Grande Ronde Retirement Residence

Based on observation, interview, and record review, it was determined the licensee failed to ensure adequate administrative oversight of facility operations and supervision, and training of staff, which posed a risk to the safety of residents. Findings include, but are not limited to:

During the relicensure survey, conducted 03/17/25 through 03/24/25, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the severity and number of citations.

1. Situations were identified where there was a failure of the facility to comply with the Departments rules that were likely to cause residents serious harm. Immediate plans of correction were requested in the following area:

OAR 411-054-0025(1)(a): Facility Administration: Operation; and
OAR 411-054-0045(1) A,C: Resident Health Services

An Immediate plan of correction was requested on 03/20/25. The facility provided a plan of correction on 03/20/25 at 3:23 pm, prior to survey exit. The immediate risk was addressed, however the facility will need to evaluate the overall systems failures associated with the licensing violation.

2. Refer to deficiencies in the report.

Based on interview and record review, it was determined the facility failed to develop and implement an effective method for responding to and resolving resident complaints. Findings include, but are not limited to:

Upon entry, resident council and food committee notes for the previous six months were requested. An interview with Staff 1 (ED) on 03/18/25 at 11:00 am revealed documented evidence of food committee and town hall meetings could not be provided for the previous six months.

During a group interview of nine unsampled residents on 03/18/25 at 1:00 pm, they stated that they do not have an opportunity to provide input in the areas of activities or food service.

An interview with Staff 1 and Staff 2 (Director of Nursing) on 03/20/25 at 3:55 pm revealed the facility did not have an established grievance process.

The need to implement effective methods of responding to and resolving resident complaints was discussed with Staff 1 and Staff 2 on 03/21/25 at 8:30 am. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to develop and conduct ongoing quality improvement programs that evaluated services, resident outcomes, and resident satisfaction. Findings included, but are not limited to:

During the re-licensure survey, conducted 03/17/25 through 03/24/25, quality improvement oversight to ensure adequate resident care, services, and satisfaction was found to be ineffective.

The need to ensure the facility developed and conducted an ongoing quality improvement program that evaluated services, resident outcomes, and satisfaction was discussed during the exit conference on 03/21/25 with Staff 1 (ED), Staff 2 (Director of Nursing), and Staff 5 (Vice President of Operations) via telephone. The findings were acknowledged.

Refer to the deficiencies in the report.

Based on observation, interview, and record review, it was determined the facility failed to treat a resident with dignity and respect related to meal assistance and incontinent care for 1 of 2 sampled residents (#2) who were bedbound and required extensive assistance from staff. Resident 2 was left in soiled briefs for extended periods. Findings include, but are not limited to:
Resident 2 was admitted to the facility in 12/2017 with diagnoses including dementia.
The resident was identified during the acuity interview on 03/17/25 to have a stage 2 pressure ulcer on his/her bottom. The resident required two staff assistance for ADL care and was bedbound due to his/her decline.
The resident's service plan dated 12/18/24, was located in the service plan binder, interim service plans, observation notes, progress notes and hospice visit notes dated 11/01/24 through 03/17/25 were reviewed. The resident additionally had experienced a change of condition and an increase in care needs on 02/28/25. The significant change was completed on 03/12/25 but was not available to staff.
The resident’s cognition had deteriorated significantly which affected his/her ability to recognize when it was time to eat and feed himself/herself. Staff were to stay with the resident during mealtimes, encourage independence as the resident was able, but provide full feeding assistance when the resident was not eating on his/her own. Staff were also to provide incontinent care at least four times per shift.
The resident was observed to need staff assistance for meal intake but could drink from a lidded water cup, with a straw, on his/her own. The resident additionally required assistance from two care staff for transfers and mobility including repositioning, and bowel and bladder management.
A hospice visit note dated 03/14/25 indicated PRN wound care was provided due to the resident’s dressing being soiled. Witness 1’s (Hospice RN) note indicated that on her arrival the resident had the same brief on for six hours. The brief, under pads and the bed were saturated with urine. The resident was also incontinent of bowel.
Multiple daily observations as well as continuous observations between 03/17/25 and 03/20/25 showed the following:
* Two meals were observed on 03/18/25. The meals were delivered to the resident’s room, placed on the over bed table, and staff left the room without providing assistance. A staff member returned within 15-20 minutes to feed the resident. The resident did not initiate any bites of food but pushed items around the plate with his/her utensils.
* Two additional meals were observed on 03/19/25. The meals were delivered to the resident’s room, placed on the over bed table and staff left the room without providing assistance. A staff member returned in approximately 30 minutes and removed the meal tray. The resident was observed to move items around the plate and took 3-4 bites of food. The resident initiated a single bite of a cookie that was later left behind for him/her.
* Two random daily observations on 03/19/25 showed the resident’s over bed table was left across the room. The resident’s water, remotes and snack were on the table and out of his/her reach.
* Continuous observations from 8:45 am to 12:25 pm were completed on 03/18/25. During the observations no staff came in to check or change the resident’s brief.
At approximately 12:25 pm, Staff 8 and 10 (Resident Assistants) entered the room to assist the resident with incontinent care. The staff pulled back the resident’s blanket and the brief could be seen with writing in place. Staff 8 read the writing while the surveyor viewed it. The brief was dated 03/18/25 at 4:00 am to indicate the last time the resident was changed. The resident’s brief was significantly soiled with dark urine and a small semi loose bowel movement.
* An incontinent care observation was made on 03/19/25 at 8:38 am. Staff 4 (RCC) and Staff 10 (Resident Assistant) entered the room, closed the door and got supplies ready to provide care. The resident’s brief was dated 03/19/25 at 4:10 am to indicate the last time the resident was changed. The resident’s brief was significantly soiled with urine.
* An incontinent care observation was made on 03/20/25 at 1:04 pm. Staff 7 (MT) and Staff 15 (Resident Assistant) entered the room to assist the resident with care. Staff 15 read the writing on the resident’s brief while read by the surveyor. The resident’s brief was dated 03/20/25 at 7:40 am. The resident’s brief was soiled with urine and a small semi loose bowel movement.
The resident was not observed to use the call light, did not request assistance with care needs and did not express any toileting needs. The resident appeared unaware of the need to toilet, nor did s/he recognize when s/he had urinated or had a bowel movement.
Witness 1 indicated the resident chronically leaked urine and stool. Frequent incontinent care was important to help the resident’s skin heal and avoid further breakdown. Witness 1 stated the resident required full assistance from two staff for his/her ADL care. The resident’s skin condition had started to improve.
Staff 8, 10, 15 and 18 (Resident Assistants) indicated the resident had a significant decline over the last few weeks and required full assistance from staff for all care. The staff stated the resident was visually checked every hour or less much of the time, and incontinent care should be provided at least every two hours. The staff further indicated the resident would not initiate assistance and was normally in good spirits. Staff had to anticipate the resident’s needs. The staff indicated the resident required feeding assistance. The resident did not consistently understand what to do when a meal arrived; staff were to stay and feed the resident. Staff 15 and 18 stated the resident was having more difficulty swallowing recently and would rarely try to feed himself/herself.
Staff 7 and 14 (MTs) indicated the resident required two staff assistance for ADL care. The resident was not able to consistently make needs known and would very rarely initiate any needs. The staff indicated the resident had skin breakdown to his/her bottom and was incontinent of bowel and bladder. Frequent incontinent care was needed to encourage healing and ensure the areas and/or dressing was clean. Staff 14 further indicated staff needed to sit with the resident to feed him/her during each meal. Staff encouraged the resident to do what s/he could but usually needed full feeding assistance. Staff 7 and 14 both indicated the resident did very well with his/her water. The resident had a lidded cup with a straw, and s/he would drink on own throughout the day as long as it was in reach.
The resident was unable to answer questions about any of his/her care or concerns with staff treatment due to cognition.
The facility failed to ensure Resident 2 was treated with dignity and respect when staff did not consistently provide meal assistance and incontinent care. The resident was left for periods as long as eight hours, without incontinent care being provided.
The need to ensure residents were provided with sufficient ADL assistance for all required needs was discussed with Staff 1 (ED), Staff 2 (Director of Nursing) and Staff 5 (Vice President of Operations) on 03/20/25. The staff acknowledged the findings.

Refer to C243.

Based on observation, interview, and record review, it was determined the facility failed to ensure incidents, accidents and injuries of unknown cause were promptly investigated to rule out abuse and suspected abuse and reported to the local SPD office when required, for 3 of 6 sampled residents (#s 2, 3 and 6) who experienced incidents and/or accidents. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 12/2017 with diagnoses including dementia.

Observations of the resident, interviews with staff, review of the resident's 12/18/24 service plan, 11/01/24 through 03/17/25 progress notes, observation notes, Interim Service Plans, incident investigations and physician communications were reviewed.

The resident required staff assistance for meal intake and two staff assistance for all ADL care. The resident was not able to consistently make needs known and would no longer initiate any care needs. The resident’s cognition had declined significantly over the last several weeks.

Review of the resident's records showed the following:

* An observation note dated 11/04/24 indicated the resident had an assisted fall which resulted in a rugburn.

* An observation note dated 12/02/24 indicated the resident experienced a fall which also resulted in an abrasion.

* An observation note dated 12/16/24 indicated the resident experienced a fall which resulted in a skin tear to the left hand.

* An observation note dated 01/28/25, indicated the resident had blood in their brief and a scratch to “private parts.” A subsequent hospice note dated 01/31/25 stated the area had a missing chunk of skin the size of a fingernail in the left groin area.

The resident was unable to provide any information regarding the incidents. No investigations were completed to rule out potential abuse and were not reported to the local SPD when required.

In interviews between 03/18/25 and 03/20/25, Staff 1 (ED) and Staff 2 (Director of Nursing) indicated they could not locate any investigations for the dates in question.

A confirmation that all incidents were reported to the local SPD office was provided to the survey team upon completion of the reports.

*During an incontinent care observation on 03/18/25 at approximately 12:25 pm, it was determined the resident's brief had not been changed since 4:00 am that same morning; over an eight hour period without required cares. The resident's brief was significantly soiled.

The observation and lack of care was reported to Staff 2 (Director of Nursing) and reported to the local SPD prior to survey exit.

The need to ensure incidents were investigated promptly to rule out potential abuse and reported to the local SPD office when required, was discussed with Staff 1 and Staff 2 on 03/21/25. The staff acknowledged the findings.

2. Resident 3 was admitted to the facility in 07/2017 with diagnoses including Cerebral Palsy.

Observations of the resident, interviews with staff, review of the resident's 12/11/24 service plan, 11/01/24 through 03/17/25 progress notes, observation notes, Interim Service Plans, incident investigations and physician communications were reviewed.

The resident required one to two person assistance for transfers, toileting, dressing and incontinent care. The resident was a high fall risk due to poor safety awareness and physical limitations. The resident had frequent behaviors including verbal aggression towards others, physical aggression towards staff, significant behaviors with care and cognitive impairment.

Review of the resident's records showed the following:

* An incident report dated 11/11/24 indicated the resident had an assisted fall. The incident report was incomplete, with blank pages attached. The resident could not say what occurred due to cognitive impairment.

A complete investigation was not documented to rule out potential abuse.

* An observation note dated 11/12/24, indicated the resident experienced a non-injury fall.
* An observation note dated, 12/29/24, indicated the resident experienced a non-injury fall.
* An observation note dated 01/01/25, indicated the resident self-reported a fall. No injuries were noted.

The resident was unable to indicate what caused any of the falls due to cognitive impairment. The falls were not investigated to determine cause and rule out potential abuse.

* An observation note dated 01/03/25, indicated the resident wanted to be changed in bed due to fear of falling. The resident “screamed and yelled” while staff assisted him/her in bed. The resident became physically aggressive with staff and continued to yell while staff proceeded with care.

* An observation note dated 01/06/25, indicated the resident became fearful during incontinent care. The resident became increasingly physically aggressive with the staff providing care. At the time of the incident three staff were attempting to assist the resident when the resident usually only required 1-2 staff.

The incident was not investigated to determine what may have caused the escalated aggression during care, why three staff were needed and to rule out any potential abuse.

* An observation note dated 01/07/25, indicated the resident requested to get changed while in bed. Staff told the resident no and assisted the resident to stand up by “bear hugging” to get the resident’s pants up. The resident's behavior escalated, continued to yell and physically lashed out at staff during the care.

The incident was not investigated to determine what may have caused the escalated aggression during care and to rule out any potential abuse.

* A progress note dated, 02/26/25, indicated the resident experienced a non-injury fall.

The resident was unable to indicate what caused the fall due to cognitive impairment. The fall was not investigated to determine cause and rule out potential abuse.

* Observations of the resident on 03/18/25 and 03/19/25 showed a bandage in place on the top of the left hand and the side of the left wrist. The resident could not say what occurred or what was under the bandages.

No information was located in the resident’s progress notes or on the March 2025 MAR/TAR to indicate what was being treated.

In interviews on 03/19/25 and 03/21/25, Staff 2 (Director of Nursing) indicated she was not aware of any injuries to the resident’s hand.

In a follow up email received after survey exit, on 03/24/24, Staff 2 stated there were two small skin tears on the resident’s left hand. The resident could not give any information on the injuries.

The injuries were reported to the local SPD and a confirmation was provided via the email communication.

The need to ensure incidents were investigated promptly to rule out potential abuse and reported to the local SPD office when required, was discussed with Staff 1 and Staff 2 on 03/21/25. The staff acknowledged the findings.
3. Resident 6 was admitted to the facility in 02/2024 with diagnoses including vascular dementia, anxiety and transient cerebral ischemic attack.

The resident’s progress notes dated 12/02/24 through 03/17/25 were reviewed, and the following was identified:

* An 01/08/25 observation note stated, “Resident is on alert because of swelling and bruising on [his/her] right wrist…[he/she] states that [he/she] didn’t know how it happened and did not let anyone know about it”.

