Suzanne Elise Assisted Living

Based on observation, interview, and record review, it was determined the facility failed to ensure evaluations accurately described the resident’s physical health status for 1 of 5 sampled residents (# 6) whose evaluations were reviewed. Findings include, but are not limited to:

Resident 6 moved into the facility in 10/2022 with diagnoses including chronic obstructive pulmonary disease and Parkinson’s.

The resident’s medical chart was reviewed, Resident 6’s apartment was observed, and the resident and staff were interviewed. The following was identified:

The “AL [Assisted Living] Level of Care and Service Plan” document dated 11/21/24 indicated the following:

* Oxygen was not used;
* The resident was independent with his/her CPAP (continuous positive airway pressure) machine;
* Adaptive devices were needed for eating;
* The resident had not “utilized [eight] or more doses of PRN medications for pain in the last 30 days”;
* S/he was independent with nebulizer treatments;
* Resident 6 did not have a catheter;
* The resident slept in a bed; and
* A leaf logo was placed outside of Resident 6’s door to let staff know s/he was a fall risk.

The resident’s apartment was observed and Resident 6 was interviewed on 12/04/24 at 10:45 am. The following was observed and confirmed by the resident:

* There was an oxygen concentrator located to the right of his/her bed and a portable oxygen tank on the floor next to a motorized wheelchair;
* A CPAP was observed and the resident verified s/he was unable to wash the tubing and change the filters independently;
* Resident 6 stated s/he did not “always” use the CPAP machine and requested staff to help him/her on the nights when the resident did use it;
* The resident reported not being able to independently administer a nebulizer treatment; and
* “Sometimes” slept in his/her bed and “sometimes” slept in the recliner depending on his/her ability to breath.

Observations of Resident 6 and interviews with staff revealed no adaptive devices were needed during meal times and there was no leaf logo observed outside of the resident’s apartment.

From 11/01/24 through 11/21/24, the MAR reflected the resident utilizing PRN pain medications 33 times.

A progress note, dated 11/04/24, verified the facility was “awaiting new catheter supplies”. On 12/04/24 at 1:55 pm, Staff 3 (Regional Nurse Consultant) verified Resident 6 was self catheterizing.

The need to ensure evaluations accurately described the resident’s physical health was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3, Staff 4 (Regional Nurse), and Staff 5 (RCC) on 12/04/24 at 2:40 pm. They acknowledged the findings.

OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation

(1) INITIAL SCREENING AND MOVE-IN.
(a) The facility must determine whether a potential resident meets the facility's admission requirements.
(b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability.
(c) Each resident record must, before move-in and when updated, include the following information:
(A) Legal name for billing purposes.
(B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding:
(i) Name.
(ii) Pronouns.
(iii) Gender identity.
(C) Prior living arrangements;
(D) Emergency contacts;
(E) Service plan involvement - resident, family, and social supports;
(F) Financial and other legal relationships, if applicable, including, but not limited to:
(i) Advance directives;
(ii) Guardianship; (iii) Conservatorship; and
(iv) Power of attorney.
(G) Primary language;
(H) Community connections; and
(I) Health and social service providers.

(2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule.
(a) Resident evaluations must be:
(A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and
(B) Performed at least quarterly, to correspond with the quarterly service plan updates.
(C) Reviewed and any updates must be documented each time a resident has a significant change in condition.
(D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident.
(E) Documented, dated, and indicate who was involved in the evaluation process.
(b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations.

(3) EVALUATION REQUIREMENTS AT MOVE-IN.
(a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in.
(b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in.
(c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs.
(d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility.
(e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation.

(4) QUARTERLY EVALUATION REQUIREMENTS.
(a) Resident evaluations must be performed quarterly after the resident moves into the facility.
(b) The quarterly evaluation is the basis of the resident's quarterly service plan.
(c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff.
(d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained.

