Princeton Village Assisted Living Community

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 07/03/25 at 10:45 am, the facility kitchen was observed to need cleaning in the following areas:

* Fan in prep area – dusty;

* Lower shelve in prep area – food debris/spills;

* Dry food storage floor – food debris under storage racks:

* Floor under dishwasher – black matter build up;

* Dishwashing machine area walls above and below the sink and caulking above back splash – brown matter build up;

* Top of dishwashing machine – significant build up of debris;

* "Range Guard" tank next to cooking equipment hood – dusty;

* Sides of stove and oven doors – grease build up/drips/spills/burnt debris in oven;

* Flooring behind stove – food debris build up;

* Trays stored and holding jugs/containers below toaster – food debris/spills; and

* Lid and sides of garbage can labeled “bottles only” – significant drips/spills.

Improper food storage:

* Food items on shelves in prep area – open packages of baking chips, cranberries, cocoa powder, cereal – not dated/baking chips not securely closed;

* Dry food storage – food bin open to air with open bag of bulk flour, dry yeast packaged not dated, open and undated bag of cocoa powder;

* Freezer – bags of tater tots, vegetable, berries not dated; and

* Refrigerator – undated and unlabeled food containers (pudding, hard boiled eggs, cucumbers, lunch meat, Jello).

Other concerns:

* Colored cutting boards – significant scoring and worn finish; and

* Lack of hair and/or beard restraints.

The areas of concern were observed and discussed with Staff 1 (Executive Chef0 and discussed with Staff 3 (Business Office Director) on 07/03/25. The findings were acknowledged by Staff 1.

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 06/03/24 and 06/04/24, it was confirmed the facility failed to keep resident records for a minimum of three years for 1 of 1 sampled resident (#1). Findings include, but are not limited to:During an interview on 06/03/23, Staff 1 (Administrator) stated they were unable to locate signed physician orders for Resident 1 or print his/her MARs as Resident 1 was deceased. In an email received on 06/04/24 Staff 1 stated "I have been working with q mar [electronic medical record] and my consultant and we have been unable to print this MAR from a year ago because it's requiring us to approve orders and start [him/her] again and we can't because [s/he] has been gone for almost a year."Resident 1's MAR was unable to be reviewed.The facility failed to keep resident records for a minimum of three years.The findings were reviewed with and acknowledged by Staff 1 on 06/04/24.Verbal plan of correction: Administrator was working with Regional Operations team to ensure he had access to everything.

Based on observation, interview and record review, during a site visit conducted on 06/03/24 and 06/04/24, it was confirmed the facility failed to complete service plans quarterly and make them available to staff for 2 of 3 sampled residents (#s 3 and 4). Findings include, but are not limited to:During an interview on 06/03/24 Staff 3 (agency CG) showed the Compliance Specialist (CS) where service plans are located on each floor and stated the service plans are available to staff for review only in the binders on each floor. Resident 3's service plan was located in the binder and dated 10/12/23.Resident 4's service plan was located in the binder and dated 10/23/23.During an interview on 06/04/24, Staff 1 stated he believed both Resident 3 and Resident 4 had more current service plans.The facility failed to complete service plans quarterly and make them available to staff.Verbal plan of correction: Administrator to audit and ensure most recent service plans are available to staff by Friday 06/07/24. LPN and Administrator will be responsible for putting new service plans in the binders.