The above incident constituted an injury of unknown cause, which required an immediate facility investigation that ruled out abuse or suspected abuse. An interview with Staff 5 (Vice President of Operations) on 03/19/25 at 10:45 am confirmed there was no documented evidence the facility completed an immediate investigation that ruled out abuse or suspected abuse for the above injury of unknown cause. Surveyor requested the facility report the injury of unknown cause to the local SPD office and confirmation was received on 03/19/25 at 4:30 pm.

The need to ensure injuries of unknown cause were immediately investigated to rule out abuse and suspected abuse and/or reported to the local SPD office if necessary was discussed with Staff 1 (ED) and Staff 2 (Director of Nursing) on 03/21/25 at 8:30 am. The findings were acknowledged.

Based on observation, interview, and record review, it was determined the facility failed to provide services to assist residents in activities of daily living for 1 of 2 sampled residents (#2) who were bedbound and required extensive assistance from staff. Resident 2 was left in soiled briefs for extended periods. Findings include, but are not limited to:
Resident 2 was admitted to the facility in 12/2017 with diagnoses including dementia.
The resident was identified during the acuity interview on 03/17/25 to have a stage 2 pressure ulcer on his/her bottom. Staff were to provide incontinent care at least four times per shift, clean the resident well, apply ordered creams and assist the resident with repositioning to encourage wound healing.
The resident's service plan dated 12/18/24, located in the service plan binder, interim service plans and hospice visit notes, dated 12/01/24 through 03/17/25, were reviewed.
The resident additionally had experienced a change of condition and an increase in care needs on 02/28/25. The resident required two staff assistance for all care, was now bed bound, required feeding/meal assistance and was unable to express care needs or initiate requests for help. The significant change was completed on 03/12/25 but was not available to staff.
Staff were to stay with the resident during mealtimes, encourage independence as the resident was able, but provide full feeding assistance when the resident was not eating on his/her own.
The resident was observed to need staff assistance for meal intake but could drink from a lidded water cup, with a straw, on his/her own. The resident additionally required assistance from two care staff for transfers and mobility including repositioning, and bowel and bladder management.
A hospice visit note dated 03/14/25 indicated PRN wound care was provided due to the resident’s dressing being soiled. Witness 1’s (Hospice RN) note indicated that on her arrival the resident had the same brief on for six hours. The brief, under pads and the bed were saturated with urine. The resident was also incontinent of bowel. The nurse provided incontinent care and wound care. The resident was noted to have an additional wound to the left buttock, “now has 2 areas to bilateral buttocks stage II pressure ulcers with maceration and erythema peri wound area.”
Multiple daily observations as well as continuous observations between 03/17/25 and 03/20/25 showed the following:
* Two meals were observed on 03/18/25. The meals were delivered to the resident’s room, placed on the over bed table, and staff left the room without providing assistance. A staff member returned within 15-20 minutes to feed the resident. The resident did not initiate any bites of food but pushed items around the plate with his/her utensils.
* Two additional meals were observed on 03/19/25. The meals were delivered to the resident’s room, placed on the over bed table, and staff left the room without providing assistance. A staff member returned in approximately 30 minutes later and removed the meal tray. The resident was observed to move items around the plate and took 3-4 bites of food. The resident initiated a single bite of a cookie that was later left behind for him/her.
* Two random daily observations on 03/19/25 showed the resident’s over bed table was left across the room. The resident’s water, remotes and snack were on the table and out of his/her reach.
* Continuous observations from 8:45 am to 12:25 pm were completed on 03/18/25. During the observations no staff came in to check or change the resident’s brief.
At approximately 12:25 pm, Staff 8 and 10 (Resident Assistants) entered the room to assist the resident with incontinent care. The staff pulled back the resident’s blanket and the brief could be seen with writing in place. Staff 8 read the writing while the surveyor viewed it. The brief was dated 03/18/25 at 4:00 am to indicate the last time the resident was changed. The resident’s brief was significantly soiled with dark urine and a small semi loose bowel movement.
* An incontinent care observation was made on 03/19/25 at 8:38 am. Staff 4 (RCC) and Staff 10 (Resident Assistant) entered the room, closed the door and got supplies ready to provide care. The resident’s brief was dated 03/19/25 at 4:10 am to indicate the last time the resident was changed. The resident’s brief was significantly soiled with urine.
* An incontinent care observation was made on 03/20/25 at 1:04 pm. Staff 7 (MT) and Staff 15 (Resident Assistant) entered the room to assist the resident with care. Staff 15 read the writing on the resident’s brief while read by the surveyor. The resident’s brief was dated 03/20/25 at 7:40 am. The resident’s brief was soiled with urine and a small semi loose bowel movement.
In interviews between 03/18/25 and 03/20/25 the following was determined:
Witness 1 indicated the resident chronically leaked urine and stool. Frequent incontinent care was important to help the resident’s skin heal and avoid further breakdown. Witness 1 stated the resident required full assistance from two staff for his/her ADL care. The resident’s skin condition had started to improve.
Staff 8, 10, 15 and 18 (Resident Assistants) indicated the resident had a significant decline over the last few weeks and required full assistance from staff for all care. The staff stated the resident physically could eat on his/her own but cognitively s/he was not consistently understanding. The staff further indicated the resident required full feeding assistance most of the time, but they would encourage him/her to do what s/he could. The resident was better about drinking than eating at this time but there was better luck with sweets. Staff 15 and 18 stated the resident had more difficulty swallowing recently which caused some variation in his/her ability and desire to eat.
Staff 7 and 14 (MTs) indicated the resident required two staff assistance for ADL care. The resident was not able to consistently make needs known and would very rarely initiate any needs. The staff indicated the resident had skin breakdown to his/her bottom and was incontinent of bowel and bladder. Frequent incontinent care was needed to encourage healing and ensure the areas and/or dressing was clean.
Staff 2 (Director of Nursing) indicated the resident at minimum should be provided incontinent care every two hours. The observations which showed a delay in care and the times documented on the resident’s brief when last completed were not sufficient to meet the resident’s needs. Staff 2 stated the resident could and would sometimes eat on his/her own but not full meals. The resident’s intake was poor to fair at this time. The expectation was staff were to stay with the resident when the meal was delivered and assist him/her with the meal.
The facility failed to ensure meal assistance and incontinent care services were provided to Resident 2. The lack of meal assistance placed the resident at risk for poor nutrition and hydration. The lack of incontinent care put the resident at increased risk for new skin breakdown and worsening of existing wounds.
The need to ensure residents were provided with sufficient ADL assistance for all required needs was discussed with Staff 1 (ED), Staff 2 and Staff 5 (Vice President of Operations) on 03/20/25. The staff acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure resident move-in evaluations addressed all required components for 1 of 1 sampled resident (#8), whose move-in evaluation was reviewed. Findings include, but are not limited to:

Resident 8 was admitted to the facility in 02/2025 with diagnoses including dementia and congestive heart failure.

The move-in evaluation, dated 02/01/25, was reviewed, and there was no documented evidence the following required elements were addressed:

* Customary routines related to sleeping, eating and bathing;
* Physical health status including list of medications and PRN use, and visits to health practitioners, emergency room, hospital or nursing facility in the past year;
* Mental health issues including presence of depression, thought disorders or behavioral or mood problems, history of treatment, and effective non drug interventions.
* Cognition, including memory, confusion and decision-making abilities;
* Personality, including how the person copes with change or challenging situations;
* Assistive devices used for hearing, vision, mobility and eating;
* Ability to manage medications;
* Pain, including non-pharmaceutical interventions for pain and how a person expresses pain or discomfort;
* Emergency evacuation ability;
* History of dehydration;
* Recent losses; and
* Unsuccessful prior placements.

The need to ensure move-in evaluations addressed all required elements was discussed with Staff 1 (ED) and Staff 2 (Director of Nursing) on 03/21/25 at 9:30 am. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction regarding the delivery of services, were readily available to staff, and were implemented for 8 of 8 residents (1, 2, 3, 4, 5, 6, 7, and 8) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 1 moved into the facility in 05/2021 with diagnoses including cerebrovascular accident (stroke) with hemiparesis, and anxiety.

Observations of the resident, interviews with staff, review of the resident's most recent service plan, dated 01/08/25, and interim service plans showed the service plan did not provide clear direction to staff and/or was not reflective of the resident's needs in the following areas:

* Verbal aggressive outbursts and instructions for staff to help minimize behavior;
* Possible triggers for escalated behavior and interventions for staff;
* Resident-to-resident altercations, including interventions to help staff prevent future occurrences;
* Specific instructions for proper use and placement of foot and arm brace;
* Use of gait belt with transfers; and
* Use of incontinence pads.

The need to ensure service plans were reflective of resident needs and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 2 (Director of Nursing) on 03/21/25. They acknowledged the findings.

2. Resident 7 moved into the facility in 09/2017 with diagnoses including early onset dementia with mild confusion, and congestive heart failure.

a. Observations of the resident, interviews with staff, review of the resident's most recent service plan, dated 12/11/24, and interim service plans showed the service plan did not provide clear direction to staff and/or was not reflective of the resident's needs in the following areas:

* Behaviors and interventions;
* Resistance to care;
* Resident-to-resident altercations, including interventions to help staff prevent future occurrences;
* Ability to perform personal hygiene;
* Incontinent care including frequency of incontinence checks and resident specific instruction; and
* Current skin condition and treatment.

b. A behavior support plan (BSP) dated 08/19/2019 was located in the resident’s clinical record; however, it was not included in the resident's service plan. There was no documented evidence the BSP had been provided to care staff for review.

The need to ensure service plans were reflective of resident needs and included clear direction to staff was discussed with Staff 1 (ED) and Staff 2 (Director of Nursing) on 03/21/25. They acknowledged the findings.

3. Resident 5 was admitted to the facility in 04/2022 with diagnoses including left sided hemi-paresis secondary to stroke, peripheral artery disease and chronic obstructive pulmonary disease.

The service plan dated 11/13/24, interim service plans and progress notes dated 12/09/24 through 03/17/25 were reviewed. Interviews with Resident 5 and care staff were completed. The resident's service plan was not reflective or failed to provide clear instruction to staff in the following areas:

* Behavioral support;
* Resistance to care and interventions for staff; and
* Preference for door being open or closed.

The need to ensure service plans were reflective of the resident's care needs and provided clear instruction to staff was discussed with Staff 1 (ED) and Staff 2 (Director of Nursing) on 03/21/25 at 8:30 am. The findings were acknowledged.

4. Resident 6 was admitted to the facility in 02/2024 with diagnoses including vascular dementia, anxiety and transient cerebral ischemic attack.

The service plan dated 12/04/24, interim service plans and progress notes dated 12/02/24 through 03/17/25 were reviewed. Interviews with Resident 6 and care staff were completed. The resident’s service plan was not reflective or failed to provide clear instruction to staff in the following areas:

* Dressing;
* Device care related to hearing aides;
* Outside services including PT provided in the facility;
* Grooming;
* Hygiene; and
* Preference for door being open or closed.

The need to ensure service plans were reflective of the resident's care needs and provided clear instruction to staff was discussed with Staff 1 (ED) and Staff 2 (Director of Nursing) on 03/21/25 at 8:30 am. The findings were acknowledged.

5. Resident 2 was admitted to the facility in 12/2017 with diagnoses including dementia.

Observations of the resident, interviews with staff and review of the service plan, dated 12/18/24, showed the service plan was not reflective of the resident's current care needs, was not consistently implemented and/or did not provide clear direction to staff in the following areas:

* Air overlay, fall mat and low bed;
* Safety checks;
* Meal assistance;
* Fluid placement and keeping over bed table in reach;
* Dressing, hygiene and grooming assistance;
* Shower vs bed bath;
* Dentures, mouth care and care of glasses;
* Transfers, toileting assistance and skin care;
* Leisure activities; and
* Bed mobility and position changes.

The service plan binder was locked in the medication room on multiple occasions between 03/18/25 and 03/20/25 and were not readily available for care staff.

The need to ensure resident service plans were readily available for care staff, were reflective of current care needs, were consistently implemented, and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 2 (Director of Nursing) on 03/21/25. They acknowledged the findings.


6. Resident 3 was admitted to the facility in 07/2017 with diagnoses including Cerebral Palsy.

Observations of the resident, interviews with staff and review of the service plan, dated 12/11/24, showed the service plan was not reflective of the resident's current care needs, was not consistently implemented and/or did not provide clear direction to staff in the following areas:

* Fall precautions and safety checks;
* Physical aggression with staff;
* Self harm behaviors;
* Dropping legs during transport, ramming walls and refusing care;
* Dressing, grooming and hygiene assistance;
* Toileting and incontinent care;
* Leisure activities;
* Stuffed animals, placement and items carried with him/her;
* Transfers, mobility and showering;
* Dentures and mouth care;
* Air overlay, fall mat and low bed;
* Safety checks; and
* Nondrug interventions for pain/discomfort.

The service plan binder was locked in the medication room on multiple occasions between 03/18/25 and 03/20/25 and not readily available to care staff.

The need to ensure resident service plans were readily available for care staff, were reflective of current care needs, were consistently implemented, and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 2 (Director of Nursing) on 03/21/25. They acknowledged the findings.

7. Resident 4 was admitted to the facility in 12/2022 with diagnoses including Parkinson’s disease, cellulitis and congestive heart failure.

Observations of the resident, interviews with resident and staff, review of the resident's service plan, dated 01/22/25, and progress notes, dated 12/01/24 to 03/14/25, were completed. The resident's service plan was not reflective and did not provide clear instruction to staff in the following areas:

* Transfer assistance including position of wheelchair, use of gait belt, extra time, where caregivers stand to provide assistance and where resident holds on for support;
* Location of wheelchair by bedside at night;
* Diagnoses including Parkinson’s disease and congestive heart failure diagnosis, including what to look for;
* Adapted utensils for eating and reminder to bring to dining room;
* Skin conditions related to cellulitis and edema in the lower extremities;
* Wound care including who is providing;
* Outside services including PT provided in the facility;
* Side rails on hospital bed, including instructions for staff on what to look for;
* Intermittent need for dressing assistance related to weakness and/or tremors;
* Use of ankle braces that no longer fit and one new brace;
* Bathing including shower days and assistance needed for transfers and washing body;
* Fall risk including fall history and updated interventions;
* Mobility in room including use of a wheelchair; and
* Significant weight gain.

