unstageable; and* 07/31/24 - no changes to wound bed.The unstageable pressure sore represented a significant change of condition.There was no documented evidence the facility completed assessment for the significant change of condition in skin, document the resident status, and interventions made as a result of the assessment.On 08/07/24, Witness 1 via phone interview, reported that she was not able to answer if there was an RN assessment or not when she was aware of the unstageable pressure sore. On 08/07/24, the need to ensure the facility RN completed an assessment for the significant change of condition was discussed with Staff 1 (Resident Care Manager) and Staff 4 (Business Office Manager). They acknowledged the findings.

2. Resident 1 moved into the facility in 07/2024 with diagnoses including type II diabetes without complication, aftercare following surgical amputation and acquired absence of left foot.During the acuity interview on 08/05/24, the resident was identified to receive outside hospice services.The resident's current service plan, updated 07/02/24, hospice visit notes, dated 07/09/24 through 07/31/24 and progress notes dated 07/03/24 through 08/04/24 were reviewed.Hospice visits showed the following:* 07/24/24 - Do not use plastic or vinyl sheets; and* 07/31/24 - Reposition the resident every two hours while awake and every four hours at night.In the review of the resident's clinical record, there was no documented evidence staff were informed of the new instructions and the service plan was updated for the recommendation.The need to ensure staff were informed of new instructions and the service plan was updated as necessary after on-site health services were provided was discussed on 08/07/24 with Staff 1 (Resident Care Manager) and Witness 1 (RN Consultant) on 08/06/24 and Staff 1 and Staff 4 (Business Office Manager) on 08/07/24. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to coordinate care with outside providers in order to ensure the continuity of care, the facility failed to ensure staff were informed of new interventions, and the service plan was adjusted if necessary for 2 of 2 sampled residents (#s 1 and 2) who received outside services. Findings include, but are not limited to:1. Resident 2 moved into the facility in 07/2024 with diagnoses including dementia and syncope.Progress notes, outside provider notes dated 07/31/24, and the service plan dated 07/09/24 were reviewed. There was no documented evidence staff were informed of the new instructions and the service plan was updated for the following recommendation:* 07/31/24-HH OT noted: The resident needs positional changes every 1-2 hours with brief checked for moisture as s/he is at a higher risk for pressure injury due to immobility. Please check brief every 1-2 hours.The need to ensure staff were informed of new instructions and the service plan was updated as necessary after on-site health services were provided was discussed on 08/07/24 with Staff 1 (Resident Care Manager). She acknowledged the findings.
Based on interview and record review, it was determined the facility failed to coordinate care with outside providers in order to ensure the continuity of care, the facility failed to ensure staff were informed of new interventions, and the service plan was adjusted if necessary for 1 of 1 sampled resident (# 6) who received outside services. This is a repeat citation. Findings include, but are not limited to:Resident 6 moved into the facility in 08/2024 with diagnoses including aftercare following joint replacement surgery.Progress notes from 10/02/24 through 12/11/24 and the 11/28/24 service plan were reviewed. There was no documented evidence staff were informed of the new instructions and the service plan was updated for the following recommendation:* 11/04/24: New instructions from HHPT to change the resident's shirt while seated at the edge of the bed; * 11/06/24: Continue encouraging the resident to sit at the edge of the bed; and* 11/19/24: New instructions from HHPT to encourage the resident sitting at the edge of the bed.The need to ensure staff were informed of new instructions and the service plan was updated as necessary after on-site health services were provided was discussed on 12/17/24 with Staff 18 (ED) and Staff 19 (RN). They acknowledged the findings.

2. Resident 1 moved into the facility in 07/2024 with diagnoses including type II diabetes without complication, aftercare following surgical amputation and acquired absence of left foot.Review of Resident 1's current physician orders and MARs from 07/01/24 through 08/06/24 identified the following:* The resident was prescribed Keflex 250 mg [antibiotic] three times a day for 5 days for suspected cellulitis, however, the MAR indicated the resident received four extra doses of the antibiotic.* The resident was prescribed wound care orders to coccyx and Polyethylene powder once a day for constipation; however, the wound care and the Polyethylene powder orders were not transcribed on the MAR for staff to follow.The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (Resident Care Manager) and Staff 4 (Business Office Manager) on 08/07/24. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 2 of 4 sampled residents (#s 1 and 2) whose orders were reviewed. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in 07/2024 with diagnoses including dementia and syncope.Resident 2's current physician orders and MAR, dated 07/01/24 through 07/31/24, were reviewed and revealed the following:The resident had physician orders dated 07/26/24 for the following:* Monitor blood pressure in the morning before giving meds; if systolic blood pressure is less than 100, let home health know.On 08/06/24 at 9:50 am, the surveyor and Staff 6 (MT) reviewed the electronic MAR and physician orders. Staff 6 confirmed the order to monitor blood pressure in the morning before giving meds; if systolic blood pressure is less than 100, let home health know, was not transcribed on the MAR for staff to follow. The need to ensure all physician orders were carried out as prescribed was discussed with Staff 1 (Resident Care Manager) on 08/07/24. She acknowledged the findings.