(5) The resident evaluation must address the following elements:
(a) For service planning purposes, if indicated by the resident,
(A) Name.
(B) Pronouns.
(C) Gender identity.
(b) Resident routines and preferences including:
(A) Customary routines, such as those related to sleeping, eating, and bathing;
(B) Interests, hobbies, and social and leisure activities;
(C) Spiritual and cultural preferences and traditions; and
(D) Additional elements as listed in 411-054-0027(2).
(c) Physical health status including:
(A) List of current diagnoses;
(B) List of medications and PRN use;
(C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and
(D) Vital signs if indicated by diagnoses, health problems, or medications.
(d) Mental health issues including:
(A) Presence of depression, thought disorders, or behavioral or mood problems;
(B) History of treatment; and (C) Effective non-drug interventions.
(e) Cognition, including:
(A) Memory;
(B) Orientation;
(C) Confusion; and
(D) Decision-making abilities.
(f) Personality, including how the person copes with change or challenging situations.
(g) Communication and sensory abilities including:
(A) Hearing;
(B) Vision;
(C) Speech;
(D) Use of assistive devices; and
(E) Ability to understand and be understood.
(h) Activities of daily living including:
(A) Toileting, bowel, and bladder management;
(B) Dressing, grooming, bathing, and personal hygiene;
(C) Mobility - ambulation, transfers, and assistive devices; and
(D) Eating, dental status, and assistive devices.
(i) Independent activities of daily living including:
(A) Ability to manage medications; (B) Ability to use call system;
(C) Housework and laundry; and
(D) Transportation.
(j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort.
(k) Skin condition.
(l) Nutrition habits, fluid preferences, and weight if indicated.
(m) List of treatments - type, frequency, and level of assistance needed.
(n) Indicators of nursing needs, including potential for delegated nursing tasks.
(o) Review of risk indicators including:
(A) Fall risk or history;
(B) Emergency evacuation ability;
(C) Complex medication regimen;
(D) History of dehydration or unexplained weight loss or gain;
(E) Recent losses;
(F) Unsuccessful prior placements;
(G) Elopement risk or history;
(H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and
(I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan.
(p) Environmental factors that impact the resident's behavior including, but not limited to:
(A) Noise.
(B) Lighting.
(C) Room temperature.
(6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference.

Stat. Auth.: ORS 410.070, 441.122, 443.450
Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, and provided clear direction to staff including a written description of who would provide the services and what, when, how, and how often the services would be provided for 2 of 6 sampled residents (#s 4 and 6). Findings include, but are not limited to:

1. Resident 4 moved into the facility in 03/2023 with diagnoses including dementia with mood disturbance.

The most recent service plan, dated 10/14/24, was reviewed. The resident was observed, and staff were interviewed. The service plan did not reflect the resident's needs and/or did not provide clear direction to staff in the following areas:

* Level of assistance with toileting;
* Level of assistance with dressing and undressing;
* Level of assistance with transfers;
* Communication; and
* Use of adaptive cups and silverware.

The need to ensure service plans reflected the residents' status and provided clear direction to staff was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (Regional Nurse Consultant), Staff 4 (Regional Nurse), and Staff 5 (RCC) on 12/04/24 at 4:25 pm. They acknowledged the findings.

2. Resident 6 moved into the facility in 10/2022 with diagnoses including chronic obstructive pulmonary disease and Parkinson’s.

The resident’s service plan, dated 11/22/24, was reviewed. The resident was observed, and staff were interviewed. The service plan did not reflect the resident's needs and/or did not provide clear direction to staff in the following areas:

* The use of a “motorized device” for mobility;
* Incontinent products used;
* The resident’s choice to self-catheter;
* Resident 6’s preferences of where s/he sleeps;
* Oxygen use; and
* Specific instruction for an emergency evacuation.

The need to ensure service plans reflected the resident’s current need and provided clear direction to staff was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (Regional Nurse Consultant), Staff 4 (Regional Nurse), and Staff 5 (RCC) on 12/04/24 at 2:40 pm. They acknowledged the findings.

OAR 411-054-0036 (1-4) Service Plan: General

(1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan.

(2) SERVICE PLAN.
The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence.
(a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations.
(b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services.
(c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided.
(d) Changes and entries made to the service plan must be dated and initialed.
(e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed.
(f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative.
(g) The facility administrator is responsible for ensuring the implementation of services.
(h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements.

(3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN.
(a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident.
(b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences.
(c) Staff must document and date adjustments or changes as applicable.

(4) QUARTERLY SERVICE PLAN REQUIREMENTS.
(a) Service plans must be completed quarterly after the resident moves into the facility.
(b) The quarterly evaluation is the basis of the resident's quarterly service plan.
(c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to determine and document actions or interventions, communicate the determined actions or interventions to staff on each shift, and monitor each resident through resolution, for 2 of 6 sampled residents (#s 5 and 6) who experienced changes of condition. Findings include, but are not limited to:

1. Resident 6 moved into the facility in 10/2022 with diagnoses including chronic obstructive pulmonary disease and Parkinson’s.