The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 2 (Director of Nursing) on 03/21/25 at 9:30 am. They acknowledged the findings.


8. Resident 8 was admitted to the facility in 02/2025 with diagnoses including dementia and congestive heart failure.

During the acuity interview on 03/17/25, the facility stated service plans were kept in the service plan binders on the counter at the two medication stations and accessible to the caregiving staff. On 3/20/25 the surveyor attempted to locate Resident 8’s service plan on the first floor where s/he resided. The service plan binder was found in the locked medication room and only MT’s had access to. When the service plan binder was retrieved, there was no service plan for Resident 8 and not available to staff to provide clear direction regarding delivery of services. On 3/20/25 Staff 2 (Director of Nursing) was present and acknowledged the service plan was missing and would print one immediately.

The need to ensure the service plans were readily available to staff, and provided clear direction regarding delivery of services was discussed with Staff 1 (ED) and Staff 2 on 03/21/25 at 9:30 am. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed for a significant change of condition for 1 of 2 sampled residents (#4), failed to determine what resident-specific action or intervention was needed for a resident following a short-term change of condition, communicate the determined action or intervention to staff, and document progress until the condition resolved for 7 of 7 sampled residents (#s 1, 2, 3, 4, 5, 6, and 7) who experienced changes of condition; and failed to evaluate and monitor service plan interventions for 1 of 1 sampled resident (#4) who had repeated falls. Resident 4 experienced a severe weight gain followed by a hospital visit, and repeated and ongoing falls with injury followed by an emergency room visit. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 12/2022 with diagnoses including Parkinson’s disease, cellulitis and congestive heart failure.

The resident's clinical record was reviewed, including 06/2024 through 12/2024 weight records, 01/22/25 service plan, 02/01/25 through 03/18/25 MARs, and 12/01/24 through 03/14/25 progress notes and interim service plans (ISPs). Observations of the resident were made, and interviews with staff and the resident were conducted.

a. Resident 4’s weight records noted the following:
* 10/2024 - 269.2 pounds;
* 11/2024 - 268.4 pounds; and
* 12/01/2024 - 334 pounds.

Between 11/20/24 and 12/01/24, Resident 4 gained 65.6 pounds, or 24% of his/her total body weight in one month, which was considered severe and triggered a significant change of condition. There was no weight records provided for 01/2025 and 02/2025. Resident 4 was weighed during survey on 3/18/25 and was 338.2 pounds.

Resident 4 was observed during the survey with multiple yellowish open sores, several with blood, and both legs were edematous. On 3/19/25 and 3/20/25 Resident 4’s legs were wrapped with a dressing.

Resident 4 was identified in the Service plan to have heart failure, cellulitis of the left lower extremity, and venous stasis ulcer of “Fight [right] calf”. The service plan lacked instructions to staff what to look for if these conditions worsened.

Resident 4’s progress notes revealed the following:

* 12/01/24: “Resident is on alert for injury fall. Residents left leg and knee is red and leg is swellon [sic] and wheeping yellowish sticky fluid”;
* 12/02/24: “Noted weakness and unsteady gait this afternoon”;
* 12/02/24: “Faxed [physician] a referral request for resident to see a skilled nurse at the hospital. Awaiting response”;
* 12/04/24: “Resident was having trouble breathing” and was admitted into emergency room ...for COPD flare up”; and
* 01/02/25: an entry from Staff 2 (Director of Nursing) “…Re-admitted to the community today on 01/02/25 from post acute rehab…no changes to the care plan or significant change of condition noted.”

Resident 4 experienced a severe weight gain on 12/01/24. There was no documented evidence the facility evaluated the resident’s significant weight gain, referred to the facility RN following a significant change of condition, determined and documented interventions regarding the weight gain, communicated the interventions to staff and monitored the resident according to his/her evaluated needs.

In an interview on 03/18/25, Staff 2 (Director of Nursing) acknowledged she was not aware of the resident’s severe weight gain from December and confirmed there were no evaluations completed, or interventions identified and communicated to staff regarding the resident’s severe weight gain.

The facility failed to identify and evaluate the resident's significant weight gain, refer to the facility RN following a significant change of condition, determine and document interventions regarding the weight gain, communicate the interventions to staff and monitor the resident according to his/her evaluated needs. The resident’s condition worsened resulting in a hospital visit and post-acute rehab stay for exacerbation of COPD and pneumonia.

Refer to C 280, example 1.

b. Interventions listed on the 01/22/25 service plan for a “Fall Prevention Plan” included “1. Staff are to ensure call pendant is in place at all times. 2. Staff are to ensure walkways are clear and free of clutter/tripping hazards. 3) Walker to remain in reach at all times. 4) [Resident 4] is to use [his/her] w/c (wheelchair) for longer distances. 5) Ensure...wearing well-fitted shoes.” Additionally, Resident 4 required “…reminders (prompting / cueing / guidance) from One (1) staff member with transfers” and had “bi-lateral ankle braces that need to go on in the morning and taken off at night.”

Resident 4 experienced the following five falls while staff provided transfer assistance:

* 12/01/24: Non-injury fall;
* 01/02/25: Non-injury fall;
* 02/06/25: Fall with skin tear to left knee;
* 02/17/25: Non-injury fall; and
* 02/25/25: Fall with abrasion to forehead and brow, lacerations to both knees and unknown injury coming from the mouth and emergency room (ER) visit.

No new interventions were identified until after Resident 4’s fourth fall on 02/17/25. An ISP instructed staff “to watch for feet positioning prior to standing.” No additional information was provided regarding how feet should be positioned prior to standing.

Progress notes revealed the following:

* 02/18/25: “Will continue to watch how [his/her] feet are positioned and have multiple people help if the RA (Resident Assistant) does not feel safe moving [him/her] alone”;
* 02/22/25: “Resident still having difficulty with transfers [his/her] ankles are turning over. Resident is going to try using [his/her] braces tomorrow”;
* 02/23/25: “Resident stayed in room [s/he] tryed [sic]..braces but took of [sic] was painful. Residents legs are swellon [sic] noted a blister an [sic] right shin”;
* 02/24/25: “Both legs are scabbed and they are slightly red in color…Resident stated both legs hurts [sic] only when [s/he] puts weight on them”;
* 02/25/25: Following the injury fall a MT noted “Have another RA present for transfers if possible.”;
* 02/28/25: “Resident is still having difficulty transfers due to ankles turning over causing imbalance.”;
* 03/02/25: Staff 2 completed a RN/LN follow-up to the 02/25/25 fall and “subsequent ER visit” and stated, “No further injuries have been noted since this incident occurred. [Resident 4] is alert and orient X4 able to make needs known and understands the fall prevention plan. [S/he] suffers from functional weakness that is felt to be a contributing factor to this incident.” Abuse and neglect were ruled out “related to staff adhering to the current plan of care…and alert charting…has been discontinued.” and
* 03/07/25: “Today when the second floor RA’s were transferring resident, it took them 15 minutes to get [him/her] from…chair to [his/her] wheelchair.”

An ISP was created on 03/07/25, 10 days after the last injury fall, and instructed staff “Resident is to be transferred with at least 2 people assisting (if you feel you need a 3rd person please ask for help) to prevent falls and/or staff getting injured.”

During an interview on 03/20/25 at 1:20 pm Staff 15 (RA) indicated they used two staff to provide transfer assistance but “Sometimes there’s just one, no one has told us that [Resident 4] is a two person [transfer].” The ISP from 03/07/25 to provide two person assist revealed only one signature from staff.

On 03/18/25 the facility provided two investigations, both incomplete, for the 02/06/25 and 02/17/25 falls. No additional information was provided for investigations into the remaining three falls that occurred when staff assisted Resident 4.

Although the facility created one ISP following the fourth fall, and another ISP 10 days after the fifth fall, there was no documented evidence the facility monitored the existing fall prevention interventions at the time of each fall or for patterns related to the falls, determined and documented what new interventions were needed for the resident subsequent to each fall. The resident continued to fall followed by injuries that required an ER visit.

Observations on 03/18/25 at 9:42 am revealed Resident 4 was assisted into his/her recliner from the wheelchair with a gait belt and two staff. Shoes were on and no braces were worn. The walker was folded up behind his/her door and a pendant was hanging from the neck.

During an interview with Resident 4 following the transfer into his/her recliner, s/he confirmed s/he used a pendant to call for staff assistance with transfers to and from the recliner and into bed, and was assisted by two staff, no longer used a walker, relied on a wheelchair for all mobility, and had not worn the braces for at least six months “because they don’t fit the size of my legs.” S/he currently worked with physical therapy and just started to trial one new brace.

During an interview on 03/20/25, Staff 21 (RA) confirmed Resident 4 had not worn any braces and confirmed s/he no longer used a walker.

During an interview on 03/20/25, Staff 2 confirmed there was no additional documentation for review.

There was no documented evidence the facility monitored the existing fall prevention interventions at the time of each fall or for patterns related to the falls, determined and documented what new interventions were needed for the resident subsequent to each fall. The resident continued to fall and sustained injuries with an ER visit.

c. There was no documented evidence the facility determined what resident-specific actions or interventions were needed for the resident, communicated the determined action or intervention to staff, or documented weekly progress through resolution for the following short-term changes of condition:
* 01/02/25: Return to the community after post-acute rehab stay;
* 01/23/25: Ketoconazole (for rash);
* 02/21/25: Leg redness;
* 02/23/25: “Residents legs are swellon [sic] noted a blister an [sic] right shin”; and
* 02/25/25: abrasion to forehead and brow, lacerations to both knees.

The need to ensure the facility evaluated the resident, referred to the facility nurse when necessary, documented the change, and updated the service plan as needed for a significant change of condition, and the need to ensure residents who had short-term changes of condition were evaluated, resident-specific instructions or interventions were developed, implemented, and reviewed for effectiveness, and the condition was monitored at least weekly to resolution was discussed with Staff 1 (ED) and Staff 2 (Director of Nursing) on 3/21/25 at 9:30 am. They acknowledged the findings.

2. Resident 2 was admitted to the facility in 12/2017 with diagnoses including dementia.

The resident's 12/18/24 service plan, 11/01/24 through 03/17/25 progress notes, observation notes, incident investigations and physician communications were reviewed.

The resident experienced multiple short-term changes without noted progress at least weekly until resolved, and/or lacked resident-specific directions to staff in the following areas:

* Medication changes;
* Falls;
* Skin injuries;
* Rash to peri area;
* Eye infection; and
* Blood in the resident’s brief.

The need to ensure short-term changes of condition had documentation of weekly progress until resolution and provided resident-specific directions to staff was discussed with Staff 1 (ED) and Staff 2 (Director of Nursing) on 03/21/25. They acknowledged the findings.

3. Resident 3 was admitted to the facility in 07/2017 with diagnoses including cerebral palsy.

The resident's 12/11/24 service plan, 11/01/24 through 03/17/25 progress notes, observation notes, incident investigations and physician communications were reviewed.

The resident experienced multiple short-term changes without noted progress at least weekly until resolved, and/or lacked resident-specific directions to staff in the following areas:

* Vomiting and diarrhea;
* Falls with and without injury;
* Skin injuries;
* Behavior with care including screaming and physical aggression with staff; and
* Weakness and two-person assistance.

The need to ensure short-term changes of condition had documentation of weekly progress until resolution and provided clear, resident-specific directions to staff was discussed with Staff 1 (ED) and Staff 2 (Director of Nursing) on 03/21/25. They acknowledged the findings.

4. Resident 1 moved into the facility in 05/2021 with diagnoses including cerebrovascular accident (stroke) with hemiparesis, and anxiety.

The resident's current service plan dated 01/08/25, interim service plans, and progress notes dated 12/12/24 to 03/17/25 were reviewed and the following changes of condition were identified:

* 12/26/24: Progress note indicated Resident 1 had been yelling down the hall most of the day, trying to get anybody to help. It was noted that the resident had been told by staff “to please give the other girls time to get down to help [the Resident Assistant] assist [Resident 1] to [his/her] chair.” “[Resident 1] started yelling and hitting [his/her] head with [his/her] fist.”

There was no documented evidence the facility determined what resident-specific actions or interventions were needed for the resident, communicated the determined action or intervention to staff on all shifts, and monitored the condition at least weekly to resolution.

* 01/08/25: New medication Ozempic (used to treat type 2 diabetes).

There was no documented evidence the facility monitored the resident at least weekly to resolution; and

* 02/17/25: Resident 1 was involved in a resident-to-resident altercation.

There was no documented evidence the facility determined resident-specific actions or interventions and communicated them to staff on each shift and monitored the condition at least weekly to resolution.

The need to ensure resident-specific actions or interventions for short-term changes of condition were determined, documented, and communicated to staff on each shift and monitored at least weekly with progress noted to resolution was discussed with Staff 1 (ED) and Staff 2 (Director of Nursing) on 03/21/25. They acknowledged the findings.

5. Resident 7’s progress notes dated 02/07/25 to 03/17/25, current service plan dated 12/11/24, and interim service plans were reviewed. The following was identified:

* 02/17/25: Resident-to-resident altercation; and

* 03/11/25: Return from urgent care with open sores on right calf and right ankle.

There was no documented evidence the facility determined what resident-specific actions or interventions were needed for the resident, communicated the determined action or intervention to staff on all shifts, and monitored the condition at least weekly to resolution.

The need to ensure resident-specific actions or interventions for short-term changes of condition were determined, documented, and communicated to staff on each shift, with monitoring at least weekly through resolution was discussed with Staff 1 (ED) and Staff 2 (Director of Nursing) on 03/21/25. They acknowledged the findings.


