Rosewood Park Retirement and Assisted Living Residence

Based on observation and interview, it was determined the facility failed to ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000.

Findings include, but are not limited to:

On 07/08/25 at 10:45 am, the facility kitchen was observed to need cleaning in the following areas:

* Glass shelving above salad bar on service line – dusty/sticky;

* Coffee grounds scattered on counter in back kitchen;

* Shelf under handwashing sink in back kitchen – drips/spills;

* Microwave interior – significant food splatters ;

* Flooring throughout the kitchen including underneath and/or behind storage racks, prep counters, cooking equipment, below coffee maker, two and three compartment sink counters – drips/spills/food debris/trash;

* Bulk food bins – exteriors with significant food debris/spills;

* Bottom shelving throughout the kitchen including below stand mixer, grill, convection oven, prep counter with can opener, counter holding soup pot, prep counter holding fresh fruit and small equipment;

* Vent and surrounding ceiling area above prep counter next to walk in refrigerator – heavy build up of dust;

* Handwashing sink and wall behind next to prep counter – brown matter build up on wall and surrounding faucet and water control handles;

* Portable air conditioner next to prep counter – significant amount of food spills/debris;

* Commercial can opener and housing – blade worn off finish and black matter/food debris build up;

* Wall behind counter holding can opener – brown matter splatter/drips;

* Hood vents above cooking equipment – significant amount of grease and dust build up;

* Oven door below grill – significant amount of grease build up on ledge of door;

* Top of dishwashing machine – significant build up of loose dried matter;

* Wall behind hose sink and dishwashing machine – drips of brown and black matter;

* Exterior of ice cream freezer – ice cream drips/spills;

* Spice shelving – build up of debris;

* Sides of stove, grill and deep fat fryer – drips of food and grease;

* Wall behind cooking equipment – grease/spills;

* Walk in freezer floor – loose pieces of food; and

* Hot holding container for soup – significant dried on drips/spills.

Improper food storage included:

* Dry food storage – open food items without dates (dry cereal, biscuit mix, gravy mix, dry yeast, tortillas, noodles);

* Containers with lids unsecured/improper fit – polenta, panko crumbs;

* Open to the air bags of bulk food – powdered sugar, brown sugar, panko crumbs, granulated sugar ;

* Three-tiered cart of cookies uncovered;

* Speed rack with four trays of uncovered desserts;

* Open box of bacon in walk in refrigerator; and

* Boxes of food on floor in walk in freezer.

Other areas of concern:

* Colored cutting boards heavily scored and finish worn off.

* Facial hair not restrained.

The areas of concern were observed and discussed with Staff 1 (Cook/Person In Charge) and discussed with Staff 2 (Interim Administrator) and Staff 3 (Business Office Manager on 07/08/25. The findings were acknowledged.

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

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

This Rule is not met as evidenced by:

Based on interview and record review, conducted during a site visit on 09/05/24, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 4 of 6 sampled residents whose medication and treatment orders were reviewed (#s 1, 15, 16 and 17). Findings include, but are not limited to:Facility self-reports for residents 1,15, 16 and 17 dated 05/10/24 indicated the facility had recognized, appropriately investigated, and corrected medication errors for sampled residents.A review of Resident 1's Physician Orders dated 01/17/23, indicated Resident 1 was to receive 50 unit of Levemir subcutaneously in the morning for diabetes management, notify MD if CBG less that 70 or over 400.* MARs dated 04/01/24 -04/30/24, indicated that Resident 1's CBG's were not recorded for Levemir administration with missed injections on 04/6/24, 04/14/24 and 04/19/24. A review of resident 15's Physician Orders dated 03/09/23, indicated Resident 15 was to receive Escitalopram 5MG TAB every morning for a mood disorder.* MARs dated 04/01/24-04/30/24, indicated the medication was not given on 04/12/24, 04/13/24, 04/15/24 and 04/16/24. The medication was not available on 04/14/24 and 04/17/24.* Progress Notes dated 04/17/24, indicated the facility called the pharmacy regarding resident's missed medication and the pharmacy said to fax and not call to refill. Medications were reordered on 04/17/24.A review of Resident 16's Physician orders dated 02/01/23, indicated the injection of Lantus 100-U/ML PEN 3 ML seven units subutaneously every morning, hold for CBG less than 100 and notify PCP if less than 80 or greater than 300 for two days or more in a row greater than 400.* MARs dated 04/01/024-04/30/24 indicated injections did not occur on 04/15/24, 04/23/24 and on 04/30/24. * Progress Notes dated 04/15/24 indicated care staff walked past residents room and resident was on the floor.A review of Resident 17's Physician Orders dated 06/02/23 indicated Metoprolol Extended Release 50 MG tablet for high blood pressure once a day.* Progress Notes dated 05/01/24 - 05/31/24 indicated the medication was not administered on 05/18/24, 05/19/24, 05/20/24 and 05/21/24.* Progress notes for Resident 17 dated 05/07/24, indicated the resident was on alert for missed Metoprolol.In an interview, Staff 1 (Administrator) stated Staff 8 (LPN) was no longer providing consultation services for the facility. Staff 8 could not be interviewed. During the interview Staff 1 confirmed the medication errors had occurred.The findings were reviewed with and acknowledged by Staff 1 (Administrator), Staff 2 (Nurse Consultant) and Staff 3 (Nurse Consultant) on 09/05/24.It was determined the facility failed to carry out medication orders as prescribed.Verbal Plan of Correction: Facility self-reported all three incidents to the local Seniors and People with Disabilities office as required. Facility to follow up on medications not available and or not given. Med-tech counseling and training on documentation of medication. Timely processing of orders in the third check system. Med Tech meetings every two weeks, next one is scheduled 09/10/2024. Based on interview and record review, conducted during a site visit on 09/05/24, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (# 9). Findings include, but are not limited to:Resident 9 had a physician order, dated 05/06/24, showed Glipizide 2.5 MG (for high blood sugar) tab one tablet by mouth every morning starting on 05/10/24.Resident 9's Medication Administration Record (MAR), dated 06/01/24 through 06/30/24, indicated Resident 9 was not administered his/her Glipizide from 06/06/24 through 06/10/24. Notes indicated "Drug not available."Resident 9's progress notes, dated 06/06/24-06/11/24, indicated the following:* The pharmacy informed the facility Glipizide 2.5 MG tab would no longer be covered by insurance;* The resident signed for an immediate delivery that S/he would pay for;* The pharmacy alleged they did not receive the delivery request faxed by the facility;* The pharmacy stated they would send medication the night of 06/10/24; and* The facility faxed a request to the resident's PCP to provide a substitute medication.Resident 9's physician order, dated 06/12/24, showed:* Glimepiride 1 MG tab (for high blood sugar) one tablet by mouth every morning to begin on 06/12/24.In an electronic communication on 10/07/24, Staff 1 (Executive Director) stated the following:* Med techs reordered medication;* Medications were to be reordered seven days prior to the last dose;* Families often purchased medications not covered by insurance; and* The facility could purchase medication in the event families could not.On 09/05/24, Staff 1 (Administrator) acknowledged the medication was not administered.It was determined the facility failed to carry out medication and treatment orders as prescribed. The findings of the investigation were reviewed with and acknowledged by Staff 1, Staff 2 (RN Consultant) and Staff 3 (RN Consultant) on 09/05/24. Verbal plan of correction: Facility's nurse consultants will follow up on medications not available and or not given. Med-tech counseling and training on documentation of medication. Timely processing of orders in the third check system. Med tech meetings every two weeks; next one is scheduled 09/10/2024.

Based on interview and record review conducted during a site visit on 09/05/24, it was confirmed the facility failed to maintain an accurate MAR for 5 of 5 sampled residents (#s 1, 13, 15, 16, 17) whose MARs were reviewed. Findings include, but not limited to the following:A review of Resident 1's MAR dated 04/01/24 -04/30/24, indicated missing signatures for the following medications:* no CBGs were recorded for Levemir administration with doses missed on 04/06/24, 04/14/24, 04/19/24, and 04/27/24.A review of Resident 13's MAR dated 04/01/24 -04/30/24, indicated missing signatures for the following medications:*1. Humalog: No CBG recorded on 04/06/24 am, 04/14/24 am, 04/14/24 pm, 04/15/24 pm, 04/27/24 am* Humulin 36 units: No CBG recorded on 04/06/24, 04/14/24, 04/27/24* Humulin 30 units: No CBG Recorded on 04/14/24 and 04/15/24A review of Resident 15's Progress notes dated 04/25/24 indicated the resident's medication was not available on day shift. Medication was delivered on evening shift. A review of resident 15's MAR dated 04/01/24-4/30/34 revealed all morning medications on 4/25/24 were signed for by Med tech. A review of Resident 16's MAR dated 04/01/24-04/30/24 indicated missing signatures 04/15/24, 04/23/24 and 04/30/34.*no CBGs were recorded for Lantus on 04/15/24, 04/23/24, and 04/30/24.A review of Resident 17's progress note dated 05/05/24 indicated the resident was not administered Dapsone from 04/15/24 to 05/07/24. A review of Resident 17's MAR dated 04/01/24 - 05/31/24 revealed Dapsone was signed as administered on the following dates:* 04/18/24, 04/25/24 ,04/26/24 04/27/24, 04/28/24 04/29/24,04/30/24, * 05/01/24, 05/02/24, 05/03/24, 05/05/24, 05/05/24In an interview on 09/05/24, Staff 1 (Administrator) confirmed the MARs were not accurate. It was determined the facility failed to maintain an accurate Medication Administration Record. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Administrator), Staff 2 (Nurse Consultant) and Staff 3 (Nurse Consultant). Verbal plan of correction: Facility self-reported all three incidents to the local Seniors and People with Disabilities office as required. Facility to follow up on medications not available and or not given. Med-tech counseling and training on documentation of medication. Timely processing of orders in the third check system. Med tech meetings every two weeks, next one is scheduled 09/10/2024.

Based on observation, interview, and record review, conducted during a site visit on 09/05/24, it was confirmed the facility failed to fully implement and update an acuity-based staffing tool (ABST). Findings include, but are not limited to:The facility's posted staffing plan showed the following:* Day shift: six care staff;* Evening: five care staff; and* Night: four care staff.A review of the facility's ABST revealed the following:* Not all residents' profiles had been updated in the last quarter.* The facility's Posted Staffing Plan did not meet the staffing hours required by the ABST.In an interview on 09/05/24, Staff 6 (Resident Care Coordinator) stated the following:* The facility's posted staffing plan had not been updated regularly.* S/he was unaware of the requirement to save resident profiles who had no changes to their service plans in the last quarter in order to reflect accurate quarterly review dates.It was confirmed the facility failed to fully implement and update an acuity-based staffing tool.The findings were reviewed with and acknowledged by Staff 1 (Administrator), Staff 2 (Nurse Consultant), and Staff 3 (Nurse Consultant) on 09/05/24.

The findings of the kitchen inspection, conducted 06/26/24, 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 first revisit to the kitchen inspection of 06/26/24, conducted 10/09/24 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 ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to:On 06/26/24 at 10:50 am, the facility kitchen was observed to need cleaning in the following areas:* Three tiered carts - food debris/crumbs - carts included in dishroom washing room holding clean dishes; salad bar and the cart used to deliver meals to residents eating in their rooms;* Commercial can opener - blade and housing - black matter on blade and food grime and mold in/on housing; * Glass shelves above salad bar - sticky residue and food debris;* Dishwashing area - booster and exterior of the dishwasher - drips/spills; and the wall behind the spray hose - black matter build up;* Front of three compartment sinks - drips/spills; * Interior of drawers on prep counters - build up of food debris; * Exterior of food bins - food debris;* Lower & upper shelves throughout kitchen - food debris/dust; * Front of glass doors to reach in portion of walk in refrigerator - drips/splatter;* Exterior of deep fat fryer - grease drips; * Exterior sides & front of convection oven - food and/or grease drips;* Hood vents - grease and dust build up;* Ceiling above walk in refrigerator fans - white matter build up;* Interior of microwave - food splatter;* Ceiling and around light fixture between stove/grill and walk in refrigerator - significant build up of dust;* Wall and ceiling above prep counter next to walk in refrigerator - significant build up of dust; and* Floor under grill/stove/deep fryer/convection oven - build up of black matter.Other areas of concern: * Colored cutting boards - finish worn off, likely uncleanable; and * Blue bin containing flour - not fully covered & scoop stored inside. The areas of concern were observed and discussed with Staff 1 (Kitchen Manager) and discussed with Staff 2 (Maintenance Director) on 06/26/24. The findings were acknowledged.