Based on interview and record review, conducted during a site visit on 06/03/24 and 06/04/24, it was confirmed the facility failed to carry out medication orders as prescribed for 1 of 1 sampled resident (#2). Findings include, but are not limited to:A review of Resident 2's signed physican orders dated 04/04/24 revealed an order for Timomptic 0.25% (eye drop) ophthalmic solution. Place 1 drop into right eye two times daily.A review of Resident 2's MAR dated 05/01/24 through 05/31/24 revealed Resident 2 did not receive the medication on 05/04/24 due to "med not here from pharmacy. pharmacy contacted".The facility failed to carry out medication orders as prescribed.The findings were reviewed with and acknowledged by Staff 1 (Administrator) on 06/04/24 who confirmed the error occurred.Verbal plan of correction: The facility was hiring new staff, including MTs, several were in training and the facility utilized agency LPNs. Administrator or RN personally went to orient each new agency nurse. LPN was reviewing missed medications Monday - Friday and Administrator reviews on the weekends and staff are followed up with.Based on interview and record review, conducted during a site visit on 06/03/24 and 06/04/24, it was confirmed the facility failed to administer medications as prescribed for 1 of 1 sampled resident (#5). Findings include, but are not limited to:A review of Resident 5's signed physican orders revealed Clomtrimazole 1% Cream 30 GM apply to right groin twice daily was ordered on 09/29/23.A review of Resident 5's MAR for 03/01/24 through 03/31/24 revealed Resident 5 did not receive the medication three times on 03/07/24 and 03/08/24 due to "med not here from pharmacy. pharmacy contacted."The facility failed to administer medications as prescribed.The findings were reviewed with and acknowledged by Staff 1 (Administrator) who confirmed the error occurred.Verbal plan of correction: The facility was hiring new staff, including MTs, several are currently in training and the facility utilizing agency LPNs. Administrator or RN personally come in to orient each new agency nurse. LPN is reviewing missed medications Monday - Friday and Administrator reviews on the weekends and staff are followed up with.Based on interview and record review, conducted during a site visit on 06/03/24 and 06/04/24, it was confirmed the facility failed to carry out medication orders as prescribed for 1 of 1 sampled residents.A review of a facility self-report dated 07/17/23 revealed at 5:51 am Resident 1 was given .25 ml of lorazepam (anxiety medication) by mouth instead of ordered haloperidol (anxiety medication). Lorazepam had been discontinued by hospice on 07/06/23.During interview on 06/03/23, Staff 1 (Administrator) stated they were unable to locate signed physician orders for Resident 1 or print his/her MARs as Resident 1 was deceased. Staff 1 stated if the facility self-reported the error, it must have occurred. The nurse who made the report was no longer employed by the facility and could not be interviewed.The facility failed to carry out medication orders as prescribed.The findings were reviewed with and acknowledged by Staff 1 on 06/04/24.Verbal plan of correction: The facility was hiring new staff, including MTs, several are currently in training and the facility utilizing agency LPNs. Administrator or RN personally come in to orient each new agency nurse. LPN is reviewing missed medications Monday - Friday and Administrator reviews on the weekends and staff are followed up with.

The findings of the change of ownership survey, conducted 07/31/23 through 08/02/23, 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 OARs 411 Division 004 for Home and Community Based Services Regulations.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day

The findings of the first re-visit to the change of ownership survey of 08/02/23, conducted 12/05/23 through 12/07/23, 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 OARs 411 Division 004 for Home and Community Based Services Regulations.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day

The findings of the second re-visit to the change of ownership survey of 08/02/23, conducted 03/25/24 through 03/28/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day

The findings of the third revisit to the re-licensure survey of 08/02/23, conducted on 06/11/24, 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 Service Regulations.

Based on observation, interview and record review, it was determined the licensee failed to provide effective oversight to ensure the quality of care and services that were rendered in the facility. Findings include, but are not limited to:During the first re-visit survey, conducted 12/05/23 through 12/07/23, oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number and severity of citations.Refer to the deficiencies identified in the report.