6. Resident 5 was admitted to the facility in 04/2022 with diagnoses including left sided hemi-paresis secondary to stroke, peripheral artery disease and chronic obstructive pulmonary disease.

The resident's clinical record was reviewed, and the following changes of condition were identified:

a. There was no documented evidence the facility determined what resident-specific actions or interventions were needed for the resident and communicated the determined action or intervention to staff on all shifts, and/or included monitoring at least weekly through resolution, for the following short-term changes of condition:

* 12/05/24: Nausea, diarrhea and vomiting;
* 12/27/24: Bump on back identified;
* 02/12/25: Started new medication (Cephalexin);
* 03/12/25: Refused AM medications; and
* 03/13/25: Refused AM medications.

The need to ensure resident-specific actions or interventions for short-term changes of condition were determined, documented, and communicated to staff on each shift, with monitoring at least weekly through resolution was discussed with Staff 1 (ED) and Staff 2 (Director of Nursing) on 03/21/25 at 8:30 am. The findings were acknowledged.

7. Resident 6 was admitted to the facility in 02/2024 with diagnoses including vascular dementia, anxiety and transient cerebral ischemic attack.

The resident's clinical record was reviewed, and the following changes of condition were identified:

a. There was no documented evidence the facility determined what resident-specific actions or interventions were needed for the resident and communicated the determined action or intervention to staff on all shifts, and/or included monitoring at least weekly through resolution, for the following short-term changes of condition:

* 12/02/24: Nausea, diarrhea and vomiting;
* 01/08/25: Swelling and bruising right wrist;
* 02/06/25: Stomach cramps;
* 02/17/25: Injury fall;
* 03/04/25: Lump in neck; and
* 03/12/25: Started medication (Levothyroxine).

The need to ensure resident-specific actions or interventions for short-term changes of condition were determined, documented, and communicated to staff on each shift, with monitoring at least weekly through resolution was discussed with Staff 1 (ED) and Staff 2 (Director of Nursing) on 03/21/25 at 8:30 am. The findings were acknowledged.

Based on observation, interview, and record review, it was determined the facility failed to ensure a significant change of condition assessment was completed by the RN, which included findings, resident status and interventions for 2 of 2 sampled residents (#s 2 and 4) who experienced significant changes of condition for weight gain and pressure ulcers. Resident 4 experienced severe weight gain followed by a hospital and post-acute rehabilitation stay. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 12/2022 with diagnoses including Parkinson’s disease, cellulitis and congestive heart failure.

Resident 4 was observed during the survey with multiple yellowish open sores, several with blood, and both legs were edematous. On 3/19/25 and 3/20/25 Resident 4’s legs were wrapped with a dressing following a visit to the wound care clinic on 03/18/25.

The resident's clinical record was reviewed, including 06/2024 through 12/2024 weight records, 01/22/25 service plan, 02/01/24 through 03/18/25 MARs, and 12/01/24 through 03/14/25 progress notes and interim service plans. Observations of the resident were made, and interviews with staff and the resident were conducted.

Resident 4’s weight records noted the following:
* 10/2024 - 269.2 pounds;
* 11/2024 - 268.4 pounds; and
* 12/01/2024 - 334 pounds.

Between 11/2024 and 12/01/24, Resident 4 gained 65.6 pounds, or 24% of his/her total body weight in one month, which was considered severe and triggered a significant change of condition. There was no weight records provided for 01/2025 and 02/2025.

Resident 4’s progress notes revealed the following:

* 12/01/24: “Resident is on alert for injury fall. Residents left leg and knee is red and leg is swellon [sic] and wheeping yellowish sticky fluid”;
* 12/02/24: Noted weakness and unsteady gait this afternoon”;
* 12/02/24: “Faxed [physician] a referral request for resident to see a skilled nurse at the hospital. Awaiting response”;
* 12/04/24: “Resident was having trouble breathing” and was admitted into emergency room “...for COPD flare up”; and
* 01/02/25: an entry from Staff 2 (Director of Nursing) “…Re-admitted to the community today on 01/02/25 from post acute rehab…no changes to the care plan or significant change of condition noted.”

On 3/20/25 at 2:42 pm, Resident 4 and Witness 2 (Outpatient PT), who had been providing physical therapy treatment since 01/18/25, confirmed s/he was hospitalized with pneumonia and required rehabilitation to get stronger prior to returning to the facility.

On 3/19/25 at 1:00 pm Staff 2 (Director of Nursing) acknowledged there was no RN assessment completed for Resident 4’s severe weight gain in December.

Resident 4's weight during the time of the survey was noted to be 338.2 pounds. The resident's weight had not been taken since the hospital stay on 12/01/24.

There was no documented evidence an RN completed an assessment of the severe weight gain. The significant weight gain represented a serious risk to the health, safety, and welfare of the resident. The resident’s condition worsened resulting in a hospital visit and post-acute rehab stay for exacerbation of COPD and pneumonia.

An immediate plan of correction was requested by the survey team on 03/20/25. The facility provided a plan of correction on 03/20/25 at 3:23 pm, prior to survey exit. The immediate risk was addressed; however, the facility will need to evaluate the overall system failure associated with the licensing violation.

The need to ensure all significant changes of condition were assessed by an RN, with documented findings, resident status, and interventions made as a result of the assessment was discussed with Staff 1 (ED), Staff 2 and Staff 5 (Vice President of Operations) on 03/20/25 and with Staff 1 and Staff 2 on 03/21/25.

2. Resident 2 was admitted to the facility in 12/2017 with diagnoses including dementia.

The resident was identified during the acuity interview on 03/17/25 to need two-person assistance for ADL care. The resident was incontinent of bowel and bladder and unable to make his/her needs known. The resident was currently bed bound and had a stage 2 pressure ulcer identified on his/her buttocks.

Multiple observations of the resident between 03/17/25 and 03/21/25 showed the resident in bed. Staff provided all meals to the apartment and indicated the resident required feeding assistance with most meals due to confusion. The resident was not able to direct his/her own care or express needs. Staff anticipated what the resident’s needs would be throughout the day and assisted him/her with care.

Observation notes and progress notes dated 11/01/24 through 03/17/25 indicated the resident had experienced a recent significant change of condition on 02/28/25. The resident had a worsening of his/her cognition and required more extensive assistance from staff. Additionally, the resident’s meal intake and ability to feed himself/herself had declined. The resident had reddened and open areas to his/her buttocks, was incontinent of bowel and bladder and was unaware of toileting needs or soilage.

a. A progress note dated 02/28/25, was completed by Staff 14 (MT) and indicated the resident had a change in condition. The resident was now bedbound, staff were to provide increased checks “to 8x per shift, hydration checks 8x per shift, assist offer help with feeding.” The resident required full assist with brief changes four times per shift and twice on night shift. Staff were to reposition the resident, keep the bed at the lowest height for fall safety, keep the head of bed elevated for comfort, and keep a fall mat in place.

An RN significant change of condition assessment was not completed by Staff 2 (Director of Nursing) until 03/12/25.
In interviews with staff between 03/18/25 and 03/21/25 the following was determined:
Staff 8, 15 and 18 (Resident Assistants) indicated the resident’s decline was ongoing but over the last several weeks s/he had declined more rapidly. The staff stated the resident was pretty confused and could not direct his/her own care and would not request help from staff with any consistency. The staff further indicated the resident required feeding assistance and full assistance of two staff for his/her care.
Staff 2 indicated she thought the significant change was completed earlier. The resident was now bedbound and required extensive assistance from staff for care and needed staff to provide meal assistance for most food intake. Staff 2 had no further information regarding the resident’s decline in condition.
b. A hospice visit note, located in the resident’s chart, dated 12/05/24, indicated the resident had a stage 2 pressure ulcer on the buttocks. The previous visit note indicated the resident’s skin was intact.

A hospice visit note, dated 02/05/25, was not originally available onsite in the facility. Hospice visit notes were requested by Staff 2 (Director of Nursing) during the survey when requested by the surveyor. The note indicated the visit was made to assess a new stage 2 open area on the resident’s buttocks.

There were no RN significant change of condition assessments completed related to the two stage 2 pressure ulcers documented.

In interviews with staff between 03/17/25 and 03/21/25 the following was determined:

Staff 7 (MT) indicated the resident had areas of red rashes, and an open area on his/her bottom. The staff stated currently there was just the one open area. Hospice had provided three creams to be applied once a day to the resident’s bottom in specific areas. Staff 7 further indicated the resident was incontinent of bowel and bladder. The open area was primarily taken care of by hospice but when the area was not covered with a dressing staff took care of the wound.

Staff 14 (MT) stated the resident currently had one open area to the bottom. The area was more of a “hole.” The resident had a second wound for a short time, but it was now resolved. Staff 14 indicated the dressing was just changed the day before so it may have become soiled as it was no longer in place. She would let hospice know so they could come and redress or provide instructions to the staff. Staff 14 further stated it was important to keep the area as clean and dry as possible.

Witness 1 (Hospice RN) indicated the resident at one point had two open areas. The second area appeared and resolved within a brief period. The current area had been open for longer, almost appeared as if a puncture wound. The staff were to provide frequent toileting and position changes to help with skin healing. The resident consistently leaked urine and stool, so it was difficult to keep the dressing clean in some cases. Witness 1 indicated there were a few issues over the last few weeks around brief changes, but it had improved, and the resident’s skin was doing well right now.

Staff 2 indicated she did include the resident’s skin breakdown in her significant change assessment. She did not have significant change assessments for the specific dates when new stage 2 areas were noted. Staff 2 stated the only current open area was the wound that appeared more as a hole/puncture. Hospice handled the dressings and treatment updates for staff regarding the resident’s skin.

The facility failed to ensure an RN assessment was completed timely for the resident’s decline in cognition, altered mental status and stage 2 pressure ulcers, which included findings, resident status and interventions made as a result of the assessment.

The need to ensure an RN assessment was completed which documented findings, resident status, and interventions made as a result of the assessment for significant changes of condition was discussed with Staff 1 (ED) and Staff 2 on 03/21/25. The staff acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to coordinate on-site health services with outside providers and have policies to ensure outside service providers left written information in the facility that addressed the on-site services provided to the resident and any clinical information necessary for facility staff to provide supplemental care and that the service plan was adjusted if necessary, and reporting protocols were in place
for 3 of 4 sampled residents (#s 2, 4 and 6) who received home health services. Findings include, but are not limited to:

1. Resident 6 moved into the facility in 02/2024 with diagnoses including vascular dementia, anxiety and transient cerebral ischemic attack.

Following the acuity interview on 03/17/25, Resident 6 was not identified by Staff 2 (Director of Nursing) as one of eleven residents who received outpatient PT services on-site in the facility.

On 3/18/25 at 10:15 am Witness 2 (Outpatient PT) was observed providing PT services to Resident 6. Documentation for the Outpatient PT was requested from Staff 2 on 03/18/25. Staff 2 acknowledged Witness 2 was not leaving any written information that addressed on-site services being provided.

The need to ensure outside service providers left written information in the facility that addressed the on-site services being provided was discussed with Staff 1 (ED) and Staff 2 (Director of Nursing) on 03/21/25 at 8:30 am. They acknowledged the findings.

2. Resident 4 was admitted to the facility in 12/2022 with diagnoses including Parkinson’s disease, cellulitis and congestive heart failure.

Following the acuity interview on 03/17/25, Resident 4 was identified by Staff 2 (Director of Nursing) as one of eleven residents who received outpatient PT services on-site in the facility.

On 3/18/25 the surveyor requested outside provider documentation for Resident 4. Staff 2 acknowledged Witness 2 (Outpatient PT) was not leaving any written information that addressed on-site services being provided.

On 3/20/25 at 2:42 pm Witness 2 revealed Resident 4 had been on PT services since 01/18/25 and had never been asked to leave any written communication for the facility.

The need to ensure outside service providers left written information in the facility that addressed the on-site services being provided was discussed with Staff 1 (ED) and Staff 2 (Director of Nursing) on 03/21/25 at 9:30 am. They acknowledged the findings.

3. Resident 2 was admitted to the facility in 12/2017 with diagnoses including dementia.

Observations of the resident, interviews with staff and review of the service plan, dated 12/18/24, progress notes, observation notes, and outside provider notes dated 11/01/24 through 03/17/25 were completed. The resident was readmitted to hospice services in 07/2024. The resident was also noted to have a stage 2 pressure ulcer to his/her bottom.

During the acuity interview on 03/17/25, Resident 2 was identified as receiving outside provider services related to hospice services and wound care.

Hospice visits occurred twice a week until March 2025 when visits were increased to three times a week due to increased wound care needs.

The resident’s record contained no hospice visit notes after 12/05/24.

In an interview on 03/18/25, Staff 2 (Director of Nursing) was unable to locate any additional visit notes within the facility. She did confirm Hospice visits were two to three times per week for wound treatments and dressing changes.

The need to ensure on-going coordination of care visit notes were available in the facility with each visit for review and implementation of new recommendations was discussed with Staff 1 (ED) and Staff 2 on 03/20/25. The staff acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to establish and maintain effective infection prevention and control protocols for 4 of 4 sampled residents (#1, 2, 3 and 5) related to incontinence care and failed to designate an individual to be the facility's trained infection control specialist. Findings include, but are not limited to:
1. Resident 2 was admitted to the facility in 12/2017 with diagnoses including dementia.

The resident was identified during the acuity interview on 03/17/25 to need two-person assistance for ADL care. The resident was incontinent of bowel and bladder and unable to make his/her needs known. The resident was currently bed bound and had a stage 2 pressure ulcer identified on his/her buttocks.

a. On 3/18/25 at approximately 12:25 pm, the surveyor observed two caregivers provide incontinent care to Resident 2. During the process, Staff 8 (Resident Assistant) assisted Staff 10 (Resident Assistant) to remove the resident’s soiled incontinent brief. The resident was rolled side to side and the perineal area was cleaned. Staff 8 used toilet paper and foam cleanser to clean the resident. Staff 8 did not change gloves after cleaning the resident or contact with the soiled brief.