The resident's medical chart, including the service plan, Interim Service Plans, progress notes, and MARs, were reviewed. Staff and Resident 6 were interviewed and the following changes of condition were identified:

* Resident 6 was not administered Sinemet, a medication to treat Parkinson’s, seven times from 10/02/24 through 11/27/24;
* 10/16/24: The resident sustained a rib fracture;
* 10/28/24: Staff documented they had to cut off Resident 6’s leg wrap (used for leg wounds) as the resident had rolled it down and the wrap was “cutting off the circulation” to his/her foot;
* 11/04/24: The facility identified the resident was self-catheterizing and s/he needed additional supplies; and
* 11/11/24: Resident 6 had physician’s orders for two new medications, MiraLax for bowel care and trospium chloride for bladder spasms.

There was no documented evidence that actions or interventions were determined, those actions or interventions were communicated to staff on each shift, and/or there was weekly progress noted through resolution for each of the above changes of condition.

2. Resident 5 was admitted to the facility on 11/08/2024 with diagnoses including diabetes and hypertension.

The resident's 11/08/24 through 12/02/24 progress notes and resident record were reviewed and revealed the following:

On Resident 5’s admission, the facility failed to have interventions or actions developed and communicated to staff on each shift and monitor the resident’s condition with progress noted at least weekly through resolution.

During an interview on 12/03/24 with Staff 3 (Regional Nurse Consultant), she reported the facility failed to implement an interim service plan with instructions for staff or monitor Resident 5’s condition after being admitted to the facility. Staff 3 completed a New Admission Follow Up Note on 12/02/24.

The need to ensure short-term changes of condition had interventions or actions developed and communicated to staff on each shift and documentation to reflect monitoring at least weekly through resolution was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3, and Staff 4 (Regional Nurse) on 12/04/24. They acknowledged the findings.

The need to ensure actions or interventions for short-term changes of condition were determined, those actions or interventions were communicated to staff on each shift, and/or there was weekly progress noted through resolution was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (Regional Nurse Consultant), Staff 4 (Regional Nurse), and Staff 5 (RCC) on 12/04/24 at 2:40 pm. They acknowledged the findings.

OAR 411-054-0040 (1-2) Change of Condition and Monitoring

(1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure physician or other legally recognized practitioner orders were carried out as prescribed for 1 of 5 sampled residents (# 6) whose orders were reviewed. Findings include, but are not limited to:

Resident 6 moved into the facility in 10/2022 with diagnoses including chronic obstructive pulmonary disease and Parkinson’s.

The resident's 10/01/24 through 12/02/24 MARs, progress notes, dated 09/03/24 through 12/02/24, and physician’s orders were reviewed. Resident 6 and staff were interviewed. The following was identified:

The following medications and treatments were not administered per physician's orders on multiple occasions:

* Daily weights (for hypertensive heart disease);
* Donning boots to lower legs for one hour, then doffing the boots once a day (for edema relating to hypertensive heart disease);
* The administration of PRN torsemide for weight gain of three pounds in one day or five pounds in one week on 11/09/24 and 11/18/24; and
* Sinemet (for Parkinson’s), buspirone (for anxiety), gabapentin (for neuropathic pain), and Blink Tears (for dry eyes).

The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (ED), Staff 2 (RN), Staff 3 (Regional Nurse Consultant), Staff 4 (Regional Nurse), and Staff 5 (RCC) on 12/04/24 at 2:40 pm. They acknowledged the findings.

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders

(f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to notify the physician or other practitioner if a resident refused to consent to an order for 2 of 3 sampled residents (#2 and 6) who had medication and treatment refusals. Findings include, but are not limited to:

1. Resident 2 moved into the facility in 12/2019 with diagnoses including bipolar disorder and emphysema. The resident's current prescriber orders, 11/01/24 to 12/03/24 MAR, and progress notes were reviewed. The following was identified:

Staff documented the resident refused the following medications and treatments:

* Tums E-X (for osteoporosis) on six occasions;
* Urea external cream (for skin) on twenty-four occasions;
* Ammonium lactate lotion (for skin) on thirty-one occasions;
* Nystatin external powder (for skin infection) on thirty-three occasions; and
* "Daily weight" on three occasions.

There was no documented evidence staff notified the prescriber of the above medication and treatment refusals.

The need to ensure the physician or other practitioner was notified if a resident refused to consent to an order was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (Regional Nurse Consultant), Staff 4 (Regional Nurse), and Staff 5 (RCC) on 12/04/24 at 1:02pm. They acknowledged the findings.

2. Resident 6 moved into the facility in 10/2022 with diagnoses including chronic obstructive pulmonary disease and Parkinson’s.