Based on interview and record review, the facility failed to report suspected incidents of abuse or neglect to the local Seniors and People with Disabilities (SPD) office and promptly investigate the incident and take measures necessary to protect the resident and prevent the reoccurrence of abuse for 1 of 2 sampled residents (#4) whose records were reviewed. Findings include, but are not limited to:Resident 4 was admitted to the facility in 06/2018 with diagnoses including type 1 diabetes.The resident's MAR dated 07/01/23 through 07/31/23, incident reports, and interim service plans (ISPs) were reviewed. The following was identified:Resident 4 had physician's orders for the following medications for diabetes:a. Tresiba 100-U/ml pen 3 ml to inject 12 units subcutaneously every night at bedtime, hold if blood sugar below 100.b. Novolog 100-U/ML pen to be administered four times per day before meals and at bedtime. The amount of insulin administered was based on the resident's CBG level according to the following sliding scale:* 70 - 150: 0 units;* 151 - 200: 2 units;* 201 - 250: 3 units;* 251 - 300: 4 units;* 301 - 350: 5 units; * 351 - 400: 6 units; and* Above 400: 7 units and call provider.There was no documented evidence the Tresiba or the Novolog were administered as prescribed on 07/25/23 at 8:00 pm secondary to blanks on the MAR. During an interview on 07/31/23 at 3:03 pm, Staff 9 (MT) confirmed she was unable to locate any additional documentation regarding the 07/25/23 blanks on the electronic MAR for the Tresiba and Novolog.On 08/01/23 at 10:50 am, Staff 1 (Administrator) confirmed the facility was not aware of the medication errors prior to the survey. There was no documented evidence the facility had immediately reported the medication errors to the local SPD office as suspected abuse/neglect. Further, the facility failed to promptly investigate the incident and take measures necessary to protect the resident and prevent the reoccurrence of abuse.The facility was directed to self-report the incident to the local SPD office. Confirmation of the report was received on 08/02/23 at 1:50 pm.The need to promptly investigate and report medication errors that could have a negative effect on the resident was discussed with Staff 1 and Staff 2 (Health Services Director) on 08/02/23. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: On 07/31/23, the facility kitchen was observed, and the following deficiencies were identified: a. The following areas were in need of cleaning:* The interior shelves and doors of multiple cabinets had dried spills, dirt and grime; and* There was black matter around the mounting plate of the industrial can opener.b. The following items were in need of repair:* The hinges of several cabinet doors were loose, so the doors did not close properly;* A ceiling vent was missing louvers; and* A pipe under the two-compartment sink was leaking water into a bucket.c. The rear kitchen door was repeatedly left open, the screen was covered with lint and it was not securely fitted to the door.d. During lunch service on 07/31/23, caregiving staff were observed serving meals to residents in the dining room. They did not don clean aprons, did not restrain their hair, and did not consistently perform hand hygiene upon entering the kitchen. Areas in the kitchen needing repair were reviewed with Staff 6 (Environmental Services Director) on 07/31/23.Surveyors reviewed the above areas with Staff 1 (Administrator) and Staff 4 (Executive Chef) on 08/01/23. They acknowledged the areas in need of cleaning and repair.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and in good repair and food was served in accordance with Food Sanitation Rules, OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to:The kitchen was toured and meal service was observed on 12/05/23.The following areas were in need of cleaning: * The insides of drawers in dining room coffee station cabinets had spills and splatters;* Open shelving in the kitchen had spills/splatters, food debris and dust/dirt;* The ice machine vent had a heavy accumulation of dirt/dust;* Interior of the ice machine had black matter;* The industrial can opener, casing and around the mounting plate had an accumulation of dirt/dust and black matter; * Walls throughout the kitchen had spills/splatters; and* Some areas of the ceiling throughout the kitchen had splatters. The following areas were in need of repair: * The interior and exterior of the cabinets in the kitchen and dining room had chipped or missing laminate and deteriorating wood;* The cabinet under the prep area sink had cracks and exposed particle board;* Ceiling vents in the kitchen were missing parts of the vent and screws; * Ceiling vents in the dining room bordering windows were missing screws and were not secure;* Sections of caulking along the warewashing counter had black matter; and* Cutting boards were heavily scored.The following poor infection control practices were observed:* Dietary staff were not washing hands after touching soiled items and before touching clean dishware; * Dietary staff failed to wash his/her hands or change single-use gloves when handling, preparing and plating resident meals; and* During meal deliveries to resident apartments, desserts were uncovered and exposed to potential contamination.Areas needing cleaning and repair were toured and issues relating to poor infection control practices were discussed with Staff 22 (ED) and Staff 25 (Environmental Services Director) on 12/05/23 and 12/06/23. They acknowledged the findings.
Based on observation, interview, and record review, it was determined the facility failed to ensure the kitchen was clean and maintained in good repair, kitchen staff did not follow hygienic practices, and proper food handling procedures were not followed in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to:a. On 03/25/24 at 11:55 am, the main kitchen was observed to need cleaning and repair in the following areas:* Excessive opening in wall above door to broom closet for electrical conduit pipe; * Exhaust hood above cooktop not securely attached to ceiling; * Plywood covering damaged flooring in front of dish washing station;* Open electrical box with exposed wires in cabinet under food serving line; * Open electrical box with exposed wires on the wall in dirty dish station area; * Plastic safety edge on exhaust hood above dish washing machine was worn and cracked; * Walls throughout the kitchen had multiple spills, smears, splatters or black streaks; * Floors throughout the kitchen including the broom closet had black matter build-up, food debris and grease in corners, under equipment and around perimeter edges;* Ceiling vents; * Open shelving and drawers throughout the kitchen;* Three light fixtures with burnt out bulbs and cracked fixture covers; * Drywall surface peeling; and* Bottom shelfs and cabinets under food serving line. b. On 03/25/24 at 12:25 pm, the following improper food handling practices were noted:* Staff 20 (Cook) was observed using single-use gloves for multiple tasks, including food handling and operating appliances; and* Kitchen staff was observed using hand sanitizer to wipe gloved hands during meal service.Additionally, multiple dishwasher racks were stored on the floor.The survey team was informed by Witness 1 (Operations Specialist) kitchen renovations were scheduled to start on 03/31/24. Residents were notified on 03/27/24 kitchen operations would be impacted for several days. The findings were discussed with Witness 1 and Staff 37 (Executive Chef) on 03/27/24 at 11:30 am. Both staff acknowledged the findings.