2. Resident 1 was admitted to the facility in 2018 with diagnoses including diabetes, aftercare following surgical amputation and acquired absence of left foot.a. Resident 1 had a physician order to administer Senna Plus one tablet once a day as needed and Bisacodyl 10 mg suppository once a day as needed for constipation. Resident 1's 07/01/24 through 08/06/24 MAR showed there were no resident-specific parameters including when to administer the PRN medication.b. Resident 1 had a physician order to administer Ativan 0.5 mg every four hours as needed for agitation/anxiety.Resident 1's 07/01/24 through 08/06/24 MAR showed there were no resident-specific instructions on how the resident expressed agitation and anxiety to determine when staff were to administer the PRN medication. The medication was administered three occasions (07/05/24, 07/10/24 and 07/13/24) during the review period.The need to ensure medications had resident-specific parameters for PRN medications and clear instructions for unlicensed staff was reviewed with Staff 1 (Resident Care Manager) and Staff 4 (Business Office Manager) on 08/07/24. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure MARs had resident-specific parameters for PRN medications and clear instructions to staff for 2 of 4 sampled residents (#s 1 and 3) whose MARs were reviewed. Findings include, but are not limited to:1. Resident 3's 07/01/24 through 07/13/24 MAR was reviewed and revealed the following:Resident 3's MAR revealed multiple PRN medications that lacked resident-specific parameters and clear instructions to staff.* Acetaminophen 325 Mg Tabs (for fever, pain or headache) 1 - 2 tabs as PRN; and* Acetaminophen 500 Mg Caplet (for pain or fever) every eight hours PRN. In an interview with Staff 1 (Resident Care Manager) at 11:00 am on 08/07/24, she acknowledged the lack of parameters and instruction for Resident 3's use of PRN Acetaminophen.The need to ensure PRN medications had resident-specific parameters and clear instructions to staff was reviewed with Staff 1 and Staff 4 (Business Office Manager) on 08/07/24. Staff acknowledged the finding.

