Brookdale River Road

Based on observation and interview it was determined the facility failed to maintain the kitchen in good repair, sanitary manner or with required food inventory levels in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include but are not limited to:
Observation of the facility kitchen, dining room and activity kitchenette on 12/02/24 from 10:30 a.m. through 1:30 pm revealed the following deficient practices:

a. An accumulation of food spills, splatters, food debris build-up, loose food and debris, dust, dirt build-up and/or uncleanable surfaces was visible on the following:
Ovens-Interior and Exterior;
Windowsill ledge behind large metal rack;
Multiple metal racks in kitchen;
Racks in Cooler/Freezers-various;
Handwashing sink faucet area;
Wall poster outside of dry storage;
Flooring Corners and edges;
Cooler/Freezer bottom shelves;
Top of dish machine;
Light switch in ware washing area;
Knife Rack;

b. The following areas needed repair:
Caulking in ware washing area with black matter debris build-up
Hole in wall below knife rack;
Walls with scrapes/dings/peeling-missing paint in various areas;
Light switch damaged;
Standing/pooling water under dish machine from possible leaking sprayer faucet;
Cooler/Freezer racks with missing/peeling coating and rusted areas creating non-cleanable surfaces.


c. The following areas needed replacement:
Multiple metal racks with non-cleanable surfaces storing food items;
Heavily scored sauté pans;
Chipped, frayed, or rusty cooking utensils;

d. Sanitation in the dishwashing process:
Dish machine was run several times by surveyors and Staff 2 (Dining Services Coordinator) and was not able to reach correct sanitation concentration for chlorine levels. Upon investigation, sanitizing chemical was empty. Staff 2 changed out sanitizer, however dish machine continued to not register correct concentration after running another several times. Facility maintenance staff was contacted and was eventually able to get the dish machine sanitation concentration to 200 ppm as required. Facility was not able to determine when the dish machine was last correctly sanitizing dishes. Facility was not able to demonstrate effective monitoring system was in place for the dish machine to ensure dishes were effectively sanitized. Facility chlorine test strips were noted to be expired.

e. Food Supply
Dry goods, Perishable goods, Freezer goods not at required inventory levels. Staff 2 validated a large order would be placed that day and facility was not typically this low. Staff 2 acknowledged current food on hand did not meet 7 days of dry/staple foods nor 2-3 days of perishables required. Staff 2 did state they could run to store down the street if/when needed.

f. Dating, labeling and/or expired food items
Various food items observed stored in reach in coolers that were not dated, labeled or past the 7 days allowed per rule. Cakes for a staff party was stored with resident food.

g. Miscellaneous areas noted
Food equipment not covered/protected from potential contamination when stored (mixer bowl/whisk), coffee filters were stored open to potential contamination, scoop observed stored with handle touching food beverage item, dining room utensils observed pre-set and exposing food contact areas, uncovered food/beverages in dry storage, cooler, and freezer.

Staff 2 toured kitchen with surveyors and acknowledged above areas in need of attention. At 1:30 surveyors reviewed with Staff 1 (Administrator) and Staff 2 (Dining Services Manager) the concerns found and they acknowledged the need for correction.

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

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

This Rule is not met as evidenced by:

The findings of the re-licensure survey, conducted 04/29/24 through 05/01/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day

The findings of the first re-visit to the re-licensure survey of 05/01/24, conducted on 02/05/25, are documented in this report. It was determined the facility was in compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, and Home and Community Based Services Regulations OARs 411 Division 004.

Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) which met the regulation. Findings include, but are not limited to:The facility's ABST was reviewed on 04/30/24.There was no documented evidence all 22 required ADLs were addressed separately on the ABST staffing tool the facility was using.The need to have all required ADLs listed separately on the ABST was discussed with Staff 1 (ED) and Staff 2 (District Director of Operations) on 04/30/24. They acknowledged the findings.

Concerns were identified and the facility was provided with technical assistance in the following areas:H1517(2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (d) Each individual has privacy in his or her own unit.

