The Lodge at Vista View

The findings of the change of ownership survey, conducted 08/05/24 through 08/08/24, 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 for Home and Community Based Services Regulations.Tag numbers beginning with H refer to the Home and Community Based Services 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 change of ownership survey of 08/08/24, conducted 12/30/24 to 01/02/25, 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 for Home and Community Based Services Regulations.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day


The findings of the second re-visit to the change of ownership survey of 08/08/24, conducted 07/15/25 through 07/16/25, 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 licensee failed to provide effective oversight to ensure the quality of care and services that were rendered in the facility. Findings include, but are not limited to:During the change of ownership survey, conducted 08/05/24 through 08/08/24, oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number of citations.Refer to deficiencies in report.

Based on observation, interview, and record review, it was determined the licensee failed to provide effective oversight to ensure the quality of care and services that were rendered in the facility. This is a repeat citation. Findings include, but are not limited to:During the first revisit of the change of ownership survey of 08/08/24, conducted 12/30/24 through 01/02/25, oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number of repeat citations and new citations.Refer to deficiencies in report.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents' right to be treated with dignity and respect, to receive services in a manner that protects privacy and dignity, and to have a homelike environment for multiple sampled and unsampled residents. Findings include, but are not limited to:1a. On 08/07/24 at 11:30 am, eight unsampled residents attended a group interview. Five of eight residents reported staff had not respected their privacy in their units due to entering units without first knocking and/or knocking and entering without waiting for a response. The following statements were made during the interview:* "A lot of us want to acknowledge the staff and respond before they come in, but they'll just barge in without waiting.";* "I don't feel like [the staff] respect us. I've asked several times for them to wait before they come into my apartment and they never do."; and* "Staff will come right in, they won't even knock."1b. Resident 1 was observed to have a sign on his/her door, asking staff to knock on the door and wait to be acknowledged prior to entering. During an observation on 08/07/24 at 10:48 am, a caregiver was observed to knock and enter the unit without waiting for the resident to respond.2. On 08/07/24 at 11:30 am, eight unsampled residents attended a group interview. Four of eight sampled residents reported the Internet and television cable services were frequently down. Sampled Resident 2 also reported during an interview on 08/05/24 at 11:50 am that there was often no Internet or television working because the Internet router needed to be restarted multiple times a week, often in the evenings and on weekends when there was no staff there who had a key to the room the router was in.Review of the facility's "Uniform Disclosure Statement" indicated that cable television and Internet service were both provided by the facility. During an interview at on 08/07/24, Staff 1 (Interim ED) stated the router was located in the administrative offices and verified it frequently required restarting. She further stated no one had access to the offices in the evening hours after and on the weekends, so residents were often without cable television and Internet services.3. Observations of meal service to resident rooms indicated the facility used disposable serveware for residents who chose to eat in their rooms.4. During the group interview held at 1:00 pm on 08/07/24, residents indicated unpleasant odors were present in the hallway near Room 142. Observations of the facility conducted during the survey, from 08/06/24 to 08/08/24, confirmed an unpleasant odor in the hallway outside of Room 142 that did not dissipate.The need to ensure residents' right to privacy, dignity, respect, and a homelike environment was discussed with with Staff 1, Staff 5 (Regional Vice President of Operations), and Staff 6 (RN Consultant) at 1:30 pm on 08/07/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents' right to be treated with dignity and respect, to receive services in a manner that protects privacy and dignity, and to have a homelike environment for multiple sampled and unsampled residents. This is a repeat citation. Findings include, but are not limited to: a. On 12/30/24, three unsampled residents approached the surveyor after finishing their lunch meal. During an interview on 12/30/24 at 12:24 pm, they reported the Internet services were frequently down, and the cable service provider had recently changed. Since the change, one of the unsampled residents reported that cable no longer worked in his/her unit. During an interview on 12/31/24 at 11:15 am, Staff 26 (ED) indicated that cable television and Internet service were both provided by the facility per their Uniform Disclosure Agreement. He confirmed the facility had recently changed cable providers, and the Internet was scheduled to be upgraded next week. b. Observations of meal service to resident rooms indicated the facility used disposable serveware for residents who chose to eat in their rooms.The need to ensure residents' right to privacy, dignity, respect, and a homelike environment was discussed with Staff 26 (ED) on 01/02/25 at 12:15 pm. He acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (# 5) and failed to ensure evaluations were performed at least quarterly, to correspond with the quarterly service plan updates, for 2 of 5 sampled residents (#3 and 6) whose evaluations were reviewed. Findings include, but are not limited to:1. Resident 5 was admitted to the facility in 06/2024 with diagnoses including chronic obstructive pulmonary disease and hypertension.The resident's 06/28/24 move-in evaluation was reviewed. There was no documented evidence the following elements were addressed:* Customary Routines: sleeping;* Visits to health practitioners, emergency room, hospital or skilled nursing facilities;* Memory, orientation, confusion and decision-making abilities;* Personality: including how the person copes with change or challenging situations;* Hearing, vision, speech, assistive devices;* Ability to use call system;* Pain: pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort;* Skin condition;* List of treatments needed;* Indicators of nursing needs including potential for delegated nursing tasks;* Emergency evacuation ability;* History of dehydration or unexplained weight loss or gain;* Recent losses;* Elopement risk or history; and* Environmental factors that impact the resident's behavior including, but not limited to: noise, lighting, room temperature.The need to ensure move-in evaluations included all required elements was discussed with Staff 1 (Interim ED), Staff 2 (RN), Staff 3 (RCC), Staff 5 (Regional Vice President of Operations), Staff 6 ( RN Consultant) and Staff 17 (MT/RCC Assistant). They acknowledged the findings.2. Resident 3 was admitted to the facility in 08/2017 with diagnoses including macular degeneration and osteoarthritis. A review of the resident's record identified that there were no quarterly evaluations completed between 06/22/23 and 08/01/24.Staff 3 (RCC) reported in an interview on 08/07/24 that there were no evaluations completed between 06/22/23 and 08/01/24.The need to ensure resident evaluations were completed quarterly was discussed with Staff 1 (Interim ED), Staff 2 (RN), Staff 3, Staff 5 (Regional Vice President of Operations), Staff 6 (RN Consultant), and Staff 17 (MT/RCC Assistant) on 08/08/24. They acknowledged the findings.
3. Resident 6 was admitted to the facility in 12/2022 with diagnoses including chronic obstructive pulmonary disease and dysphagia (difficulty swallowing) due to Schatzki ring.The resident's evaluation was dated 06/20/24. The resident's most recent evaluation prior to 06/20/24 was dated 01/10/24.There was no documented evidence the resident's evaluation had been updated quarterly.The need to update evaluations quarterly was reviewed with Staff 1 (Interim ED), Staff 2 (RN), Staff 3 (RCC), Staff 5 (Regional Vice President of Operations), Staff 6 (RN Consultant), and Staff 17 (MT/RCC Assistant) on 08/08/24 at 11:34 am. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements and described the current condition of the resident for 1 of 1 sampled residents reviewed for new move in (#7), and failed to be updated within 30 days of move in, quarterly and/or after significant changes of condition for 4 of 4 sampled residents (#s 7, 8, 9, and 10). This is a repeat citation. Findings include, but are not limited to:1. Resident 7 was admitted to the facility in 11/2024 with diagnoses including type II diabetes, bacteremia, encephalopathy, and post surgery recovery from an intraspinal abscess.a. The resident's 11/25/24 move-in evaluation was reviewed. There was no documented evidence the following elements were accurately evaluated:* Customary Routines: eating, sleeping, bathing;* Visits to health practitioners, emergency room, hospital;* Memory, orientation, confusion and decision-making abilities;* Pain: pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort;* Skin condition;* Indicators of nursing needs including potential for delegated nursing tasks;* History of dehydration or unexplained weight loss or gain;* Transfers and assistive devices including use of bilateral side rails; * To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: Name; Pronouns; and Gender identity. b. Resident 7's move-in evaluation documented no skin issues.In interview on 01/02/25, Staff 2 (RN) stated Resident 7 had been admitted with a pressure ulcer, however, there was no documented evidence the wound had been noted on the admission evaluation, the initial service plan, or the MAR. c. In interview on 01/02/25 Staff 2 (RN) acknowledged the initial evaluation was not updated and modified as needed during the 30 days following the resident's move into the facility.The need to accurately evaluate all required areas of the move-in evaluation, and update within 30 days after admission was reviewed with Staff 26 (ED) and Staff 17 (RCC) on 01/02/25. They acknowledged the findings.
2. Resident 10 was admitted to the facility in 07/2023 with diagnoses including suspected lung cancer and severe protein-calorie malnutrition. Resident 10's quarterly evaluation, due in 11/2024, was not completed. The need to ensure quarterly evaluations were completed timely was discussed with Staff 26 (ED) and Staff 17 (RCC) on 01/02/25. They acknowledged the findings.
3. Resident 9 moved into the facility in 10/2011 with diagnosis including diabetes mellitus type II, neuropathy, and Binswanger disease. The resident's record was reviewed, and the following was identified:a. The resident's most recent evaluation was dated 08/27/24 and was not performed at least quarterly. b. On 12/09/24, the resident experienced a significant change of condition, related to an ankle fracture, and there was no documented evidence an evaluation was reviewed and completed for the significant change.The need to ensure evaluations were performed at least quarterly and were reviewed and updated each time a resident experienced a significant change of condition was discussed with Staff 26 (ED) on 01/02/25 at 3:32 pm. He acknowledged the findings.