Staff 10 removed the brief and incontinence pad that was underneath resident’s bare bottom. Staff 10 threw the soiled brief and the incontinence pad over the end of the bed and onto the floor several feet away. The soiled items were not bagged and landed directly on the resident’s carpet. Staff 8 was asked to clean the outside of the foam cleanser bottle of a brown substance that was observed on multiple sides of the bottle. When care was completed, the soiled items were bagged for removal.

b. Additional incontinent care observations on 03/19/25 and 03/20/25 and dressing assistance/morning care showed gloves were in place at the start of care. Staff 4 (RCC), Staff 7 (MT), Staff 10 (Resident Assistant) and Staff 15 (Resident Assistant) were observed to work in pairs to assist the resident with care. Gloves were not changed after cleansing the resident’s perineal area or removal of the soiled brief. Soiled items were placed in a garbage bag before being placed on the floor. Staff 7 was observed to assist with care and apply three physician-ordered creams to the resident’s bottom and wound. Staff 7 did not remove the soiled gloves used for care or to apply the creams to the resident’s buttocks before continuing to assist with the placement of a new brief.

The need to ensure staff consistently used proper infection control and universal precautions when incontinent care was provided was discussed with Staff 1 (ED), Staff 2 (Director of Nursing) and Staff 5 (Vice President of Operations) on 03/19/25 and 03/20/25. They acknowledged appropriate infection control practices were not being followed.

2. Resident 3 was admitted to the facility in 07/2017 with diagnoses including cerebral palsy.

The resident was identified during the acuity interview on 03/17/25 to require staff assistance for ADL care and had frequent behaviors around care and mobility/ambulation. The resident was also noted to have some cognitive impairment that affected his/her safety awareness, and the resident was a fall risk.

Observations on 03/18/25 of the resident during toileting/incontinent care showed one staff assistance was provided. Staff 16 (Resident Assistant) assisted the resident into the bathroom, gloves put on prior to transfer to the toilet. The resident’s pants and soiled brief were removed. Staff 16 did not change gloves prior to retrieving a clean brief and pajamas for the resident. When the resident was finished using the bathroom s/he was assisted to a standing position and perineal area/bottom was cleaned by Staff 16. Gloves were not changed prior to pulling up the resident’s clean brief and pajama bottoms.
The need to ensure staff used proper infection control and universal precautions when incontinent care was provided was discussed with Staff 1 (ED) and Staff 2 (Director of Nursing) on 03/20/25. They acknowledged appropriate infection control practices were not being followed.

3. Resident 1 moved into the facility in 05/2021 with diagnoses including cerebrovascular accident (stroke) with hemiparesis and anxiety. Resident 1 was identified in the acuity interview as dependent on staff for ADLs.

Staff 18 (Resident Assistant) and Staff 19 (MT) were observed providing incontinence care for Resident 1 at 10:30 am on 03/18/25. They did not perform hand hygiene prior to donning single-use gloves. Staff 18 changed the resident's soiled brief, then performed perineal care and donned cleaned briefs and pants without removing soiled gloves and performing hand hygiene in between. After incontinence care was provided, Staff 18 proceeded to touch the handles of the resident’s wheelchair with the soiled gloves still on. Both staff removed the soiled gloves in the resident's room, but did not perform hand hygiene before exiting the room.

The need to maintain effective infection prevention and control protocols was discussed with Staff 1 (ED) and Staff 2 (Director of Nursing) on 03/21/25. They acknowledged the findings.

4. Resident 5 moved into the facility in 04/2022 with diagnoses including left sided hemiparesis secondary to stroke, peripheral artery disease and chronic obstructive pulmonary disease.

Observations of the resident and interviews with staff and the resident from 03/17/25 through 03/21/25 revealed Resident 5 relied on two staff for all ADL needs.

On 03/19/25 at 12:51 pm, Staff 14 (MT) and Staff 15 (Resident Assistant) provided ADL incontinence care for Resident 5. Staff 14 and 15 donned gloves prior to providing incontinence care. Staff 15 removed the resident's soiled brief, deposited the soiled brief into a garbage bag and performed perineal care without doffing soiled gloves. Staff 14 and Staff 15 then placed a clean brief on the resident, repositioned the resident all while wearing the same gloves. Soiled gloves were removed and placed in the garbage bag with the soiled brief. Hand hygiene was not performed prior to exiting the room.

The need to establish and maintain effective infection prevention and control protocols while performing ADL care was discussed with Staff 1 (ED) and Staff 2 (Director of Nursing) on 03/21/25 at 8:30 am. They acknowledged the findings.

5. Upon entrance to the facility on 03/17/25, the facility's designated "Infection Control Specialist" and documentation of completed specialized training in infection prevention was requested.

On 03/18/25 Staff 1 (ED) acknowledged the facility did not currently have an “Infection Control Specialist.” She indicated the staff that was previously qualified was no longer employed at the facility.

The need to ensure designation of an "Infection Control Specialist" was discussed with Staff 1, Staff 2 (Director of Nursing) on 03/21/25 at 9:30 am. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure a safe medication and treatment administration system. Findings include, but are not limited to:

During the re-licensure survey, conducted 03/17/25 through 03/24/25, professional oversight of the medication and treatment administration system was found to be ineffective, based on deficiencies in the following areas:

* C 302 - Tracking Controlled Substances;
* C 303 - Medication and Treatment Orders;
* C 305 - Resident Right to Refuse;
* C 310 - Medication Administration; and
* C 325 - Self-Administration of Medication.

The need to ensure a safe medication and treatment system was discussed with Staff 1 (ED), Staff 2 (Director of Nursing), and Staff 5 (Vice President of Operations) via telephone 03/21/25. The findings were acknowledged.

Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 2 of 3 sampled residents (#s 2 and 9) whose MARs and Controlled Substance Disposition logs were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 12/2017 with diagnoses including dementia.

Observations of the resident, interviews with staff and record review were completed. The resident's signed physician orders dated 01/02/25 included the following order:

* Morphine Sulfate 20 mg/ml, give 0.5 ml every hour PRN for severe pain or shortness of breath.

The resident's Controlled Substance Disposition logs and MARS, reviewed from 01/01/25 through 02/25/25 showed the following:

* A dose was signed out in the disposition log. The month was written over and appeared to be 01/05/25. The dose was not reflected on the MAR.

In an interview on 03/18/25, Staff 19 (MT) indicated she was the one who wrote over the month in question. She stated the number was a “1.”

* A dose was signed out in the disposition log on 02/28/25, and the dose was not reflected in the MAR.
* A dose was signed out in the MAR on 02/05/25 but was not reflected on the disposition log.

Comparison of the prefilled syringes to the disposition logs showed the amount of medication left was reflected accurately on the log.

The need to ensure narcotic disposition logs accurately reflected the medications administered was discussed with Staff 1 (ED) and Staff 2 (Director of Nursing) on 03/21/25. The staff acknowledged the findings.

2. Resident 9 was admitted to the facility in 09/2018 with diagnoses including chronic pain.

Observations of the resident, interviews with staff and record review were completed. The resident's signed physician orders dated 02/12/25 included the following order:

* Morphine Sulfate IR 15 mg tablet, give four times daily at 2:00 am, 8:00 am, 2:00 pm and 8:00 pm for pain.

The resident's Controlled Substance Disposition logs and MARS, reviewed from 02/01/25 through 03/17/25 showed the following:

* On 02/09/25 the 2:00 pm dose was blank and an “!” was recorded for the 8:00 pm dose. There was one untimed note which indicated the medication was not available.

The am doses were signed as given on the MAR. The disposition log reflected no administrations for 02/09/25.

* On 02/10/25 the 2:00 am dose was circled, an “!” recorded for the 8:00 am and 2:00 pm doses and the 8:00 pm dose was blank. There was one note for 8:00 pm which said not available and an untimed note “out of morphine.”

There were no doses recorded for the am or pm on the disposition log.

* On 02/11/25 the 2:00 am dose was circled, 8:00 am signed as given, 2:00 pm was blank and the 8:00 pm was circled. There was one untimed note that said, “out of morphine.”

The disposition log reflected a dose near 8:00 am and the two pm doses.

* On 02/15/25 a dose was signed out on the disposition log for the resident’s 2:00 pm administration.

The dose was not reflected on the MAR as the sign out was left blank.

Comparison of the medication bubble packs to the disposition logs, showed the amount of medication left was reflected accurately on the log.

The need to ensure narcotic disposition logs accurately reflected the medications administered was discussed with Staff 1 (ED) and Staff 2 (Director of Nursing) on 03/21/25. The staff 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 orders were documented in the resident's facility record for all medications and treatments the facility was responsible to administer for 3 of 7 sampled residents (# 1, 4 and 5) whose MARs and orders were reviewed. Findings include, but are not limited to:

1. Resident 1 moved into the facility in 05/2021 with diagnoses including cerebrovascular accident (stroke) with hemiparesis, and anxiety.

The resident's 02/01/25 to 03/17/25 MARs and physician orders dated 11/12/24 were reviewed. The following was identified:

The resident had orders for:

* Aspirin 81 mg (for heart health), administer one tablet in the morning;
* Atorvastatin 80 mg (for high cholesterol), administer one tablet nightly;
* Duloxetine 20 mg (for depression), administer one capsule every day;
* Trazadone 50 mg (for depression), administer one and a half tablet every night.

The 02/01/25 – 02/28/25 MAR revealed the following medications were not given as prescribed on the following dates:

* Aspirin on 02/17/25 and 02/18/25;
* Atorvastatin on 02/07/25;
* Duloxetine on 02/02/25 and 02/03/25; and
* Trazadone on 02/15/25 and 02/26/25.

During an interview on 03/21/25 at 12:10 pm, Staff 1 (ED) and Staff 2 (Director of Nursing) confirmed the medications were not administered on those dates.

Resident 1’s 03/01/25 – 03/17/25 MAR showed Duloxetine 40 mg administer one capsule by mouth every day. There was no documented evidence the facility had a signed physician order to administer the medication.

The need to have signed physician orders in the resident's record and to ensure physician orders were carried out as prescribed was discussed with Staff 1 and Staff 2 on 03/21/25. They acknowledged the findings.

2. Resident 5 moved into the facility in 04/2022 with diagnoses including left sided hemiparesis secondary to stroke, peripheral artery disease and chronic obstructive pulmonary disease.

The resident's 02/01/25 to 03/17/25 MARs and physician orders dated 02/09/25 were reviewed. The following was identified:

The following orders were missing and/or not being followed on the 03/01/25 through 03/17/25 MAR:

* Ex-Lax Oral Tablet Chewable 15 mg (for reflux);
* Spironolactone Oral Tablet 25 mg (for edema);
* Oxygen 3L via nasal cannula (for respiratory comfort);
* Remedy phytoplex antifungal external powder (for rash); and
* Diphenhydramine-zinc acetate cream (for itching).

In an interview with Staff 2 (Director of Nursing) on 03/20/25 at 10:05 am, it was acknowledged the above orders were missing from the 03/01/25 through 03/17/25 MAR. An updated MAR was requested by the surveyor and provided by Staff 2 on 03/20/25 at 5:10 pm.

The need to ensure all written, signed orders from a legally recognized practitioner were carried out as prescribed was discussed with Staff 1 (ED) and Staff 2 on 3/21/25 at 8:30 am. They acknowledged the findings.

3. Resident 4 was admitted to the facility in 12/2022 with diagnoses including Parkinson’s disease, cellulitis and congestive heart failure.

1. Review of physician orders, dated 03/06/25, indicated the following medications should be given:

* Furosemide (for fluid retention) 20 mg, 2 tablets every morning for five days and then 1 tablet daily for seven days; and
* Potassium Cl (supplement) 40 mEq (milliequivalents), 1 tablet for 12 days.

The 03/01/25 through 03/18/25 MAR revealed the following:

* Two tablets of furosemide were given for four days, from 03/7/25 through 03/10/25;
* No furosemide was administered on 03/11/25;
* One tablet of furosemide was given for six days, from 03/12/25 through 03/17/25; and
* Potassium chloride was administered for 11 days, from 03/11/25 through 03/17/25.

During an interview with Staff 7 (MT) on 03/21/25 at 8:45 am regarding the administration of furosemide and potassium chloride, she indicated the pharmacy puts the medications on the MAR the day they receive the order “…but we could receive the medication a day later so the dates don’t always match.”

Additionally, the 03/06/25 physician order also instructed the facility:
“Keep wraps (for legs) in place…until Saturday [3/8/25], then remove and give patient shower”; and
* “If worsening shortness of breath GO TO ER [emergency room].”

There was no documented evidence the physician instructions were followed.

2. Quarterly physician orders, dated 11/12/24 and 02/12/25, indicated Resident 4 was to take Chlorthalidone 25 mg (for hypertension) daily. The 02/01/25 through 03/18/25 MAR was reviewed and revealed the medication was last given on 02/01/25, the medication was crossed out and stated “D/C” (discontinue).

On 03/19/25 at 1:00 pm survey requested a discontinue order for the medication. On 03/20/25 Staff 2 (Director of Nursing) confirmed there was no documented evidence this medication had been discontinued and was currently clarifying with Resident 4’s physician. No further information was provided.

The need to ensure all written, signed orders from a legally recognized practitioner were carried out as prescribed was discussed with Staff 1 (ED) and Staff 2 on 03/21/25 at 9:30 am. 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 2 of 2 sampled residents (#s 5 and 9) who had documented medication refusals. Findings include, but are not limited to:

1. Resident 5 was admitted to the facility in 04/2022 with diagnoses including left sided hemi-paresis secondary to stroke, peripheral artery disease and chronic obstructive pulmonary disease. The resident's 02/01/25 through 03/17/25 MARs and progress notes dated 12/09/24 through 03/17/25 were reviewed and revealed the resident refused to consent to orders for the following medications:

* Breo Ell (for shortness of breath) on five occasions;
* Clonazepam (for anxiety) on seven occasions;
* Diclofenac sodium 1% gel (for pain) on eight occasions;
* Docusate sodium (for constipation) on seven occasions;
* IPRAT/Albuterol (for shortness of breath) on two occasions;
* Metoprolol Succ ER (for hypertension) on seven occasions;
* Omeprazole (for reflux) on seven occasions;
* Potassium CHL ER (supplement) on seven occasions; and
* Prednisone (for respiratory inflammation) on seven occasions.