The resident's physician’s orders, 10/01/24 through 12/02/24 MARs, and progress notes were reviewed. Staff documented the resident refused the following medications and treatments on multiple occasions:

* Daily weights (for hypertensive heart disease);
* Donning boots to lower legs for one hour, then doffing the boots once a day (for edema relating to hypertensive heart disease);
* Questran packet (for diarrhea);
* MiraLax packet (for bowel care); and
* Torsemide (for edema).

There was no documented evidence staff notified the prescriber of the above medication and treatment refusals.

The need to ensure the physician or other practitioner was notified if a resident refused to consent to an order was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (Regional Nurse Consultant), Staff 4 (Regional Nurse), and Staff 5 (RCC) on 12/04/24 at 2:40 pm. They acknowledged the findings.

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse

(j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber.

This Rule is not met as evidenced by:

The findings of the kitchen inspection, conducted 10/05/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.
The findings of the first revisit of the kitchen inspection of 10/05/23, conducted on 01/11/24, 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 the kitchen was clean, in good repair, and food was stored appropriately in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:The facility's kitchen was toured on 10/05/23 at 10:15 am.a. An accumulation of food spills, splatters, loose food debris, dirt, and dust was observed on, in and/or underneath the following:* Walls and ceiling in the hot food prep and service area;* Drawer interior to the right of the hot food prep area;* Windowsill in the food service area;* Knife block on the wall near the cold food prep area;* Open laminate shelving under the hot food prep area;* Open metal shelving under the food pass area;* All kitchen drains;* Plastic shelving in the dry food storage area; and* Gray bin with baking supplies in the kitchen storage area.b. Observation of the facility's walk-in refrigerator and freezer revealed the following foods were not covered, dated, and/or labeled appropriately:* Shredded cheese;* Ham;* Various containers of salad dressing;* Pudding;* Walnuts; and* Beets.c. The following items were observed in poor repair:* The ceiling light cover above the food pass area was separated from the base;* The freezer door had ice buildup around the frame and covering the thermometer;* The warewasher rinse thermometer; * The refrigerator to the right of the hot food station was leaking;* The open laminate shelving under the hot food station was cracked exposing bare wood;* The kitchen door frame was worn exposing bare wood;* A laminate seam cover to the right of the kitchen door was cracked exposing a bare seam; and* The wood door to the right of the bulletin board was scuffed exposing bare wood and had black marks.d. The following items were covered in rust:* The open metal shelving above the food prep sink; * The open metal shelving to the right of the dishwashing sinks; and* The metal legs of a plastic food service cart.e. The following items were worn with cut marks and stains:* All cutting boards; and* The plastic hot food prep countertop.f. The following was noted with dead bugs and black debris:* All kitchen ceiling lights.e. One kitchen ceiling light had burned out lightbulbs.The kitchen was toured with Staff 1 (Administrator) 10/05/23. The items that required cleaning, dates, labels, and repairs/replacements were observed and discussed. She acknowledged the findings.

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes. This report reflects the findings of the complaint investigation conducted 08/01/2022. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified:Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

Based on interview and record review, it has been confirmed that the facility failed to have sufficient staff to meet the scheduled and unscheduled needs of residents. Findings include:During an unannounced site visit on 08/01/2022; the Compliance Specialist (CS) interviewed Staff #1, Staff #2, Staff #4 and Resident #1-Resident #3, separately. It was stated that in July staffing was a concern. It was stated that there were multiple call outs due to staff illness, which resulted in short staffing and missed needs.CS reviewed Service plans for Resident #1-Resident #3, Staff Schedules for July and August 2022, Acuity Based Staffing Tool and call light logs from 07/05/2022-07/08/2022; which revealed multiple dates where the facility was not staffed to their posted staffing plan. CS revealed 42 instances from 07/05/2022-07/08/2022 where call light response times exceeded 15 minutes, with multiple instances with 30 plus minute wait times.The above information was shared with Staff #1 on 08/01/2022 who was in agreement.

The findings of the re-licensure survey, conducted 5/17/21 through 5/18/21 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day
The findings of the re-visit to the relicensure survey of 5/18/21, conducted 8/31/21 through 9/2/21, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities. Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day



The findings of the second re-visit to the re-licensure survey of 5/18/21, conducted on 11/5/21, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