The findings of the on-site investigation, conducted 09/08/23 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 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 11/15/22 through 11/17/22, 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 revisit to the re-licensure survey of 11/22/22, conducted 07/10/23 through 07/14/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities 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 daySituations were identified where there was a failure of the facility to comply with the Department's rules that were likely to cause residents serious harm. Immediate plans of correction were requested in the following areas:OAR 411-054-0025(1) Facility Operation;OAR 411-054-0045 Resident Health Services; andOAR 411-054-0055(1)(a) Medication and Treatment Administration Systems.The facility put immediate plans of correction in place during the survey and the situations were abated.



The findings of the second re-visit to the re-licensure survey of 11/22/22, conducted 12/18/23 through 12/20/23, are documented in this report. The survey was conducted to determine compliance with the 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 third revisit to the re-licensure survey of 07/14/23, conducted on 3/07/24, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Based on observation, interview and record review, it was determined the facility failed to provide effective oversight to ensure quality of care and services that were rendered in the facility. Findings include, but are not limited to:During the survey, conducted 11/15/22 through 11/17/22, administrative oversight to ensure adequate resident care and quality of services rendered in the facility were found to be ineffective based on the number of citations.Refer to deficiencies in report.

Based on observation, interview and record review, it was determined the facility failed to provide effective administrative oversight to ensure the quality of care and services rendered in the facility based on the number and severity of citations. This is a repeat citation. Findings include, but are not limited to:During the first re-visit to the 11/22/22 re-licensure survey, conducted 07/10/23 through 07/14/23, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number and severity of repeat citations, and new citations.A situation was identified which constituted a threat to residents health and safety and required an immediate plan of correction in the following areas:OAR 411-054-0025(1) Facility Operation;OAR 411-054-0045 Resident Health Services; andOAR 411-054-0055(1)(a) Medication and Treatment Administration Systems.On 07/11/23 at 3:30 pm, the survey team requested an immediate plan of correction to address the issues identified. The plan was received at 4:12 pm and accepted by the survey team. The immediate jeopardy situation was abated at that time.Refer to deficiencies in the report.

Based on interview and record review, it was determined the facility failed to implement effective methods of responding to and resolving resident complaints. Findings include, but are not limited to:1. A review of Resident Council minutes dated 11/2022 revealed the following resident concerns: * No response regarding resident request for a rack to be placed near the front desk for flyers;* No response regarding resident request for an ADA-compliant door to be installed to the courtyard; and* No response regarding resident request for a flu shot clinic.2. During a group interview conducted on 11/16/22 with six un-sampled residents, the following complaints or concerns were brought up:* The intercom was out with no plans to replace it;* The bathroom heaters could not be turned on;* The internet was down since 11/03/22; * Residents were concerned about MTs and lack of training;* The voicemail box wasn't set up when they called for help at night; and* There were multiple complaints about the food. There was no documented evidence the above concerns identified during the meetings had been addressed, responded to or resolved.In an interview on 11/17/22 with Staff 1 (ED), she acknowledged she did not currently have a procedure for documenting resident complaints and how the facility attempted to resolve resident complaints.

Based on observation, interview and record review, it was determined the facility failed to ensure residents received services in a manner that promoted privacy, respect and dignity in a homelike environment. Findings include, but are not limited to:Resident 2 was admitted to the facility in 08/2022 with diagnoses including hemiplegia and hemiparesis following a cerebral infarction.During the survey, the resident's room was observed and there was a urinal in the bathroom and the surveyor was informed the resident used the urinal for bladder elimination.The resident's clinical records were reviewed and revealed the following:* 09/01/22 home health staff documented "concerns....during night shift of staff caregiver moving [him/her] quickly/roughly with pad change/rolling....[s/he] was told by staff during this shift to urinate in [his/her] brief instead of being provided opportunity to use urinal for urination...;" and* Staff 2 (RN) initialed on the home health note that she reviewed the note.This represented staff failing to provide resident services in a respectful and dignified manner. The need to ensure services provided to residents were done in a way to promote dignity and respect was discussed with Staff 1 (ED), Staff 2 and Staff 3 (RCC) on 11/17/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to immediately investigate incidents to rule out potential abuse or neglect, report to the local SPD office when unable to reasonably conclude the incidents were not abuse or neglect and have documented evidence of the Administrator's review for 2 of 3 sampled residents (#s 2 and 6) who were reviewed. Findings include but are not limited to: 1. Resident 2 was admitted to the facility in 08/2022 with diagnoses including hemiplegia and hemiparesis following cerebral infarction.a. During the survey, the resident's room was observed and had a urinal in the bathroom and the surveyor was informed the resident used the urinal for bladder elimination.The resident's clinical records were reviewed and revealed the following:* 09/01/22 home health staff documented "concerns....during night shift of staff caregiver moving [him/her] quickly/roughly with pad change/rolling....[s/he] was told by staff during this shift to urinate in [his/her] brief instead of being provided opportunity to use urinal for urination..."; and* Staff 2 (RN) initialed on the home health note that she reviewed the note.Survey requested an incident report for the incident during the survey and was informed that there was no incident report to investigate the incident.The facility failed to conduct an immediate investigation to reasonably conclude the incident was not a result of neglect. Staff 3 (RCC) confirmed the incident was not reported to the local unit, at which time the surveyor requested Staff 3 to immediately self-report the incident to the local SPD office. Confirmation the report had been sent to the SPD office was received on 11/17/22 prior to survey exit.b. Progress notes and incident reports dated 08/14/22 through 11/14/22 indicated the following:* On 08/14/22 at 12:45 am, staff documented on a facility incident report "... found resident on the floor by [his/her] bed..." Staff noted the resident's pendent got lost. The resident requested to be sent out due to shoulder pain.* On 08/14/22 at 8:30 pm, "... found [him/her] lying on the floor next to [his/her] bed." ... "was trying to sit up to use urinal by [himself/herself] and slipped off bed." Staff noted the resident lost [his/her] pendent and bedrail was up position at the time of fall. Staff further documented "N/A" on the question of the last time toileted.The resident's 08/11/22 service plan indicated the resident was able to use call system and "care staff to make sure [s/he] has [his/her] pendent on at all times or at night next to [his/her] bedside. The service plan also indicated "facility to provide physical assistance with the toileting task..." There was no documented evidence the facility conducted an investigation to reasonably conclude the above incidents were not the result of abuse or neglect due to the possibility of not ensuring the call system was within Resident 2's reach and not receiving bladder management. Staff 3 (RCC) confirmed she had not reported the above incidents to the local unit, at which time the surveyor requested Staff 3 to immediately report the incidents. Confirmation that the incidents were reported was received prior to the survey team exiting from facility.The need to investigate incidents of repeated falls and suspected abuse or neglect of care and to report the incidents when the facility's investigation was unable to rule out abuse was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 on 11/17/22.
2. Resident 6 was admitted to the facility in 03/2021.The resident's progress notes and incident reports dated 04/01/22 through 11/01/22 were reviewed and the following was identified:On 04/16/22, staff identified Resident 6 was "assaulted" by another resident. An unsampled resident hit Resident 6 with a dog statue. The incident report dated 04/18/22 lacked documented evidence of the Administrator's review. The need to ensure there was documented evidence the Administrator reviewed all reports of abuse or suspected abuse was discussed with Staff 2 (RN) and Staff 3 (RCC). They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to investigate incidents to rule out potential abuse or neglect and have documented evidence of the Administrator's review for 1 of 2 sampled residents (#8) who experienced repeated falls. This is a repeat citation. Findings include, but are not limited to: Resident 8 was admitted to the facility in 01/2020 with diagnoses including hypertension and dementia. The resident had a history of falls.Progress notes and incident reports dated 04/10/23 through 07/10/23 indicated the following:* On 04/27/23, staff documented on an incident report "... [resident] came out of [his/her] apartment asking for help, stated [s/he] fell. Skin tears, 911 was called and sent out to be evaluated." The incident report investigation did not include any information related to a review of the service plan or whether fall interventions were being followed at the time of the incident in order to rule out abuse or neglect. The incident report was not signed by the Administrator.* On 06/05/23, staff documented on an incident report "... resident was in the dining room, grabbed onto walker to get up, and while standing, fell onto [his/her] bottom." The incident report investigation did not include any information related to a review of the service plan or whether fall interventions were followed in order to rule out abuse or neglect. The incident report was not signed by the Administrator.* On 07/10/23, staff documented the resident experienced another fall and sustained a "gash" to his/her forehead when found in the staff lounge. The incident report completed following the fall did not include any information on whether recent fall interventions were being followed in order to rule out abuse or neglect. The incident report was not signed by the Administrator.The resident's 05/28/21 service plan indicated the resident would often forget to use the walker and needed reminders to use it, required frequent safety checks and proper footwear. An interim service plan, dated 07/06/23, instructed staff to "ice resident's knee ...and keep ace wrap for support to decrease swelling..." The fall investigation did not include any information whether these interventions were being followed. The need to ensure investigations of incidents of repeated falls included adequate information in order to rule out abuse or neglect was discussed with Staff 3 (RCC), Staff 10 (MT) and Staff 25 (MT) on 07/13/23. The need to ensure an administrative review and signature by the Administrator was discussed with Staff 1 (Administrator) and Staff 28 (ED) on 07/13/23. They acknowledged the findings.

1. Incident reports and investigations for Resident 8 will be reviewed with staff by consultant and training on how to do and document an incident investgation will be provided. 2. All incident reports will be reviewed by the administrator. The consultant team is reviewing incident reports and providing feedback. All staff will be trained on abuse and neglect identification and reporting. All staff will be trained in how to document incident observations. The management team will be trained by consultants on how to investigate incidents. 3. Monthly.4. Administrator.