4. Resident 8 moved into the facility in 06/2024 with diagnoses including prostate cancer, congestive heart failure, and ascites (excessive abdominal swelling).The resident's record was reviewed, and the following was identified:On 12/07/24, the resident experienced a significant change of condition, related to significant weight gain, and there was no documented evidence his/her evaluation was reviewed and completed for the significant change, as the resident's most recent evaluation was dated 10/08/24. The need to ensure evaluations were performed at least quarterly and were reviewed and updated each time a resident experienced a significant change of condition was discussed with Staff 26 (ED) on 01/02/25 at 12:20 pm. He acknowledged the findings.
1. A checklist for all required evaluation and service plan elements has been obtained. Evaluations for residents 7, 8, and 9 were revised by 1/30/2025 to include missing elements. Resident 10 is no longer in the community.2. Resident evaluations to be conducted at move-in and updated within 30 days, with significant change of condition, and at least quarterly. An audit to be conducted to ensure that all residents have had an evaluation within the last 90 days. Overdue evaluations will be brought into compliance by 2/16/25. The community will create, maintain, and follow an evaluation schedule for each resident in Point Click Care. An evaluation checklist to be utilized to ensure all components are addressed.3. Evaluation due dates to be reviewed in daily clinical meeting. Weekly audit to ensure the schedule is being followed. Evaluations completed as scheduled to be added to QA program agenda.4. Health Services Director, Care Coordinator(s), Executive Director

2. Resident 2 moved into the facility in 12/2021 with diagnoses including rheumatoid arthritis, depression, hepatic cirrhosis, and chronic pain.The current service plan, dated 06/19/24, and interim service plans, progress notes, outside provider visit notes, and incident reports from 05/05/24 through 08/05/24 were reviewed. Observations and interviews with staff and Resident 2 were completed during the survey. The following was identified:The service plan was not reflective and did not provide clear instructions for staff in the following areas:* History of significant weight loss;* Pressure reducing cushion in wheelchair;* Cigarette smoking; and* Cat care.The need to ensure the service plan reflected Resident 2's care needs and included clear directions to staff regarding the delivery of services was discussed with Staff 1 (Interim ED), Staff 2 (RN), Staff 3 (RCC), Staff 5 (Vice President of Clinical Operations), Staff 6 (RN Consultant), and Staff 17 (MT/RCC Assistance) on 08/08/24. They acknowledged the findings.3. Resident 3 moved into the facility in 08/2017 with diagnoses including macular degeneration, osteoarthritis, and cerebral vascular accident.Observations and interviews with staff and Resident 3, and a review of the resident's most current service plan, dated 08/01/24, showed the service plan was not reflective, did not provide clear direction to staff, and/or was not implemented in the following areas:* Edentulous (no teeth or dentures worn);* Nicotine use (chewing tobacco);* Divided section plate for meals;* Preference for all meals in room;* Dressing;* Visual impairment with staff instructions;* Compression stocking compliance;* Side rails;* Ambulation assistance;* Wheelchair use; and* Preference to sleep in during the morning. The need to ensure service plans were reflective of current care needs, provided clear direction to staff, and were implemented was discussed with Staff 1 (Interim ED), Staff 2 (RN), Staff 3 (RCC), Staff 5 (Vice President of Clinical Operations), Staff 6 (RN Consultant), and Staff 17 (MT/RCC Assistance) on 08/08/24. 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 and preferences, provided clear direction regarding the delivery of services, and/or were implemented for 3 of 5 sampled residents (#s 2, 3, and 4) whose service plans were reviewed. Findings include, but are not limited to:1. Resident 4 moved into the facility in 04/2017 and had diagnoses including delusions and aortic valve stenosis.The resident's current service plan, dated 07/25/24, was reviewed, observations were made, and interviews were conducted. The service plan was not reflective of the resident's needs and preferences, did not provide clear instruction to staff, and/or was not implemented in the following areas:* Toileting reminders and assistance needed;* Safety checks;* Assistive devices, including use of a bed cane and shower chair;* Use of emergency pendent and monitoring;* Outside providers, including home health nursing, PT, and OT; * Ability to wear glasses independently;* Skin conditions, including monitoring and instruction to staff;* Meal reminders and escorts to the dining room;* Nutritional shakes, including instruction to staff; and* Self-administration of medication left at bedside.The need to ensure service plans were reflective of resident needs and preferences, provided clear direction to staff, and were implemented was discussed with Staff 1 (Interim ED), Staff 2 (RN), Staff 3 (RCC), Staff 5 (Regional Vice President of Operations), Staff 6 (RN Consultant), and Staff 17 (MT/RCC Assistant) on 05/08/24. They acknowledged the findings.
2. Resident 7 was admitted to the facility in 11/2024 with diagnoses including type II diabetes, bacteremia, encephalopathy, and post surgery recovery from an intraspinal abscess.The resident's initial service plan, dated 11/25/24, was reviewed, observations were made, and interviews were conducted with the resident, resident's family, and caregivers. The service plan was not reflective of the resident's needs, did not provide clear instruction to staff, and/or was not implemented in the following areas:* Bilateral side rail use; instructions for caregivers and precautions related to the devices;* Presence of coccyx wound with precautions and monitoring instructions;* Instructions for caregivers providing catheter care; and* Home health services and contact information.The need to ensure service plans were updated quarterly was discussed with Staff 2 (RN, Health Services Director), Staff 26 (ED) and Staff 17 (RCC) on 01/02/25. They acknowledged the findings.
Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were completed following quarterly evaluations, were reflective of the resident's needs, provided clear direction to staff, reviewed and updated as needed when the resident experienced a significant change of condition, and/or were implemented for 4 of 4 sampled residents (#s 7, 8, 9 and 10) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:1. Resident 10 was admitted to the facility in 07/2023 with diagnoses including suspected lung cancer and severe protein-calorie malnutrition. The current service plan, dated 08/28/24, had not been updated quarterly.The need to ensure service plans were updated quarterly was discussed with Staff 26 (ED) and Staff 17 (RCC) on 01/02/25. They acknowledged the findings.

3. Resident 8 was admitted to the facility in 06/2024 with diagnoses including prostate cancer, congestive heart failure, and ascites (excessive abdominal swelling).a. The current service plan, dated 08/16/24, had not been updated quarterly following an evaluation. b. The resident's current service plan, dated 08/16/24, was reviewed, observations were made, and interviews were conducted with the staff. The service plan was not reflective of the resident's needs, did not provide clear instruction to staff, and/or was not implemented in the following areas:* Assistive devices and assistance required for mobility;* Assistance required for ADLs;* Hospice provider and contact information;* Bathing services were provided by hospice;* Recent losses, including death of family members;* Assistance required with catheter management;* Assistance required with medication management and administration;* Use of oxygen;* Weight changes; and* History of fluid retention. c. On 12/07/24, the resident had a significant and severe weight gain, which constituted a significant change of condition. There was no documented evidence the resident's service plan was reviewed and updated to reflect the resident's current care needs. The need to ensure service plans were reflective of resident's current care needs, completed at least quarterly, and were reviewed and updated each time a resident experienced a significant change of condition was discussed with Staff 26 (ED) on 01/02/25. He acknowledged the findings.
4. Resident 9 moved into the facility in 10/2011 with diagnosis including diabetes mellitus type II, neuropathy, and Binswanger disease. The resident's record was reviewed, and the following was identified:a. Resident 9's current service plan was dated 08/27/24 and was not updated at least quarterly following an evaluation. b. The resident's service plan dated 08/27/24 was not readily available to staff. c. On 12/09/24, the resident experienced a fall that resulted in an ankle fracture which constituted a significant change of condition. There was no documented evidence the resident's service plan was reviewed and updated to reflect the resident's current care needs. The need to ensure service plans were completed at least quarterly and were reviewed and updated each time a resident experienced a significant change of condition was discussed with Staff 26 (ED) on 01/02/25 at 3:32 pm. He acknowledged the findings.Surveyor: Cataldo, Debby

Based on interview and record review, it was determined the facility failed to ensure the service plan was developed by a service planning team consisting 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 who was going to provide services to, the resident for multiple sampled and unsampled residents. Findings include, but are not limited to:* On 08/07/24 at 11:30 am, eight unsampled residents attended a group interview. All eight residents confirmed they had not been involved in developing their service plans; and* Records for Residents 1, 4, and 6 were reviewed, and residents were interviewed. There was no documented evidence of a service planning team, and the residents confirmed they had not been involved in their service planning. The need to ensure a service planning team was used to update service plans was discussed with Staff 1 (Interim ED) on 08/07/24. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure the service plan was developed by a service planning team consisting 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 who was going to provide services to, the resident for 4 of 4 sampled residents (#s 7, 8, 9, and 10). This is a repeat citation. Findings include, but are not limited to:Records for Residents 7, 8, 9, and 10 were reviewed. There was no documented evidence of a service planning team. Residents 7, 9, and 10 confirmed they had not been involved in their service planning. The need to ensure a service planning team was used to update service plans was discussed with Staff 26 (ED) on 01/02/25. He acknowledged the findings.