The findings of the kitchen inspection, conducted 11/07/23, 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 re-visit to the kitchen inspection of 11/07/23, conducted 01/12/24, 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 facility kitchen was conducted on 11/07/23 from 10:30 am through 2:00 pm and found the following: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and/or black matter was visible on or underneath the following: * Refrigerator and oven in activity room;* Floors and walls under dish machine;* Reach-in coolers and freezers;* Metal racks storing spices;* Metal shelves storing pots/pans/dishes;* Industrial can opener and housing;* Steamer with scale build-up and dirty on interior and exterior;* Industrial mixer;* Interior of plate warmer;* Wood knife holder;* Walls and door thresholds with food debris/splatter; and* Handles of reach-in coolers and freezers.b. The following areas were in need of repair: * Large open area in janitor room next to mops;* Large open gap by air duct in janitor room;* Caulking behind hand washing sink and ware washing area with black mold-like substance;* Piece of wood flooring missing by entry way threshold;* Walls in kitchen with pealing/chipped paint;* Light switch with crack and chip in outlet;* Visible mineral/scale build-up in ware washing machine; and* Stand-up freezer with large accumulation of ice/frost buildup.c. Scoops/spoons observed in bulk food containers with handles touching food surfaces. Coffee filters stored uncovered and open to potential contamination.d. Multiple cutting boards and cutting surfaces were found heavily stained and scored. Utility cart noted to be damaged with burn rings from coffee or hot beverage containers, making cart an unsmooth surface. Multiple pans/utensils with damage and wear needing to be replaced.e. Two containers of cottage cheese were found past their manufacturer's use-by date. Multiple food items found in reach-in refrigerators without proper labels and/or dates as required.f. Multiple food packages were found open in dry storage.g. Facility did not have a small diameter thermometer probe for thin foods.h. Multiple cooking/prep dishes were not stored inverted as required and were observed to have visible debris in them. i. Kitchen staff observed during tray line service to use single service gloves incorrectly. On multiple occasions ready-to-eat items were handled with gloves that had been used for other tasks, including handling pen to write down room numbers on containers.At approximately 2:00 pm on 11/07/23, surveyors reviewed above areas with Staff 2 (Dining Service Coordinator) and Staff 1 (Administrator), who acknowledged the identified areas.

The findings of the on-site investigation, conducted 08/02/2023, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities. Abbreviations possibly used in this document:ADL: activities of daily livingCBG: capillary blood glucose or blood sugar CG: caregiverCS: Compliance Specialistcm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMT: Medication TechMAR: Medication Administration RecordMCC: Memory Care CommunityOT: Occupational TherapistPT: Physical TherapistPRN: as neededRCC: Resident Care CoordinatorRN: Registered NurseNotes on Abbreviations: "The abbreviations listed above can be used in the report without identifying the abbreviation within the report itself. "Residents will be identified by "Resident 1", "Resident 2" etc, do not abbreviate."Staff will be identified by "Staff 1", "Staff 2" etc. do not abbreviate. "If you introduce an abbreviation in the report, make sure it is a word that has a standard abbreviation associated with it and that it needs to be abbreviated. You don't need to abbreviate a word that you only use once in a report.

Based on interview and record review, conducted during a site visit on 08/02/23, it was confirmed the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident for 1 of 1 sampled resident (#1). Findings include, but are not limited to: CS was unable to interview Resident 1 who no longer resided in the facility. During an interview on 08/02/23, Staff 1 (Executive Director) stated, "The call light response time is between 5-10 minutes." Staff 1 acknowledged the long response times on the call light report printed. A record review of the call light report for Resident 1 from April 2023, showed occurrences where the response time exceeded 10 minutes. On 04/08/23 the response time was 20 minutes 39 seconds. On 04/25/23 the response time was 24 minutes 23 seconds. It was confirmed the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each residentOn 08/02/23, the findings were reviewed with and acknowledged by Staff 1. Verbal plan of correction: Staff 1 will continue to run reports for the call lights and having staff meetings if s/he sees a pattern that exceeds their timeframe.

Based on interview and record review, conducted during a site visit on 08/02/23, it was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool (ABST). Findings include, but are not limited to: During an interview on 03/28/2023, Staff #1 (Executive Director) stated their ABST was the same tool they had been using provided by their home office, called the resident services summary report. A review of the facility's ABST showed the tool did not have all 22 activities of daily living (ADL's) outlined individually for each resident and the amount of staff time needed to provide care. The facility's ABST had multiple ADLs grouped together in subcategories. The ABST stated on day and swing shift, 1 MT and 3 CG were required and on NOC shift, 1 MT and 2 CG were required. On 08/02/23, the findings were reviewed with and acknowledged by Staff 1.Verbal plan of correction: Staff 1 will contact the OPA and CAC for ABST to further understand the tool within the month.