Based on interview and record review, it was determined the facility failed to ensure all pre-service orientation topics for 4 of 4 newly-hired staff (#s 6, 12, 15 and 17) and pre-service dementia training for 4 of 4 newly-hired staff (#s 6, 7, 10 and 12) had been completed prior to staff beginning their job duties and HCBS training for 1 of 4 long-term staff (# 9) had been completed. Findings include, but are not limited to:The facility's training records were reviewed on 08/06/24 and the following was identified:a. There was no documented evidence Staff 6 (MT), Staff 12 (CG), Staff 15 (Cook), and Staff 17 (Dietary Server), hired 05/14/24, 06/03/24, 06/19/24, and 07/08/24, respectively, completed the following pre-service orientation topics prior to beginning their job duties:* Resident rights and the values of community-based care;* Fire safety and emergency procedures;* Infectious disease prevention training; * Fire safety and emergency procedures; and* Approved HCBS course.b. There was no documented evidence Staff 6, 7, 10, and 12 completed the following pre-service dementia training courses prior to providing care to residents:* Dementia disease process including progression, memory loss, psychiatric and behavioral symptoms;* Techniques for understanding, communicating and responding to behaviors, including, but not limited to, reducing use of antipsychotic medications;* Strategies for addressing social needs & engaging persons with dementia in meaningful activities; and* Specific aspects of dementia including pain, providing food/fluids, preventing wandering, and the use of a person-centered approach.c. There was no documented evidence Staff 9 (CG), hired 11/01/22, completed HCBS training by 03/31/24.The requirements for pre-service orientation and training for all employees was reviewed with Staff 1 (Resident Care Manager) and Staff 4 (Business Office Manager) on 08/07/24. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure all pre-service orientation topics for 4 of 4 newly-hired staff (#s 20, 21, 22 and 23) and pre-service dementia training for 2 of 4 newly-hired staff (#s 20 and 21) had been completed prior to staff beginning their job duties. This is a repeat citation. Findings include, but are not limited to:The facility's training records were reviewed on 12/17/24 and the following was identified:1. There was no documented evidence Staff 20 (MT), hired 10/8/24, and Staff 21 (MT), hired 10/18/24 completed the following pre-service orientation topics prior to beginning their job duties:* Infectious disease prevention training; and* Pre-service dementia training.2. There was no documented evidence Staff 22 (MT), hired 10/2/24, and Staff 23 (CG), hired 11/5/24, completed the following pre-service orientation topics prior to beginning their job duties:* Resident Rights and values of CBC care;* Abuse Reporting; and* Fire Safety and emergency procedures.The requirements for pre-service orientation and training for all employees was reviewed with Staff 18 (ED), Staff 4 (Business Office Manager), and Staff 8 (RCC) on 10/17/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure and document that direct care staff demonstrated knowledge and performance in all required areas within 30 days of hire for 4 of 4 newly-hired staff (#s 6, 7, 10 and 12). Findings include, but are not limited to:The facility's training records were reviewed on 08/06/24 and the following was identified:There was no documented evidence Staff 6 (MT), Staff 7 (CG), Staff 10 (CG) and Staff 12 (CG), hired 05/14/24, 05/10/24, 02/15/24, and 06/03/24, respectively, demonstrated knowledge and satisfactory performance in the following topics:* Role of service plans in providing individualized care;* Providing assistance with ADLs;* Changes associated with normal aging;* Identification, documentation and reporting of changes of condition;* Conditions that require assessment, treatment, observation and reporting;* General food safety, serving and sanitation; and* Fire aid/abdominal thrust.The need to ensure the facility documented direct care staff demonstrated knowledge and performance in all required areas within 30 days of hire was discussed with Staff 1 (Resident Care Manager) and Staff 2 (Business Office Manager) on 08/06/24 and 08/07/24. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure and document that direct care staff demonstrated knowledge and performance in all required areas within 30 days of hire for 4 of 4 newly-hired staff (#s 20, 21, 22 and 23). This is a repeat citation. Findings include, but are not limited to:The facility's training records were reviewed on 12/17/24 and the following was identified:There was no documented evidence Staff 20 (MT), hired 10/8/24, Staff 21 (MT), hired 10/8/24, Staff 22 (MT), hired 10/2/24, and Staff 23 (CG), hired 11/5/24, demonstrated knowledge and satisfactory performance in the following topics:* Role of service plans in providing individualized care;* Providing assistance with ADLs;* Changes associated with normal aging;* Identification, documentation and reporting of changes of condition;* Conditions that require assessment, treatment, observation and reporting;* General food safety, serving and sanitation; and* Fire aid/abdominal thrust.Staff 20 (MT), Staff 21 (MT), and Staff 22 (MT), lacked evidence of demonstrating competence in medication pass. The need to ensure the staff had documented evidence of demonstrating competence in passing medications before working as a medication aide and passing medications was discussed with Staff 18 (ED) and Staff 8 (RCC). Staff 18 (ED) and Staff 8 (RCC) agreed the staff would not pass medications until they had demonstrated competence. The need to ensure the facility documented direct care staff demonstrated knowledge and performance in all required areas within 30 days of hire was discussed with Staff 18, Staff 4 (Business Office Manager), and Staff 8 on 12/17/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to have documented evidence that 12 hours of annual in-service training, including six hours related to the care of the dementia resident, was completed for 2 of 4 long-term staff (#s 8 and 9) and completed infectious disease training for 2 of 2 non-direct long-term staff (#s 14 and 16) whose training records were reviewed. Findings include, but are not limited to:Facility staff training records were reviewed on 08/06/24 and revealed the following:a. Training records for Staff 8 (MT/CG), hired 12/14/21 and Staff 9 (CG), hired 11/01/22, did not have documented evidence of required annual in-service training, including six hours relating to the care of residents with dementia.b. Training records for Staff 14 (Cook), hired 12/06/03 and Staff 16 (Dietary Server), re-hired 07/2023, did not have documented evidence of annual required infectious disease training.The need to ensure staff completed the required annual in-service training, based on anniversary dates of hire and infectious disease training was discussed with Staff 1 (Resident Care Manager) and Staff 4 (Business Office Manager) on 08/07/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to provide documentation that fire drills were being conducted every other month, all required components of fire drills were documented, and fire and life safety instruction was provided on alternate months to staff. Findings include, but are not limited to:1. Review of fire drill records on 08/05/24, dated 07/02/24, showed the facility failed to document the following required components:* Escape routes used;* Problems encountered, comments relating to residents who resisted or failed to participate in the drills; * Evacuation time-period needed; and* Number of occupants evacuated.2. The facility failed to provide documented evidence that fire and life safety instruction was being provided to staff on alternating months from fire drills. On 08/06/24, the need to ensure all required components of fire drills were documented, fire and life safety instruction was provided on alternate months to staff was discussed with Staff 3 (Maintenance Director). He acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure each resident was instructed within 24 hours of admission and 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. Findings include, but are not limited to:In an interview on 08/06/24 at 9:00 am with Staff 3 (Maintenance Director), he stated the facility was not providing or documenting annual instruction for residents 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.Resident fire life safety training records were reviewed on 08/07/24 at 11:00 am with Staff 1 (Resident Care Manager). Staff 1 stated going forward she would be completing fire life safety instruction with residents within 24 hours of admission.The requirements for fire life safety instruction for residents were reviewed with Staff 1 and Staff 4 (Business Office Manager) on 08/07/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure their change of ownership survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to C240, C290, C370 and C372.