2. Resident 2 was admitted to the facility in 12/2021 with diagnoses including hepatic cirrhosis, depression, and insomnia.The resident's current service plan dated 06/19/24, progress notes, temporary service plans, and incident reports dated 05/05/24 through 08/05/24 were reviewed.The following short-term changes of condition lacked monitoring of progress noted at least weekly through resolution:* 05/05/24 - Ongoing coccyx wound;* 05/05/24 - New order for multivitamin daily;* 05/11/24 - Boost drink supplement ordered twice daily;* 06/09/24 - Symptoms of urinary tract infection;* 06/17/24 - Fall with head strike;* 06/17/24 - Fall with skin tear to right arm;* 06/24/24 - Non-injury fall;* 06/24/24 - Fall with head strike;* 07/15/24 - Non-injury fall;* 07/17/24 - Two non-injury falls;* 07/24/24 - Fall with skin tear to right upper arm; and* 07/26/24 - Fall with skin tears to right lower arm.The need to ensure changes of condition had actions/interventions determined and monitored through resolution was discussed with Staff 1 (Interim ED), Staff 2 (RN), Staff 3 (RCC), Staff 5 (Regional Vice President of Operations), Staff 6 (RN Consultant), and Staff 17 (MT/Assistant RCC) on 08/08/24. They acknowledged the findings.3. Resident 3 was admitted to the facility in 08/2017 with diagnoses including cerebral vascular accident, hypertension, and macular degeneration.The resident's 08/01/24 service plan, progress notes, temporary service plans, and incident reports dated 05/05/24 through 08/05/24 were reviewed.The following short-term changes of condition lacked monitoring of progress noted weekly through resolution:* 05/07/24 - Re-admit from hospital;* 05/27/24 - Rash;* 06/03/24 - Symptoms of urinary tract infection;* 06/09/24 - Emergency room transport for pain, dysuria. Diagnosis Urinary tract infection. Antibiotic ordered;* 06/20/24 - Rash with MD order for cream to treat; and* 07/22/24 - Increase in pregabalin medication.The need to ensure changes of condition had actions/interventions determined and monitored through resolution was discussed with Staff 1 (Interim ED), Staff 2 (RN), Staff 3 (RCC), Staff 5 (Regional Vice President of Operations), Staff 6 (RN Consultant), and Staff 17 (MT/Assistant RCC) on 08/08/24. They acknowledged the findings.4. Resident 5 was admitted to the facility in 06/2024 with diagnoses including chronic obstructive pulmonary disease and hypertension.The resident's 07/28/24 service plan and progress notes dated 06/28/24 through 08/05/24 were reviewed.The following short-term changes of condition lacked monitoring of progress noted weekly through resolution:* 06/2024 - Admit to facility; and* 07/12/24 - Heat rash to right leg and elbow.The need to ensure changes of condition had actions/interventions determined monitored through resolution was discussed with Staff 1 (Interim ED), Staff 2 (RN), Staff 3 (RCC), Staff 5 (Regional Vice President of Operations), Staff 6 (RN Consultant), and Staff 17 (MT/Assistant RCC) on 08/08/24. They acknowledged the findings.
5. Resident 4 moved into the facility in 04/2017 and had diagnoses including delusions and aortic valve stenosis.The resident's 07/25/24 service plan, interim service plans (ISPs), incident reports, and 05/13/24 through 08/05/24 progress notes were reviewed. Observations were made, and staff and the resident were interviewed. The following was identified:There was no documented evidence resident-specific actions or interventions were determined for short-term changes of condition, the actions or interventions were communicated to staff on all shifts, and/or changes were monitored through resolution, with progress noted at least weekly, for the following:* 06/14/24 - Positive for COVID, cough, and sore throat;* 06/14/24 - New medications;* 07/08/24 - Injury fall in bedroom;* 07/14/24 - New confusion and diagnosis of pneumonia;* 07/18/24 - New medications;* 07/18/24 - Injury fall in resident's living room and new complaints of pain;* 07/24/24 - Change of condition, updated service plan, change in ADLs;* 07/29/24 - New medications;* 07/30/24 - New medications;* 07/29/24 - New nutritional shake order; and* 07/29/24 - Medication discontinuation.On 08/07/24 at 1:50 pm, Staff 3 (RCC) and Staff 17 (MT/RCC Assistant) confirmed there was not a consistent system in place to monitor and ensure actions or interventions were effective through resolution.The need to ensure there was a system to identify short-term changes of condition, determine and document what actions or interventions were needed, ensure actions or interventions were communicated with staff on all shifts, and ensure changes were monitored, with at least weekly documentation of progress, through resolution was discussed with Staff 1 (Interim ED), Staff 2 (RN), Staff 3, Staff 5 (Regional Vice President of Operations), Staff 6 (RN Consultant,) and Staff 17 on 08/08/24. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to, determine actions/interventions needed, communicate actions or interventions to staff on all shifts, and monitor changes through resolution, with at least weekly documentation for 5 of 6 sampled residents (#s 2, 3, 4, 5, and 6) reviewed with short term changes of condition? Findings include, but are not limited to:1. Resident 6 was admitted to the facility in 12/2022 with diagnoses including chronic obstructive pulmonary disease and dysphagia (difficulty swallowing) due to Schatzki ring. The resident's 06/20/24 service plan, 05/13/24 through 07/29/24 progress notes, and interim service plans (ISPs) were reviewed, and interviews with staff and the resident were completed. The following was identified:* The resident experienced symptoms of a urinary tract infection on 05/16/24; and* A progress note written on 05/31/24 indicated the resident had an order for Nystatin suspension (for a fungal infection in the mouth), to be taken four times a day "until lesions have been gone for 2 days" and to notify the prescriber if there was no improvement after 28 days.There was no documented evidence these changes were monitored through resolution, with at least weekly documentation.The need to monitor short-term changes of condition and document progress at least weekly was discussed with Staff 1 (Interim ED), Staff 2 (RN), Staff 3 (RCC), Staff 5 (Regional Vice President of Operations), Staff 6 (RN Consultant), and Staff 17 (MT/RCC Assistant) on 08/08/24. They acknowledged the findings. No additional information was provided.
2. Resident 7 was admitted to the facility in 11/2024 with diagnoses including type II diabetes, bacteremia, encephalopathy, and post surgery recovery from an intraspinal abscess.The resident's 11/25/24 service plan, 11/25/24 through 12/30/24 progress and observations notes, and interim service plans (ISPs) were reviewed, and interviews with staff and the resident were completed. The following was identified:An 11/30/24 progress note documented the discovery of a coccyx wound. An ISP was created on 12/2/24 with the instruction to report changes to the RN, RCC and med tech. The wound was monitored from 12/2/24 until 12/17/24 with no further documentation.In interview on 1/02/24, Staff 2 (RN) stated the coccyx wound was present at admission, however, there was no documented evidence the wound had been evaluated, interventions developed, and monitored weekly until resolution. Staff 2 stated the wound was now closed, however, there was no documented evidence of wound monitoring after 12/17/24 or when it had resolved. The need to ensure resident care needs were evaluated, interventions developed and communicated to staff on all shifts, and monitored until resolution was discussed with Staff 2 (RN) and Staff 26 (ED) on 01/02/25. They acknowledged the findings.