The findings of the kitchen inspection, conducted 11/30/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.
The findings of the revisit to the kitchen inspection of 11/30/22, conducted 2/16/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and accepted sanitation standards were in accordance with the Food Sanitation Rules OARs 333-150-0000. Finding include, but are not limited to: On 11/30/22 at 10:30 am, the facility kitchen was observed to need cleaning in the following areas: * Vents within the hood over the stove had accumulation of grease/dust; * The wall beside the stove had accumulation of grease/dust; * The back of the stove/grill had grease buildup; * The end of the stove near the spice shelf had grease/splatters; * The grill top had grease buildup; * The lower shelf below the spice shelf/prep area had dried food debris; * The lower shelf below the steam table had dried food debris; * Drains below the coffee/juice counter and in the dish washing area had accumulation of black matter; and * The floor throughout the kitchen and dish washing area had scattered food debris. The garbage can near the two compartment sink in the kitchen was uncovered when not in use.The dry storage area had the following items observed directly on the floor: * Cardboard box of foam containers; * Bag of potato chips, raw potato, Ziploc bag of chips, box of Crystal Lite, box of cornbread mix; and * Large black plastic bag of towels. A bag of granulated sugar was open and not sealed closed. A scoop was observed in the flour bin. Two cardboard boxes of lids were directly on the floor near the large sugar bin. The above areas of concern were discussed with the Staff 1 (Executive Director) on 11/30/22. The findings were acknowledged.

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes. This report reflects the findings of the complaint investigation conducted 10/6/2022. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified:Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

The findings of the re-licensure survey, conducted 4/19/21 through 4/21/21 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 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 cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day
The findings of the first revisit to the re-licensure survey of 4/21/21, conducted 7/26/21 through 7/27/21 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 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 cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

The findings of the second revisit to the re-licensure survey of 4/21/21, conducted 10/7/21, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and maintained in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:During a tour of the kitchen on 4/19/21 at 10:30 am, it was determined the following areas were in need of cleaning or repair:* The floor perimeters near the dishwashing area, food prep area, beverage counter and cooking area had buildup of food debris and/or a thick brown substance;* The walls, floors, drains in the dishwashing area had a buildup of food debris and splattered brown and/or black matter; * The floor in the janitor closet had a gap in the middle and around the perimeter creating a surface that was not smooth and cleanable;* Staff were not using sanitation test strips when using the red sanitation buckets for sanitizing counters and kitchen equipment and were not knowledgeable in how to use the sanitation test strips;* On 4/19/21 the surveyor observed cold foods were not being maintained at 41 degrees F. or below when served from the tray line; and* On 4/19/21 the surveyor observed Staff 10 (Cook) handle food with bare hands while transferring food onto the tray line. Staff 4 (Dining Services Manager) asked Staff 10 to stop what he was doing, wash his hands and don gloves before touching food. Findings were reviewed with Staff 4 (Dining Services Manager) on 4/19/21 at 11:30 am. He acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure ancillary services were obtained for 1 of 1 sampled resident (#4) who was reviewed. Findings include, but are not limited to:An anonymous complaint was received during the survey stating Resident 4 had not received foot care, specifically toenails were not being clipped. The complainant alleged the resident had toenails that had "curled" due to the length of them.On 4/20/21 at 10:00 am, with the resident's permission, his/her right foot and nails were observed and revealed long toenails that had started to curl over the toes. In an interview on 4/20/21, Witness 1 revealed the facility had talked about arranging services for a podiatrist to come to the facility over a year ago. Witness 1 stated "...not sure it happened ..." Observation of both feet and nails was completed with Staff 1 (RN) on 4/21/21 who verified the nails were long and some had curled, and podiatry services were needed.The failure to ensure ancillary services were obtained was reviewed with Staff 1 (Executive Director) during the survey. No further information was received.