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:The facilities kitchen, including food storage, preparation and service areas, were toured on 11/15/22. The following areas were observed:1. Areas in need of cleaning: a. Splatters, spills, debris, and drips were observed in the following areas:* On the wall to the left of the kitchen entrance;* On the wall behind the beverage area vestibule between the dining room and the kitchen;* On the open cabinetry of the dining room beverage station;* On the wood beverage station in the vestibule between the dining room and the kitchen;* In the gray condiment bins on the wood beverage station; * On the kitchen entrance door and frame;* On the hot food service area laminate base;* On the hot food service area knobs;* In and around the hot food service area drain;* In and outside of both microwaves;* On the grill sides;* On the oven sides;* On the floor under the grill;* On the toaster/microwave station;* In the toaster/microwave station gray plastic silverware tray;* On the bread table to the right of the toaster oven;* On all walls of the food service area;* On the food service area Staff Only door;* On the food mixer stainless steel guard;* On the inside and outside of the waffle maker; and* In all the kitchen drawers.b. Black matter buildup observed:* Around the hot food service area drain;* Around the beverage area sink;* In the seam between the stainless steel dishwashing station and the wall; and* In the seam between the counter and the wall in the dining room beverage area.c. Black scuff marks observed:* On the kitchen entrance door and frame; and* On the Staff Only door in the food service area.d. The carpet in the vestibule between the dining room and kitchen was stained.e. The grill area ceiling had brown grime and dust buildup.f. The seam between the floor and walk-in refrigerator in the grill area had grime buildup and caulk missing.g. The kitchen door frame top left corner had cobwebs and dust buildup.2. Areas in disrepair: * The beverage station had unfinished wood cabinets rendering them uncleanable;* Four sections of the laminate flooring were peeling away from the wall corners;* Approximately 12-inch long crack in the laminate flooring between the hot food service area and the grill area;* Kitchen beverage area laminate storage cabinet frames and interiors had chips rendering areas uncleanable;* Kitchen beverage area laminate counter was worn, stained, and scratched;* Kitchen manager stated the meat slicer and food mixer were not functioning;* Gray tray in the drawer in the grill area to the left of the refrigerator door was cracked;* Two overhead lights in the grill area were missing covers;* The drawer to the right of the food prep sink in the back of the kitchen did not fully close; * The interior of the drawer to the right of the prep area in front of the refrigerator was in disrepair; * The wall behind the main kitchen door was dented; and* The dining room beverage area counter had five chips on the front edge.3. Food Storage:* Left and right front bottom corners of the freezer had ice buildup; and* Food boxes were stored less than six inches from the top of the freezer.4. Food Preparation: * The kitchen manager confirmed that the eggs used for soft preparations were not pasteurized; and* A cook observed not temping food (hamburger, chicken) for entire length of lunch service.5. Food Service:*Serving staff were not consistently performing hand hygiene upon entering the kitchen or after touching their masks or faces.The kitchen was toured with Staff 5 (Kitchen Manager) on 11/17/22 at 2:15 pm. She acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and maintained in good repair and in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to: The facility's kitchen, including food storage, preparation and service areas, was toured on 07/10/23. The following areas were observed:1. Areas in need of cleaning: a. Splatters, spills, debris, and drips were observed in the following areas:* On the hot food service area knobs;* In and outside of both microwaves;* On the grill sides;* On the oven sides;* On the floor under the grill;* On the toaster/microwave station;* In the toaster/microwave station gray plastic silverware tray;* On the bread table to the right of the toaster oven; and* On all walls of the food service area.b. Black matter buildup was observed:* In the seam between the stainless steel dishwashing station and the wall; and* Interior of ice machine.2. Areas in disrepair: * Two sections of the laminate flooring along the wall in serving area and staff bulletin board area were peeling away from the wall corners; and* The wall behind the main kitchen door was dented.3. Food Storage:* Food boxes were stored less than six inches from the top of the walk-in refrigerator and freezer; and* Two bags of hot dog buns and a bag of raisin toast bread were moldy. 4. Food Preparation: * Observations made during cooking (lasagna, baked zucchini, baked cauliflower, hamburger) showed no temperatures were obtained of the foods during cooking or prior to serving.5. Food Service:* Serving staff did not consistently perform hand hygiene upon entering the kitchen or discard single-use gloves when interruptions occurred while working with ready-to-eat foods during lunch service; and * Multiple kitchen staff preparing and/or serving food did not have hair and/or facial hair effectively restrained as required.The need to ensure the facility maintained a safe and sanitary environment was discussed with Staff 1 (Administrator) and Staff 5 (Dining Services Director) on 07/12/2023 at 1:52 pm. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements with documented updates and changes as appropriate within the first 30 days for 2 of 2 sampled residents (#s 2 and 4) whose records were reviewed. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in 08/2022. a. A review of the resident's move-in evaluation failed to address the following:* Interest, hobbies, social, leisure activities;* Spiritual, cultural preference & traditions;* Personality including how a person copes with change or challenging situations;* Communication and sensory;* Indicators of nursing needs including potential for delegated nursing tasks;* Emergency evacuation ability;* History of dehydration or unexplained weight loss or gain;* Recent losses; * Elopement risk or history; and* Environmental factors that impact the residents behavior, including but not limited to: noise, lighting and room temperature.b. Resident 2's 30-day updated or modified evaluation due in 09/2022 was not completed. The facility's failure to complete all required elements for Resident 2's move-in evaluation and 30-day update evaluation was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (RCC) on 11/17/22. They acknowledged the findings.
2. Resident 4 was admitted to the facility on 11/01/22. The move-in evaluation dated 10/26/22 was reviewed. The following required elements were not addressed:* Spiritual, cultural preferences and traditions; * Indicators of nursing needs including potential for delegated nursing tasks; * History of dehydration or unexplained weight loss or gain; and * Recent losses.The need to ensure move-in evaluations included all required elements was discussed with Staff 2 (RN) and Staff 3 (RCC) on 11/17/22. No additional documentation was received.
Based on interview and record review, it was determined the facility failed to ensure evaluations were completed quarterly and were reflective of the residents' current needs for 3 of 3 residents (#s 7, 8 and 10) whose evaluations were reviewed. This is a repeat citation. Findings include, but are not limited to:1. Resident 10 was admitted to the facility in 05/2022 with diagnoses including bipolar I disorder and dementia.Review of Resident 10's record on 07/10/23 showed the quarterly evaluation and service plan were combined into one document. The document available for staff to review was completed at admission on 05/09/22, and showed staff review signatures dated up until 06/29/23.A review of the residents current service plan available to staff, dated 05/09/22, and a service plan printed by the facility on 07/11/23 and dated 03/23/23, revealed the resident had not been evaluated to obtain information that included the resident's mental health status and history, physical health status, and the environmental factors that help the individual function at their optimal level.Additional documentation of the evaluation done by the facility in order to develop the service plan was requested on 07/11/23 and 07/13/23. No additional information was provided.The need to ensure a resident evaluation was completed, at least quarterly, and was the foundation for developing the service plan, was discussed with Staff 1 (Administrator) and Staff 28 (ED) on 07/13/23. They acknowledged the findings.


3. Resident 7 was admitted to the facility in 11/2022 with diagnoses including dementia. On 07/10/23 the service plan available to staff was located in the staff charting area on the first floor. The service plan was dated 11/22/22. During an interview on 07/10/23, Staff 3 (RCC) reported the facility had last completed an evaluation and updated Resident 7's service plan in 03/2022. She printed a copy of a service plan, dated 03/22/23, from her computer. Review of the 03/22/23 service plan revealed the facility failed to evaluate Resident 7 for visual impairment and use of assistive mobility devices.On 07/10/23 and 07/13/23 the facility was asked to provide documentation of the most recent quarterly evaluation used to develop the service plan. No additional information was provided. The need to ensure an evaluation was completed at least quarterly and was the foundation for developing the service plan, was discussed with Staff 1 (Administrator) on 07/14/23. She acknowledged the findings.
2. Resident 8 moved in to the facility in 01/2020 with diagnoses including hypertension and dementia. A review of the resident's service plan available to staff, dated 05/28/21, and the current service plan provided by the facility, dated 03/23/23, revealed the resident had not been evaluated to obtain information that included the resident's physical health status, cognitive status, and the environmental factors that help the individual function at their optimal level.Additional documentation of the evaluation done by the facility in order to develop the service plan was requested on 07/11/23 and 07/13/23. No additional information was provided.The need to ensure a resident evaluation was completed, at least quarterly, and was the foundation for developing the service plan, was discussed with Staff 1 (Administrator) and Staff 28 (ED) on 07/13/23. They acknowledged the findings.1. Evaluations for Resident 7, 8, and 10 have been updated. All evaluations are being reviewed and updated. A new evaluation form and checklist were provided by consultant. Training was provided to RCC on how to conduct and document an evaluation.2. The health services team will be trained in how to conduct and document an evaluation. An evaluation schedule will be developed. Evaluations will be reviewed by the administrator for completeness.3. Weekly.4. Administrator and Resident Care Coordinator.

2. Resident 2 was admitted to the facility in 08/2022 with diagnoses including hemiplegia and hemiparesis following cerebral infarction.During the survey, the resident was identified to have a private caregiving staff seven days a week.Resident 2's service plan, dated 08/11/22, was reviewed during the survey and was not reflective, did not provide specific instruction to staff and was not followed in the following areas: * No clear instruction of what the private care staff and what the facility care staff provided to the resident; * Private care staff schedule and coordination of care;* Use of a hand splint;* Use of an arm sling;* Use of C-PAP machine (a treatment of sleep apnea);* Use of compression stocking;* Bathing or Shower status;* Transfer status;* Ambulation status; and* Toileting status.The need to ensure the resident service plans provided specific instruction to staff, were reflective and were followed was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (RCC) on 11/17/22. They acknowledged the findings.
3. Resident 3 was admitted to the facility in 06/2021. A review of the resident's clinical record showed the most current care plan available to staff was dated 06/25/21. The need to have current care plans available to staff was reviewed with Staff 3 (RCC) on 11/17/22. She acknowledged the findings.
4. Resident 6 was admitted to the facility in 03/2021 with diagnoses including seizures.The service plan available to staff dated 04/04/21, temporary service plans and progress notes dated 04/01/22 through 11/01/22 were reviewed. Interviews with care staff and Resident 6 were conducted and observations were made. The resident's service plan was not reflective or provide clear caregiving instruction in the following areas: * The use of compression stockings;* Laundry services; * Ambulation relating to having a walker; * Dining; * Interventions for behaviors;* Home health services provided; * Side rail use; * Bathing; and* Grooming. The need to ensure service plans were current, reflective of the residents' care needs and provided clear caregiving instruction was discussed with Staff 2 (RN) and Staff 3 (RCC) on 11/17/22. They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to ensure service plans were available to direct care staff, updated quarterly, reflective of current care needs, provided clear instruction for staff regarding delivery of services, and were followed for 4 of 4 sampled residents (#s 2, 3, 5, and 6) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 04/2016. A review of the resident's clinical record showed the most current service plan was not available for direct care staff to review. The need to have current care plans available to staff was reviewed with Staff 2 (RN) and Staff 3 (RCC) on 11/17/22. They acknowledged the findings.

3. Resident 10 was admitted to the facility in 05/2022 with diagnoses including bipolar I disorder and dementia.On 07/10/23, Staff 24 (MT) stated the service plans they used were located in a binder. Review of the facility "service plan binder" that direct care staff accessed showed the service plan was dated 05/09/22. A signature sheet attached for staff to sign upon review of the service plan contained staff signatures dated from 05/09/22 through 06/29/23.A review of the resident's service plan available to staff, dated 05/09/22, and a service plan printed by the facility on 07/11/23 and dated 03/23/23 was not reflective and/or did not provide instructions in the following areas:* Mental health status and interventions; * Mood disorder;* Behaviors;* Activities;* Environmental factors; and* At return from a hospitalization on 04/18/23 an "outpatient behavioral health patient safety plan" was developed and provided by the hospital. However, it was not included on the resident's service plan or provided to staff.The need to ensure the current service plan was available to staff and the service plan contained accurate information on the resident's care needs with clear instructions to staff was discussed with Staff 1 (Administrator) and Staff 28 (ED) on 07/13/23. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were updated quarterly, reflective of residents' needs, provided clear direction to caregiving staff and were implemented for 3 of 4 sampled residents (#s 7, 8, and 10) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:1. Resident 7 was admitted to the facility in 11/2022 with diagnoses including dementia.On 07/10/23, the service plan available to staff was located in the staff charting area on the first floor. The service plan was dated 11/22/22. During a 07/10/23 interview with Staff 3 (RCC) she reported the facility had last completed an evaluation and updated Resident 7's service plan in 03/2022. She printed a copy of a service plan, dated 03/22/23, from her computer and stated she was unsure why the service plan had not been placed in the binder for staff to review. Resident's 7's 03/22/23 service plan was not updated quarterly, available to staff, or reflective of the resident's current needs in the following areas:* Use of glasses; and* Use of assistive mobility devices.On 07/14/23, the service plan was discussed with Staff 1 (Administrator). She acknowledged the service plan was not updated quarterly, available to staff, or reflective of the resident's needs.
2. Resident 8 moved into the facility in 01/2020 with diagnoses including hypertension and dementia.On 07/10/23, a copy of the current service plan was requested. Staff 3 (RCC) provided a copy of a service plan dated 03/23/23. Upon review of the facility "service plan binder" that direct care staff accessed to review the service plans, the 03/23/23 service plan was not available. The binder contained a service plan for Resident 8, dated 05/28/21. A signature sheet attached for staff to sign upon review of the service plan contained staff signatures dated from 04/22/22 through 06/29/23.The 05/28/21 service plan, available to staff, was reviewed. The service plan was not reflective of the residents needs and preferences or did not provide clear instruction to staff in the following areas:* Interventions to be provided when resistive, restless or wandering behaviors occurred;* Pain interventions;* Ability to manage keys to apartment and mail box;* Current fall interventions; and* Level of assistance needed for ADL's including dressing, personal hygiene, toileting, incontinence care and bathing.The need to ensure the current service plan was available to staff and the service plan contained accurate information on the resident's care needs with clear instructions to staff was discussed with Staff 1 (Administrator), Staff 3 and Staff 28 (ED) on 07/13/23. They acknowledged the findings.




Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs, and provided clear directions to staff regarding the delivery of services for 3 of 5 sampled residents (#s 13, 14 and 16) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:1. Resident 14 was admitted to the facility in 7/2023 with diagnoses including cerebral vascular accident (stroke), fall risk and chronic pain.Observations were made of the resident's care on 12/18/23. Interviews with facility staff and the resident were conducted. The current service plan dated 12/18/23 was reviewed. Resident 14's service plan was not reflective of the resident's current needs and lacked clear instructions to staff in the following areas:* Oxygen instructions for PRN use;* Sign/symptoms of hallucinations;* Side rails, use and precautions;* Wound care instructions; and* Recent falls and fall interventions.The need to ensure the service plan reflected residents' current needs and provided clear instructions to staff regarding delivery of services was reviewed with Staff 1 (ED), Staff 23 (RCC Assistant), Staff 42 (RN, Director of Health Services), Staff 43 (Consultant), and Staff 41 (LPN, Health and Wellness Director) on 12/19/23. They acknowledged the findings.

3. Resident 16 was admitted to the facility in 10/2021 with diagnoses including cerebrovascular accident. Observations were made of the resident's care on 12/18/23. Interviews with facility staff and the resident were conducted. The current service plan dated 09/28/23 was reviewed. Resident 16's service plan was not reflective of the resident's current needs and lacked clear instructions to staff in the following areas:* Use of hearing aids;* Use of dentures;* Escorts to meals; * Transportation; * Orientation status; * Hospice admission date; and* Assistive devices used for evacuation. The need to ensure the service plan reflected residents' current needs and provided clear instructions to staff regarding delivery of services was reviewed with Staff 1 (ED), Staff 23 (RCC Assistant), Staff 42 (RN, Director of Health Services), Staff 43 (Consultant), and Staff 41 (LPN, Health and Wellness Director) on 12/19/23. They acknowledged the findings. No further information was provided.
2. Resident 13 was admitted to the facility in 02/2022 with diagnoses including acute exacerbation of chronic obstructive pulmonary disease (COPD), anxiety, bipolar mood disorder, and depression. Observations were made of the resident's care on 12/19/23. Interviews with facility staff and the resident were conducted. The current service plan dated 12/14/23 was reviewed. Resident 13's service plan was not reflective of the resident's current needs and lacked clear instructions to staff in the following areas:* Dental status; * Smoking and vaping;* Alcohol use;* Recent losses;* Ambulation and use of assistive devices;* Non-pharmaceutical interventions for pain, including how a person expresses pain or discomfort;* Oxygen equipment precautions and instructions for proper maintenance; and* Electric mobility equipment precautions and instructions for proper maintenance.The need to ensure the service plan reflected residents' current needs and provided clear instructions to staff regarding delivery of services was reviewed with Staff 1 (ED), Staff 23 (RCC Assistant), staff 42 (RN, Director of Health Services), staff 43 (Consultant), and Staff 41 (LPN, Health and Wellness Director) on 12/20/23. They acknowledged the findings. No further information was provided.

2. A resident group interview was conducted on 11/16/22 at 12:00 pm. Five of the residents in the group stated they were not involved in the development of their service plans.On 11/17/22 at approximately 12:45 pm, Staff 1 (ED) confirmed that the development of service plans, which included residents in the process, was a system the facility was working on and acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that included the resident, the resident's legal representative if applicable, any person of the resident's choice, the Administrator or designee, and at least one other staff person who was familiar with or who was going to provide services to the resident for 2 of 3 sampled residents (#s 2 and 3) whose service plans were reviewed and five unsampled residents who were interviewed. Findings include, but are not limited to:1. Review of Resident 2 and 3's most recent service plans determined the documents lacked evidence a Service Planning Team reviewed and participated in the development of the service plans.On 11/17/22 the need to ensure service plans were developed by a Service Planning Team that included the resident, the resident's legal representative if applicable, any person of the resident's choice, the Administrator or designee, and at least one other staff person who was familiar with the resident was discussed with Staff 2 (RN) and Staff 3 (RCC). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that included the resident, the resident's legal representative if applicable, any person of the resident's choice, the Administrator or designee, at least one other staff person who was familiar with or who was going to provide services to the resident and a licensed nurse if the resident shall need, or is receiving nursing services for 4 of 4 sampled residents (#s 7, 8, 9, and 10) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:Resident 7, 8, 9, and 10's current service plans were reviewed during the survey. The service plans lacked evidence a Service Planning Team reviewed and participated in the development of the service plans. The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (Administrator) and Staff 28 (ED) on 07/12/23 at 11:45 am. They acknowledged the findings.
1. Training on how to document who participated in the service planning team was provided by the consultant. Resident 7, 8, and 10 will have documentation of the service planning process.2. Documentation of service planning team participation will be in the progress notes and on the service plan.3. Weekly.4. Administrator and Resident Care Coordinator.

3. Resident 3 was admitted to the facility in 06/2021 with diagnoses including dementia.The resident's progress notes dated 08/24/22 through 11/13/22, temporary service plans and interim service plans were reviewed. The following short term changes of condition were identified:* 08/24/22 - rash in groin area and chest;* 09/19/22 - resident had a fall on 09/18/22;* 09/29/22 - resident had a fall on 09/28/22;* 09/29/22 - resident had another fall on 09/29/22, resulting in right heel pain; * 10/01/22 - resident with steak knife "creeping into residents rooms" and threatening a staff member; * 10/03/22 - bruise on inner left thigh, open area on left knee and abrasions on right foot; and* 11/02/22 - resident found to have a box cutter in his/her room. There was no documented evidence the facility determined and documented what action or intervention was needed for the resident or monitored the resident until the condition resolved. The need to ensure the facility determined and documented what action or intervention was needed for the resident's short term changes of condition and monitored the resident until the condition was resolved was discussed with Staff 3 (RCC) on 11/17/22. She acknowledged the findings.
2. Resident 6 was admitted to the facility in 03/2021 with diagnoses including seizures and intestinal obstruction.The resident's progress notes dated 04/06/22 through 11/01/22, temporary service plans and interim service plans were reviewed. The following short term changes of condition were identified:* 04/16/22 - resident to resident physical altercation; * 04/18/22 - resident to resident verbal altercation; * 05/31/22 - loose stool and upset stomach; * 09/08/22 and 09/14/22 - elevated blood pressure; * 10/07/22 - resident to resident verbal altercation; * 11/01/22 - late entry for 10/31/22 stating resident reported missing medications "yesterday;" and* There were multiple entries stating the resident was consuming alcohol. The resident was on a medication that was contra-indicated to take with alcohol.There was no documented evidence the facility determined and documented what action or intervention was needed for the resident or monitored the resident until the conditions resolved. The need to ensure the facility determined and documented what action or intervention was needed for the resident's short term changes of condition and monitored the resident until the condition was resolved was discussed with Staff 2 (RN) and Staff 3 (RCC) on 11/17/22. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to identify and evaluate changes of condition, determine actions or interventions needed, provide written communication of those interventions to staff on each shift, and/or monitor the conditions to resolution for 3 of 4 sampled residents (#s 3, 5 and 6) who experienced changes of condition. Findings include, but are not limited to:1. Resident 5 was admitted to the facility in 04/2016. A review of the clinical record revealed the following:Resident 5 was placed on alert charting 05/03/22 for a rash under the breast. The RN skin log noted monitoring on 05/03/22 and 05/10/22. A progress note, dated 06/11/22, stated new orders were received for nystatin cream treatment for the rash to continue for two weeks. A progress note, dated 06/24/22, stated a new order to continue the nystatin cream for an additional two weeks. The RN documentation with resolution for this skin issue was dated 11/01/22. The facility failed to document on the progress of these changes at least weekly until resolved.The need to ensure the facility monitored short term changes of condition with weekly progress noted until resolution was shared with Staff 2 (RN) and Staff 3 (RCC) on 11/17/22. They acknowledged the findings.


3. Resident 10 was admitted to the facility in 05/2022 with diagnoses including Bipolar I Depression and dementia.Resident 10's progress notes dated 04/10/23 through 07/10/23, 03/23/23 service plan, interim service plans, discharge instructions and incident reports were reviewed and indicated the following:* 03/31/23 "resident has urinary tract infection and orders"; * 04/27/23 "resident has a large rash under left breast";* 07/05/23 "resident was sent out to the hospital today due to being in a manic state and daughter agreed was a danger to themselves and others"; and* 07/08/23 "resident was on the verge of going manic this morning. [S/he] went downstairs pants less screaming until we found [her/him]". There was no documented evidence the facility determined and documented what actions or interventions were needed for the resident or monitored the resident until the conditions resolved. The need to ensure the facility had a system to monitor each resident, consistent with his or her evaluated needs and service plan, determine and document what actions or interventions were needed for the resident's short term changes of condition, and monitored until conditions were resolved was discussed with Staff 2 (RCC) on 07/12/23 and with Staff 1 (Administrator) and Staff 28 (ED) on 07/13/23. They acknowledged the findings.
2. Resident 7 was admitted to the facility in 11/2022. The resident's 03/22/23 service plan indicated the resident had a potential for falls.The resident's progress notes dated 04/10/23 through 07/10/23, 03/22/23 service plan, interim service plans, discharge instructions and incident reports were reviewed and indicated the following:a. Resident 7 experienced a fall on 04/29/23 after tripping over his/her walker. The resident was transferred to the emergency room, returning the same evening with a new diagnosis of a fracture to the right humerus. There was no documented evidence the facility determined and documented any actions or interventions for the resident related to the new diagnosis and return to the facility.On 04/30/23 (one day following the return to the facility), the resident was transferred to the emergency room for complaints of increasing pain and refusals to eat or hydrate. The resident was then transferred to a skilled nursing facility for rehabilitation related to the right humerus fracture. The resident returned to the facility on 05/29/23. On 06/02/23 (four days after returning to the facility), Resident 7 experienced another fall while in his/her apartment. There was no documented evidence the facility had determined and documented any actions or interventions needed related to the resident's recent return to the facility, or communicated interventions for staff on each shift. The record lacked evidence the condition was monitored, with progress noted at least weekly, through resolution. On 06/26/23 the resident experienced another fall in his/her apartment. The facilities failure to develop actions or interventions, communicate the actions or interventions to staff on each shift, and monitor the conditions with progress noted at least weekly through resolution for Resident 7's fall with fracture constituted harm and the resident continued to experience falls. b. Review of the records revealed Resident 7 also experienced the following short-term changes of condition:* 05/29/23 - Return from rehabilitation facility;* 05/31/23 - Confusion, paranoia;* 06/15/23 - Confusion; and* 06/28/23- Biopsy, left leg.There was no documentation the facility developed actions or interventions, communicated the actions or interventions to staff on each shift, and monitored each condition with progress noted at least weekly through resolution for Residents 7's return from rehabilitation facility, confusion, paranoia and biopsy.The need to ensure interventions were determined for short term changes of condition, communicated to staff and conditions monitored at least weekly through resolution was discussed with Staff 1 (Administrator) on 07/14/23. She acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to determine and document what actions or interventions were needed for residents who experienced short term changes of condition, ensure actions or interventions were communicated to staff on each shift and documented, at least weekly, progress until the conditions resolved for 3 of 3 sampled residents (#s 7, 8 and 10) who experienced changes of condition. Resident 8 experienced a fall requiring intervention that was not provided and the resident had continued falls resulting in injury. Resident 7 experienced falls which required fall interventions which were not developed and continued to experience falls. This is a repeat citation. Findings include, but are not limited to:1. Resident 8 moved into the facility in 01/2020 with diagnoses including hypertension and dementia.Review of clinical records, including the service plan dated 05/28/21, interim service plans (ISPs), progress notes from 04/10/23 through 07/10/23, and incident reports, revealed the following information:a. On 07/04/23, a progress note documented the resident had a fall while out of the facility. The resident was placed on alert for monitoring. On 07/05/23, a progress note documented the resident had gone to the emergency room following the fall and "doctor is stating we need to ice [his/her] knee as much as possible over the next 3 days, doctor is also stating to give Tylenol when needed." An ISP was completed on 07/06/23 for knee pain. The ISP instructed staff to "apply ice and an ace wrap to the knee for support and to decrease swelling and to offer Tylenol for pain." Following a review of the MAR, treatment records, notes and interviews, the facility was unable to provide evidence the treatment had been provided.On 07/07/23 (three days later), Resident 8 experienced another fall and was hospitalized for injuries. There was no documented evidence the facility provided interventions to prevent falls and the resident continued to experience falls.b. Review of the record showed the following short term changes of condition were identified:* 04/27/23 - skin tear to right arm. The alert monitoring ended 05/01/23 but the skin tear was still present;* 05/10/23 - knee pain;* 06/05/23 through 06/21/23 - increasing agitation and aggressive behaviors;* 06/23/23 - new medication, the first dose was taken 06/26/23 and the alert monitoring was ended the same day; and* 06/28/23 - knee pain.There was no documented evidence the facility determined and documented what actions or interventions were needed for the resident or monitored the resident until the conditions resolved. The need to ensure the facility had a system to monitor each resident, determine and document what actions or interventions were needed for the resident's short term changes of condition, and monitored until conditions were resolved was discussed with Staff 3 (RCC) on 07/12/23 and with Staff 1 (Administrator) and Staff 28 (ED) on 07/13/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure an RN assessment was completed for residents who had significant changes of condition which included documented findings, resident status, and interventions made as a result of the assessment for 1 of 2 sampled residents (# 2) who experienced a significant change of condition. Findings include, but are not limited to:Resident 2 was admitted to the facility in 08/2022 with diagnoses including hemiplegia and hemiparesis following a cerebral infarction.During the acuity interview on 11/15/22, the resident was identified to have a catheter in place and that it was new to the resident. A 11/01/22 progress note indicated "Resident is placed on alert for return from ER...was diagnosed with urinary retention...Resident returned with a catheter on."The new diagnosis of the urinary retention and the catheter placement for bladder elimination represented a significant change of condition for the resident.On 11/16/22 at 1:55 pm, Staff 2 (RN) confirmed there was no RN assessment which included documented findings and a development of interventions for the significant change of condition. Staff 2 further stated it happened "while I was gone"..."there was no back up for the absence."The failure to conduct an RN assessment following a significant change in condition was discussed with Staff 1 (ED), Staff 2 and Staff 3 (RCC) on 11/17/22. They acknowledged the findings.
3. Resident 10 was admitted to the facility in 05/2022 with diagnoses including Bipolar I depression and dementia.Resident 10's medical chart, progress notes dated 04/10/23 through 07/10/23, 03/23/23 service plan, interim service plans, discharge instructions and incident reports were reviewed and indicated the following changes of condition:* 04/07/23 - "resident had a manic episode ...POA was called and immediately requested for 911 to be called". At return from the hospital on 04/18/23, Resident 10 arrived with an "outpatient behavioral health patient safety plan"; * 07/05/23 - "resident was sent out to the hospital today due to being in a manic state and daughter agreed was a danger to themselves and others"; and the next day on 07/06/23 - "return to facility after being sent out to the ER and having planned surgery for kidney stones completed".The facility lacked documented evidence Resident 10 was assessed by a facility RN with documented findings, resident status, and interventions after returning from the hospitalizations.The need to ensure residents who experienced a significant change of condition were assessed by an RN including documented findings, resident status, and interventions made as a result of the assessment was discussed with Staff 1 (Administrator) and Staff 28 (ED) on 07/14/23. They acknowledged the findings.