3. Resident 8 moved into the facility in 06/2024 with diagnoses including prostate cancer and congestive heart failure.The resident's 08/16/24 service plan, 10/07/24 through 12/30/24 progress and observations notes, and interim service plans (ISPs) were reviewed, and interviews with staff and the resident were completed. The following was identified:a. The following short-term changes of condition lacked monitoring of progress noted at least weekly through resolution:* 10/16/24 - Death of a family member;* 10/27/24 - Bedroom had flooded;* 11/01/24 - New medication;* 11/09/24 - New medication;* 11/15/24 - Multiple medication changes;* 11/20/24 - Return from emergency room;* 11/22/24 - New medication;* 11/26/24 - Multiple medication changes;* 12/05/24 - Multiple medication changes;* 12/07/24 - Blood in catheter bag;* 12/12/24 - Multiple medication changes;* 12/19/24 - New wound to the buttocks;* 12/26/24 - Resident experienced hallucinations; and * 12/28/24 - Discontinued medications. b. On 12/07/24, the resident had a significant and severe weight gain. There was no documented evidence the facility evaluated the resident, referred to the facility nurse, documented the change, and updated the service plan as needed. Refer to C 280, example 1.The need to ensure changes of condition were monitored through resolution and were evaluated, referred to the facility nurse, and changes documented was discussed with Staff 26 (ED) on 01/02/25. He acknowledged the findings.
Based on observation, interview, and record review, it was determined the facility failed to determine actions/interventions needed, communicate actions or interventions to staff on all shifts, and monitor changes through resolution, with at least weekly documentation for 4 of 4 sampled residents (#s 7, 8, 9, and 10) reviewed with changes of condition and/or failed to refer to the facility nurse, document the change and update the service plan for residents with significant changes of condition. This is a repeat citation. Findings include, but are not limited to:referred to the facility nurse, documented the change, and updated the service plan as needed1. Resident 9 moved into the facility in 10/2011 with diagnosis including diabetes mellitus type II, neuropathy, and Binswanger disease.The resident's 08/27/24 service plan, 10/11/24 through 12/25/24 charting and observation notes, skin monitoring sheets, and Interim Service Plans (ISPs) were reviewed. Observations of the resident were made, and interviews with staff and the resident were conducted. The following changes of condition were identified:* 10/07/24: Redness under left breast and groin;* 10/10/24: Open area on bottom;* 10/12/24: Received vaccines;* 10/14/24: New PRN medication;* 10/18/24: New treatment order;* 10/18/24: Medication change;* 10/18/24: Tooth pulled;* 10/18/24: New medication;* 10/21/24: Refusals to care between 10:00 pm and 5:00 am;* 10/23/24: New treatment order;* 10/24/24: Start antibiotic medication;* 10/31/24: Start new medication;* 10/31/24: Medication change;* 11/05/24: Resident to resident altercation;* 11/19/24: Medication change;* 12/09/24: Fall in shower;* 12/09/24: Fracture to left ankle;* 12/13/24: Routine wound care and abrasion to ankle;* 12/17/24: New medication;* 12/18/24: Resident hygiene; and* 12/25/24: Pink discharge in brief.The facility lacked documented evidence the above changes of condition had been identified, had determined actions/interventions, communicated actions or interventions to staff on all shifts, and/or changes were monitored through resolution.On 01/02/25 at 2:18 pm, Staff 2 (RN) confirmed there was no additional documentation for the above changes of condition. The need to ensure changes of condition were identified, resident-specific actions or interventions for changes of condition were determined, documented, and communicated to staff on each shift, and were monitored at least weekly through resolution was discussed with Staff 26 (ED) on 01/02/25 at 3:32 pm. He acknowledged the findings.
4. Resident 10 was admitted to the facility in 07/2023 with diagnoses including suspected lung cancer and severe protein-calorie malnutrition. The resident's 08/28/24 service plan, temporary service plans and progress notes from 10/07/24 to 12/29/24, and weight records from 07/2024 to 12/30/24 were reviewed. Observations of the resident were made, and interviews with staff and the resident were conducted.The following weights were documented in the resident record:07/02/24- 132.8 pounds;10/04/24- 130.2 pounds;12/04/24- 133.2 pounds;12/23/24- 120.2 pounds; and01/02/25- 119.0 pounds (taken during survey).Between 12/04/24 to 12/23/24 the resident lost 13 pounds, or 9.6 percent of his/her bodyweight, constituting a severe weight loss. The weight loss constituted a significant change of condition for which the facility was required to evaluate, refer to the facility nurse, document the change, and update the service plan. Review of the resident's record revealed no documented evidence the weight loss was evaluated, the facility nurse was notified, the change was documented, and the service plan was updated, and there were no documented interventions for the weight loss.During an interview at 1:01 pm on 01/02/25, Staff 17 (RCC) confirmed there was no documented evidence the weight loss was referred to the facility nurse. During an interview at 1:16 pm on 01/02/25, Staff 2 (RN) confirmed Resident 6's weight loss had not been evaluated or documented, and the service plan had not been updated.The need to ensure resident significant changes of condition were evaluated, referred to the facility nurse, documented, and the service plan was updated was discussed with Staff 26 (ED), Staff 17 and Staff 2 on 01/02/25. They acknowledged the findings.
1. A change of condition evaluation was completed, the service plan updated, and weekly monitoring initiated for resident 9 by 1/15/2025. A change of condition evaluation was completed, the service plan updated, and weekly monitoring was initiated for resident 7 by1/15/2025. A change of condition evaluation was completed, the service plan updated, and weekly monitoring was initiated for resident 8 by 1/14/2025. Resident 10 is no longer in the community. 2. System Corrections:a. Training to be provided to the RN regarding identification and documentation of temporary and significant changes of condition. b. Med Techs to receive re-training by HSD on Alert Charting and TSP systems. Consultant RN to review systems and recommend changes to procedures as indicated.c. Training for all staff necessary notifications to nurse, retrain on completion of 24-hour communicationd. Training to be provided on root-cause analysis for falls and implementing fall interventions. Falls will be tracked and monitored monthly in the quality assurance meeting.e. Method for skin evaluation and monitoring updated to include use of whiteboard and updated skin tracking system.f. Alert/TSP to be created for all new or changed medications.g. Alert/TSP to be created for outside provider treatment and procedures.h. Alert/TSP to be created when resident experiences a significant loss.i. Alert/TSP to be created for hospitalization.j. Alert/TSP to be created for unusual behaviors, hallucinations.k. Create white-board tracking system for critical clinical issuesl. RN to initiate SCOC assessment within 48 hours and monitor weekly until resolved or becomes the new baseline.m. RN to complete NurseLearn courses on Change of Condition.3. Method of evaluation:a. 24-hour, Skin, Fall, Alert charting logs completed every shiftb. Daily clinical meeting to include the above.c. COC documentation compliance to be added to quality assurance program agenda.4. Executive Director, Health Services Director

Based on interview and record review, it was determined the facility failed to ensure an RN significant change of condition assessment was completed for 1 of 1 sampled resident (# 2) who had significant weight gain. Findings include, but are not limited to:Resident 2 was admitted to the facility in 12/2021 with diagnoses including rheumatoid arthritis, depression, and hepatic cirrhosis.A review of the resident's clinical record, including progress notes dated 05/05/24 through 08/05/24 and weight records dated 05/01/24 through 07/31/24, was completed, and staff were interviewed. The following was identified:* On 06/05/24 Resident 2's weight was 119 pounds; and* On 07/03/24 Resident 2's weight was 130 pounds.The resident experienced a weight gain of 11 pounds, or 9% of his/her total body weight, in one month. This was considered a severe weight gain and a significant change of condition.* On 05/01/24 Resident 2's weight was 111.7 pounds; and* On 07/31/24 Resident 2's weight was 131 pounds.The resident experienced a weight gain of 12.3 pounds, or 9% of his/her total body weight, in three months. This was considered a significant weight gain and a significant change of condition.There was no documented evidence an RN assessment was completed for the resident's weight gain.On 08/07/24, Staff 2 (RN) stated that she had not completed a significant change of condition assessment for Resident 2's significant/severe weight gains, but that the weight gain was positive for the resident.The resident was observed and reported by staff to eat at all meals in his/her room independently, and s/he received protein supplement drinks twice a day.The surveyor requested the resident be weighed on 08/07/24. A record of weekly weights was provided, with the most recent being 08/07/24. Resident 2's weight was 129.5 pounds.The need for an RN to complete an assessment of all significant changes of condition was discussed with Staff 1 (Interim ED), Staff 2, Staff 3 (RCC), Staff 5 (Regional Vice President of Operations), Staff 6 (RN Consultant), and Staff 17 (MT/RCC Assistant) on 08/08/24. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure an RN significant change of condition assessment was completed for 2 of 2 sampled residents (#s 8 and 9) who experienced significant changes of condition. This is a repeat citation. Findings include, but are not limited to:1. Resident 8 was admitted to the facility in 06/2024 with diagnoses including congestive heart failure and ascites (excessive abdominal fluid). A review of the resident's clinical record, including progress and observation notes dated 10/07/24 to 12/30/24 and weight records dated 11/07/24 through 12/07/24, was completed, and staff were interviewed. The following was identified:* On 11/07/24, Resident 8's weight was 150 pounds; and* On 12/07/24, Resident 8's weight was 162.8 pounds.The resident experienced a weight gain of 12.8 pounds, or 8.5% of his/her total body weight, in one month. This was considered a severe weight gain and a significant change of condition.There was no documented evidence an RN assessment was completed for the resident's weight gain.On 01/02/25 at 10:30 am, Staff 2 (RN, Health Services Director) stated she was aware of the weight gain. She confirmed she had not completed a significant change of condition assessment for Resident 8's significant and severe weight gain, but that the weight gain was expected due to his/her diagnoses of ascites and congestive heart failure. The resident was reported by staff to be independent with eating meals. S/he also varied whether s/he ate meals in his/her room or in the dining room. The resident was unable to be weighed during survey.The need for a RN to complete an assessment of significant changes of condition was discussed with Staff 2 and Staff 26 (ED) on 01/02/25. The findings were acknowledged.

2. Resident 9 moved into the facility in 10/2011 with diagnosis including diabetes mellitus type II, neuropathy, and Binswanger disease. The resident was identified in the acuity interview as heavy care due to a recent fall on 12/09/24 that resulted in a fractured left ankle. The residents room was observed to have a transfer pole on the left side of a reclining chair and the resident was observed to have a boot on his/her left foot. The resident's 08/27/24 service plan, 10/11/24 through 12/25/24 charting and observation notes, skin monitoring sheets, and Interim Service Plans (ISPs) were reviewed. Observations of the resident were made, and interviews with staff and the resident were conducted. The following was identified:An ISP dated 12/09/24 identified Resident 9 had returned from the hospital with a "double fracture in ankle" with interventions that stated the "Resident will be needing extra assistance's [to be determined]" and "Resident need extra assistance with transfers at this time". The following was noted in the resident's record:* 12/09/24: Emergency Department and resident social worker stated resident is unable to weight bear at this time;* 12/10/24: Direct-care staff documented the resident required two to three staff assistance to transfer the resident and staff do not feel safe completing transfers; and* 12/15/24: Resident is a "3 person assist with incontinence changes from [his/her] chair" and "Resident unable to pivot to commode".On 12/30/24 at 11:28 am, Staff 9 (MT) stated the resident used to be independent with transfers prior to his/her fractured ankle and now required two to three staff to assist with transfers and two to four staff to assist with incontinent care. On 01/02/24 at 10:05 am, Resident 9 verified s/he initially required three to four staff for transfers and now required one to three staff to assist with transfers and incontinent care.An RN assessment was initiated on 12/12/24, however it was incomplete and did not include the resident's condition, resident status, or interventions made as a result of the assessment to address the resident's ankle fracture.The need to ensure the facility RN completed an assessment for the significant change in condition was discussed with Staff 26 (ED) on 01/02/25 at 3:32 pm. He acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure it had a trained and designated Infection Control Specialist and failed to establish and maintain effective infection prevention and control protocols. Findings include, but are not limited to:a. On 08/07/24 at approximately 10:30 am, Staff 1 (Interim ED) reported the facility did not have a trained and designated Infection Control Specialist.b. Observations of dining services were performed throughout survey. The following was identified:* On 08/06/24 at 11:55 am, Staff 8 (Dietary Aide) did not perform hand hygiene between tasks and was observed to touch a resident's back, handle dirty and clean glassware by the rim of the glass, remove dirty glassware from a table, and serve beverages to multiple residents.* On 08/07/24 at 12:50 pm, Staff 7 (Dietary Aide) did not perform hand hygiene between delivering meals to resident rooms. When Staff 7 delivered each meal she also assisted with meal set-up, removed dirty dishes, threw away old meals and beverages, handled residents' personal food and beverages, and assisted with other meal related requests.On 08/07/24 at 1:14 pm, Staff 7 acknowledged the lack of hand hygiene when delivering resident meals to rooms and stated she had a plan and would address it immediately.The need to ensure the facility had a designated Infection Control Specialist and to establish and maintain infection prevention and control protocol to provide a safe, sanitary, and comfortable environment was discussed with Staff 1 (Interim ED), Staff 2 (RN), Staff 3 (RCC), Staff 5 (Regional Vice President of Operations), Staff 6 (RN Consultant), and Staff 17 (MT/RCC Assistant) on 08/08/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 1 of 1 sampled resident (#4) whose MARs and Controlled Substance Disposition logs were reviewed for accuracy. Findings include, but are not limited to:Resident 4 moved into the facility in 04/2017 and had diagnoses including delusions and aortic valve stenosis.The resident's physician orders, the Controlled Substance Disposition logs, the 07/01/24 through 08/05/24 MARs, and 05/13/24 through 08/05/24 progress notes were reviewed, and interviews with staff were conducted. The following was identified:Resident 4 had a physician order for hydrocodone/apap 5-325 mg - one tablet by mouth twice daily for pain.The MAR and Controlled Substance Disposition logs noted the medication was administered on three occasions between 07/19/24 to 07/20/24. During that time, the resident's progress notes indicated s/he was out of the facility.The need to ensure the facility had an effective system for tracking controlled substances was reviewed with Staff 1 (Interim ED), Staff 2, Staff 3 (RCC), Staff 5 (Regional Vice President of Operations), Staff 6 (RN Consultant), and Staff 17 (MT/RCC Assistant) on 08/08/24. They acknowledged the findings.