2. Resident 4 was identified as high care and with weight loss during the acuity interview of 4/19/21. During the survey, the resident, who was up in a high back wheelchair in his/her room, was observed on 4/21/21 in the morning to have an empty paper cup with brown residue at the bottom of it sitting on a table. Later observation revealed unopened cartons of nutritional supplements in the resident's refrigerator. On 4/21/21 at 1:42 pm, a lunch plate was on his/her table uneaten and the resident was noted in his/her wheelchair next to the bed with his/her back towards the table. Shortly after, Staff 9 (CG) entered the room and assisted the resident to bed per his/her request without offering encouragement of the lunch meal or offering an alternative. Staff 9 stated "[he/she] doesn't need assistance with meals ..." and the resident had a supplement. Interview with Witness 1 on 4/21/21 at 2:00 pm revealed the resident had a pacemaker that required a yearly office visit, was a picky eater and named a few of his/her favorite foods including a peanut butter and jelly sandwich. On 4/22/21, a review of the resident's electronic 4/1 through 4/19/21 MAR with Staff 5 (MT) revealed staff were to monitor meal consumption but there were no further instructions on what to do based on the documented meal consumption. The resident's most current plan of care failed to be reflective, provided clear caregiving instructions and was followed in the following areas: * No identification the resident had a pacemaker and maintenance of the device;* Identified the resident may be reluctant to eat and instructed staff to " ...encourage [resident's name] to eat ...";* Some favorite foods were identified except the peanut butter and jelly sandwich. There were no further instructions on when the favorite foods were to be offered;* Instructed staff to "cut up tough foods like meats ..." An uneaten whole fried chicken was observed on the resident's lunch plate on 4/21/21; and* No information on the use of supplements, when to provide and by whom.Failure to ensure service plans were reflective, provided clear caregiving instructions and were followed was discussed with Staff 1 and Staff 2 (RN) during the survey. No further information was provided.
Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of resident's current health status and care needs, lacked clear direction to staff regarding the delivery of services, were followed or updated quarterly or following a change of condition for 3 of 4 sampled residents (#s 1, 3 and 4) whose service plans were reviewed. Findings include, but are not limited to:1. Observations and an interview with the resident and interviews with staff revealed Resident 3's service plan, dated 12/30/20, was not reflective and lacked clear direction to staff in the following areas: * Cognition; * Ambulation and mobility; and* Bowel and bladder management related to incontinence. Resident 3 was hospitalized for COVID related illness on 3/9/21, moved to a rehabilitation facility on 3/19/21, and returned to the community on 3/26/21. Progress notes and interview with staff on 4/20/21 revealed that the resident's service plan had not been updated since return, and was not reflective of his/her current status and care needs.The need to ensure service plans were reflective of the residents needs and included clear direction to staff was discussed with Staff 1 (Executive Director) on 4/21/21. He acknowledged the findings.
3. During the acuity interview on 4/19/21, Resident 1 was identified as high care needs and had a pressure ulcer.During an interview with the resident and staff, and record review the service plan was not reflective or updated after a significant change of condition in the following areas:* Pain management and the use of a TENS unit; and* Stage two pressure ulcer on buttocks and treatment.The need to ensure the service plan was reflective of the resident's needs, current status and was updated after a change of condition was discussed with Staff 1 (Executive Director) and Staff 2 (RN) on 4/21/21. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of a resident's current status and provided clear direction to staff, for 1 of 3 sampled residents (# 8) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:Resident 8 was admitted to the facility in April 2021 with diagnoses including hallucinations and congestive heart failure. Resident 8's service plan was not reflective of the resident's current status and/or lacked clear direction to staff in the following areas:* Edema/leg elevation;* Refusal of ADL care; * Call light use;* Hallucinations/agitation;* Wheelchair use;* Chronic knee pain; and* Inappropriate/unsafe heating pad use.The need to ensure all resident service plans were reflective and provided clear directions to staff was discussed on 7/27/21 with Staff 1 (Executive Director) and Staff 2 (RN). The staff acknowledged the findings.