2. Resident 7 was admitted to the facility in 11/2022. The resident's 03/22/23 service plan indicated the resident had a potential for falls.Resident 7's medical chart, progress notes dated 04/10/23 through 07/10/23, 03/22/23 service plan, interim service plans, discharge instructions and incident reports were reviewed and indicated the following:* 04/29/23 - Resident 7 experienced a fall and was transferred to the emergency room. The resident returned to the facility the same day with a diagnosis of a right humerus fracture, a significant change of condition; * 04/30/23 - The resident was transferred to the emergency room for complaints of increasing pain and refusals to eat or hydrate and then transferred to a skilled nursing facility for rehab after the right humerus fracture; and* 05/23/23 - The resident was re-admitted to the assisted living facility.In a 07/11/23 interview with Staff 3 (RCC) she stated she was unable to locate an RN assessment for the resident's significant change of condition. The facility lacked evidence Resident 7 was assessed by a facility RN with documented findings, resident status, and interventions made as a result of the assessment after the humerus fracture and return to the facility. The need to ensure residents who experienced a significant change of condition were assessed by an RN, including documented findings, resident status, and interventions made as a result of the assessment was discussed with Staff 1 (Administrator) and Staff 28 (ED) on 07/14/23. They acknowledged the findings.
A. Based on observation and interview, it was determined the facility failed to provide health services and have systems in place to respond to the 24-hour care needs of residents including an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation. Resident health and care needs were placed at risk. Findings include, but are not limited to:During the first re-visit survey on 07/10/23 through 07/14/23, it was disclosed the facility had been without an Oregon licensed nurse "for at least three months", who was regularly scheduled to be onsite or available for phone consultation. In an interview on 07/11/23, Staff 1 (Administrator) and Staff 28 (ED), confirmed the facility had an RN doing delegation reviews but had been without a regularly scheduled RN to perform other nursing duties or have regular hours at the facility for at least three months. Surveyors requested an immediate plan of correction to ensure an Oregon licensed nurse to be scheduled onsite or available for phone consultation.The facilities' failure to provide health services and have systems in place to respond to the 24-hour care needs of residents, including an Oregon licensed nurse who was regularly scheduled for onsite duties, placed resident's health and care needs at risk.On 07/11/23, Staff 1 provided a plan of correction noting the facility had retained a regularly scheduled or onsite Oregon licensed nurse and the situation was abated. B. Based on interview and record review, it was determined the facility failed to ensure an RN assessment was completed for residents who had significant changes of condition for 3 of 3 sampled residents (#s 7, 8 and 10) who experienced significant changes of condition. Resident 8 was not assessed upon return from hospitalization and was at risk of harm. This is a repeat citation. Findings include, but are not limited to:1. Resident 8 moved into the facility in 01/2020 with diagnoses including hypertension and dementia.a. During the acuity interview on 07/10/23, the resident was identified to have recently experienced a fall and returned to the facility from hospitalization. A progress note, dated 07/10/23, indicated "Resident on alert for return from hospital with 5 dissolvable stitches, no discharge instructions..." The clinical record included a document faxed to the facility, dated 07/09/23, from the hospital. The resident had been evaluated in the emergency department following the fall on 07/06/23 and admitted to the hospital, returning to the facility on 07/09/23 with new diagnoses of small frontal subarachnoid bleed (closed head injury) and left eyebrow laceration with sutures. The document provided the following discharge summary:* Physical Therapy referral;* Fall precautions:* Control SBP (systolic blood pressure) less than 170 mmHg;* Left leg swelling; and* Ultrasound duplex to evaluate for DVT (deep vein thrombosis).The new diagnoses of small brain bleed and laceration to eyebrow following a fall and hospitalization represented a significant change of condition for the resident.On 07/11/23 at 9:30 am, Staff 1 (Administrator) confirmed there was no RN available to perform an assessment upon the resident's return from the hospital, to include findings and development of interventions for the significant change of condition. There was no direction to staff related to treatments, if needed, for the laceration or instructions related to blood pressure monitoring. The lack of an RN to perform the assessment placed the resident at risk of potential serious harm. b. Progress notes between 06/03/23 and 07/04/23 were reviewed and documented Resident 8 experienced episodes of increased confusion, agitation, restless behaviors and multiple falls. On 06/06/23 and 06/20/23, the notes documented "management is looking for a memory care" and the resident's family member was "looking into a memory care setting" for the resident.During an interview on 07/12/23, Staff 8 (CG) provided information that Resident 8 required increased assistance and cueing with ADL's including bathing, dressing, daily hygiene, toileting and escorts to the dining room. The resident required increased cueing and supervision related to wandering into other resident's rooms and re-direction to use his/her walker.The overall decline in multiple areas, including cognition, safety, mobility and ADL functioning documented in the record represented a significant change of condition and required assessment by an RN. There was no RN assessment in the record. On 07/13/23, Staff 1 verified an RN assessment had not been completed.The need to ensure an RN assessment was conducted following a significant change in condition was discussed with Staff 1, Staff 28 (ED) and Staff 31 (Regional Director) on 07/13/23. They acknowledged the findings.

1. Resident 2 was admitted to the facility in 08/2022 with diagnoses including hemiplegia and hemiparesis following a cerebral infarction.During the acuity interview on 11/15/22, the resident was identified to receive home health therapy and nursing services for catheter care and muscle strengthening.Resident 2's home health visit notes, dated 09/01/22 through 11/03/22, were reviewed during the survey and revealed the following:* 10/04/22 HH OT recommended "caregivers to don left brace on left hand/wrist at night for all night wear and wrist protection. Doff in AM and check skin for any irritation" and "caregivers to use left arm sling (hung on wall) for use with transfers to protect left arm/shoulder and reduce shoulder pain";* 10/18/22 HH OT noted "requested caregivers to encourage patient with donning shirts (short sleeve T-shirt)"; and* 10/25/22 HH OT instructed "...not have side rail up so [s/he] can reach pole to help turning and scooting...".There was no documented evidence the facility ensured staff were informed of the new interventions or the service plan was adjusted when necessary. On 11/17/22, the need to ensure on-going coordination of care was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (RCC). Staff acknowledged the findings.
2. Resident 6 was admitted to the facility in 03/2021. Home Health/Outside Provider Visit Notes dated 08/30/22 through 10/13/22 and progress notes dated 09/09/22 through 11/01/22 were reviewed. The following recommendations were made from HH OT: * 09/07/22 - two elevated blood pressure readings and the recommendation for the resident to minimize activity level for the day; * 09/13/22 - instructed resident on use of alternate seat cushion for wheelchair to promote comfort, pedal propulsion and safety; and* 09/20/22 - educated on resident's wheelchair and need to have seat cushion fastened. There was no documented evidence the facility ensured staff were informed of the new interventions or that the service plan was adjusted when necessary. The need to ensure the facility notified staff of new interventions from on-site health services and that the service plan was adjusted when necessary was discussed with Staff 2 (RN) and Staff 3 (RCC) on 11/17/22. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure staff were informed of new interventions, the service plan was adjusted if necessary, and reporting protocols were in place for those residents who received services from outside providers, for 2 of 2 sampled residents (#s 2 and 6). Findings include, but are not limited to:
Based on interview and record review, it was determined the facility failed to review information obtained from an outside provider and adjust the service plan for 1 of 2 sampled residents (#10) reviewed for coordination of care. This is a repeat citation. Findings include:Resident 10 was admitted to the facility in 05/2022 with diagnoses including bipolar I disorder and dementia.Review of Resident 10's medical record from 04/09/23 to 07/09/23 showed Resident 10 returned to the facility on 04/18/23 after an 11 day psychiatric hospitalization.The hospital provided Resident 10's "outpatient behavioral patient safety plan" to the facility, including individualized warning signs, internal coping strategies, and people and resources to help in a mental health crisis. There was no documented evidence the recommendations and plan by the outside service provider was communicated to staff or the service plan updated.Reviewing and following up with outside provider recommendations was discussed with Staff 1 (Administrator), Staff 28 (ED) and Staff 31 (Regional Director) on 07/13/23. Staff acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure it consistently complied with masking requirements as prescribed in OAR 333-019-1011. Findings include, but are not limited to:Per Oregon Administrative Rule 333-019-1011(6), (8) and (10), persons employed in an assisted living or residential care facility are required to wear a face mask while they are in the facility except when the employee is alone in a closed room.Observations of kitchen and dining room staff during the survey revealed multiple instances where staff failed to wear their face mask properly (exposing their nose, or nose and mouth). * A staff member was observed to touch mask to adjust back up over nose three times without performing hand hygiene immediately after;* A staff member was observed taking a resident's order with nose exposed approximately five inches from a resident's face;* A staff member was observed wearing a cloth mask; and* On 11/16/22 at 1:30 pm, two staff members were observed to have masks pulled down from their faces.The need to ensure staff consistently and properly wore face masks was discussed with Staff 5 (Kitchen Manager) on 11/17/22. She acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure it had a trained Infection Control Specialist as required in OAR 411-054-0050. Findings include, but are not limited to:In an interview on 07/11/23, Staff 1 (Administrator) reported Staff 35 (MT) was the facility's designated Infection Control Specialist. The interview with Staff 1 and review of Staff 35's infection control training revealed she did not have the required education, training and experience or certification and she had not completed the required specialized Department approved training in infection prevention and control protocols for an assisted living facility Infection Control Specialist.The need to ensure the designated Infection Control Specialist was qualified by education, training and experience or certification and completed all required training was reviewed with Staff 1 and Staff 28 (ED) on 07/14/23. They acknowledged training had not been completed as required.