In an interview on 03/19/25 at 9:55 am, Staff 7 (MT) stated the facility's process was to document the refusal in the "MAR Notes" and/or progress notes and document the provider was notified by phone of the refusal. Staff 7 and the surveyor found there was no documented evidence the facility had notified the physician of the refusals.

The need to ensure the facility notified the physician or other practitioner if the resident refused consent to an order was discussed with Staff 1 (ED) and Staff 2 (Director of Nursing) on 03/21/25 at 8:30 am. The findings were acknowledged.

2. Resident 9 was admitted to the facility in 09/2018 with diagnoses including history of multiple fractures and chronic pain.

The resident's 02/01/25 through 03/17/25 MAR and signed physician orders dated 02/12/25 were reviewed.

The following medications were documented as refused between 02/01/25 and 03/17/25:

* Docusate Sodium (bowel medication) was refused on 12 occasions; and
* Polyethylene glycol (bowel medication) was refused on seven occasions.

There was no documented evidence the prescriber was notified after each refusal for the above medications.

The need to notify the physician or other practitioner of resident medication refusals was discussed with Staff 1(ED) and Staff 2 (Director of Nursing) on 03/21/25. The staff acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate including reasons for use, resident-specific PRN parameters and medication-specific instructions for 7 of 7 sampled residents (#s 1, 2, 3, 4, 5, 6 and 9) whose MARs were reviewed. Findings include but are not limited to:

1. Resident 1 moved into the facility in 05/2021 with diagnoses including cerebrovascular accident (stroke) with hemiparesis and anxiety.

Review of Resident 1's 02/01/25 through 03/17/25 MARs were reviewed, and the following was identified:

* All medications on the 02/01/25 – 02/26/25 MAR lacked reasons for use; and

* The MARs directed staff to subcutaneously inject semaglutide (for type 2 diabetes) 0.75 ml once weekly. The MARs showed that staff signed the medication had been administered, but had not documented the location of the injections.

In an interview on 03/21/25 at 12:15 pm with Staff 1 (ED) and Staff 2 (Director of Nursing), it was confirmed that staff had not been documenting the sites of the injections.

On 03/21/25, the need to ensure accurate documentation of the MAR was discussed with Staff 1 and Staff 2. They acknowledged the findings.


2. Resident 4 was admitted to the facility in 12/2022 with diagnoses including Parkinson’s disease, cellulitis and congestive heart failure.

a. The resident's 02/01/25 through 03/18/25 MARs and physician's orders were reviewed and revealed the following inaccuracies:

There was no direction to staff on the sequential order for the PRN administration of physician-prescribed senna, bisacodyl or polyethylene glycol for constipation, or if the resident was able to self-direct.

b. The handwritten 02/01/25 through 02/27/25 MAR was missing initials of the person who administered medications or treatments as follows:

* Carbidopa/Levo 25-100 mg (for Parkinson’s disease) on 14 occasions;
* Ketoconazole 2% cream (for rash) on 2 occasions;
* Meloxicam (anti-inflammatory) on 2 occasions; and
* Ropinirole (Parkinson’s disease) on 1 occasion.

c. The following medications were noted as “!” with no indication what the symbol represented:
* Chlorthalidone (hypertension) for 15 occasions; and
* Vitamin D3 (supplement) for 3 occasions.

The need to ensure MARs were reviewed for accuracy was discussed with Staff 1 (ED) and Staff 2 (Director of Nursing) on 3/21/25 at 9:30 am. They acknowledged the findings.

3. Resident 5 moved into the facility in 04/2022 with diagnoses including left-sided hemiparesis secondary to stroke, peripheral artery disease and chronic obstructive pulmonary disease. The resident's 02/01/25 through 03/17/25 MARs and physician orders were reviewed, and the following was identified:

a. The handwritten 02/01/25 through 02/27/25 MAR was missing the initials of the person who administered medications or treatments as follows:

* Breo Ell 200-25 mcg (for shortness of breath) on one occasion;
* Cephalexin 500 mg (for urinary tract infection) on one occasion;
* Clonazepam 0.5 mg (for anxiety) on two occasions;
* Diclofenac sodium 1% gel (for pain) on one occasion;
* Eliquis 5 mg (for clot prevention) on three occasions;
* Fentanyl 50 mcg/HR patch (for pain) on two occasions;
* IPRAT/Albuterol 0.5-2.5 mg (for shortness of breath) on five occasions;
* Remedy antifungal 2% powder (for rash) on four occasions; and
* Sertraline 100 mg (for depression) on three occasions.

In an interview with Staff 7 (MT) on 03/19/25 at 9:55 am, she stated it was “possible someone forgot to initial the MAR” but could not confirm if the medication or treatment had been administered.

b. The following medications were noted as “!” with no indication on the MAR what the symbol represented:

* Breo Ell 200-25 mcg (for shortness of breath) on one occasion.

An interview with Staff 7 (MT) on 03/19/25 at 9:55 am she stated that the “!” meant that the med was not available.

The need to ensure MARs were reviewed for accuracy was discussed with Staff 1 (ED) and Staff 2 (Director of Nursing) on 03/21/25 at 8:30 am. They acknowledged the findings.

4. Resident 6 moved into the facility in 02/2024 with diagnoses including vascular dementia, anxiety and transient cerebral ischemic attack. The resident's 02/01/25 through 03/17/25 MARs and physician orders were reviewed, and the following was identified:

a. The handwritten 02/01/25 through 02/27/25 MAR was missing initials of the person who administered medications or treatments as follows:

* Atoravastin 20 mg (for cholesterol) on two occasions;
* Cephalexin 250 mg (for urinary prolactin) on one occasion;
* Duloxetine 60 mg (for depression) on two occasions;
* Eliquis 5 mg (for anticoagulation) on two occasions;
* Gabapentin 300 mg (for nerve pain/neuropathy) on two occasions; and
* Preservision (for eye supplement) on three occasions.

In an interview with Staff 7 (MT) on 03/19/25 at 9:55 am, she stated it was “possible someone forgot to initial the MAR” but could not confirm whether or not the medication or treatment had been administered.

b. The following medications were noted as “!” with no indication on the MAR what the symbol represented:

* Lidocaine 5% patch (for pain) on 25 occasions.

Staff 7 (MT) on 03/19/25 at 9:55 am stated that the “!” meant that the med was not available.

The need to ensure MARs were reviewed for accuracy was discussed with Staff 1 (ED) and Staff 2 (Director of Nursing) on 3/21/25 at 8:30 am. They acknowledged the findings.

5. Resident 2 was admitted to the facility in 11/2021 with diagnoses including Alzheimer’s disease and chronic pain.

Review of the resident's 02/01/25 through 03/17/25 progress notes, MAR and physician communications and the 01/02/25 signed physician orders showed the following:

* Guaifenesin (for congestion) doses circled on 02/02/25, 02/03/25, 02/08/25, 02/09/25 for the 8:00 pm doses;
* Levothyroxine (thyroid medication) was blank on 02/06/25;
* Tramadol (for pain) was blank on 02/03/25 and 02/09/25 for the 2:00 pm doses;
* Docusate sodium (bowel medication), marked “!” on 02/08/25, 02/09/25, 02/10/25 and 02/11/25;
* Calmoseptine, moisturizing ointment was blank on 02/09/25 for the 1:00 pm and 8:00 pm administrations;
* Preparation H cream (hemorrhoid cream) apply bid and an order for Preparation H cream PRN were both noted on the March MAR, and both orders had times of 8:00 am and 8:00 pm for application;
* Preparation H cream was marked “9” on both the scheduled and PRN order for 03/02/25. The exception note indicated a duplicate order for both of the entries;
* Vitamin A+D ointment (for skin protection) was ordered TID. Blanks were noted on 03/13/25 for all three applications, and marked as “9” on 03/14/25 for the 6:30 am and the 1:00 pm applications;
* Lidocaine 3% Cream (for pain) was blank on 03/13/25 for the am and pm doses. The cream was signed as given on the 03/14/25 am dose, marked as “9” not available for the pm dose, given on 03/15/25 for the am dose and then marked “9” unavailable for the pm dose.

There was no other documentation to indicate why the medications were circled, blank or marked with “!”.

The need to ensure medication/treatment administration records were complete and included resident-specific parameters for PRN use was discussed with Staff 1 (ED) and Staff 2 (Director of Nursing) on 03/21/25. The staff acknowledged the findings.

6. Resident 3 was admitted to the facility in 07/2017 with diagnoses including developmental delay and cerebral palsy.

Review of the resident's 02/01/25 through 03/17/25 progress notes, MAR and physician communications and the 02/05/25 signed physician orders showed the following:

* Levothyroxine (for thyroid health), was blank on 02/16/25; and
* Ferrous Sulfate (iron supplement), was marked as “!” on 02/09/25 and 02/10/25, and blank on 02/19/25.

No additional information was documented to indicate why the medications were blank or marked as “!”.

The need to ensure medication/treatment administration records were complete and included resident specific parameters for PRN use was discussed with Staff 1 (ED) and Staff 2 (Director of Nursing) on 03/21/25. The staff acknowledged the findings.

7. Resident 9 was admitted to the facility in 09/2018 with diagnoses including hypertension and history of multiple fractures.

Review of the resident's 02/01/25 through 02/17/25 progress notes, MAR and physician communications and the 02/12/25 signed physician orders showed the following:

* Morphine Sulfate (for pain) was marked as “!” on 02/10/25 at 8:00 am and 2:00 pm;
* Polyethylene glycol (bowel medication) was marked as “!” on 02/06/25, and circled on 02/08/25, 02/09/25, 02/16/25 and 02/20/25;
* Daily blood pressures were blank on 02/09/25, 02/20/25 and 02/25/25 for the 8:00 pm doses and 02/11/25 for the 8:00 am dose.

There was no other documentation to indicate why the medications were circled, blank or marked with “!”.

The need to ensure medication/treatment administration records were complete and included resident specific parameters for PRN use was discussed with Staff 1 (ED) and Staff 2 (Director of Nursing) on 03/21/25. The staff acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents who chose to self-administer medications had a physician’s order of approval for 1 of 1 sampled resident (# 9) reviewed for self-administration of medication. Findings include, but are not limited to:

Resident 9 was admitted to the facility in 09/2018.

The resident was identified during the acuity interview on 03/19/25 as a resident who self-administered their own medication.

The resident’s most recent signed physician’s orders, dated 02/12/25, contained no information regarding self-administration of any medications.

In interviews on 03/20/25 and 03/21/25, Staff 15 and 17 (Resident Assistants) stated they were not aware if the resident administered any of his/her medications.

The need to ensure residents who self-administered their medications had a current physician’s order to administer their own medications, was discussed with Staff 1 (ED) and Staff 2 (Director of Nursing) on 03/20/25 and 03/21/25. The staff acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities was assessed by an RN, PT, or OT, other less restrictive alternatives evaluated prior to use of the device were documented, caregivers were instructed on the correct use of and precautions for the device, and use of the device was included in the resident's service plan for 1 of 1 sampled resident (#4), who had supportive devices with restraining qualities. Findings include, but are not limited to:

Resident 4 was admitted to the facility in 12/2022 with diagnoses including Parkinson’s disease, cellulitis and congestive heart failure.

During the acuity interview on 03/17/25, Resident 4 was identified as having two side rails on his/her bed.

Observations of the resident and the resident's room on 03/18/25 at 9:42 am showed the side rails were on each side of the bed in the up position and represented a device with restraining qualities. Additionally, one of the rails was loose and Resident 4 acknowledged the rail needed to be secured.

Review of Resident 4's record revealed there was no documented evidence the devices with restraining qualities had been assessed by an RN, PT, or OT, no documentation of other less restrictive alternatives evaluated prior to use of the devices, no documentation of instruction to caregivers on correct use of and precautions for the device, and no documentation of the use of the side rails in the resident's service plan.

During an interview on 03/18/25 at 12:30 pm, Staff 2 (Director of Nursing) acknowledged no assessment had been completed for Resident 4's side rails. She was notified one rail was loose by the surveyor and she stated she would have maintenance secure it immediately. On 03/18/25 at 2:32 pm Staff 2 confirmed the rail had been secured and provided an assessment for a “Supportive Device with Restraining-like Qualities” dated 03/18/25.


The need to ensure the use of a supportive device with potentially restraining qualities included documentation of all required elements and was included in the resident's service plan was discussed with Staff 1 (ED) and Staff 2 on 03/21/25 at 9:30 am. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to have a sufficient number of direct care staff to meet the 24-hour scheduled and unscheduled needs of each resident and to meet the fire safety evacuation standards during the night shift. Findings include, but are not limited to:

During the entrance conference on 03/17/25 with Staff 1 (ED), Staff 2 (Director of Nursing) and Staff 9 (MT) the following was identified:

*The assisted living community was home to 61 residents at the time of the re-licensure survey and resided in a two story building;
* Six residents required two-person assistance for transfers and/or ADL care;
* Six residents required meal assistance;
* Five residents required support for behavioral symptoms; and
* Five residents required support for cognitive impairments.

The facility's posted staffing plan and the staffing schedule from 03/09/25 to 03/16/25 were reviewed.

The facility's posted staffing plan indicated the following:

* Day Shift: 6:00 am - 2:00 pm - 5 RAs (Resident Assistant) and 2 MTs;
* Swing Shift: 2:00 pm - 10:00 pm - 4 RAs and 2 MTs; and
* Night Shift: 10:00 pm - 6:00 am - 2 RAs and 1 MT.