2. Resident 2 was admitted in 2018 and was observed during the survey to ambulate with a walker in his/her apartment. The service plan, dated 2/12/21, indicated s/he was a fall risk and several fall prevention interventions were identified. Resident 2's record revealed s/he fell on 3/29/21 and 3/31/21. On 4/19/21, Staff 1 (Executive Director) provided incident investigations for both falls. The documents contained a section titled "Post-Fall Evaluation". Review of this section revealed several areas had not been completed and were blank.The facility failed to investigate if service-planned interventions were implemented, were effective or if new interventions were needed. The need to ensure the facility reviewed fall interventions to determine if they were effective and appropriate was shared with Staff 1 (Executive Director) and Staff 2 (RN) on 4/20/21 at 11:45 am. They acknowledged the investigations were incomplete and a review of fall interventions had not been done. No new information was provided.
3. Resident 3 was admitted to the facility in 1/2019 with diagnoses including Alzheimer's disease. Review of the resident's clinical record indicated the following issues were not monitored or evaluated:a. Resident 3 complained of burning with urination on 3/2/21 and a fax was sent to the primary care physician requesting an order for a urinalysis (UA). No documented follow-up or intervention was conducted. In an interview on 4/20/21 Staff 2 (RN) confirmed that no further action was taken, and the resident's urinary tract infection was treated when the resident was hospitalized on 3/9/21 for COVID related illness. There was no documented evidence of monitoring of his/her condition from 3/2/21 to 3/9/21. The failure to monitor the resident's condition following the request for a UA was discussed with Staff 1 (Executive Director). No further information was received. b. Resident 3 was hospitalized due to COVID related illness from 3/9/21 until 3/19/21, stayed in a rehabilitation facility from 3/19/21, and returned to facility on 3/26/21. A temporary service plan was completed on 3/26/21 upon return, instructing staff to "observe for changes in mobility, pain, and skin issues." There was no evidence the facility had evaluated the resident's condition upon return to the facility. The following progress notes were entered following the resident's return the facility:*3/31/21 "Resident is on alert for increasing confusion .....Resident has been very weak and has had trouble supporting [his/her] own weight";*4/1/21 "Resident has been very confused today. [S/he] has been calling around every half hour for staff to come in. Resident did not eat all of [his/her] meal. [S/he] only had about half of it ..."; and*4/7/21 "Resident used call light over 30 times during the 14:00-22:00 [2:00 pm - 10:00 pm] shift. [S/he] was also yelling out for help every 5 min .....[S/he] could not remember [his/her] room number. [S/he] is refusing to assist with transfers. [S/he] says [s/he] cannot move [his/her] feet."In an interview on 4/20/21 with Staff 9 (CG) she stated "[Resident 3] is our hardest transfer, even with the gait belt ....doesn't use [his/her] legs for transfer .....it's been worse since returning from COVID [hospitalization]."Failure to evaluate or monitor the change in condition, refer to the RN following the hospitalization, and subsequent mobility and cognition changes was discussed with Staff 2 (RN) on 4/20/21 and Staff 1 (Executive Director) on 4/21/21. No further information was received.
Based on observation, interview and record review, it was determined the facility failed to ensure significant changes of conditions were evaluated and referred to the RN, failed to ensure short term changes were evaluated, specific resident interventions determined and documented and the condition monitored with weekly progress until resolved for 3 of 3 sampled residents (#s 1, 2 and 3) who experienced changes of condition in the areas of skin, pain management, infection, falls and ADL care needs. Findings include, but are not limited to:1. Resident 1's record from 1/1/21-4/19/21, identified the following changes of condition: a. On 2/24/21 Home Health provider notes that indicated Resident 1 had a stage two wound on the buttocks with instructions for staff to apply barrier cream twice per day. There was no documented evidence the facility had evaluated the wound, monitored the condition of the wound to resolution, or notified the RN of the significant change of condition. b. On 3/30/21 Resident 1 had a non-injury fall. The facility failed to investigate causal factors for the fall or review the service planned fall interventions for effectiveness. c. Resident 1 was prescribed Hydrocodone (narcotic pain medication) to be taken four times per day. The resident had routinely taken the medication since 6/12/2020. The facility failed to reorder the medication timely, therefore ran out of the medication. The resident missed the following doses of the medication: * 4/14/21 at 5:00 pm and 11:00 pm;* 4/15/21 at 5:00 am, 12:00 pm, 5:00 pm, 11:00 pm; and* 4/16/21 at 5:00 am, 12:00 pm, and 5:00 pm. The facility failed to evaluate and monitor the resident's pain level until 4/17/21, after the resident received the medication again. The need to have a system in place to ensure significant changes of conditions were referred to the RN, and short term changes were evaluated, specific resident interventions determined and documented and the condition was monitored, weekly until resolved was discussed with Staff 1 (Executive Director) and Staff 2 (RN) on 4/21/21. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure the facility RN performed an assessment, developed interventions based on the condition of the resident, or updated the service plan for 2 of 2 sampled residents (#s 1 and 3) who experienced a significant change of condition. Findings include, but are not limited to:1. Resident 3 was admitted to the facility in 1/2019 with diagnoses including Alzheimer's disease. Resident 3's clinical records, observations made during survey and interviews with staff indicated the resident had experienced an overall decline in physical status including cognition decline, change in ambulation, and increase in ADL assistance following a hospitalization and rehabilitation for COVID related illness from 3/9/21 to 3/26/21.On 4/20/21, Staff 2 (RN) confirmed there had been no change of condition assessment completed for the resident, the service plan had not been updated, and no interventions had been implemented regarding the resident's current status. The lack of an RN assessment regarding Resident 3's significant change in condition was reviewed with Staff 1 (Executive Director) on 4/21/21. He acknowledged the findings.
2. Resident 1 was identified as having a pressure ulcer on the coccyx during the acuity interview on 4/19/21. On 2/24/21, a Home Health provider note indicated the resident had a stage two wound on his/her right buttocks that measured 0.7 X 0.4 X 0.1 cm and instructed staff to apply barrier cream twice per day. The stage two pressure area constituted a significant change of condition.There was no documented evidence the facility RN completed an assessment of the wound. On 4/19/21, the surveyor interviewed Resident 1, who stated " I don't have that anymore, it's healed now."The lack of an RN assessment regarding Resident 1's significant change in condition was reviewed with Staff 1 (Executive Director) and Staff 2 (RN) on 4/21/21. They acknowledged the findings.