Based on interview and record review, it was determined the facility failed to ensure a safe medication system and to ensure adequate professional oversight of the medication and treatment administration system. Findings include, but are not limited to:1. On 11/15/22 the survey team received a complaint of medications being found on a resident's bed and floor.On 11/03/22, a HH OT note indicated "...found meds in patients bed and there have been [occurrences] meds are given to patient but they leave before [s/he] takes them all...". The documentation further noted the incident was discussed with Staff 3 (RCC) during their visit.2. Administrative oversight of the medication administration system was found to be ineffective based on deficiencies identified in the following areas:C 302: Systems: Tracking Controlled Substances;C 303: Systems: Medication and Treatment Orders;C 305: Systems: Resident Right to Refuse;C 310: Systems: Medication Administration; andC 325: Systems: Self-Administration of Medications.The requirement to ensure a safe medication system and adequate professional oversight of the medication administration system was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 on 11/17/22. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure a safe medication and treatment system was in place and failed to ensure adequate professional oversight of the medication and treatment administration systems. Residents were put at risk related to staff did not know how to use the current electronic MAR system, were signing as having administered medications which were administered by another staff member and were administering medications without current physician orders. The facility also failed to ensure accurate narcotic count records, or to ensure a registered pharmacist or registered nurse reviewed all medications and treatments administered by the facility at least every 90 days. The findings constituted an immediate plan of correction for the health and safety of residents. This is a repeat citation. Findings include, but are not limited to:During the first re-visit to the re-licensure survey, conducted 07/10/23 through 07/14/23, administrative oversight of the facility's medication system was found to be ineffective based on deficiencies in the following areas:* C 301: Systems: Medication Administration; * C 302: Systems: Tracking Control Substances; * C 303: Systems: Treatment Orders; * C 304: Systems: Medication and Treatment Review; * C 310: Systems: Medication Administration; * C 325: Systems: Self-Administration of Meds; and* C 330: Systems: Psychotropic Mediation. On 07/11/23 at 3:30 pm, the survey team requested an immediate plan of correction to address the issues identified. At 4:12 pm, a plan was received and accepted by the survey team. The immediate jeopardy situation was abated at that point in time.

2. Resident 10 was admitted to the facility in 05/2023 with diagnoses including bipolar I disorder and dementia. Review of the MAR provided on 07/10/23 showed all medications listed as leave of absence (LOA) from 07/04/23 through 07/10/23.In an interview on 07/10/23, Staff 3 (RCC) confirmed "LOA" indicated leave of absence, and acknowledged the MAR did not contain a record of the medications Resident 10 had received since 07/04/23. Staff 3 stated the facility was unable to correct Resident 10's status in the computer system and therefore could not use the electronic MAR.Staff 10 (MT) stated the MT's had been using a paper MAR to record the medications administered. The surveyor requested a copy of the paper MAR at 10:10 am. At 10:30 am on 07/11/23, Staff 10 provided a paper document time stamped as created 10:17 am 07/11/23. The document had handwritten initials showing medications administered and was completed through 07/17/23.At 10:45 am, Staff 10 acknowledged she had just created the document and filled in the initials herself, based on the schedule of which MT's had worked and projecting who was scheduled to work in the future.The need to ensure medications administered by the facility were documented by the same person who administered the medications was discussed in an interview on 07/11/23 with Staff 1 (Administrator), Staff 28 (ED) and Staff 31 (Regional Director). They acknowledged the findings.
4. Resident 7 was admitted to the facility in 11/2022 with diagnoses including dementia.The resident's 06/01/23 through 07/12/23 MARs were reviewed during the survey. The record review revealed Staff 29 (MT/CG) had signed the MAR as having administered the resident's medication during the day and evening shifts over the course of 20 days in 06/2023 and for at least four days between 07/01/2023 and 07/10/23. In a 07/14/23 interview, Staff 1 (Administrator) confirmed multiple staff had been unable to login to the facility's medication administration system and the person initialing the MAR for multiple residents in the facility was frequently not the person administering the medications. Staff 1 reported Staff 29 typically worked the night shift and could not have administered the medications as documented on Resident 7's MARs.The need to ensure medications administered by the facility were documented by the same person who administered the medication was discussed with Staff 1 and Staff 28 (ED) on 07/14/23. They acknowledged the findings.
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 4 of 4 sampled residents (#s 7, 8, 10, and 12). Findings include, but are not limited to: 1. Resident 12 was admitted to the facility in 04/2022 with diagnoses including diabetes, which required daily CBG's and insulin injections. Resident 12's MARS dated 07/01/23 through 07/12/23 were reviewed during the survey. Record review indicated Staff 29 (MT/CG) had been signing on the MAR as having administered the resident's insulin nine times between 07/01/23 and 07/12/23. Staff 29 was confirmed by Staff 1 and Staff 3 (RCC) to have not been on shift when the insulin was administered to Resident 12.On 07/12/23, Staff 1 (Administrator) confirmed multiple staff had been unable to log into the facility's system and the person initialing the MAR for multiple residents throughout the facility was frequently not the person administering 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 and Staff 28 (ED) on 07/13/23. They acknowledged the findings.
3. Resident 8 moved into the facility in 01/2020 and was receiving Oxycodone PRN for pain.Review of the 07/2023 MAR showed the resident received Oxycodone on 07/02/23. However, the staff who signed the disposition log on 07/02/23 was not the same staff who signed the MAR as having administered the medication. In an interview on 07/13/23, Staff 25 (MT) explained the initials on the MAR were different from the signature on the disposition log because multiple staff who administered medications were not able to log into the facility's electronic MAR system, and staff would login under another staff's name in order to access the system and document the administration.The need to ensure medications administered by the facility were documented by the same person who administered the medications was discussed with Staff 1 (Administrator), Staff 28 (ED) and Staff 31 (Regional Director) on 07/11/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 1 of 1 sampled resident (# 2) whose MARs and Controlled Substance Drug Disposition logs were reviewed for accuracy. Findings include, but are not limited to:Resident 2 was admitted to the facility in 08/2022 with diagnoses which included shoulder pain.Resident 2 had an order for Tramadol 500 mg as needed for pain.a. Resident 2's Controlled Substance Disposition Logs and MARs, dated from 10/01/22 through 11/15/22, were reviewed and revealed three occasions (10/17/22, 10/25/22 and 11/11/22) when staff signed on the drug disposition log that the medication was given. However, the MAR lacked documentation that the resident received the medication.b. Staff documented on the Resident 2's MAR that they administered Tramadol 500 mg on 10/09/22. However, the drug disposition log lacked documentation that the medication was dispensed.The inconsistencies between the MARs and Controlled Substance Disposition logs were reviewed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (RCC) on 11/17/22. They reviewed the documentation and acknowledged the discrepancies.

Based on observation, 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 7 and 10) whose MAR and Controlled Substance Drug Disposition logs were reviewed for accuracy. This is a repeat citation. Findings include, but are not limited to:1. Resident 10 was admitted to the facility in 05/2022 with diagnoses including bipolar I disorder and dementia.Resident 10 had an order for PRN oxycodone 5mg tab as needed for moderate pain.The Controlled Substance Disposition Log and MAR reviewed from 07/04/23 through 07/11/23 noted eight occasions when staff signed the drug disposition log documenting a tablet of oxycodone was removed, however, the MAR from 07/04/23 to 07/11/23 documented only one occasion when the resident received oxycodone.Comparison of the medication dosing card to the disposition log showed the amount of medication left was reflected accurately on the log. The discrepancies between the eight tablets noted on the drug disposition log and the tablet documented on the MAR were reviewed with Staff 1 (Administrator), Staff 28 (ED), and Staff 31 (Regional Director). They acknowledged the findings.
2. Resident 7 was admitted to the facility in 11/2022. The resident's 05/30/23 physician orders and 06/01/23 through 07/10/23 MARs were reviewed on 07/12/23. Resident 7 had a physician's order for oxycodone 0.5 mg tablet every six hours PRN (for pain).The resident's 05/23/23 through 07/13/23 Controlled Substance Disposition log and medication card #79 showed the following: * Page 30 of the disposition log showed a total of 17 whole tablets on hand; and* The medication card showed a total of 16 and one half pills. The half pill was secured with tape into cell 19.The comparison of the disposition log to the medication card, showed the amount of medication on the card was not reflected accurately on the log. In a 07/12/23 interview with Staff 12 (MT), she stated "I have no idea why it's like that, I don't know how we missed this during the count."On 07/14/23 the requirement to have a system in place to accurately track controlled substances administered by the facility was discussed with Staff 1 (Administrator). She acknowledged the findings.

2. Resident 2 was admitted to the facility in 08/2022 with diagnoses which included sleep apnea.a. During the survey, a C-PAP (to treat sleep apnea) machine was observed in the resident's room.The review of Resident 2's clinical records revealed the resident was prescribed to have staff assist with putting the C-PAP machine on at night and off in the morning.Resident 2's 11/01/22 through 11/15/22 MAR indicated there was no documented evidence the order was transcribed to the MAR to ensure staff would carry out the physician's order as prescribed.b. Review of Resident 2's clinical records revealed s/he was prescribed the following:* Administer house supplement (for weight management) two times a day; and* To assist with putting compression stockings on during the daytime and remove at night. Resident 2's 11/01/22 through 11/15/22 MAR indicated there was no documented evidence the order was transcribed to the MAR to ensure staff would carry out the physician's order as prescribed.c. Resident 2's MAR indicated the following:* To apply secura protective cream to reddened or excoriated area as needed;* To provide wound care for scrapes, small cuts or abrasion as needed; and* To provide wound care for skin tears as needed.There were no physician orders for the above treatment.On 11/17/22, the physician's orders and the MARs were reviewed with Staff 2 (RN) and Staff 3 (RCC). Staff acknowledged the findings and no further documentation was provided prior to exit.
3. Resident 6 was admitted to the facility in 03/2021 with diagnoses including hypertension. The resident's 08/01/22 through 11/15/22 MARs and physician's orders were reviewed and revealed the following: a. Resident 6 had physician orders for blood pressure readings to be done twice daily prior to administering Losartan 50 mg and Metoprolol Tartrate 25 mg (both medications were to treat for hypertension). The physician's orders gave unlicensed staff parameters to hold the medication for systolic blood pressure below 100 and/or if his/her heart rate was below 55. The following information revealed staff administering the medications without obtaining the resident's blood pressure: * 09/2022 - two times;* 10/2022 - six times; and* 11/1/22 through 11/15/22 - two times.b. Resident 6 had physician orders for daily weights. The physician's order gave the unlicensed staff parameters to take the weight before breakfast or the first meal of the day and to fax the provider and call facility RN if the weight gained was more than three pounds in a day and more than five pounds in a week. There were blanks on the resident's MARs, which indicated the weights were not documented on the following occasions: * 08/2022 - 22 times;* 09/2022 - 29 times; * 10/2022 - 26 times; and* 11/01/22 through 11/15/2022 - eight times.The need to ensure the facility followed physician orders was discussed with Staff 2 (RN) and Staff 3 (RCC) on 11/17/22. 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 4 sampled residents (#s 2, 5 and 6) whose orders were reviewed. Findings include, but are not limited to:1. Resident 5 moved into the facility in 04/2016 and had diagnoses which included multiple sclerosis and osteoporosis.Resident 5's MAR and physician orders, dated 11/01/22 through 11/15/22, and weight records revealed the following: * The resident had an order for staff to check his/her weight weekly. Between 06/20/22 and 10/30/22, no weight was documented.* There was no current, signed order in Resident 5's record for Antac + Sim 200-20 MG (for GERD).* The MAR instructed staff to administer hydrocodone/APAP 3-325 mg tablets (for pain) at 8:00 am, 12:00 pm, 4:00 pm, 8:00 pm and 12:00 am. There was no 8:00 pm time on the MAR.* Resident 5 had a current order for gabapentin (for pain) to be administered at 8:00 am, 2:00 pm and 8:00 pm. The 11/2022 MAR had time ranges of "8 - 10 am," "2 - 4 pm" and "8 - 9 pm." The need to ensure medication and treatment orders were carried out as prescribed and current signed orders were in resident's records was discussed with Staff 2 (RN) and Staff 3 (RCC) on 11/17/22. 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 2 of 3 sampled residents (#s 8 and 10) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to:1. Resident 10 was admitted to the facility in 05/2022 with diagnoses including bipolar I depressionResident 10's July 2023 MAR listed the following medications without a corresponding physician's order:* Acetaminophen 500 MG 2 tablets x 3 per day PRN ;* Tamsulosin .4 mg caplet;* Mouthkote Spray PRN;* Naphcon-A .025 drops PRN; and* Systane Lubricant Eye .3% PRN.The need to ensure current signed orders were in resident's records was discussed with Staff 1 (Administrator) and Staff 3 (RCC) on 07/12/23. They acknowledged the findings.