2. Resident 4 was admitted to the facility in May 2019 with diagnoses including aphasia. During the acuity interview, facility staff identified Resident 4 as having limited communication abilities.Review of the 2/19/21- 5/18/21 progress notes and a 2/22/21 hospital discharge summary revealed the following: * 2/19/21: Resident 4 was noted to have a new skin issue on his/her 2nd toe on his/her right foot;* 2/21/21: "Right foot toe is all the way black/purple now";* 2/22/21: Emergency department discharge summary on 2/22/21 indicated Resident 4 had sustained a closed non-displaced fracture of phalanx of toe of right foot;* 3/4/21: RN progress note: the resident "doesn't know how this happened."Staff 1 (ED) and Staff 2 (RN) reported during an interview on 5/17/21 the injury of unknown cause had not been investigated to rule out abuse or reported to the local SPD office. The surveyor requested the facility report the injury of unknown cause to the local SPD office. A fax confirmation was provided by the facility on 5/18/21.
Based on interview and record review, it was determined the facility failed to ensure that a complete and thorough investigation for all incidents/accidents was documented and reported to the local SPD office as appropriate for 2 of 5 sampled residents (#s 2 and 4). Findings include, but are not limited to:1. Resident 2 was admitted to the facility in 2011 with diagnoses including blindness and a history of falls.Resident 2's service plan dated 2/18/21 noted numerous fall interventions including but not limited to:* Safety checks to be done every 30 minutes to one hour "to anticipate care needs and in hopes to reduce the number of avoidable falls"; and*During safety check ensure lighting was on and wheelchair seat belt was in place.An incident report dated 5/3/21 indicated the resident had an unwitnessed fall and was sent to the hospital with a head injury. The incident report stated abuse/neglect was ruled out because the resident gave a clear account of how s/he fell. However, the incident report provided unclear information related to Resident 2's cognition and recollection of the fall and did not provide information related to if the service planned fall interventions were in place and followed by staff prior to the fall.The need to ensure a complete and thorough investigation was documented and reported to the local SPD office, as appropriate, for all incidents/accidents was discussed with Staff 1 (Executive Director), Staff 2 (RN) and Staff 3 (RCC) on 5/18/21. They acknowledged the findings and reported the incident to the local SPD office per the surveyor's request. A fax confirmation was provided by the facility on 5/18/21.

Based on interview and record review, it was determined the facility failed to ensure quarterly evaluations were reflective of resident's current needs and condition for 1 of 5 sampled residents (#2) whose evaluations were reviewed. Findings include, but are not limited to:Resident 2 was admitted to the facility in 2011.Resident 2's quarterly evaluation dated 2/16/21 was not reflective of his/her current status and/or needs in the following areas:* Weight changes as indicated in weight records from 5/2020 - 2/1/2021;* Behaviors related to resisting care "that may contribute to falls;"* Swallowing difficulty as indicated on the 2/18/21 service plan; and* Safety checks every 30 minutes to 1 hour as indicated on the 2/18/21 service plan.The need to ensure evaluations were reflective of the resident's current needs and condition was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (RCC) on 5/18/21. They acknowledged the findings.