2. Resident 7 was admitted to the facility on 11/25/24 from a skilled nursing facility (SNF) with diagnoses including type II diabetes, bacteremia, encephalopathy, and post surgery recovery from an intraspinal abscess.On 12/31/24 Resident 7's current prescriber orders were requested and provided by Staff 17 (RCC). The orders dated 11/08/24 were Resident 7's admission orders.The orders instructed wound care: "cleanse bilateral buttocks with normal saline, pat dry. Apply no sting to peri wound. Foam adhesive dressing. Change 1-2 times per week and prn every evening shift every Tuesday, Friday for wound care until resolved".In interview on 1/2/25 Staff 2 (RN, Resident Health Services Director) stated facility staff had provided wound care, however there was no documented evidence wound care was provided, or the order was discontinued in Resident 7's record. Staff 2 stated the wound was now closed, however, there was no documented evidence of wound monitoring or when it had resolved.The need to ensure all medications and treatments the facility was responsible to administer were carried out as prescribed and documented in the resident's record was reviewed with Staff 2 RN and Staff 26 (Executive Director) on 1/02/25. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed, and written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record for all medications and treatments the facility was responsible to administer for 2 of 4 sampled residents (#s 7 and 8) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 8 moved into the facility in 06/2024 with diagnoses including prostate cancer.The resident's 12/01/24 to 12/30/24 MAR and prescriber orders were reviewed and revealed the following:There were multiple blanks on the resident's MAR for 14 different medications between 12/09/24 and 12/13/24.On 01/02/25 at 10:20 am, Staff 2 (RN, Health Services Director) stated she was unaware of these occurrences and acknowledged the inaccuracy of the 12/01/24 to 12/30/24 MAR. She was unable to confirm if the medications had been carried out as prescribed.The need to ensure medication orders were carried out as prescribed was discussed with Staff 26 (ED) on 01/02/25 at 12:20 pm. He acknowledged the findings.

Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused to consent to orders for 1 of 1 sampled resident (#2) who had documented medication refusals. Findings include, but are not limited to:Resident 2 was admitted to the facility in 12/2021 with diagnoses including anxiety, depression, and hepatic cirrhosis.The resident's 07/01/24 through 08/05/24 MARs and signed physician orders were reviewed.The resident had a signed physician order which included directions for staff to notify the physician after refusal of any medications.Medications documented as refused multiple times between 07/01/24 and 08/05/24 included:* Furosemide 20 mg two times daily (for edema); and* Varenicline Tartrate 0.5 mg two times daily for 90 days (for smoking cessation).There was no documented evidence the physician was notified after each refusal for the above medications.The need to notify the practitioner of resident medication refusals was discussed with Staff 1 (Interim ED), Staff 2 (RN), Staff 3 (RCC), Staff 5 (Vice President of Operations), Staff 6 (RN Consultant), and Staff 17 (MT/RCC Assistant) on 08/08/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused to consent to orders for 1 of 1 sampled resident (# 8) who had documented medication and treatment refusals. This is a repeat citation. Findings include, but are not limited to:Resident 8 moved into the facility in 06/2024 with diagnoses including prostate cancer, hypertension, congestive heart failure, and ascites (excessive abdominal fluid). The resident's 12/01/24 through 12/30/24 MAR and signed prescriber orders were reviewed.The following medications and a treatment were documented as refused multiple times between 12/01/24 and 12/30/24: * Acetaminophen 500 mg two times daily (for pain);* Acyclovir 400 mg two times daily (no reason listed);* Diphenhydramine/zinc cream twice daily (for rash);* Lactulose 15 ml by mouth four times daily (for constipation);* Morphine sulfate 0.25 ml three times daily (for pain);* Morphine sulfate 0.25 ml daily at bedtime (for pain);* Omeprazole 40 mg daily (no reason listed);* Potassium chloride ER 20 milliequivelents once daily (no reason listed);* Senna 8.6-50 mg twice daily (no reason listed);* Spironolactone 100 mg daily (for edema);* Torsemide 20 mg daily (for edema); and * Barrier cream three times daily (for wound care). On 01/02/25 at 10:22 am, Staff 2 (RN, Health Services Director) confirmed medication and treatment refusals were either to be faxed to the practitioner, or the practitioner was to be called and documented in the progress notes. There was no documented evidence the prescriber was notified after each refusal for the above medications and treatment. The need to notify the physician or other practitioner of resident medication refusals was discussed with Staff 26 (ED) on 01/02/25. He acknowledged the findings.

3. Resident 2 admitted to the facility in 12/2021 with diagnoses including chronic pain. Resident 3 admitted to the facility in 08/2017 with diagnoses including osteoarthritis. Resident 2 and 3's 07/01/24 through 08/03/24 MARs were reviewed and noted the following: * The MARs for Residents 2 and 3 each included multiple prn bowel care medications which lacked parameters and clear instruction to staff for administration.The need to ensure medications had resident-specific parameters for PRN medications and clear instructions to staff was reviewed with Staff 1 (ED), Staff 2 (RN), Staff 3 (RCC), Staff 5 (Regional Vice President of Operations), Staff 6 (RN Consultant), and Staff 17 (MT/Assistant RCC) on 08/08/24. They acknowledged the findings.
Based on observation, interview, and record review, it was determined the facility failed to ensure MARs were accurate, included medication-specific instructions, and had resident-specific parameters and instructions for PRN medications for 4 of 6 sampled residents (#s 1, 2, 3, and 4) whose MARs were reviewed. Findings include, but are not limited to:1. Resident 4 moved into the facility in 04/2017 with diagnoses including delusions and aortic value stenosis.The resident's 07/01/24 to 08/05/24 MAR and prescriber orders signed 03/18/24 were reviewed and revealed the following:a. Three scheduled medications lacked reasons for use.b. One treatment administered four times daily lacked medication-specific instructions for administration, including the amount of gel to apply and where to apply.c. Two medications with blood pressure parameters were documented as administered on 12 occasions where the blood pressure was not documented.On 08/06/24 at 10:40 am, Staff 2 (RN) stated she was unaware of these occurrences and acknowledged the need to have reasons for use and medication-specific instructions for administration, and to ensure parameters were documented and followed.The need to ensure MARs were accurate and included all required elements was discussed with Staff 1 (Interim ED), Staff 2, Staff 3 (RCC), Staff 5 (Regional Vice President of Operations), Staff 6 (RN Consultant), and Staff 17 (MT/RCC Assistant) on 08/08/24. They acknowledged the findings.
2. Resident 1 was admitted to the facility in 05/2004 with diagnoses including chronic heart failure and chronic kidney disease.The resident's 07/01/24 through 08/05/24 MARs and physician orders were reviewed, and interviews with staff and the resident were conducted. The following was identified:* The resident self-administered his/her medication, with the exception of insulin injections and application of a fentynal patch (for pain).* The resident received two insulin injections before breakfast (one fast-acting and one long-acting), and one injection of fast-acting insulin before lunch and dinner. The physician order for the fast-acting insulin stated to "hold" the injection if the resident was skipping a meal.* Between 07/18/24 and 07/31/24 there were multiple blanks on the resident's MAR for his/her insulin injections. The greatest number of blanks was for the 11:00 am insulin injection.* Interviews with multiple staff between 08/05/24 and 08/07/24 indicated the resident did not each lunch, only breakfast and dinner, and had a health shake at lunch time.In an interview on 08/07/24, Staff 15 (MT) reported MTs were not delegated until they had been in their position for 90 days. She stated during the time period in July when there were blanks on the resident's MAR that there was a newer MT who was not delegated, so he would ask another MT on duty to administer the resident's insulin. Staff 15 reported if the MT requested to give the insulin injection to Resident 1 was busy, the administration would not always get documented.In an interview with the resident on 08/07/24 at 10:40 am, s/he verified they did not eat lunch so did not receive the insulin injection scheduled for 11:00 am. The resident reported s/he received all of his/her insulin injections during the month of July, with the exception of the 11:00 am administration.The need for the MAR to be accurate was discussed with Staff 1 (Interim ED), Staff 2 (RN), Staff 3 (RCC), Staff 5 (Regional Vice President of Operations), Staff 6 (RN Consultant), and Staff 17 (MT/RCC Assistant) on 08/08/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents who chose to self-administer their medications had a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications and were evaluated at least quarterly, to assure their ability to safely self-administer medications for 1 of 1 sampled residents (#9) who was reviewed for self-administration. Findings include, but are not limited to:1. Resident 9 moved into the facility in 10/2011 with diagnosis including diabetes mellitus type II, neuropathy, and Binswanger disease. The resident's current physician orders and self-administration evaluations were reviewed, observations of the resident were made, and interviews with staff and the resident were conducted. The following was identified:On 12/30/24 at 11:28 am, Staff 9 (MT) stated the resident self-administered all his/her medications. On 12/31/24 at 11:14 am, Staff 17 (RCC) stated there was no documented evidence a self-administration evaluation had been completed since 07/22/24 and she could not find a physician's order for the self-administration of medications. On 01/02/25 at 10:05 am, Resident 9 was observed in his/her room and reviewed his/her current medications with this surveyor and identified the resident self-administered tramadol 50 mg tablet, two times daily, however the medication was discontinued 12/09/24. On 01/02/25 at 11:08 am, Staff 2 (RN) confirmed there was no additional documentation available. The need to ensure residents who chose to self-administer their medications had a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications and the resident was evaluated at least quarterly, was reviewed Staff 26 (ED) on 01/02/25 at 3:32 pm. He acknowledged the findings.