2. Resident 8 was admitted to the facility in 01/2020 with diagnoses including osteoporosis.Resident 8's MAR dated 06/01/23 through 07/10/23 and corresponding physician orders were reviewed and revealed the following:On 06/21/23, the resident was prescribed alendronate (bone density regulator) 1 tablet once weekly in the morning.Review of the MAR indicated the resident was not administered the medication as prescribed on 07/03/23 and 07/10/23. Staff documented on the MAR "drug not available."During observations and an interview on 07/12/23, Staff 3 (RCC) and Staff 36 (MT) conducted a search for the medication and located it in the "noc shift" drawer of a medication cart. Staff 3 was able to verify the medication had not been given and the two pills were still in the package.The need to ensure medications were administered as prescribed was discussed with Staff 1 (Administrator) and Staff 28 (ED) on 07/13/23. 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 by the facility to residents at least every 90 days for 4 of 4 residents (#s 7, 8, 9 and 10) whose medication and treatment orders were reviewed. Findings include, but are not limited to:In a 07/14/23 interview, Staff 1 (Administrator) confirmed medications and treatments administered by the facility to Residents 7, 8, 9 and 10 had not been reviewed by a registered pharmacist or RN at least every 90 days. The need to ensure a registered pharmacist or RN reviewed medications and treatments administered by the facility to residents at least every 90 days was discussed with Staff 1 (Administrator) and Staff 28 (ED) on 07/14/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to notify the physician when a resident refused to consent to orders for 2 of 2 sampled residents (#s 3 and 6) who had documented refusals. Findings include, but are not limited to:1. Resident 3 was admitted to the facility in 06/2021 with diagnoses including dementia. Review of the current physician's orders stated the facility was to notify the provider monthly of any refusals. The resident's 10/01/22 through 11/15/22 MARs revealed the resident refused to consent to orders for the following medications and treatments: * 10/28/22 - Atorvastatin (for cholesterol);* 10/28/22 - Carvedilol (for blood pressure);* 10/01/22 - Levothyroxine (for thyroid);* 10/28/22 - Namenda (for dementia);* 10/2022 - Clean under the Resident's belly folds twelve times;* 10/2022 - Clotrimazole (antifungal) cream twelve times;* 10/2022 - Daily blood pressure seven times;* 11/13/22 - Clean under the Resident's belly folds; and* 11/13/22 - Clotrimazole cream. A physician's order dated 10/10/22 directed staff to fax provider monthly for any missed/refused medications/treatments. The October and November MARs directed staff to notify the provider on the first of each month. Staff documented on the MARs reviewed the provider was not faxed.The need to ensure the facility contacted the physician each month the resident refused to consent to orders was discussed with Staff 3 (RCC). She acknowledged the findings.
2. Resident 6 was admitted to the facility in 03/2021 with diagnoses including hypertension. Review of the current physician's orders stated the facility was to notify the provider monthly of any refusals. The resident's 08/01/22 through 11/15/22 MARs revealed the resident refused to consent to orders for the following treatments: * 08/2022 - daily weights 22 times;* 09/2022 - daily weights 29 times and daily blood pressure twice; * 10/2022 - daily weights 26 times and daily blood pressure six times; and* 11/01/22 through 11/15/22 - daily weights eight times and daily blood pressure twice. A physician's order dated 08/15/22 directed staff to "fax provider monthly for any missed/refused medications/treatments," and listed the resident's physician's name. The August, September, October and November MARs directed staff to notify the provider on the first of each month. Staff documented on all four MARs reviewed that the provider was not faxed.The need to ensure the facility contacted the physician each month the resident refused to consent to orders was discussed with Staff 2 (RN) and Staff 3 (RCC). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate for 3 of 4 sampled residents (#s 2, 3 and 6) whose MARs were reviewed. Findings include, but are not limited to:1. Resident 3 was admitted in 06/2021 with diagnoses which included dementia.Residents 3's MARs were reviewed from 10/01/22 through 11/15/22 and the following was noted:* Reasons for use was not indicated for Losartan (for blood pressure); and* Lack of resident-specific parameters for daily blood pressures. On 11/17/22, the need for the facility to ensure MARs were accurate was discussed with Staff 3 (RCC). She reviewed the MARs and acknowledged the findings.
2. Resident 2 was admitted to the facility in 08/2022 with diagnoses including shoulder pain and insomnia.Review of the resident's 11/01/22 through 11/15/22 MAR noted the following:* Magnesium 30 ml as needed for bowel care;* Melatonin 3 mg 2 tablets as needed for insomnia;* Methyl Salic topical to lower back as needed for pain; and* Polyvinyl eye drops as needed for dry eyes.The PRN medications lacked clear parameters for the frequency of the administration.On 11/17/22, the above findings were reviewed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (RCC). Staff acknowledged the findings.
3. Resident 6 was admitted to the facility 03/2021. Resident 6's 08/01/22 through 11/15/2022 MARs and current physician's orders were reviewed and identified the following: *Two PRN bowel medications lacked resident-specific parameters for use; and*Triamcinolone 0.1% cream (for skin irritation) was a duplicate entry on the MAR.The need to ensure that an accurate MAR was kept of all medications that were ordered by a legally recognized prescriber and were administered by the facility and the need for resident specific parameters relating to multiple PRN bowel medications was discussed with Staff 2 (RN) and Staff 3 (RCC). They acknowledged the findings.

2. Resident 10 was admitted to the facility in 05/2023 with diagnoses including bipolar I disorder and dementia. Review of the MAR from 07/01/23 through 07/10/23 showed from 07/04/23 to 07/10/23 there was no record of medications given, the MAR recorded only "LOA" meaning leave of absence. In interview on 07/10/23, Staff 3 (RCC) acknowledged Resident 10 was in the facility and receiving medications, however, the MAR did not contain a record of the medications Resident 10 had received since 07/04/23. Staff 3 stated the facility was unable to correct Resident 10's status in the computer system and therefore could not use the electronic MAR to document the medications administered.On 7/10/23 a paper MAR was created, however, the initials recorded were not the initials of the person who had administered the medications, and the MAR was filled out through 07/17/23. The requirement to maintain an accurate record of medications administered and accurate initials of the person administering the medication was discussed in interview on 07/11/23 with Staff 1 (Administrator), Staff (Executive Director) and Staff (Regional Director). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure accurate MARs were kept for any medications and treatments administered by the facility for 3 of 4 sampled residents (#s 7, 8 and 10) whose MARs were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 7 was admitted to the facility in 11/2022 with diagnoses including dementia. The resident's 06/01/23 through 07/10/23 MARs and 05/30/23 physician's orders were reviewed and identified the following:* Milk of Magnesia 30 ml every 24 hours PRN (for constipation); and * Senna/Docusate 8.6 mg tablets, one tablet by mouth twice daily PRN (for constipation).The bowel medications lacked resident-specific parameters on when to administer one versus the other.The requirement for MARs to be accurate, including resident-specific parameters for PRN medications, was discussed with Staff 1 (Administrator) on 07/14/23. She acknowledged the findings.

3. Resident 8 moved into the facility in 01/2023 with diagnoses including dementia and hypertension. The resident had been experiencing frequent falls and elevated blood pressure.Resident 8's physician orders and 06/01/23 through 07/10/23 MAR/TARs were reviewed. Resident 8 had a physician's order for amlodipine (for hypertension) and metoprolol (for hypertension). The physician's orders, dated 08/04/22, instructed staff to take the resident's blood pressure weekly. There were no resident specific instructions for direct care staff to determine when to call the prescriber or nurse.During an interview with Staff 3 (RCC), it was determined there were no facility protocols or other direction to staff to instruct them on when to contact the facility nurse or physician related to the resident's blood pressure and use of the medications.The need to ensure an accurate MAR that included clear instructions for staff was discussed with Staff 1 (Administrator) and Staff 28 (ED) on 07/13/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to evaluate a resident's ability to safely self-administer medication and failed to have a physician or other legally recognized practitioner's written order of approval for self-administration of medication for 2 of 2 sampled residents (#s 1 and 6) who self-administered medication. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in 04/2022 with diagnoses including edema and neuropathy.On 11/15/22 at approximately 10:00 am, Staff 3 (RCC), identified the resident was self-administering all of his/her own medications. Review of the resident's record and an interview with Resident 1 on 11/15/22 at 1:48 pm confirmed the resident was self-administering medications.Physician's orders dated 04/21/22 stated, "Medication Management: Resident may take medications out of the facility when given to family members." There was no documentation the resident's physician had given approval for the resident to self-administer all of his/her medications. On 11/15/22 at 2:18 pm, updated physician's orders were requested from Staff 3 (RCC). On 11/16/22 at 9:12 am, Staff 3 confirmed there were no updated orders for Resident 1. The need to ensure residents who administer their own medications had written approval by a physician or other legally recognized practitioner was discussed with Staff 3 on 11/16/22. She acknowledged the finding.
2. Resident 6 was admitted to the facility in 03/2021. The resident's 08/01/22 through 11/15/22 MARs and physician's orders were reviewed and revealed the following two medications were "not given by facility."*Diclofenac Sodium 1% gel (for pain); and *Triamcinolone 0.1% cream (skin irritation).Interviews with Resident 6 on 11/16/22, Staff 2 (RN) on 11/18/22 confirmed the resident self-administered the medications. There was no documented evidence the resident was evaluated on the ability to safely administer the medications or of physician's order of approval to self-administer. The need to ensure residents who self-administered their medications were evaluated to assure ability to safely self-administer medications and have physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications was discussed with Staff 2 and Staff 3 (RCC). They acknowledged the findings.
Based on interview and record review, it was determined that the facility failed to ensure that residents who choose to self-administer their medications were evaluated at least quarterly, to assure ability to safely self-administer medication for 1 of 1 sampled resident (#11). This is a repeat citation. Findings include, but are not limited to: Resident 11 was admitted to the facility in 09/2021 with diagnoses including diabetes. Interviews with Staff 3 (RCC) and Staff 8 (CG) on 07/11/23 and with the resident on 07/12/23 confirmed that the resident self-administered his/her medications. Review of the resident's medical records and an interview with Staff 3 revealed at the time of the survey the last self-medication evaluation had been completed on 01/24/23. The need to ensure that residents who self-administered their medications were evaluated at least quarterly to assure ability to safely self-administer medications was discussed with Staff 1 (Administrator) and Staff 28 (ED) on 07/13/23 at 11:45 am. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to define a reason for use, identify side effects, when to contact a health professional regarding side effects, and develop non-pharmacological interventions for 1 of 1 sampled resident (#10) who was prescribed a PRN psychotropic. Findings include, but are not limited to:Resident 10 was admitted to the facility in 05/2023 with diagnoses including bipolar I disorder and dementia.Resident 10's MAR, dated 07/01/23 through 07/10/23, indicated the resident was prescribed psychotropic medication Lorazepam "by mouth every 4 hours as needed". Resident 10's record failed to document:* The specific reason for the use of the psychotropic medication;* The common side effects of the medication;* When to contact a health professional regarding side effects; and* Documented non-pharmacological interventions to attempt before administration. On 07/13/23 the need to ensure non-pharmacological interventions were developed and attempted before use of a PRN psychotropic medication, and that the resident's record included a reason for use, identify side effects, and when to contact a health professional regarding side effects was discussed with Staff 1 (Administrator), Staff 28 (ED) and Staff 31 (Regional Director). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) that met the regulation. Findings include, but are not limited to:There was no documented evidence the facility was using an ABST which would determine a staffing plan reflective to meet the 24-hour scheduled and unscheduled needs of residents.On 11/17/22, Staff 1 (ED) reported the facility had not implemented an ABST. Staff 1 stated she would follow up to ensure the ABST was implemented as required.