3. Resident 6 was admitted to the facility in 06/2023 with diagnoses including congestive heart failure.The new move-in evaluation failed to address the following elements:* Customary routines: eating and bathing;* Mental Health issues including: effective non-drug interventions;* Personality, including how a person copes with change or challenging situations; * Activities of daily living including: dental status; and* Recent losses.The need to ensure move-in evaluations included all required elements was discussed with Staff 1 (Administrator) and Staff 2 (Health Services Director) on 08/02/23. They acknowledged the findings.
2. Resident 2 was admitted to facility in 01/2017 with diagnoses including right side hemiplegia and aphasia.a. The most recent quarterly evaluation for Resident 2 was completed on 03/28/23. The next evaluation was due on 06/20/23. The evaluation was not updated quarterly. b. The current evaluation failed to be reflective of the resident's current condition in the following areas:* Level of assistance required for ADLs;* Significant weight loss;* Use of gait belt with transfers; and* Considerations for activity participation, including physical ability limitations.The need to ensure quarterly evaluations were completed and reflective of the resident's condition was discussed with Staff 1 (Administrator) and Staff 2 (Health Services Director) on 08/02/23. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure a move-in evaluation addressed all required elements for 1 of 1 sampled resident (#6) whose initial evaluation was reviewed, and the facility failed to ensure quarterly evaluations were completed for 2 of 3 sampled residents (#s 1 and 2) whose quarterly evaluations were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 05/2021 with diagnoses including osteoarthritis of the knee. a. The resident's quarterly evaluation was completed on 04/03/23. The next quarterly evaluation was due on 07/02/23 and was not completed. b. The current evaluation was not reflective of the resident's current condition in the following areas:* Level of assistance for toileting;* Fall risk and interventions;* Pain management and interventions;* Assistive devices including use of bilateral 1/2 length side rails; and* Behavior management including triggers and interventions.The need to ensure the quarterly evaluation was updated and reflective of the resident's condition was discussed with Staff 1 (Administrator) and Staff 2 (Health Services Director) on 08/01/23. They acknowledged the findings.