Based on interview and record review, it was determined the Administrator failed to show documented evidence of a current Residential Care Facility Administrator license. Findings include, but are not limited to:Upon survey entry on 12/30/24 at 10:15 am, Staff 26 (ED) confirmed he was the acting administrator of the facility. On 01/02/25 at 2:00 pm, Staff 26 was asked to provide documentation of his Residential Care Facility Administrator license. Staff 26 revealed his license had expired. The requirement to have a current Residential Care Facility Administrator was discussed with Staff 1 on 01/02/25 at 2:00 pm. He acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly-hired staff (#s 16, 19, 20, and 21) completed all required pre-service orientation training and 3 of 3 newly-hired direct care staff (#s 16, 19, and 20) completed required pre-service dementia training. Findings include, but are not limited to:Staff training records were reviewed on 08/07/24 with Staff 1 (Interim ED), and the following was identified:a. There was no documented evidence Staff 16 (CG), Staff 19 (CG), Staff 20 (MT), or Staff 21 (Dietary Aide), hired 04/13/24, 05/16/24, 02/13/24, and 06/28/24, respectively, had completed one or more of the following required pre-service orientation topics prior to beginning their job responsibilities:* Resident rights and values of CBC care;* Abuse reporting requirements;* Fire safety and emergency procedures;* Written job description;* Infectious disease prevention training; and* Home and Community-Based Services training.b. There was no documented evidence Staff 16, Staff 19, and Staff 20 had completed one or more of the following pre-service dementia care training topics:* Dementia disease process including progression, memory loss, psychiatric and behavioral symptoms;* Techniques for understanding, communicating and responding to behaviors; reducing use of antipsychotics;* Strategies for addressing social needs and engaging them in meaningful activities; and* Specific aspects of dementia including addressing pain, providing food/fluids, preventing wandering, use of person-centered approach.The need for staff to complete all required pre-service orientation training and for direct care staff to complete required pre-service dementia training was discussed with Staff 1, Staff 5 (Regional Vice President of Operations), and Staff 6 (RN Consultant) at 1:30 pm on 08/07/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly-hired staff (#s 16, 19, and 20) demonstrated competency in assigned duties within 30 days of hire. Findings include, but are not limited to:Staff training records were reviewed on 08/07/24 with Staff 1 (Interim ED), and the following was identified:* There was no documented evidence Staff 16 (CG), Staff 19 (CG), of Staff 20 (MT), hired 04/13/24, 05/16/24, and 02/13/24, respectively, completed training in changes associated with normal aging and in first aid and abdominal thrust within 30 days of hire; and* There was no documented evidence Staff 19 and 20 completed training in general food safety, serving, and sanitation within 30 days of hire.The need for staff to complete all required training within the specified time frames was discussed with Staff 1, Staff 5 (Regional Vice President of Operations), and Staff 6 (RN Consultant) at 1:30 pm on 08/07/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 long-term staff (#s 13, 22, and 23) completed 12 hours of annual in-service training, including at least six hours of dementia care, and failed to ensure 2 of 2 long-term non-care staff (#s 24 and 25) completed infectious disease training. Findings include, but are not limited to:Staff training records were reviewed on 08/07/24 with Staff 1 (Interim ED), and the following was identified:a. There was no documented evidence Staff 13 (CG), Staff 22 (CG), and Staff 23 (CG), hired 01/01/13, 06/18/20, and 03/10/21, respectively, completed at least 12 hours of training based on their anniversary date of hire related to the provision of care in CBC, including a minimum of six hours of training on dementia care topics.b. There was no documented evidence Staff 24 (Housekeeper), hired 01/01/13, or Staff 25 (Dietary Aide), hired 09/25/17, completed annual training on infectious disease outbreak and control.The need to ensure and document that long-term direct care staff completed the required number of hours of annual in-service training and that long-term non-care staff completed annual infectious disease training was discussed with Staff 1 (Interim ED), Staff 5 (Regional Vice President of Operations), and Staff 6 (RN Consultant) at 1:30 pm on 08/07/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to conduct fire drills in accordance with the Oregon Fire Code and to provide fire and life safety instruction on alternate months. Findings include, but are not limited to:Six months of fire drill and fire and life safety training records were requested on 08/07/24. The following was identified:a. Fire drill documentation failed to address the following:* Problems encountered and comments relating to residents who resisted or failed to participate in the drills;* Evacuation time period needed; and* Number of occupants evacuated.During an interview at 11:00 am on 08/07/24, Staff 4 (Environmental Director) confirmed that the facility was not evacuating residents during fire drills.b. There was no documented evidence the facility was providing fire and life safety training to staff on alternating months from fire drills.The need to ensure fire drills were conducted in accordance with the Oregon Fire Code and fire and life safety instruction was provided to staff on alternate months was discussed with Staff 1 (Interim ED), Staff 5 (Regional Vice President of Operations), and Staff 6 (RN Consultant) at 1:30 pm on 08/07/24. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to conduct fire drills in accordance with the Oregon Fire Code. This is a repeat citation. Findings include, but are not limited to:Fire drill records were requested and reviewed on 12/30/24. The following was identified:Fire drill documentation lacked the following required components:* Problems encountered and comments relating to residents who resisted or failed to participate in the drills;* Evacuation time period needed; and* Number of occupants evacuated.On 12/31/24 at 12:34 pm, Staff 4 (Maintenance) confirmed the facility was not evacuating residents during fire drills.The need to ensure fire drills were conducted in accordance with the Oregon Fire Code was discussed with Staff 26 (ED) on 01/02/25 at 4:06 pm. He acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure residents were instructed on general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places inside or outside the building within 24 hours of admission; and failed to re-instruct residents on fire and life safety at least annually, with a written record of the content of the training sessions and the residents attending, per the Oregon Fire Code (OFC). Findings include, but are not limited to:Fire and life safety records were reviewed on 08/07/24.During an interview on 08/07/24 at approximately 11:00 am, Staff 4 (Environmental Director) reported residents had not been receiving fire and life safety training on admission, nor had the facility been re-instructing residents at least annually.The need to instruct and re-instruct residents on fire and life safety training per the OFC requirements was discussed with Staff 1 (Interim ED), Staff 5 (Regional Vice President of Operations), and Staff 6 (RN Consultant) at 1:30 pm on 08/07/24. They acknowledged the findings.

Based on observation, 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 C 150, C 200, C 252, C 260, C 262, C 270, C 280, C 305, C 420, and C 613.