Based on interview and record review, it was determined the facility failed to ensure the Acuity-Based Staffing Tool (ABST) was updated at least quarterly and with significant changes of condition to accurately reflect resident care needs for 3 of 3 sampled residents (#s 7, 8 and 10), whose ABST data was reviewed. This is a repeat citation. Findings include, but are not limited to:Review of three sampled residents' records, interviews with staff, interviews and observations of the residents noted ABST entries were not updated at least quarterly, were not reflective of all care needs for Residents 7, 8 and 10 and was not updated with significant change of condition. In an interview on 07/13/23, Staff 1 (Administrator) reported the ABST was updated following the quarterly evaluation and service plan review for all residents. The facility was unable to show documented evidence evaluations or service plans were updated at least quarterly for the sampled resident's. The need to ensure the ABST was updated at least quarterly and with significant changes of condition and were reflective of resident's care needs was discussed with Staff 1 on 07/14/23. She acknowledged the findings. Refer to C 260.

Based on interview and record review, it was determined the facility failed to ensure documentation that 4 of 4 sampled newly hired employees (#s 11, 14, 15 and 18) completed required pre-service orientation training prior to assuming their job duties, and 2 of 2 long-term staff (#s 6 and 20) completed infectious disease prevention training by 07/01/22. Findings include, but are not limited to:Staff training records were reviewed with Staff 7 (Finance) on 11/16/22. The following deficiencies were identified:* Staff 11 (Cook), Staff 14 (CG), Staff 15 (CG), and Staff 18 (CG), hired on 07/30/22, 09/02/22, 09/14/22, and 10/06/22 respectively, did not complete all required pre-service orientation topics prior to beginning job duties; and* Staff 6 (MT) and Staff 20 (Housekeeper), hired 01/09/2018 and 07/10/2018 respectively, did not complete required infectious disease training by 07/01/22.The need to ensure documentation of completion of pre-service orientation and infectious disease training timely was discussed with Staff 7. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to verify and document that 4 of 4 newly hired direct-care staff (#s 14, 15, 18 and 21) demonstrated satisfactory performance in all assigned duties within 30 days of hire. Findings include, but are not limited to:Staff training records were reviewed on 11/16/22 with Staff 7 (Finance) and revealed the following:Staff 14 (CG), 15 (CG), 18 (CG), and 21 (CG), hired on 09/02/22, 09/14/22, 10/06/22, and 10/02/22 respectively, lacked evidence of completing the required training or demonstrating competency in the following areas:* Role of service plans in providing individualized care;* Changes associated with normal aging;* Identification, documentation and reporting changes of condition; and* Conditions that require assessment, treatment, observation and reporting.The need to ensure documentation that newly hired staff completed training and demonstrated competency in all assigned duties within 30 days of hire was discussed with Staff 7. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to conduct and record unannounced fire drills every other month at different times of the day, evening, and night shifts and document all required components on fire drill records. Findings include, but are not limited to:Fire drill records were requested for 05/2022 through 11/2022.Review of the records revealed:The last fire drill conducted was on 05/17/22 at 2:20 pm. The records lacked documentation of the following required information:* The escape route used; * Problems encountered, comments relating to resident who resisted or failed to participate in drills; * Evacuation time period needed; * Staff members on duty and participating; * Number of occupants evacuated; and* Evidence alternate routes were used during the drills. The fire drill documentation requirements was discussed with Staff 4 (Environmental Director) on 11/16/22. He acknowledged the findings.
Based on interview and record review, it was determined the facility failed to document all required components of fire drill records in accordance with Oregon Fire Code. This is a repeat citation. Findings include, but are not limited to:Fire drill records were requested for 02/2023 to 07/2023.Review of the records revealed:Fire drills were conducted on 04/21/23 and 06/20/23. The records lacked documentation of the following required information:* The escape route used; * Problems encountered, comments relating to resident who resisted or failed to participate in drills; * Evacuation time period needed; * Number of occupants evacuated; and* Evidence alternate routes were used during the drills. During an interview on 07/12/23, Staff 1 (Administrator) and Staff 28 (ED) acknowledged the facility had not been relocating residents during fire drills. The fire drill documentation requirements were discussed with Staff 1 and Staff 28 on 07/12/23. They acknowledged the findings.
1. Consultant provided a new form for fire drill documentation. Consultant will assist with next fire drill.2. The Maintenance Director and Administrator will be trained in how to run, debrief, and document a fire drill. All staff will be trained on the location of the evacuation point of safety.3. Monthly.4. Administrator and Maintenance Director.

Based on interview and record review, it was determined the facility failed to ensure residents were instructed about the facility's fire and life safety procedures with 24 hours of admission and re-instructed, at least annually. Findings include, but are not limited to:Fire and Life Safety records, dated 05/2022 through 11/2022, were reviewed and a group of six non-sampled residents were interviewed on 11/16/22 at 12:00 pm. There was no documented evidence the facility instructed the resident or family within 24 hours of admission or re-instructed at least annually on general safety procedures, evacuation methods, responsibilities during fire drills and designated meeting places inside or outside the building in the event of an actual fire. All six non-sampled residents who attended the group interview confirmed they had not received fire and life safety information upon admission nor had they been instructed annually on the facility's fire and life safety procedures. The need to ensure residents received training in fire and life safety requirements within the first 24 hours of admission and at least annually thereafter was discussed with Staff 4 (Environmental Director) on 11/16/22. He acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure its re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to C 150, C 231, C 240, C 252, C 260, C 262, C 270, C 280, C 290, C 295, C 300, C 302, C 303, C 310, C 325, C 361, C 420, C 613 and C 655.
Based on observation, interview and record review, it was determined the facility failed to ensure its re-licensure survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include, but are not limited to:Refer to C 260.

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 interior of the facility was toured on 11/15/22 at 9:30 am. The following areas were in need of cleaning or repair:* Hallway doors throughout the first floor had scraped paint, scuff marks on the doors and/or jambs; * The carpet in the dining room had large stains; * The floor in the spa room had multiple stains and gouges;* The laundry room across from the Med-Tech desk on the first floor was missing a threshold;* All wall vents in the hallways and dining room throughout first and second floors contained a large amount of dust;* Several dining room chair seats were worn and had gouges in the legs;* The bench seat located in the hall across from the courtyard to the left of the dining room was worn;* The chairs in the hallway outside of the 2nd floor activity room were stained and worn;* The door for room 247 had black scuff marks on the bottom;* The second-floor laundry room had a large amount of lint and splatters on the wall behind the machines; and* The Activity Room on the second floor had large black marks on the wall.The building was toured and areas needing cleaning or repair were discussed with Staff 4 (Environmental Director) on 11/16/22. The findings were acknowledged.

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. This is a repeat citation. Findings include, but are not limited to:The interior of the facility was toured on 07/11/23 at 10:45 am. The following areas were in need of cleaning or repair:* The carpet in the dining room had large stains; * Room 162 had multiple stains and spills on the living room carpet; * The floor in the spa room had multiple stains and gouges;* The laundry room across from the MT desk on the first floor was missing a threshold;* Multiple dining room chair seats were torn and had gouges in the legs;* The bench seat located in the hall across from the courtyard to the left of the dining room was worn; and* The chairs in the hallway outside of the 2nd floor activity room were stained and worn.In an interview on 07/12/23, an unsampled resident stated s/he had requested to have the carpet cleaned in Room 162, however, the cleaning had not been done.The building was toured and areas needing cleaning or repair were discussed with Staff 1 (Administrator) and Staff 28 (ED) on 07/12/23. The findings were acknowledged.1.Carpet in the dining room and assisted living hallways have been professionally cleaned. All stains removed. Rm 162 carpet was professionally cleaned to resident satisfaction. Missing threshold at laundry room on the first floor has been fixed. New dining room chairs will be ordered. All chairs in public hallways that are stained will be replaced. The spa room floor will be replaced.2. The Administrator and Maintenance Director will do a weekly walk through of the physical plan and environment. If concerns are noted a work order will be processed and completed. 3. Weekly.4. Administrator and Maintenance Director.

Based on observation and interview, it was determined the facility failed to ensure residents had keys to a lockable storage space (e.g., drawer, cabinet, or closet) for the safekeeping of their small valuable items and funds. Findings include, but are not limited to:On 11/16/22 at 12:00 pm, six non-sampled residents attended a group interview. Five of the six residents interviewed confirmed that although they had a lockable storage space in their apartments, they did not have a key to the space.While following up with some the residents who attended the group, a lockable storage area was identified in the kitchenette and the non-sampled residents confirmed they did not have a key. The need to ensure residents had a key to their lockable storage space was discussed with Staff 1 (ED) on 11/17/22. She acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure soiled clothing and linens were laundered in a machine with a minimum rinse temperature of 140 degrees Fahrenheit or with a chemical disinfectant. Findings include, but are not limited to:The facility soiled laundry process was reviewed with Staff 9 (CG) on 11/15/22. The washing machines had general temperature settings but no device to determine the water temperature. Interview with Staff 4 (Environmental Director) and Staff 16 (Housekeeping Service Coordinator) on 11/16/22 revealed that soiled resident linens were washed with laundry detergent, which was identified as lacking a chemical disinfectant. The facility's failure to properly launder soiled resident linens and clothing was reviewed with Staff 4 and Staff 16 on 11/16/22. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure exit doors were equipped with an alarming device to alert staff when residents exited the building. Findings include, but are not limited to:The facility was toured on 11/15/22 and revealed there were no exit door alarms or other acceptable systems provided to alert staff when residents exited the building into the courtyards. The lack of exit door alarms was observed and discussed with Staff 4 (Environmental Director) on 11/16/22. The findings were acknowledged.
Based on observation and interview, it was determined the facility failed to ensure exit doors were equipped with an alarming device to alert staff when residents exited the building. This is a repeat citation. Findings include, but are not limited to:The facility was toured on 07/11/23 at 10:45 am and revealed there were exit door alarms on ALF courtyard doors but staff were not alerted when residents exited the building. During an interview, Staff 1 (Administrator) acknowledged exit door alarm notifications were sent to a mobile device kept at the front reception desk but the device was not operable or in use and staff were unaware of the exit door alarm system. The need to ensure an acceptable system to alert staff when residents exited the building was discussed with Staff 1 and Staff 28 (ED) on 07/14/23. They acknowledged the findings.
1. New door alarms were purchased and will be installed. The alert call system used by care givers will be connected to all door alarms. The front desk personnel were trained on how to monitor door alarm system.2. The Administrator and Maintenance Director will do weekly walk throughs to ensure all door alarms are fucntional. Staff will be trained to be aware of door alarm functionality. 3. Weekly.4. Administrator and Maintenance Director.