Based on observation and interview, it was determined the facility failed to maintain all exterior pathways in good repair, and to ensure all facility grounds were kept orderly and free of refuse. Findings include, but are not limited to:The exterior of the building was toured on 08/05/24. The following issues were noted:* Multiple sections of the concrete path that encircled the building had drop-offs from the surface of the path to the planting bed of greater than two inches. This represented a fall risk for residents; and* An area observed on the rear grounds which included a mixture of old medical equipment, furniture, and building materials. This area was not kept orderly and presented a potential safety hazard for residents.On 08/06/24 at 9:00 am the need to ensure all exterior areas were maintained in good repair was discussed with Staff 1 (Resident Care Manager) and Staff 3 (Maintenance Director). They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to maintain all interior surfaces in good repair. Findings include, but are not limited to:The interior of the building was toured on 08/05/24. The following areas needed repair:* The carpet transition next to the front to the first floor wing was frayed and tearing; * The carpet throughout the first and second floors had spots and stains, particularly in the first floor activity room, and outside rooms 213, 216 and 223; and* The settee on the second floor (across from room 202) had a stain on it. On 08/06/23 at 9:00 am, the areas in need of repair were reviewed with Staff 3 (Maintenance Director). He acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure operable windows were designed to prevent accidental falls when sill heights were lower than 36 inches and above the first floor. Findings include, but are not limited to:The facility was toured on 08/05/24. Resident unit windows on the second floor opened vertically, and windowsills were lower than 36 inches. The windows lacked a system which limited how much the window could be opened to prevent accidental falls.The lack of a mechanism to prevent accidental falls was discussed with Staff 3 (Maintenance Director) on 08/06/24 at 9:00 am. He acknowledged the findings.

The findings of the on-site investigation, conducted 09/01/2023 through 09/15/2023, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

Based on interview and record review, conducted during a site visit on 09/01/23, it was confirmed the facility failed to ensure medication and treatment orders were carried out as prescribed for 1 of 1 sampled resident (# 1) whose MAR was reviewed. Findings include, but are not limited to:A review of Resident 1's progress notes, dated 01/2021, indicated on 01/12/21, Resident 1 was determined to no longer be safe to self-administer medications after an RN assessment and the physician was notified and requested prescriptions for Resident 1's medications. A second request was made the Resident 1's physician on 01/14/21. A review of Resident 1's MAR, dated 01/2021, indicated facility had created a MAR to begin facility administration on 01/23/21 with several medications denoted as "self-administration". Two of eight orders were not administered between 01/23/21 and 01/28/23. There was no evidence to indicate that eight of eight orders were administered between 01/12/23 and 01/23/21.Progress notes, dated 01/26/21, indicated the Health and Wellness Director "will talk with staff tomorrow about a plan" in reference to facility administering Resident 1's medications. In an interview on 09/01/23, Staff 1 (Administrator) stated s/he was did not know who Resident 1 was and was unaware of any concerns with Resident 1.The facility failed to ensure physician orders were carried out as prescribed.The findings of the investigation were reviewed with and acknowledged by Staff 1 on 09/15/23.Verbal Plan of CorrectionThere is a new management team in the building to make sure this doesn't happen again. The Health and Wellness Director makes sure there are no changes to residents medication status' until the facility has received physician orders then s/he will fax Omnicare to either add a resident if s/he is going from self-medicating to facility management or to remove a resident if going from facility managing to self-medicating, then the Health and Wellness Director will update the residents care plan, print it and have all of the med techs review the information followed by the caregivers.

Based on interview and record review, conducted during a site visit on 09/01/23 it was determined the facility failed to implement an acuity-based staffing tool (ABST) for 2 of 3 sampled residents (#s 2 and 3). Findings include, but are not limited to: In an interview on 09/01/23, Staff 1 (Administrator) stated the facility uses ElderMark and there is a point value assigned that has a time allotted to it, and the facility currently staffs based on the number of residents and the point values for time.A review of the facility's ABST indicated the tool failed to include all of the 22 required ADL components for the 3 sampled residents to include;· If multiple staff are required to assist with transferring and completing tasks in previous question, how much additional time is needed. · Providing treatments (e.g., skin care, wound care, antibiotic treatment.)Resident 2 and 3s' ABST failed to address the following required ADL components: · Providing non-drug interventions for pain management.· Monitoring physical conditions or symptoms.· Providing additional care service, such as smoking assistance or pet care.Resident 3's ABST also failed to address the following required ADL component: · Ensuring non-drug interventions for behaviors. The facility failed to fully implement an acuity-based staffing tool that met regulations.The findings of this investigation were reviewed with and acknowledged by Staff 1 on 09/15/23.