Based on interview and record review, it was determined the facility failed to ensure a move-in evaluation addressed all required elements for 1 of 1 sampled resident (#9) whose initial evaluation was reviewed. This is a repeat citation. Findings include, but are not limited to: Resident 9 moved into the facility in 12/2023.The new move-in evaluation was reviewed and did not contain some of the required elements or sufficient information to develop the service plan in the following areas: * Documentation the evaluation was performed before the resident moved into the facility and who was involved in the evaluation process; * Customary routines: eating and sleeping;* Interests, hobbies, and social and leisure activities;* Cultural preferences and traditions;* Mental health issues including: presence of depression, thought disorders, or behavioral or mood problems, history of treatment and effective non-drug interventions;* Personality, including how a person copes with change or challenging situations; * Activities of daily living including mobility, eating, dental status;* Pain: pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort;* Fall risk or history;* History of dehydration;* Recent losses; * Elopement risk or history; and* Environmental factors that impact the resident's behavior including, but not limited to noise, lighting and room temperature.The need to ensure move-in evaluations included all required elements was discussed with Staff 22 (ED) and Staff 23 (RCC) on 12/07/23. They acknowledged the findings.

3. Resident 3 was admitted to the facility in 09/2020 with diagnoses including paraplegia, asthma and anxiety disorder.The current service plan dated 05/31/23 and Interim Service Plans (ISPs) from 05/29/23 to 07/20/23 were reviewed, and observations and interviews with staff and Resident 3 were completed during the survey.The service plan was not reflective of the resident's current status and did not provide clear direction to staff in the following areas:* HH PT services;* Oxygen needs and monitoring required with supplemental oxygen;* Number of caregivers required for dressing and showering;* Location of and behaviors around incontinence care;* Management of behaviors toward staff;* Cannabis use and monitoring around driving a motorized wheelchair;* Required daily maintenance with the motorized wheelchair;* Presence of a pet and who provides care for the pet; and* Current primary care physician.The need to ensure service plans were reflective of residents' current needs and included a written description of who shall provide the services and what, when, how, and how often the services shall be provided was discussed with Staff 1 (Administrator) and Staff 2 (Health Services Director) on 08/02/23. They acknowledged the findings.
2. Resident 2 was admitted to facility in 01/2017 with diagnoses including right side hemiplegia and aphasia. The current service plan dated 03/28/23 and Interim Service Plans (ISPs) from 04/19/23 to 06/27/23 were reviewed, and observations and interviews with staff and Resident 2 were completed during the survey. The following was identified:a. The service plan was not updated quarterly. b. The service plan was not reflective of the resident's current status and did not provide clear direction to staff in the following areas:* Level of assistance required for ADLs;* Significant weight loss;* Use of gait belt with transfers; and* Considerations for activity participation, including physical ability limitations.The need to ensure service plans were completed quarterly, were reflective of residents' current needs, and included a written description of who shall provide the services and what, when, how, and how often the services shall be provided was discussed with Staff 1 (Administrator) and Staff 2 (Health Services Director) on 08/02/23. They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to ensure service plans were completed quarterly, were reflective of resident needs, and provided clear direction regarding delivery of services for 3 of 3 sampled residents (#s 1, 2 and 3) whose records were reviewed. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in 05/2021 with diagnoses including osteoarthritis of the knee.Review of the current service plan dated 04/23/23, interim service plans (ISPs), observations and interviews with staff and Resident 1 were completed during the survey. The following was identified:a. The service plan was not updated quarterly.b. The service plan was not reflective and lacked clear instructions regarding the delivery of services in the following areas:* Level of assistance for toileting;* Fall risk and interventions;* Pain management and interventions;* Behavior management including triggers and interventions;* Assistive devices and use of bilateral 1/2 length side rails lacked clear instructions for staff; and* Emergency evacuation and level of assistance needed. The need to ensure service plans were updated quarterly, were reflective and provided clear instructions for staff was discussed with Staff 1 (Administrator) and Staff 2 (Health Services Director) on 08/01/23. They acknowledged the findings.
2. Resident 7 was admitted to the facility in 06/2023 with diagnoses including vascular dementia and Type 2 diabetes. The current service plan, dated 10/03/23 and Interim Service Plans (ISPs) from 10/01/23 to 12/05/23 were reviewed. Observations and interviews with staff and Resident 7 were completed during the survey. The following was identified:The service plan was not reflective of the resident's current status and did not provide clear direction to staff in the following areas:* Recent visits to the emergency department; * Suicidal ideations and interventions;* Recent fall with injuries and interventions to minimize falls; and* Current skin status and treatment. The need to ensure service plans were reflective of residents' status and included clear directions to staff was discussed with Staff 22 (Executive Director) and Staff 23 (RCC) on 12/07/23. They acknowledged the findings.


Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of the resident's needs, readily available to staff and provided clear direction regarding the delivery of services for 2 of 2 sampled residents (#s 7 and 8) whose records were reviewed. This is a repeat citation. Findings include, but are not limited to:1. Resident 8 was admitted to the facility on 09/2023 with diagnoses including end stage renal disease and congestive heart failure. Resident 8 was dependent on renal dialysis. The current service plan, dated 12/04/23, was reviewed. Observations and interviews with staff and Resident 8 were completed during the survey. The following was identified:a. The Service Plan and the Interim Service Plan binders were stored in the locked medication room and not readily available to caregiving staff. In an interview on 12/06/23, Staff 29 (CG) stated she needs to ask an MT to unlock the door to gain access to the binders. b. The service plan was not reflective of the resident's current status and did not provide clear direction to staff in the following areas:* Shower instructions, related to keeping the dialysis port dry, and use of shower chair; * Mobility and level of assist for transfers and bed mobility;* Assistive devices, including hospital bed and side rail;* Recent falls and interventions to minimize falls; * Dietary restrictions, including food and fluids related to dialysis;* Precautions for staff to follow regarding risks related to dialysis; * Evacuation assistance needed in an emergency;* Toileting assistance, including use of incontinence briefs; and* Current skin status, including port, wounds and treatment. The need to ensure service plans were reflective of residents' status, readily available to staff and included clear directions was discussed with Staff 22 (ED) and Staff 23 (RCC) on 12/07/23. They acknowledged the findings.


3. Resident 13 was admitted to the facility on 12/2022 with diagnoses including Type 2 diabetes and idiopathic cardiomyopathy.The current service plan, dated 01/03/24, was reviewed. Observations and interviews with staff and Resident 13 were completed during the survey. The following was identified:The service plan was not readily available to caregiving staff. The service plan binders were stored at the MT's desk. In an interview on 03/26/24, Staff 19 (MT) confirmed Resident 13's current service plan was not available in the service plan binder.The need to ensure service plans were readily available to staff was discussed with Witness 1 (Operations Specialist) on 03/28/24. She acknowledged the findings.