Based on 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 service being provided and any clinical information necessary for facility staff to provide supplemental care, for 1 of 1 sampled resident (#1) who received Home Health services. Findings include, but are not limited to:During the acuity interview on 4/19/21, Resident 1 had a pressure ulcer. Interviews with staff and resident, and record review was conducted during the survey. a. On 2/24/21, a Home Health provider note indicated the resident had a stage two wound on the right buttocks that measured 0.7 X 0.4 X 0.1 cm and required staff to apply barrier cream twice per day. On 2/24/21 the community RN signed and acknowledged the home health provider note. Upon review of the 2/2021-4/19/21 MAR, there was no evidence the facility had applied the barrier cream to the wound. The facility was unable to provide further Home Health notes regarding the status of the wound or if the wound was resolved.On 4/19/21 surveyor interviewed Resident 1, who stated " I don't have that anymore, it's healed now."b. On 3/5/21 Home Health recommended the use of a TENS (transcutaneous electrical nerve stimulation) unit for pain management. On 3/6/21, the facility licensed nurse signed the provider note, and indicated the recommendation was entered into the MAR. Upon review of the 3/2021 MAR there was no entry to include the use of the TENS unit and there was no temporary service plan informing care staff of the changes in care. During an interview with Resident 1 on 4/21/21, s/he stated, "I can only use it sometimes, because only one person knows how to use it and I can't reach to put it on myself." During an interview with Staff 9 (CG) on 4/21/21 she stated "I don't even know what that is."The need to ensure the facility had a system in place 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 clinical information necessary for facility staff to provide supplemental care was discussed with Staff 1 (Executive Director) and Staff 2 (RN) on 4/21/21. They acknowledged the findings.

2. On 2/22/21 a home health agency for Resident 5 documented " ...large number of pills found in room. Returned to med tech as pt [patient] does not manage own meds ..."A review of the incident was requested during the survey. There was no documented evidence a review had been completed in order to determine follow-up action. That was verified by interview with Staff 1 (Executive Director) during the survey.
Based on observation, interview and record review, it was determined the facility failed to ensure a safe medication system and failed to ensure adequate professional oversight. Findings include, but are not limited to:1. During the relicensure survey, conducted 4/19/21 through 4/21/21, the facility failed to ensure a safe medication and treatment system, and administrative oversight was found to be ineffective based on deficiencies in the following areas:C 301: Systems: Medication Administration;C 303: Systems: Medication and Treatment Orders;C 304: Systems: Medication and Treatment Review;C 305: Systems: Resident Right to Refuse; and C 310: Systems: Medication Administration.Failure to ensure a safe medication system and to ensure adequate professional oversight based on deficiencies related to medication administration was discussed during the exit meeting on 4/21/21.

Based on observation, interview and record review, it was determined the facility failed to ensure a safe medication system and failed to ensure adequate professional oversight for 1 of 1 sampled resident (#5). This is a repeat citation. Findings include, but are not limited to:During the Acuity review on 7/26/21, Resident 5 was identified to require assistance with ADLs and medication administration.Observation of the resident in her/his room revealed the resident had a pill box with pills in it. The resident was unable to answer how s/he obtained the pills. Resident 5's clinical records revealed s/he did not have an order to self administer medications. The facility staff were to administer the medications.In an interview with Staff 14 (Med Tech) on 7/26/21, he was unaware the resident had medications in her/his room. Staff 14 removed the medications from the resident's room.The incident was shared with Staff 1 (ED) on 7/26/21. He indicated a family member sometimes would bring in medications for the resident and had been told not to. He further stated, a system would be put in place to visit the resident after the family member left to check to see if medications were left for the resident.