The staffing schedule from 03/09/25 to 03/16/25 showed seven swing and seven night shifts where the facility failed to follow their staffing plan. This was confirmed in an interview with Staff 1 (ED) on 03/18/25 at 4:25 pm.

The facility failed to have sufficient swing and night shift staff to meet the scheduled and unscheduled needs of the residents and adequate direct care staff on night shift to meet the fire safety evacuation standards as required by the Department.

The need to have a sufficient number of staff to meet all scheduled and unscheduled needs of residents on the swing and night shift was discussed with Staff 1 on 03/18/25 and 03/20/25. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) that identified all residents currently residing in the facility, the care elements for each of the residents and the staff time required to complete each care element for each resident. Findings include, but are not limited to:

The facility's ABST was reviewed with Staff 1 (ED) and Staff 2 (Director of Nursing) on 03/20/25 at 4:00 pm. The facility had implemented the Department’s ABST. The following was identified:

* One former resident was entered into the ABST; and
* Two unsampled residents were not entered into the ABST.

The need to implement an ABST which met the regulation was discussed with Staff 1 and Staff 2 on 03/20/25 at 4:00 pm. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure they accurately captured care time and care elements that staff were providing to each resident as outlined in each individual service plan for 7 of 7 sampled residents (#s 1, 2, 3, 4, 5, 6 and 7) whose Acuity Based Staffing Tool (ABST) was reviewed. Findings include, but are not limited to:

The facility's ABST was reviewed and discussed with Staff 1 (ED) on 03/18/25 and 03/20/25.

Review of Residents 1, 2, 3, 4, 5, 6 and 7’s ABST input revealed multiple ADLs were not reflective of the residents' evaluated care needs.

The need to ensure the facility's ABST addressed all evaluated care needs of residents, including the amount of staff time needed to provide care, was discussed with Staff 1, Staff 2 (Director of Nursing) on 03/20/25 at 4:00 pm. They acknowledged the findings. No further information was provided.

Based on interview and record review, it was determined the facility failed to ensure documentation of consistently staffing to meet or exceed the posted staffing plan. Findings include, but are not limited to:

The facility’s posted staffing plan and staffing schedule from 03/09/25 to 03/16/25 were reviewed with Staff 1 (ED) and Staff 2 (Director of Nursing) at 4:00 pm on 03/20/25. The following was identified:

The posted staffing plan for the facility was as follows:

* Day shift: 5 RAs (Resident Assistant), 2 MTs;
* Evening shift: 4 RAs, 2 MTs; and
* Night shift: 2 RAs, 1 MT.

Review of the facility schedule from 03/09/25 to 03/16/25 revealed the facility failed to staff per the posted staffing plan on nineteen shifts, or 80% of the total shifts reviewed.

During an interview with Staff 1 on 3/18/25 at 4:25 pm she acknowledged not following the posted staffing plan and had been staffing three RA’s on swing shift and one RA on night shift instead.

The need to ensure consistent staffing to meet or exceed the posted staffing plan was discussed with Staff 1 and Staff 2 on 03/20/25 at 4:00 pm. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure fire and life safety instruction was provided to staff on alternating months. Findings include, but are not limited to:

Review of fire and life safety records for 11/2024 through 03/2025 and an interview with Staff 1 (ED) and Staff 6 (Business Office Manager) on 03/19/25 at 11:25 am revealed the facility lacked documentation of fire and life safety instruction to staff on alternate months.

On 03/21/25 at 8:30 am, the need to ensure staff received required fire and life safety training on alternate months was reviewed with Staff 1 and Staff 2 (Director of Nursing). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure residents were instructed within 24 hours of admission in fire and life safety procedures as required by the Oregon Fire Code (OFC). Findings include, but are not limited to:

Fire and life safety records were reviewed on 03/18/25 at 12:35 pm, Staff 1 (ED) and Staff 5 (Business Office Manager) were interviewed on 03/19/25 at 11:25 am, and the following were identified:

There was no documented evidence residents were instructed within 24 hours of admission on general fire and life safety procedures, evacuation methods, responsibilities, and designated meeting places inside or outside the building in the event of an actual fire.

On 03/19/25, the need to ensure fire and life safety instruction was provided to each resident within 24 hours of admission as required by the OFC was discussed with Staff 1 and Staff 2 (Director of Nursing). They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure courtyard surfaces and surrounding pathways were maintained in good repair. Findings include, but are not limited to:

Observations of facility pathways and patio areas on 03/17/25 and 03/18/25 identified the following:

* Multiple drop-offs of two to five inches were noted in the courtyard, along pathways around the perimeter of the facility and outside exterior doorways;
* Cracked, lifting and/or broken sidewalk pieces in the courtyard and the exterior pathways near the side and front of the facility; and
* Cracked, chipped, bent and/or missing pieces of siding on pillars at the front of both entrances into the building.

The need to ensure pathways around the facility were in good repair with no potential tripping hazards were shown to and discussed with Staff 1 (ED), Staff 5 (Vice President of Operations) and Staff 3 (Environmental Services Director) on 03/19/25. The staff acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure the environment was maintained clean and in good repair. Findings include, but are not limited to:

Observations of the facility between 03/17/25 and 03/20/25 showed the following areas in need of cleaning or repair:

* Strong odors consisting of body odor, urine/bowel movement, stale smoke and marijuana were present on the first and second floors throughout survey. The odors were strongest near the elevators and the back halls near rooms 234-244 and rooms 135-139.
* Common area bathrooms were found to have missing and/or discolored sealant around the base of the toilet, discolored and rough counter tops, exposed wood at the top of the back splash and brown substance on the seat, bowl and base of the toilet;
* “Clean Room” and tub room, on the second floor and eye washroom on the first floor had chips, dings and gouges to the wall corners, linoleum and/or rubber baseboards and stains around toilet bases;
* Medication rooms and “soda room,” were noted with splatters to the ceiling, stains in windowsills, streaks, gouges and/or missing pieces of flooring;
* Room 161, 163 and 166 had chips, scrapes and dings to wall corners, discoloration around the base of the toilets, and exposed wood edges on counter back splash. Toilet seats had stains, scrapes and exposed under surface where the white top layer had worn away. Room 166 had brown substance and debris on the commode chair over the toilet and along the bowl of the toilet. The lower shelf in the kitchenette of room166 had the white top surface scraped, peeling and pulling away from the base of the shelf;
* Room 234 and 235 had chips, dings and scrapes to bathroom walls, worn surface on the top and bottom of toilet seat with exposed under layer and stains, and exposed wood at the top of the counter back splash. Room 235 had a crack on the shelf under the mini refrigerator that was pulling up; and
* Shower room on first floor had black stains/scrapes along the tile on the floor of the shower and partially up the wall. Chips, dings and/or scrapes were noted to walls and corners in the shower room.

The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (ED), Staff 3 (Environmental Services Director) and Staff 4 (Vice President of Operations) on 03/19/25 and 03/20/25. The staff acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents’ right to privacy and dignity for 1 of 2 sampled residents (# 2) who were bedbound and required extensive assistance for ADL care. Findings include, but are not limited to:

Resident 2 was not treated with dignity and respect related to provision of timely incontinent care. The resident was dependent on care and required two-person assistance for his/her incontinent care needs. The resident’s brief was not changed for extended periods ranging from 4-8 hours based on observation of staff visits to the resident’s room and information noted on the resident’s briefs which indicated the last change that was completed.

Refer to C 200.

Based on observation and interview, it was determined the facility failed to ensure each individual had privacy in his or her own unit for multiple unsampled and sampled residents who resided in the facility. Findings include, but are not limited to:

Observations made throughout the duration of the survey revealed multiple doors of unsampled and sampled residents were propped open.

In an interview on 03/18/25 at 2:00 pm, Resident 5 stated he/she “does not want (his/her) door opened all the time.” Throughout the period of the survey Resident 5’s door was observed to be propped open.

In an interview on 03/18/25 at 10:00 am Resident 6 was asked if it was his/her desire to have the door propped open and the resident responded “no.” When asked if the resident was aware as to the reason the door was being propped open, he/she stated, “I think it is convenient for them”.

On 03/21/25 at 8:30 am, the need to ensure the facility was respecting resident’s privacy preferences related to doors being propped open was reviewed with Staff 1 (ED) and Staff 2 (Director of Nursing). They acknowledged the findings.

Based on interview and record review, conducted during a site visit on 12/03/24, the facility's failure to ensure the service plan must reflect the resident's needs as identified in the evaluation was substantiated for 1 of 1 resident (#2). Findings include, but are not limited to:A review of Resident 2's behavioral support plan (BSS), dated 04/16/24, indicated the following:* Resident 2 had a history of declining meals;* Resident 2 had a history of declining meals, then later alleging s/he was never offered food;* Staff were to have Resident 2 sign the days s/he declined meals; and* Staff were to record when Resident 2 accepted meals.In separate interviews, Staff 4 (MT) and Staff 5 (CG) stated they had no knowledge of the facility having documentation of Resident 2's signature on days s/he declined meals.A review of Resident 2's progress notes, dated 11/04/24 to 11/29/24, showed the following:* Staff documented when Resident 2 refused meals;* Staff did not document all instances when Resident 2 accepted meals; and* There was no indication Resident 2 was signing documentation of his/her meal refusals.The findings were reviewed with and acknowledged by Staff 1 (Administrator), Staff 2 (Health Services Director), and Staff 3 (Resident Care Coordinator).The facility's failure to ensure the service plan must reflect the resident's needs as identified in the evaluation was substantiated.Verbal Plan of Correction: The facility will implement the resident's BSS recommended documentation for resident's refusal of meals.

Based on interview and record review, conducted during a site visit on 08/14/24 through 08/16/24, it was confirmed the facility failed to ensure the completeness of resident records for 1 of 1 sampled resident (#7). Findings include, but are not limited to: A review of Resident 7's records, including progress notes, dated 10/28/23 through 01/23/24, indicated the following: * S/He was admitted on 10/27/23. * The facility's initial screening "Offline Evaluation Form" was undated and unsigned. * Resident 7's move-in 'Temporary Plan of Care', dated 10/27/23, contained areas that were blank, which included: hearing, grooming, behaviors, safety, pain issues, and devices; and lacked clear direction; and lacked who and how services are to be provided. In an interview on 08/16/24, Staff 3 (Health Services Director) and Staff 4 (Resident Care Coordinator) stated the "Temporary Plan of Care" is initial service plan they implement upon move in and after 30 days generate a full service plan. On 08/16/24, these findings were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 3, Staff 4, and Staff 22 (Regional Director of Operations). Verbal Plan of Correction: The Administrator in collaboration with Health Services Director and Resident Care Coordinator will ensure a newly admitted resident's service plan will be completed.

A. Based on interview and record review, conducted during a site visit on 08/14/24 through 08/16/24, it was confirmed the facility failed to complete a service plan before resident move-in; and the facility failed to include written description of who shall provide the services, and what, when, how, and how often the service shall be provided for 1 of 1 sampled resident (#7). Findings include, but are not limited to: A review of Resident 7's records, including progress notes, dated 10/28/23 through 01/23/24, indicated s/he was admitted on 10/27/23. The facility's initial screening "Offline Evaluation Form", (undated), indicated Resident 7 required the following: * In area of mobility, s/he requires escorts for meals and activities;* Cues and reminders for dressing/grooming; * Partial assistance with bathing. * One person assist with toileting and cleaning; * S/He "needs reminders/cues during meal times; assist with directions".* S/He was able to recognize family by face and name, but otherwise had "no recall ability".* S/He uses glasses. * Resident 7's move-in 'Temporary Plan of Care', dated 10/27/23, contained areas that were blank, which included: hearing, grooming, behaviors, safety, pain issues, and devices; and lacked clear direction; and lacked who and how services are to be provided. In an interview on 08/16/24, Staff 3 (Health Services Director) and Staff 4 (Resident Care Coordinator) stated initial screenings of perspective residents occur before move-in and are completed by them. Staff 3 conducts the nursing assessments and Resident Care Coordinators develop the service plan. On 08/16/24, these findings were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 3, Staff 4, and Staff 22 (Regional Director of Operations). Verbal Plan of Correction: Health Services Coordinator will ensure residents' service plan provide clear directions to staff. B. Based on observation, interview, and record review, conducted during a site visit on 08/14/24 through 08/16/24, the facility's failure to have a service plan that is reflective of the resident's needs for 1 of 1 sampled resident (#2) was substantiated; and failed to include a written description of who shall provide the services and what, when, how, and how often services shall be provided. Findings include, but are not limited to:In an interview on 08/15/24, at 2:27 pm, Resident 2 stated the following: · S/He gets showers two to three times per week unless s/he doesn't feel like it and described his/her other care needs. · Described the quality of care provided by direct care staff as "good". · When asked if Resident 2 had seen his/her service plan, s/he stated: "No. I've refused to sign." · Is able to transfer independently. On 08/15/24, at approximately 2:27pm, Resident 2 was observed to use a urinal and bed pan.In an interview on 08/16/24 at approximately 8:52am, Staff 20 (CG) stated Resident 2's care needs included emptying urinals and bed pans, and transfers with one staff person assistance. A review of Resident 2's records including his/her service plan dated 05/22/24, temporary service plans, dated 03/11/24 through 07/29/24, and Behavior Support Plan, dated 04/16/24, indicated the following:· His/Her service plan was signed by the resident on 05/22/24.· Transfers are to be completed with two-person assistance. · Toileting required staff assistance and used a commode and is incontinent of bladder and bowels.· S/He has experienced behaviors which include making rude or inappropriate comments toward staff members; reporting to staff and Department personnel that property has been stolen and investigations have been completed and does not confirm the allegation; and refusing to attend meals or refusing meal trays, and then reporting to Department personnel staff have refused to provide meals. Staff are to document all refusals of food. Resident 2's service plan lacked the frequency of toileting needs and omitted any references to his/her Behavior Support Plan and the interventions used to address the identified behaviors. It was determined the facility failed to have a service plan that is reflective of the resident's needs and failed to provide a frequency for services to be provided. On 08/16/24, these findings were reviewed with Staff 1 (Executive Director), Staff 3 (RN), Staff 4 (RCC), and Staff 22 (Regional Director of Operations). Plan of Correction: Within five days, Staff 3 and Staff 4 will review Resident 2's current needs and conduct a quarterly evaluation.