2. Resident 11 was admitted to the facility in 09/2020 with diagnoses including disorder of the white blood cells (WBC), bipolar disorder, major depressive disorder, and epilepsy.Observation of care on 03/25/24 through 03/028/24, interviews with the resident and staff, and review of the current service plan, dated 01/02/24, revealed Resident 11's service plan was not reflective of the resident's current needs or lacked clear instructions to staff in the following areas:* Incorrect reference to presence of suprapubic catheter;* Incorrect reference to resident self-administering medications; * Number of staff needed to assist with activities of daily living;* Electric mobility equipment precautions and instructions for proper maintenance;* Wound condition monitoring;* Monthly mental health meeting;* Prophylactic antibiotic treatment;* Skin integrity and instructions on to whom to report skin impairments;* Instructions on skin care;* Instructions for signs and symptoms of infection to report when providing wound care;* Instructions on signs and symptoms of depression to report while on anti-depressant therapy;* Instructions on signs and symptoms of seizure activity to report while on anti-seizure therapy;* Instructions on to whom to report weight gain or loss;* Instructions on edema management; and * Instructions on weight management. The need to ensure the service plan reflected residents' current needs and provided clear instructions to staff regarding the delivery of services was reviewed with Witness 1 (Operations Specialist) and Witness 2 (RN Consultant) on 03/28/24. They acknowledged the findings. No further information was provided.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of the residents' needs, readily available to staff, provided clear direction regarding the delivery of services and services were implemented for 3 of 3 sampled residents (#s 11, 12 and 13) whose records were reviewed. This is a repeat citation. Findings include, but are not limited to:1. Resident 12 was admitted to the facility in 07/2023 with diagnoses including congestive heart failure and non-dialysis end stage renal disease. The current service plan, dated 01/18/24, was reviewed. Observations and interviews with staff, Resident 12 and Resident 12's family were completed during the survey. The following was identified:a. The resident's service plan was not implemented in the following areas:* Incontinence checks; and* Repositioning in the setting of bedbound status and history of wounds.b. The service plan was not reflective of the resident's current status and did not provide clear direction to staff in the following areas:* Meal refusals;* Denture status including preference to wear during waking hours;* Cognitive status including memory;* Precautions for use of siderails; and* Dry skin including RN recommendation to apply lotion twice daily.The need to ensure the service plan was reflective of resident's current status, included clear directions and services were implemented was discussed with Witness 1 (Operations Specialist) on 03/28/24. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure resident service plans were developed by a Service Planning Team that consisted of the resident or the resident's legal representative, any person of the resident's choice, the facility administrator or designee, a licensed nurse if the resident needed or was receiving nursing services or experienced a significant change of condition and at least one other staff person who was familiar with or who was going to provide services to the resident for 2 of 2 sampled residents (#s 7 and 8) who were receiving nursing services. Findings include, but are not limited to:Resident 7 and 8's most recent service plans were reviewed during the survey. Each service plan lacked documented evidence it was developed and reviewed by the licensed nurse and other required members of his/her Service Planning Team.The need to ensure service plans were developed with a Service Planning Team was discussed with Staff 22 (Executive Director) and Staff 23 (RCC) on 12/07/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure resident service plans were developed by a Service Planning Team that consisted of the resident or the resident's legal representative, any person of the resident's choice, the facility administrator or designee, a licensed nurse if the resident needed or was receiving nursing services or experienced a significant change of condition, and at least one other staff person who was familiar with or who was going to provide services to the resident for 2 of 2 sampled residents (#s 11 and 13) who were receiving nursing services. This is a repeat citation. Findings include, but are not limited to:Resident 11 and 13's most recent service plans were reviewed during the survey. Each service plan lacked documented evidence it was developed and reviewed by the licensed nurse and other required members of his/her Service Planning Team.The need to ensure service plans were developed with a Service Planning Team was discussed with Witness 1 (Operations Specialist) on 03/28/24. She acknowledged the findings.