2. Resident 3 was admitted to the facility in December 2019 with atrial fibrillationReview of Resident 3's 3/5/21 service plan and interviews with staff and the resident revealed the service plan was not reflective of the resident's current care needs or followed in the following areas: * Transfers;* Aspiration precautions; * Edema;* Pet care; and* Chronic pain.The failure of the facility to ensure the resident's service plan was reflective of the resident's current care needs and was followed was discussed with Staff 1 (ED) and Staff 2 (RN) on 5/18/21. They acknowledged the findings. 3. Resident 4 was admitted to the facility in May 2019 with diagnoses including left below the knee amputation. Review of Resident 4's 2/18/21 service plan revealed it was not reflective of the resident's current status, not followed or did not provide clear instruction to staff in the following areas: * Hoyer transfers;* Finger and toenail care;* Left below the knee amputation; and* Wounds on 2nd toe of right foot. The failure of the facility to ensure the resident's service plan was reflective, followed and provided clear instruction to staff was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (RCC) on 5/18/21. They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of resident needs, provided clear instructions to staff and/or were followed by staff for 3 of 6 sampled residents (#'s 2, 3 and 4) whose service plans were reviewed. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in 2011 with diagnoses including blindness and a history of falls.Resident 2's service plan dated 2/18/21, directed staff to provide safety checks every "30 minutes - 1 hour on shift to anticipate care needs and in hopes to reduce the number of avoidable falls."During observations made on 5/17/21, facility staff did not check on the resident for over one and a half hours.During interviews on 5/18/21, Staff 8 (MT) stated safety checks were every two hours and Staff 13 (CG) stated safety checks were every hour to hour and a half.The need to ensure staff followed all service planned interventions was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (RCC) on 5/18/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to determine and document what actions or interventions were needed for changes of condition including resident specific instructions communicated to staff on each shift and weekly progress notes were documented until the condition resolved for 5 of 6 sampled residents (#s 1, 2, 3, 4 and 5) who had changes of condition. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in May 2019 with diagnoses including chronic kidney disease and diabetes. The resident's 2/17/21 through 5/17/21 progress notes, physician communications and outside provider notes were reviewed. The resident experienced multiple short term changes of condition without documented monitoring until resolution and/or resident specific directions to staff in the following areas:* Arm swelling;* Scratches to the neck/upper back, bruises to the armpit and knee;* Fall;* COVID 19 vaccine;* Infusion, injection;* Medication changes; and* Toe infection.The need to monitor short term changes to resolution with clear direction to staff was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (RCC) on 5/18/21. The staff acknowledged the findings.2. Resident 5 was admitted to the facility in October 2016 with diagnoses including delusional disorder and epilepsy.The resident's 2/17/21 through 5/17/21 progress notes, physician communications and outside provider notes were reviewed. The resident experienced multiple short term changes of condition without documented monitoring until resolution and/or resident specific directions to staff in the following areas:* Falls;* Seizure;* COVID 19 vaccine;* Swollen eye with stitches and ER visit;* Rib pain and bruised knee; and* Medication changes.The need to monitor short term changes to resolution with clear direction to staff was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (RCC) on 5/18/21. The staff acknowledged the findings.
3. Resident 4 was admitted to the facility in May 2019 with diagnoses including left cerebral infarction. Resident 4's 2/19/21- 5/18/21 progress notes, wound monitoring notes and hospital after visit-summaries were reviewed. The resident experienced multiple short term changes of condition without documented monitoring until resolution and/or no documented resident specific directions to staff in the following areas:* Second toe wound, skin issue;* ER visit, toe fracture and "cast shoe" use;* Edema and cellulitis; * COVID 19 vaccine; and* Medication changes. The need to monitor short term changes to resolution with clear direction to staff was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (RCC) on 5/18/21. The staff acknowledged the findings.4. Resident 3 was admitted to the facility in December 2019 with atrial fibrillation.Resident 3's 5/1/21 through 5/17/21 MARS, 2/19/21 through 5/19/21 progress notes, hospital discharge summaries and home health notes were reviewed. The resident experienced multiple short term changes of condition without documented monitoring until resolution and/or no documented resident specific directions to staff in the following areas:* Hospitalizations, fluid removal, UTI and heart attack;* Weeping edema;* Back pain, compression fracture and rib pain;* Falls with injuries; and* Medication changes.The need to monitor short term changes to resolution with clear direction to staff was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (RCC) on 5/18/21. The staff acknowledged the findings.
5. Resident 2 was admitted to the facility in 2011 with diagnoses including blindness and a history of falls.Review of incident reports and progress notes dated 11/25/20 through 5/19/21 showed the resident experienced two unwitnessed falls on 11/25/20 and 5/3/21. There was no documented evidence the facility monitored and determined the effectiveness of interventions that were implemented. The need to ensure interventions were monitored for effectiveness was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (RCC) on 5/18/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure services provided by and recommendations made by outside providers were communicated to staff and implemented as appropriate for 1 of 4 sampled residents (#3). Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 5/2019.Resident 3's 2/17/21 through 5/17/21 progress notes and outside provider notes were reviewed. There was inconsistent implementation of outside provider recommendations as follows: * On 2/24/21 a PT note indicated "[Resident] should use a walker for all gait ...Encourage [resident] to walk." There was no documented evidence this was communicated to staff and implemented as appropriate.* On 3/11/21 an RN visit note indicated "Gluteal wound healed. Upper gums remain red and sore." No indication this was communicated to staff.* On 4/12/21 an OT note indicated "due to pain from recent compression fracture, OT instructed resident in proper posture." * On 5/3/21 an OT note indicated "Back /rib pain 9/10" Proposed changes: recommend PRN given at designated intervals. Encourage use of cold pack to decrease inflammation in back." There was no evidence the recommendations were communicated to staff or implemented as appropriate. The failure of the facility to ensure recommendations provided by outside providers were communicated to staff and implemented as appropriate was discussed with Staff 1 (ED) and Staff 2 (RN) on 5/18/21. They acknowledged the findings. 2. Resident 4 was admitted to the facility in December 2019.Resident 4's 2/17/21 through 5/17/21 progress notes and outside provider notes were reviewed. There was inconsistent implementation of outside provider recommendations as follows: * The 2/22/21 hospital discharge summary indicated the resident had sustained an unspecified non-displaced fracture to the right foot and instructed staff that the resident was to "wear cast shoe to protect toe fracture for the next four weeks. May remove for sleeping and bathing." There was no indication these recommendations were communicated to staff or added to the service plan as appropriate. The failure of the facility to ensure that recommendations provided by outside providers were communicated to staff and implemented as appropriate was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (RCC) on 5/18/21. 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 4 sampled residents (#3) whose MARs and Controlled Substance Disposition logs were reviewed for accuracy. Findings include, but are not limited to:Resident 3's signed physician orders dated 4/19/21 to 4/26/21 contained orders for the following narcotic pain medications: * Oxycodone 5 mg tablets, take 1.5 tablets up to two times daily as needed for pain; and* Oxycodone 5 mg tablets, take 1.5 tablets two times daily for pain. Review of Resident 3's Controlled Substance Disposition logs and MARs from 5/1/21 through 5/17/21 revealed the following discrepancies: * On 5/4/21 three doses of Oxycodone were initialed as given on the MAR but four doses were signed out on the disposition log;* On 5/7/21 five doses of Oxycodone were initialed as administered on the MAR but four doses were signed out on the disposition log;* On 5/9/21 three doses of Oxycodone were initialed as administered on the MAR but four doses were signed out on the disposition log; and* On 5/15/21 three doses of Oxycodone were initialed as administered on the MAR but four doses were signed out on the disposition log.The need to ensure narcotic disposition logs and MARs were accurate and medications were recorded appropriately was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (RCC ) on 5/15/21. 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 3 of 3 sampled residents (#s 3, 7 and 8) whose MARs and Controlled Substance Drug Disposition logs were reviewed for accuracy. This is a repeat citation. Findings include, but are not limited to:1. Resident 7 was admitted in 2014 and had diagnoses which included Alzheimer's dementia.Resident 7 had an order for hydrocodone-acetaminophen (narcotic analgesic) 5-325 mg, one tablet every four hours PRN pain.Resident 7's Controlled Substance Disposition Logs and MARs, reviewed from 8/1/21 - 8/30/21, revealed 22 occasions when staff signed on the drug disposition log that the hydrocodone was given. However, the MAR lacked documentation that the resident received the medication inconsistencies between the MARs and Controlled Substance Disposition logs were reviewed with Staff 9 (LPN) and Staff 14 (Regional RN) on 9/1/21. They reviewed the documentation and acknowledged the discrepancies. The above information was reviewed with Staff 1 (Administrator) on 9/1/21. She acknowledged the findings.2. Resident 8 was admitted in 2016 and had diagnoses which included dementia.Resident 8 had an order for oxycodone (narcotic analgesic) 5 mg, one tablet every four hours PRN pain.Resident 8's Controlled Substance Disposition Logs and MARs, reviewed from 8/1/21 - 8/30/21, revealed 17 occasions when staff signed that oxycodone was given. However, the MAR lacked documentation that the resident received the medication.Inconsistencies between the MARs and Controlled Substance Disposition logs were reviewed with Staff 9 (LPN) and Staff 14 (Regional RN) on 9/1/21. They reviewed the documentation and acknowledged the discrepancies. The above information was reviewed with Staff 1 (Administrator) on 9/1/21. She acknowledged the findings.