Based on interview, observation, and record review, conducted during a site visit on 8/14/24 through 08/16/24, it was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool. Finding include, but are not limited to: In an interview on 08/16/24 at 2:17 pm, Staff 1 (Executive Director) stated the following: * The facility uses proprietary software for their ABST. * Software is tied into resident service plans. * Facility takes the total care times (6791) divided by 60 (minutes in an hour), and divided by 7.5 hour shifts resulting in the total number of staff (15.09) per day * Two residents are expected to move out by end of day. * The facility's census was 58.In an interview on 08/16/24 at 2:50 pm, Staff 4 (RCC) stated s/he does the staff schedule and schedules staff to the maximum number of staff that was set approximately three years ago and the facility's ABST is not referenced.A review of the facility's ABST and resident rosters (undated) indicated the following: * There were 57 residents were entered. One of the resident's entered had their move-in date postponed. * All residents entered had their profiles updated within the last quarter. * Two residents- Resident 10 and Resident 11 - were not listed on the ABST list.The facility's posted staffing plan showed a total of 14 direct care staff are needed and this did not match or exceed the ABST. c.In separate interviews, direct care staff stated on day shift the facility is regularly staffed with two-to-three caregivers per floor and one medication technician per floor, and one bath aide per floor for a total of approximately 10 direct care staff on day shift, and approximately 6-8 direct care staff on swing shift. A review of the facility's staff schedule, dated 08/01/24 through 0/31/24, indicated the facility was staffed consistently above their ABST. d. In an interview on 08/15/24, at 1:25 pm, Resident 1 stated what his/her care needs were, call light response times were within 15 minutes, and had no complaints about his/her care needs. On 08/15/24, at 2:01 pm, staff was observed responding to Resident 1's activated call light and provided toileting assistance. In an interview on 08/15/24, at 2:27 pm, Resident 2 stated s/he gets showers two to three times per week unless s/he doesn't feel like it, and described the quality of care provided by direct care staff as "good". In an interview on 08/15/24 at 3:07 pm, Resident 3 stated what his/her care needs were, described the quality of care provided by direct care staff as "good" and their response times to call lights as "fast". The facility failed to fully implement and update an Acuity Based Staffing Tool after Resident 10 and Resident 11 were not listed in the facility's ABST. On 08/16/24, these findings were reviewed with and acknowledged by Staff 1 (Administrator).

The findings of the kitchen inspection, conducted 12/18/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.
The findings of the revisit to the kitchen inspection of 12/18/23, conducted 03/14/24, 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 2nd revisit to the kitchen inspection of 12/18/23, conducted 06/24/24, 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 and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observation of the main kitchen and dining room service area was conducted on 12/18/23 from 1:00 pm through 4:15 pm. a. An accumulation of food spills, splatters, dirt, dust, and/or black matter was visible on or underneath the following:* Multiple food carts, upright carts and service carts throughout the kitchen and dry food storage area;* Multiple stainless steel racks throughout the kitchen;* Walk-in refrigerator and freezer shelves and flooring;* Walk-in refrigerator blower cage and ceiling;* Dry food storage floor and shelving;* Exterior dry food storage bins;* Walls, floors and doors throughout the kitchen;* White cabinets and shelving below the steam table;* Wall behind the steam table;* Prep table below microwave;* Interior/exterior microwave;* Wall behind the prep table and underneath spice shelves;* Wall above and below two compartment sink;* Interior, exterior and behind the "Wolf" grill /ovens;* Interior, exterior and behind the "Sunfire" oven;* Drawer underneath "Cleveland" steamer;* Multiple soiled oven mitts;* Interior of the two drawer warmer wells;* Exterior conveyor toaster protective coating was peeling off;* White food bins underneath prep table (near walk-in refrigerator);* The walls above and below the warewash area had a buildup of brown matter;* There was no dedicated eyewash sink (currently shared with handwashing sink); and* Wall, light switch and janitor's tub had a buildup of black matter in and around the drain.Mt. Harris dining room:* Interior and exterior cabinet below coffee counter; * Juice machine drip tray was rusting; and* Pre-set tableware was set more than 30 minutes prior to meal service and tableware was not inverted.The following areas were in need of repair:* Janitors closet door and door frame;* Dry storage door and door frame;* Floor thresholds into dry food storage, walk-in refrigerator, wash machine area and dining room;* The walk-in refrigerator door sweep/seal;* Multiple floor tiles throughout the kitchen had worn, missing grout and pieces of broken tile;* Wood panel on the end of the steam table was porous and uncleanable;* Missing trim on the steam table that exposed wood underneath;* Multiple utensils were made of wood which created a porous and uncleanable surface; and* Multiple plastic utensils and scrapers were broken down and in need of replacement. b. Food Storage:* Multiple uncovered, unlabeled and undated food items in the reach-in refrigerator and freezer; * Multiple perishable food items in the walk-in were held past the expiration date; and* Multiple food items were left uncovered. c. Infection control: * Chloride sanitizer bucket was not at proper concentration for surface sanitation;* Staff failed to clean prep table surfaces in the back of the kitchen and on the tray line between uses; * Staff failed to wash hands and/or don gloves during meal preparation; and* Staff failed to have hair restrained while in the kitchen.At approximately 3:30 pm on 12/18/23, the kitchen was toured and the above areas of concern were discussed with Staff 2 (Dining Services Director). He acknowledged the findings.
Based on observation and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to: Observation of the main kitchen and dining room service area was conducted on 03/14/24 at 2:15 pm. a. An accumulation of food spills, splatters, dirt, dust, and/or black matter was visible on or underneath the following:* Several walls throughout the kitchen;* Floor grout, thresholds and underneath appliances;* Cabinets and shelving below the steam table;* Wall behind the steam table;* Wall behind spice shelves;* Pipes and wall above and below the two compartment sink;* Exterior and behind the "Wolf" grill /ovens;* Interior, exterior and behind the "Sunfire" oven;* Metal shelf below the steamer;* Floor thresholds between the kitchen and dry storage;* Drawer underneath the "Cleveland" steamer; and * Interior of the two drawer warmer wells.Mt. Harris dining room:* Interior and exterior cabinets below coffee counter.b. The following areas were in need of repair:* Floor threshold into dry food storage had a gap between the tile and transition strip.At approximately 3:30 pm on 03/14/24, the kitchen was toured, and the above areas of concern were discussed with Staff 2 (Dining Services Director). He acknowledged the findings.The need to ensure the kitchen was maintained in good repair and in a sanitary manner in accordance with Food Sanitation Rules was discussed with Staff 1 (Executive Director) and Staff 2 during the exit conference on 03/14/24. They acknowledged the findings.

Based on observation and interview, 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 240.

The findings of the re-licensure survey, conducted 05/16/22 through 05/18/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities 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 first re-visit to the re-licensure survey of 05/18/22, conducted 12/12/22, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004. Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day


The findings of the second revisit to the re-licensure survey of 05/18/22, conducted on 05/09/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs Division 54 for Residential Care and Assisted Living Facilities.

Based on observation and interview, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents. Findings include, but are not limited to:Resident 6's current service plan, dated 4/18/22, noted the resident smoked and used supplemental oxygen. During observations on 05/17/22 at 3:45 pm, Resident 6 was observed in the smoking area with five other residents. Resident 6 had a nasal cannula in place attached to a portable oxygen tank, and was observed lighting and smoking cigarettes. The tank of concentrated oxygen and tubing next to an open flame created a fire hazard.Staff were notified, and at 3:50 pm removed the oxygen tank from the smoking area. Resident 6's service plan was updated to require staff assistance when smoking.The following morning, on 05/18/22 at 8:15 am, Resident 6 was observed in the smoking area, with oxygen tank and oxygen tubing, lighting and smoking cigarettes.Staff were notified, and by 8:20 am removed the oxygen tank from the smoking area.In interview on 05/18/22, the need to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents was discussed with Staff 1 (Executive Director) and Staff 2 (RN). They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was kept clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:1. Observations of the central kitchen on 05/16/22 revealed the following areas were in need of cleaning or repair:* The walk in freezer door was damaged, hinges corroded with metal flaking off, and ice and water had accumulated around the bottom of the door;* The compressor inside the freezer had accumulated ice that blocked airflow; and* Several containers in the freezer and walk in were undated, with several containers not closed or covered.2. Observations of both first floor kitchenettes on 05/16/22 revealed the following: * A build-up of brown matter inside the cabinet underneath both sinks;* Multiple broken or loose cabinet hinges; and* Multiple dining room chairs were tilted forward (were not seated level).The need to ensure the kitchen was kept clean and in good repair was shown to and discussed with Staff 1 (ED), Staff 7 (Environmental Services Director), and Staff 9 (Executive Chef). They acknowledged the findings.
Based on observation, interview, and record review it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:The kitchen was toured with Staff 9 (Executive Chef) on 12/12/22. Observations of the facilities kitchen, food storage areas, food preparation and food service revealed:* Splatters, spills, drips, and debris noted on: - Surfaces and underneath storage shelves, cabinets, and drawers throughout the kitchen and cabinets in the dining rooms; - Storage shelves and metal rack shelving throughout the kitchen and in the walk in refrigerator and freezer; - Cages of fans in the refrigerator; - Food storage bin handles, lids, and surfaces; - Interiors of cupboards and drawers throughout the kitchen and dining rooms; - Walls throughout the kitchen; - The dishwashing area walls, floors, drain, and equipment; - Floor drains throughout the kitchen; - Cove base; - Both sides of the range, grill, oven, and warming/confection oven; - Behind and underneath appliances; - Baking rack shelving; - The stand mixers; - The blender; - Food processor; - The cage and blades of fans; - Garbage can surfaces; and - Carts.* The laminate shelving throughout the kitchen and dining rooms was damaged, creating un-cleanable surfaces.* The surface of the stand mixer was corroded with metal chipping off. * The cove base throughout the kitchen was damaged creating areas filled with debris.The areas in need of cleaning and repair were observed with Staff 1 (Executive Director). She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure orders were carried out as prescribed for all medications and treatments the facility was responsible to administer, for 1 of 5 sampled residents (# 1) whose orders were reviewed. Findings include, but are not limited to:Resident 1 was admitted to the facility in 04/2022 with diagnoses including stroke with left side hemi-paresis.Resident 1's 05/1/22-05/16/22 MAR and current signed physician orders revealed the following:* Physician orders instructed staff to hold Prazosin (for urinary retention) if blood pressure was less than 100/60. There was no documented evidence the facility was checking Resident 1's blood pressure prior to administering the medication;* Baclofen (for muscle spasms) was not administered for 25 doses;* Omeperzole (for stomach acid) was not administered for 22 doses;* Prednisone (for arthritis) was not administered for 12 doses; and* There were no signed orders for PRN Bisocodyl suppository.On 05/17/22, Staff 10 (MT) confirmed the Baclofen and Omeperzole were received from the pharmacy on 05/11/22, the day s/he sent a fax to the pharmacy. Staff 10 stated the Prednisone still hasn't been received and the pharmacy faxes go to the Resident Care Cordinator for resolution. On 05/17/22, Staff 3 (RCC) reported the MT's were supposed to send faxes daily for medications that haven't been received and notify the RCC's if there was an ongoing issue. Resident 1's MARs and orders were reviewed with Staff 1 (ED), Staff 2 (RN), and Staff 3 on 05/18/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure all required elements were documented for fire drills in accordance with Oregon Fire Code (OFC) and fire and life safety instruction was provided on alternate months. Findings include, but are not limited to:Review of fire drill and fire and life safety records from December 2021 through March 2022 identified the following:* The facility failed to provide fire and life safety instruction to staff on alternate months: and * Problems encountered, comments relating to residents who resisted or failed to participate in the drill;* Number of occupants evacuated; and* Alternate routes used during fire drills were not documented. The need to ensure the facility documented all required elements for fire drills was reviewed with Staff 1 (Executive Director) and Staff 7 (Environmental Service Director). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to provide Fire and Life Safety instruction to residents annually. Findings include, but are not limited to:Fire drill records from 12/2021 through 03/2022 were reviewed. The facility lacked documentation that residents were being instructed on fire and life safety procedures at least annually and more if needed.The requirements for Fire and Life Safety instruction for residents were reviewed with Staff 1 and Staff 7 on 05/17/22. They acknowledged the findings.

Based on observation and interview, 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 240.

Based on observation and interview the facility failed to have handrails secured to the wall in resident use corridors. Findings include, but are not limited to:The interior environment of the facility was toured on 05/16/22 at 1:30 pm. The facility is a two story assisted living community. The following was identified:* Multiple sections of handrails on the first and second floors were not secured to the wall or were loose. The facility was toured and findings were shown to Staff 1 (ED) and Staff 7 (Environmental Services Director on 05/17/22 at 8:58 am. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure all interior materials and surfaces were kept clean and in good repair. Findings include, but are not limited to:The facility was toured on 05/16/22 at 1:30 pm. The following areas required cleaning or repair:* There were gouges and scratches to all exit doors, multiple resident unit doors, shower room doors;* There were white stains on the hallway carpet near the second floor nurses station and multiple dark spots throughout the entire carpet on the second floor; and* There were dark spots and debris built-up on the carpet in the first and second floor elevators. The facility was toured and findings were shown to Staff 1 (ED) and Staff 7 (Environmental Services Director) on 05/17/22 at 8:58 am. They acknowledged the findings.