Based on observation and interview, it was determined the facility failed to ensure all interior and exterior materials and surfaces and all equipment necessary for the health, safety, and comfort of the resident were kept clean and in good repair and the interior of the facility was kept free from unpleasant odors. Findings include, but are not limited to:Observations of the facility from 08/06/24 to 08/08/24 revealed the following:a. Facility Wide* Multiple resident rooms and facility doors and doorframes had scrapes, gouges, and scuffs;* The windows in common areas and resident rooms were dusty;* The carpets in all common areas, both elevators, and resident rooms 105, 111, 113, 114, 132, 142, 210, 212, and 227 were stained and/or bulging; and* Ceiling sprinklers and ceiling and wall vents throughout the facility had dust and black matter build-up.b. First Floor Staff Laundry Hall and Room* The walls and exit door in the hall to the staff laundry room had splatters, black marks, and spills;* The doorframe to enter the hall had a piece of metal pulled away from the frame;* Several ceiling tiles had holes and/or cracks;* Both doors into the staff laundry room had black scuffs and stains;* The hopper sink was missing caulk around the base;* The floors had black matter build-up and stains; and* A ceiling light was missing a cover.c. First Floor Activity Room * The seats of several chairs were torn;* The oven interior had a build-up of food spills and stains;* The walls were dented and had chipped wallpaper; and* An outlet cover was broken.d. First Floor Resident Lounge and Laundry Room* The dryers had lint and dust build-up on the vents; * The walls and baseboards were dented and had black scuff marks; and* The window screen was torn.e. Dining Room* The fabric backs of the dining chairs had stains and splatters;* The baseboards had chipped paint and black scuffs;* The hardwood floor in the service station was scuffed and scratched, and had black matter build-up;* The service station had multiple broken drawers;* There was moisture and small flying insects in the cupboard below the beverage sink;* The beverage sink was rusted and stained; and* The corners of the service station had dents and chipped paint, exposing wood.f. Second Floor Great Room* The parquet flooring was scratched; and* The backs and seats of chairs were stained.g. Second Floor Fireplace Seating Area* The couch seats and arms had multiple stains; and* The fireplace was non-functioning.h. Second Floor Spa Room* The spa was non-functioning; and* The wall next to the wheelchair scale had paint chips and stains.i. Second Floor Resident Lounge and Laundry Room:* The walls were dented and had paint chips;* The door was dented and had black scuffs;* The dryer vents and back had lint and dust build-up; and* The window frame had peeling and cracked paint.j. Second Floor Library* The arms and seats of the chairs were stained.k. Resident Rooms 129 and 149 had water damage with sheetrock and bubbled paint on the walls/ceilings in the respective unit bathrooms.l. Exterior of building * The gazebo seating in the courtyard and the benches in the courtyard and south and west sides of the building had exposed, rough wood and chipped paint.m. There was a pervasive unpleasant odor in the hall near Rooms 139, 141, and 142 that did not dissipate during the survey.The above areas were toured with Staff 1 (Interim ED) at 2:12 pm on 08/07/24. She acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure all interior and exterior materials and surfaces and all equipment necessary for the health, safety, and comfort of the resident were kept clean and in good repair. This is a repeat citation. Findings include, but are not limited to: Observations of the facility from 12/30/24 to 01/02/25 revealed the following:a. Facility Wide* Multiple resident rooms and facility doors and doorframes had scrapes, gouges, and scuffs; and* The carpets in resident rooms 105, 113, 114, 142, 210 and 212 were stained and/or bulging.b. First Floor Staff Laundry Hall and Room* The doorframe to enter the hall had a piece of metal pulled away from the frame;* Several ceiling tiles had holes and/or cracks;* The hopper sink was missing caulk around the base; and* A ceiling light was missing a cover.c. First Floor Activity Room * The seats of several chairs were torn;* The oven interior had a build-up of food spills and stains; and* The walls were dented and had chipped wallpaper.d. First Floor Resident Lounge and Laundry Room* The dryers had lint and dust build-up on the vents; * The walls and baseboards were dented and had black scuff marks; and* The window screen was torn.e. Dining Room* The service station had multiple broken drawers;* There was moisture and black matter in the cupboard below the beverage sink;* The beverage sink was rusted and stained; and* The countertop of the service station had missing laminate, exposing wood.f. Second Floor Spa Room* The wall next to the wheelchair scale had paint chips and stains.g. Second Floor Resident Lounge and Laundry Room:* The window frame had peeling and cracked paint.h. Second Floor Library* The arms and seats of the chairs were stained.i. Exterior of building * The gazebo seating in the courtyard had exposed, rough wood and chipped paint.The above areas were toured with Staff 26 (ED) at 10:05 am on 01/02/25. He acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure a lockable storage space was provided for the safekeeping of residents' small valuable items and funds for multiple sampled and unsampled residents. Findings include, but are not limited to:* On 08/07/24 at 11:30 am, eight unsampled residents attended a group interview. All eight residents interviewed confirmed that although they had a lockable storage space in their apartments, they did not have a key to the space;* Observations of two unsampled resident units revealed a cabinet with a lock in both unit bathrooms. The two unsampled residents did not have keys for the cabinets; and* Two of five sampled residents (#s 2 and 6) confirmed during interviews they did not have a key for the lockable storage in their units. The need to ensure residents had a key to their lockable storage space was discussed with Staff 1 (Interim ED) on 08/07/24. She acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure residents rights of privacy in his or her own unit for multiple sampled and unsampled residents. Findings include, but are not limited to:Refer to C200.

During observation and interview, conducted during a site visit on 07/29/24, it was confirmed the facility failed to ensure that the service plan must reflect the resident's needs as identified in the evaluation and be available to staff for 2 of 2 sampled residents (#s 9 and 10). Findings include, but are not limited to:An observation of the first floor service plan binder revealed a current service plan for Resident 9 was not available to caregiving staff.Resident 10's service plan dated 03/15/24 was available in the service plan binder, but was not current.The findings were reviewed with and acknowledged by Staff 1 (Interim ED) and Staff 5 (RCC) on 07/29/24.The facility failed to ensure that the service plan must reflect the resident's needs as identified in the evaluation and be available to staff.Verbal Plan of Correction: An audit will be conducted weekly on Fridays (section by section), to setup service planning meetings for the following Thursdays to involve residents and their families. All service plans will be updated and current by the end of August 2024.

Based on interview and record review, conducted during a site visit on 07/29/24, it was confirmed the facility failed to carry out medication orders as prescribed for 1 of 1 sampled resident (#5). Findings include, but are not limited to:A review of Resident 5's MAR for 11/01/23 through 11/02/23 revealed an order for Oxycodone 20mg (a narcotic pain medication) take 2 tabs by mouth every 12 hours. Resident 5's MAR revealed the medication was not given on 11/02/23.During an interview on 07/29/23, Staff 1(Interim ED) stated the medication was not given if it was not on the MAR.The findings were reviewed with and acknowlegded by Staff 1 and Staff 5 (RCC) on 07/29/24.The facility failed to carry our medication orders as prescribed.Verbal plan of correction: The facility RCC had started checking missed medications, new medications and exceptions at daily standup meeting. Nurse then completed the investigation and follow up with MT. Re-training occurring with MTs who lack documentation of training. Based on interview and record review, conducted during a site visit on 07/29/24, it was confirmed the facility failed carry out medication orders as prescribed for 2 of 4 sampled residents (#s 1 and 4). Findings include, but are not limited to:A review of Resident 1's MAR for 09/01/23 through 09/30/23 revealed an order for Insulin Glargine (Diabetes medication) 100 unit/ML solution inject 14 units under the skin nightly. The MAR revealed the medication was not given 09/16/23.A review of Resident 4's MAR for 09/01/23 through 09/30/23 revealed an order for insulin glargene (Diabetes medication) inject 30 units subcutaneously nightly. The MAR revealed the medication was not given on 09/12/23, 09/13/23, 09/14/23 or 09/15/23.During an interview on 07/29/24, Staff 1 (Interim ED) stated the incidents occurred under the previous ownership as the facility had a change of ownership on 11/01/23.The findings were reviewed with and acknowledged by Staff 1 on 07/29/24.The facility failed to carry out medication orders as prescribed.Verbal plan of correction: Facility leadership has started checking missed medications, new medications and exceptions at daily standup meeting. Nurse investigates and follows up with MT. Re-training occurring with MTs who lack documentation of training to be completed by 08/15/24.

Based on observation, interview and record review, conducted during a site visit on 07/29/24, it was confirmed the facility failed to fully implement and update an acuity-based staffing tool (ABST) for 1 of 3 sampled residents (# 10). Findings include, but are not limited to:During the site visit on 07/29/24, the facility's posted staffing plan was observed and reviewed which contained the following staffing plan with a total of 20 direct care staff:Day shift: 5 CGs and 3 MTsSwing shift: 5 CGs and 2 MTsNight shift: 4 CGs and 1 MTA review of the facility's ABST indicated the facility had a need for 20.61 direct care staff.During an interview on 07/29/24, Staff 1 (Interim ED) agreed the facility was staffed short of their ABST.Resident 10's service plan dated 03/15/24 was reviewed and interviews were conducted revealing a discrepancy in the following ADL need:*Toileting and incontinence care.The facility failed to fully implement and update an ABST.The findings were reviewed with and acknowledged by Staff 1 and Staff 5 (RCC) on 07/29/24.

Based on observation, interview and record review, conducted during a site visit on 07/29/24, it was confirmed the facility failed to document that they have observed and evaluated the individual's ability to perform safe medication and treatment administration unsupervised for 2 of 2 sampled staff (#s 3 and 10). Findings include, but are not limited to:During the site visit on 07/29/24, Staff 3 (MT) was observed working independently.A review of Staff 3's MT competencies checklist revealed Staff 3 was hired 09/28/21. Their MT training started on 10/02/21 and was signed by Staff 5 (RCC) on 07/29/24.Training documents for Staff 10 (MT) were requested. There was no documented evidence that Staff 10 had completed any competency training.During an interview on 07/29/24 Staff 1 (Interim ED) stated facility leadership had conducted an audit of all staff training documents and competencies around 07/19/24 and had determined many staff lacked documentation of training. Staff 1 further stated all staff were in the process of completing the competency checklists.The findings were reviewed with and acknowledged by Staff 1 and Staff 5(RCC) on 07/29/24.The facility failed to document that they have observed and evaluated the individual's ability to perform safe medication and treatment administration unsupervised.Verbal plan of correction: All staff will have training documents completed by 08/15/24.

Based on observation and interview, conducted during a site visit on 07/29/24, it was confirmed the facility failed to keep clean all interior and exterior materials and surfaces. Findings include, but are not limited to:Observations of the first and second floor hallways and the facility elevator revealed multiple carpet stains of various sizes.Observations of the first and second floor walls revealed multiple areas of peeling and chipped paint.Observations of the second floor staffing station revealed part of the flooring was scraped off or removed.In an interview a resident stated the facility was undergoing remodeling.The findings were reviewed with and acknowledged by Staff 1 (Interim ED) and Staff 5 (RCC) on 07/29/24.The facility failed to keep clean all interior and exterior materials and surfaces.Verbal Plan of Correction: Carpet replacement and facility remodel will be completed by October 2024.