3. Resident 3 was admitted to the facility in December 2019 with diagnoses including chronic pain. Resident 3 was prescribed oxycodone (a narcotic pain medication) 5 mg, 1.5 tablets up to two times daily as needed for pain. The resident's Controlled Substance Disposition Logs and MARs, reviewed from 8/1/21 - 8/31/21, revealed multiple occasions staff signed the oxycodone was administered on the Controlled Substance Disposition Log. There was no documented evidence on the MAR the medication was administered to the resident. The need to ensure the Controlled Disposition Logs and MARs were accurate and medications were documented appropriately was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (RCC) and Staff 9 (LPN) on 9/2/21. The staff acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure signed physician orders were located in the residents' facility records for all medications and that physician or other prescriber orders were carried out as ordered for 2 of 6 sampled residents (#s 3 and 4). Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in May 2019 with diagnoses including hypertension and stroke. Review of Resident 4's 5/1/21 through 5/18/21 MARs and 9/20/20 signed physician orders revealed the following: Signed physician orders dated 9/20/20 and located in the resident's clinical record instructed the facility to "continue all above orders for 120 days". There was no documented evidence the facility had obtained new orders for the following medications when the 9/20/20 orders expired: *Acetaminophen (pain and fever);*Atenolol (hypertension);*Atorvastatin (cholesterol);*Cholorthalidone (hypertension);*Losartan (hypertension);*Omeprazole (acid reflux);*Levetiracetam (epilepsy);*Potassium Chloride (edema); and *Vitamin B-12 (supplement). The failure of the facility to ensure signed physician orders were documented in the resident's clinical record was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (RCC) on 5/18/21. They acknowledged the findings. 2. Resident 3 was admitted to the facility in December 2019 with diagnoses including heart attack. Resident 3's 3/24/21 physician orders and 5/1/19 through 5/17/21 MAR revealed the following: * Aspirin 81 mg was to be given daily to the resident but the 5/1/21 through 5/17/21 MAR revealed the medication was listed as PRN and was not administered during the time frame reviewed. * Oxycodone 5 mg tab was to be administered as follows: take 1.5 tablets by mouth up to two times daily as needed for pain. The resident was administered the medication three times on 5/7/21 and 5/8/21. The failure of the facility to administer medications as prescribed was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (RCC) on 5/18/21. They acknowledged the findings. No further information was provided.