Based on interview and record review, it was determined the facility failed to ensure medications administered by the facility were documented by the same person who administered the medication for 1 of 1 sampled resident (#1). Findings include, but are not limited to:Resident 1 had diagnoses which included Type I Diabetes, which required daily CBGs and sliding scale insulin injections. Resident 1's 2/2021-4/19/2021 MARs and 1/1/21-4/19/21 progress notes were reviewed during the survey. Progress notes and MARS indicated some medications were administered by one staff member and signed by another staff member at a later time for the following medications and dates:* 1/30/21 Humalog inject 12 units before meals and Lantus Solution Inject 20 units in the morning was administered by a former staff member (MT) and signed by Staff 6 (MT);* 3/4/21 and 3/5/21 Levetiracetam Tablet (seizure medication) was administered by a former staff member (MT) and signed by Staff 5 (MT); and* 3/25/21 Pantoprazole was administered by a former staff member (MT) and signed by Staff 6 (MT). During an interview on 4/21/21, Staff 2 (RN) explained, staff were working 12 hour shifts and the night shift was administering some medications before the day shift started at 6:00 am. Day shift staff were then initialing the MAR, indicating they had administered the medications. The need to ensure medications administered by the facility were documented by the same person who administered the medication was discussed with Staff 1 (Executive Director) and Staff 2 (RN) on 4/21/21. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure orders were carried out as prescribed, and signed provider orders were documented in the resident's record for all medications and treatments the facility was responsible to administer, for 3 of 3 sampled residents (#s 1, 2 and 3) whose orders were reviewed. Findings include, but are not limited to:1. Resident 2 moved into the facility in 2018 and had diagnoses which included hypertension and chronic obstructive pulmonary disease.Resident 2's MAR and physician orders, reviewed from 4/1/21 - 4/19/21, revealed the following:* The resident had an order for staff to check his/her weight every three days and notify the physician if s/he gained more than seven pounds in one week. Between 4/1/21 and 4/19/21, one weight was documented.* On 4/1/21, the physician instructed staff to obtain a daily BP and pulse. From 4/1/21 and 4/19/21, no pulse was documented. Additionally, there were six days when no BP was documented. * The MAR also instructed staff to notify the facility RN if the systolic BP (upper number) was greater than 150 or lower than 90, and if the diastolic BP (lower number) was greater than 90 or lower than 60. Staff failed to notify the RN of BPs outside of parameters on two occasions.Resident 2's MARs and orders were reviewed with Staff 2 (RN) on 4/19/21. She acknowledged that staff failed to ensure orders were carried out as prescribed.
2. Resident 3 was admitted to the facility in 2019 with diagnoses including Alzheimer's disease. a. Resident 3's physician order dated 10/23/20, directed staff to administer 600 mg of Gokshuradi Guggulu (supplement) twice daily to prevent future UTIs. MARs from 3/1/21 to 4/19/21 were reviewed. The supplement was not administered over 30 times due to not being at the facility.b. Resident 3's physician order dated 10/23/20, directed staff to administer 10 mg Norvasc daily for high blood pressure.MARs from 3/1/21 to 4/19/21 were reviewed. The medication was not administered four times (3/4/21, 3/18/21, 4/7/21 and 4/8/21) due to the medication not being at the facility.The lack of following medication orders was discussed with Staff 1 (Executive Director) on 4/21/21. He acknowledged the findings.
3. Resident 1 moved into the facility in 2008 and had diagnoses which included cellulitis and urinary tract infection (UTI). Resident 1's MAR from 2/1/21 - 4/19/21 and current physician orders were reviewed and identified the following:a. Signed orders were not available upon request for the following medications:* Nitrofuranation Mono Macro Capsule (for UTI);* Acetaminophen tablet every four hours (for pain); * Bisacodyl tablet (for constipation);* Diclofenac Sodium gel (for pain);* Solifenacin Succinate tablet (for bladder spasm); and* Nystatin Cream (for yeast infection).b. The 4/2021 MAR instructed staff to notify the MD when blood sugar level was over 400. Staff failed to notify MD when blood sugar was outside parameters on 3/6/21, 3/12/21 and 3/30/21.c. The MAR instructed staff to administer Humalog insulin at 8:00 am, 12:00 pm, 5:00 pm and before meals. Between 4/1/21 and 4/19/21 there were seven occasions when the insulin was administered over an hour past the scheduled dose times and past the scheduled meal time. On 4/19/21 the surveyor observed Staff 7 (MT) administer the insulin at 1:02 pm, after the resident had consumed lunch. Staff 7 stated, "yes, you will see that the medication is in the red, it's late today because I was pulled to do other stuff." On 4/19/21, Resident 1 stated "I know the insulin should be given before I eat, but if my meal is here, am I supposed to wait 30 minutes or an hour sometimes for them to come in with my insulin? No, I'm going to eat my lunch."Resident 1's MARs and orders were reviewed with Staff 1 (Executive Director) and Staff 2 (RN) on 4/21/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure a registered pharmacist or registered nurse reviewed all medications and treatments administered to residents by the facility at least every 90 days for 2 of 2 sampled residents (#s 1 and 3). Findings include, but are not limited to:Resident 1 and 3's records were reviewed and showed a lack of documented pharmacist or RN reviews. The last documented pharmacist medication and treatment reviews were completed in October 2020. There was no additional documentation by a pharmacist or RN. The need to ensure a pharmacist or an RN reviewed medication and treatments administered by the facility at least every 90 days was discussed with Staff 1 (Executive Director) 4/21/21. He acknowledged the findings.

Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused to consent to orders for 1 of 1 sampled resident (#2) who had documented medication and treatment refusals. Findings include, but are not limited to:Resident 2's MARs were reviewed for the time period of 4/1/21 through 4/19/21. Staff documented Resident 2 refused:* Refresh eye ointment (relieves eye dryness) 16 times;* Zocor 20 mg (to treat high cholesterol) once;* Azelastine nasal spray (for allergies) once;* Colace 100 mg (stool softener) once;* Eliquis 2.5 mg (for atrial fibrillation) once;* Prozac 20 mg (for depression) once; and * Wellbutrin 150 mg (for depression) once.There was no documented evidence the facility notified Resident 2's physician of the refusals.In an interview on 4/19/21, Staff 2 (RN) reviewed the record and acknowledged there was no documented evidence the facility had notified the physician of the refusals.

2. Resident 3 was admitted to the facility in 2019 with diagnoses including Alzheimer's disease.The resident's 3/1/21 through 4/19/21 MARs and physician orders were reviewed. The MARs contained inaccuracies in the documentation for the following treatments and medications:a. Norvasc 10 mg daily for high blood pressure. Recorded as not administered due to medication not being available on 4/4/21 and 4/18/21, however the medication was administered day before and after. b. Gokshuradi Guggulu (supplement) 600 mg twice daily for prevention of UTIs. Recorded as administered once on 3/7/21 and twice on 3/29/21 when the supplement was not available. Additionally, the supplement was not administered on 4/2/21 and 3/30/21 with no documented reason on the MAR as to why. The need to ensure MARs were accurate was discussed with Staff 1 (Executive Director) on 4/21/21. He acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure that MARs/TARs were complete and accurate for 2 of 3 sampled residents (#s 1 and 3) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in October 2008.Review of the residents 2/1/21 through 4/19/21 MAR/TAR showed the following incomplete or inaccurate entries:* On 3/24/21 and 3/25/21 there were no initials for the staff member who administered routine Hydrocodone.The need to ensure MARs/TARs were complete and accurate was discussed on 4/21/21 with Staff 1 (Executive Director) and Staff 2 (RN). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired caregiving staff (#s 7, 11 and 12) demonstrated satisfactory performance in all required areas within 30 days of hire. Findings include, but are not limited to:Training records were reviewed and interview with Staff 1 (Executive Director) on 4/21/21 revealed the following:There was no documented evidence Staff 7 (MT) hired 3/1/21, Staff 11 (CG) hired 2/15/21 and Staff 12 (CG) hired 2/18/21 had demonstrated competency in all required areas within 30 days of hire including:* Providing assistance with activities of daily living; and * Staff 7, who also had responsibilities including administering medications, had no documented evidence of demonstrated competency in medication administration.The above areas were verified during the record review with Staff 1 on 4/21/21.

Based on interview and record review, it was determined the facility failed to have documented evidence that six hours of annual in-service training related to the care of the dementia resident was completed out of the required 12 hours of annual in-service training for 1 of 1 long-term staff (#5) whose training records were reviewed. Findings include, but are not limited to:The annual in-service training records for the Year 2020 were reviewed on 4/20 and 4/21/21 and revealed the following:* Staff 5 (MA), hired 10/2017, failed to have documented evidence of completing six hours of dementia care in-service training as part of their annual 12 hours of required in-service training. Staff 1 (Executive Director) acknowledged the findings on 4/21/21.

Based on interview and record review, it was determined the facility failed to ensure residents received fire and life safety training within 24 hours of move in and annually. Findings include, but are not limited to:Fire and life safety records were requested during the survey. The following deficiencies were identified:* Documentation of fire and life safety training provided to residents within 24 hours of move in; and * Documentation of annual fire and life safety training provided to residents.The need to ensure residents received fire and life safety training within 24 hours of admission and re-instructed, at least annually, was discussed with Staff 1 (Executive Director) and Staff 3 (Maintenance) on 4/20/21 at 1:55 pm. They acknowledged the findings. No further information was provided.

Based on observation, interview and record review, it was determined the facility failed to ensure their re-visit survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to C260 and C300.

Based on observation and interview, it was determined the facility failed to ensure the environment was kept in good repair and free from unpleasant odors. Findings include, but are not limited to:1. Observations of the facility between 4/19/21 and 4/21/21 revealed the following:* Handrails, door frames and base boards throughout the facility had chipped paint and exposed wood; and* Unpleasant odors outside of Rooms 107, 108 and 228.The surveyor and Staff 3 (Maintenance) toured the environment on 4/20/21. He acknowledged the findings.2. The following was observed in Room 225 during the survey:* Stained carpet throughout the unit;* A persistent odor was noted;* Gouged walls; and* Extensive dried spillage of food/liquid matter on the exterior drawers of the writer's desk. The areas observed in Room 225 were discussed with Staff 1 (Executive Director) during the survey. No further information was provided.