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes. This report reflects the findings of the complaint investigation conducted 1/5/2023. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified:Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

Based on record review and interview, it was confirmed that the facility failed to implement effective methods to responding to and resolving resident complaints. Findings include but not limited to:During an unannounced site visit on 1/5/2023, Compliance Specialist (CS) reviewed the facility's grievance binder. The policy on the cover of the binder dated 5/19/2017 stated "All grievances will be follow-up[ed] on and have a plan towards resolution in place within 5 working days from date of notification to the executive director." There were no grievances in the binder from the last four months and several grievances including the first one dated 1/23/22 had no investigation or follow up.During interview, Staff #1 stated they had not had any complaints in the last few months and they were not tracking grievances.These findings were reviewed with Staff #1, Staff #10, Staff #12, Staff #15 and Staff #16 on 1/5/2023 who were agreement.Plan of Correction: Facility to re-implement grievance binder to track concerns and ensure resolutions.

Based on observation, interview, and record review, it was confirmed that the facility failed to have the service plan be readily available to staff. Findings include but not limited to:During an unannounced site visit on 1/5/2023, Compliance Specialist (CS) reviewed all four of the facility's service planning binders that are available to staff. CS was unable to locate a service plan for Resident #2 (R2). There were two Interim Service Plan updates dated 11/27/22 and 12/13/22 available for R2.During interview, Staff #10 stated that R2's service plan was updated about a week ago, that R2's care needs had increased but that they were not able to print the service plan at that time because the printers were not working.CS requested a copy of R2's service plan which was updated on 12/24/2022. These findings were reviewed with Staff #1, Staff #10, Staff #12, Staff #15, and Staff #16 on 1/5/2023 who were in agreement.Plan of Correction: Audit of service plan binders to be completed and all missing service plans to be added to binders by end of day on 1/6/2023.

Based on observation, record review and interview, it was confirmed that the facility failed to carry out medication orders as prescribed. Findings include but not limited to:During an unannounced site visit on 1/5/2023, Compliance Specialist (CS) observed a resident request an as needed pain medication at 10:38am on 1/5/2023. It was administered after 1:00pm.A review of Resident #9 (R9)'s Medication Administration Record (MAR) for July-August 2022 revealed 12 occasions when a medication was not given due to not being available. A review of Resident #11 (R11) MAR for March 2022 revealed 3 occasions when a medication was not given due to not being availableThese findings were reviewed with Staff #1, Staff #10, Staff #12, Staff #15 and Staff #16 on 1/5/2023 who were in agreement.Plan of Correction: Review of medication administration policies/chain of commands and communication between CGs and Med Techs at all staff on 1/10/23.

Based on record review and interview, it was confirmed that the facility failed to keep an accurate Medication Administration Record (MAR). Findings include but not limited to:A review of Resident #11 (R11)'s MAR for March 2022 revealed an incident on 3/9/2022 when an employee administered a medication to R11 other than the person who signed off on the MAR.During interview, Staff #16 (S16) stated it was likely because the assigned Med Tech had not been delegated for this task, so another Med Tech on duty who was delegated gave them medication. These findings were reviewed with Staff #1, Staff #10, Staff #12, Staff #15 and Staff #16 on 1/5/2023 who were in agreement.Plan of Correction: Review MAR documentation at all-staff on 1/10/23. New Registered Nurse (RN) starting on 1/9/23 and will take over and confirm all delegations.

Based on observation, interview and record review, it was confirmed that the facility failed to have enough staff to meet the scheduled and unscheduled needs of the residents. Findings include but not limited to:During an unannounced site visit on 1/5/2023, (CS) observed a resident request an as needed pain medication at 10:38am on 1/5/2023. It was administered after 1:00pm.During interview Staff #3 (S3) stated that it can take up to two hours to assist individuals with toileting at times.A review of Resident #9 (R9) ' s July - August 2022 Medication Administration Record and Treatment Administration Record (MAR/TAR) revealed four instances when resident was not given a shower, because "not enough staff " , "not done" and "caregiver didn't have enough time "and two instances when COVID-19 monitoring was not done because "only two med techs no time. "These findings were reviewed with and acknowledged by Staff #1, Staff #10, Staff #12 Staff #15 and Staff #16 on 1/5/2023 who were in agreement. Plan of Correction: Facility is currently hiring and actively recruiting staff on indeed and in their community.

Based on record review and interview, the facility failed to verify direct care staff have demonstrated satisfactory performance in any duty they are assigned During an unannounced site visit on 1/5/2023, Compliance Specialist reviewed all staff training documents for Staff #13 (S13) which revealed many Med Tech (MT) and Caregiver skills in which competencies were not verified by observation, evaluation, or written testing.During interview, Staff #12 (S12) stated that competencies should have been verified by another MT and a nurse, as per their policy. Staff #4 (S4) stated that some caregivers did not know how to close Resident #9 (R9)'s catheter bag which would result in urine spills.These findings were reviewed with Staff #1, Staff #10, S12 Staff #15 and Staff #16 on 1/5/2023 who were in agreement. Plan of Correction: Resident Care Coordinators and Registered Nurses to verify training competencies completed for all new-hires. Catheter care in-service to be conducted at all-staff meeting on 1/10/23. Business Office Manager to audit staff training for current employees and verify competencies.

Based on observation, interview and record review, it was confirmed that the facility failed to ensure all interior and exterior materials and surfaces (eg floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of residents must be kept clean and in good repair. Findings include but not limited to:During an unannounced site visit on 1/5/2023, Compliance Specialist (CS) completed several walk throughs of the facility and observed R3's room which was under construction. There were areas of the carpet throughout the facility that were stained with black matter. CS observed an unrepaired whole in a vacant resident room. An area behind the first floor caregiver station had damaged laminate flooring that was lifting up. CS observed an unrepaired whole in a vacant resident room. Resident #9 (R9's) room had a strong, pervasive odor of urine.During an interview, Staff #11 (S11) stated that the roof leaks in several places and the facility has obtained bids to replace it. Staff #4 (S4) stated that some caregivers did not know how to close R9's catheter bag which would result in urine spills, that there is a cat in the room with a litter box, and that the resident often spills things resulting in odors and stains.CS reviewed three separate bids for roof replacement dated 2/10/2020, 12/6/2022 and 8/24/2022.These findings were reviewed with Staff #1, Staff #10, Staff #12, Staff #15 and Staff #16 on 1/5/2023 who were in agreementPlan of Correction: Facility has received bids for new roof and has sent to corporate for approval to move forward. All carpet to be shampooed by 1/27/2023.

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes. This report reflects the findings of the complaint investigation conducted 1/5/2023. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified:Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes. This report reflects the findings of the complaint investigation conducted 1/5/2023. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified:Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

The findings of the kitchen inspection, conducted 9/13/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the first revisit to the kitchen inspection survey of 9/13/22, conducted on 12/20/22 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 ensure a clean kitchen environment, in accordance with the Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:Observations of the kitchen with Staff 2 (Executive Chef), on 9/13/22 at 9:54 am, revealed the following:*The ceiling had two areas of peeling paint; one above the back food preparation area and the other one near ceiling vents in the front food service area. There was a hole in the ceiling near the back food prep area.*Light fixtures and vents had a significant accumulation of dirt and dust. Several light fixtures were missing covers. *The dish machine had dried food matter and splattered debris on the sides, front, legs and top of the dish machine. A layer of dust and dirt had accumulated on the pipes and temperature box below the dish machine. The wall directly behind the dish machine and sink beside the dish machine had splattered food, dust and dirt. *The floor and drain in the dish machine area had accumulations of dirt, loose food debris and black-colored matter.*Two trash can did not have lids in the area near the stove.* The can opener blade had a build-up of food debris.*The knife holder was cover with dust, dirt and debris.*Walls, flooring and pipes beneath the food prep compartment sink was covered with food splatters and dirt. *The plate warmer had a layer of dirt and food matter on its top, sides, legs and wheel covers.*The rack at the end of the stove with food items on it had a build-up of dirt and debris on the shelves.*Electrical outlets throughout the kitchen had layers of dust and black-colored matter. Electrical box cover was missing near the kitchen entrance exposing wires.*Multiple appliance knobs and handles had sticky matter and dried food debris. *Metal shelves, storing clean pots and pans, had an accumulation of dirt and food matter.*Oven handles and knobs had a layer of food matter and grease in the creases. Splattered grease and food debris on the sides, front of the stove, fryer, and steamer. The hood vents had an accumulation of dust, grease and debris.*Dry food storage bins had dirt and food matter on their tops and sides. The flour and brown sugar bins contained scoops.*The dry storage room wall behind the door had black matter on it, and the Cadet heater had dirt and debris on the grill.*Flooring throughout the kitchen had dried food matter, loose food debris and thick, black matter along the perimeter and around the appliances.*Staff 3 (Cook) was unable to explain the proper cooling methods of food.*The beverage station cabinet fronts were peeling off leaving an uncleanable surface.The surveyor reviewed the above areas with Staff 1 (Interim Executive Director), Staff 2, and Staff 4 (Environmental Director) the areas needing cleaning and repair. Staff 2 had a kitchen list of items that needed to be cleaned, however staff were not initialing areas indicating the areas were being cleaned. Staff 1 and Staff 2 acknowledged the above areas needed to be cleaned and repaired. Staff 4 acknowledged the areas that needed to be repaired.