Based on interview and record review, it was determined the facility failed to ensure the physician or other practitioner was notified when when 1 of 4 sampled residents (#4) refused to consent to medication and treatment orders. Findings include, but are not limited to: Review of Resident 4's 5/1/21 through 5/17/21 MAR revealed the resident refused Potassium Chloride eight times and refused wound care treatments to his/her buttocks seven times during the time period reviewed. There was no documented evidence the facility notified the physician or other practitioner of the refusals. The failure of the facility to ensure the physician or other practitioner was notified when the resident failed to consent to orders was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (RCC) on 5/18/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure their relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to C302.

Based on observation and interview, it was determined the facility failed to ensure courtyard pathway edges did not contain drop-offs in the resident outdoor area. Findings include, but are not limited to:Observations of the courtyard of the facility and pathways near the resident smoking area on 5/17/21 showed drop-offs at the pathway edges in excess of four inches in multiple areas. The need to ensure pathways did not have drop-offs which created potential tripping hazards was discussed with Staff 1 (ED) and Staff 4 (Director of Maintenance) on 5/17/21. The staff acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure the environment was maintained in clean and good repair. Findings include, but are not limited to:Observations of the facility on 5/17/21 showed:* Rooms 101, 102, 117 and 242 had significant large, dark stains to the carpets in the living room and/or bedrooms;* Carpet at the door to the smoking area was stained black and torn;* A large piece of missing siding was noted on the side of the building in the courtyard area;* Rooms 119, 160, 161 and 168 had chipped, dinged or scraped door frames; and* Room 117's door would not fully close and latch.The need to ensure the facility was in clean and in good repair was discussed with Staff 1 (ED) and Staff 4 (Director of Maintenance) on 5/17/21. The staff acknowledged the findings.

Based on interview and observation, it has been confirmed that the facility failed to exercise reasonable precautions against any condition that may threaten the health, safety, or welfare of residents. Findings include; but are not limited to:During an unannounced inspection on 03/10/2021; Compliance Specialist (CS) observed all staff members to include direct care staff, kitchen staff and housekeeping staff to be wearing a mask; but no eye protection.CS interviewed Staff #1 (S1) in regard to the facilities infection control practices. S1 stated that his/her staff members are aware of the requirement to be wearing eye protection. The above information was shared with Staff #1.Facility Plan of Correction: Facility Administrator ensured all staff members were wearing appropriate PPE; to include eye protection prior to this CS leaving the community. Facility Administrator held an All Staff meeting on 03/10/2021; where PPE was addressed to include the requirement of staff to wear eye protection.

Based on interview and record review, it has been confirmed that the facility failed to report physical injury of unknown cause to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. Findings include; but are not limited to:During an unannounced site visit on 03/10/2021; Compliance Specialist (CS) reviewed the facilities incident reports from 01/01/2021-03/10/2021; which revealed 7 instances for resident #1 (R1) and Resident #5-9 (R5-R9) where the resident experienced a fall resulting in injury; the resident was unable to recall the event/what took place; and the instances were not reported to Adult Protective Services (APS). The facility completed internal investigations for each incident; and unreasonably ruled out abuse.During an interview with Staff #1 (S1); S1 stated that incident reports are filled out by facility Med Tech ' s; then reviewed by the Resident Care Coordinator, Administrator and Registered Nurse. S1 was unaware that these instances needed to be reported to APS. Facility Plan of Correction: Facility Administrator immediately held a All Staff Meeting; where APS reporting was discussed. The Facility Administrator will be meeting daily with the RCC and Nurse to ensure incidents are reviewed and instances can either reasonably rule out Abuse and/or incidents are reported to APS.