2. Resident 3 was admitted to the facility in 09/2020 with diagnoses including paraplegia, asthma and anxiety disorder.Observations of the resident, interviews with staff, review of the resident's service plan dated 05/31/23, interim service plans and progress notes dated 05/31/23 through 07/20/23 were reviewed.a. The following short-term changes of condition lacked documentation of actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, progress noted at least weekly, and documentation of resolution:* 07/02/23 - Missed dose of omeprazole (for gastroesophageal reflux disease);* 07/07/23 - Missed dose of venlafaxine (for depression); and* 07/16/23 - Shortness of breath.b. The following short-term changes of condition lacked documentation of progress noted at least weekly through resolution:* 07/18/23 - Discontinuation of albuterol (for shortness of breath) and aripiprazole (for depression).The need to ensure actions or interventions for short-term changes of condition were documented, communicated to staff on each shift and the changes of condition were monitored through resolution was discussed with Staff 1 (Administrator) and Staff 2 (Health Services Director) on 08/02/23. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure resident-specific instructions or interventions were developed for short-term changes of condition, the interventions were communicated to the staff, and the condition was monitored at least weekly through resolution for 3 of 3 sampled residents (#s 1, 2 and 3) who experienced changes of condition. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in 01/2017 with diagnoses including right side hemiplegia and aphasia.Staff were interviewed, and interim service plans, incident investigations, and progress notes dated 05/31/23 through 07/05/23 were reviewed.a. The following short-term changes of condition lacked documentation of actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, progress noted at least weekly and documentation of resolution:* 06/09/23 - Dark spot under right eye; and* 06/29/23 - Increased difficulty with transfers. b. The following short-term changes of condition lacked documentation of progress noted at least weekly and documentation of resolution:* 06/16/23 - Decrease in metoprolol (for hypertension); and* 06/18/23 - Dark red urine, strong odor.The need to ensure actions or interventions for short-term changes of condition were documented, communicated to staff on each shift, and the changes of condition were monitored through resolution was discussed with Staff 1 (Administrator) and Staff 2 (Health Services Director) on 08/02/23. They acknowledged the findings.
3. Resident 1 was admitted to the facility in 05/2021 with diagnoses including osteoarthritis of the knee.Staff were interviewed, and interim service plans, incident investigations, and progress notes dated 05/31/23 through 07/31/23 were reviewed.a. The following short-term changes of condition lacked documentation of progress noted at least weekly until resolved: * 05/28/23 - Redness under breast. The chart notes read as follows: "alert charting: resident is on alert for redness under breasts." There was no further documentation on the condition of the resident's skin.b. The following short-term changes of condition lacked documentation of actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, and progress noted at least weekly until resolved: * 07/13/23 - Bright red blood in stool; and* 07/23/23 - Injury fall. The need to ensure actions or interventions for short-term changes of condition were documented and communicated to staff on each shift, and the changes of condition were monitored through resolution was discussed with Staff 1 (Administrator) and Staff 2 (Health Services Director) on 08/01/23. They acknowledged the findings.

2. Resident 7 was admitted to the facility in 06/2023 with diagnoses including vascular dementia and Type 2 diabetes.Resident 7's clinical record, charting notes and physician communications were reviewed from 10/02/23 through 12/05/23. Interviews with facility staff and the resident were conducted.The following changes of condition lacked documentation of actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, progress noted at least weekly and documentation of resolution:* 10/16/23 - Fall with injuries;* 10/17/23 - Return from the emergency room;* 11/02/23 - Resident making suicidal ideation remarks to staff; and* 11/10/23 - Resident sent to the emergency room and treated for right foot cellulitis, anorectal abscess, and hyperglycemia.The need to ensure actions or interventions for changes of condition were documented, communicated to staff on each shift and the changes of condition were monitored through resolution was discussed with Staff 22 (Executive Director) and Staff 23 (RCC) on 12/07/23. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to evaluate the resident, refer to the facility nurse, document the change and update the service plan as needed for a significant change of condition and failed to determine what action or interventions were needed following short-term changes of condition, communicate the interventions to staff and document weekly progress until resolved for 2 of 2 sampled residents (#s 7 and 8) who experienced changes of condition. Resident 8 experienced the onset of shortness of breath and elevated heart rate, which put the resident at serious risk. This is a repeat citation. Findings include, but are not limited to:1. Resident 8 was admitted to the facility on 09/2023 with diagnoses including end stage renal disease and congestive heart failure (CHF). Resident 8 was dependent on renal dialysis. Review of clinical records including the service plan dated 12/04/23, progress notes from 10/01/23 through 12/04/23 and outside provider notes revealed the following information:a. On 11/02/23 progress notes indicated Resident 8's family member reported to Staff 23 (RCC) the resident "has been SOB [short of breath] and has had high heart rate." Between 11/02/23 and 11/04/23 there was no further documented evidence of monitoring the resident or actions determined or communicated to staff related to the change of condition.On 11/04/23 at 1:04 pm progress notes indicated care staff responded to a call from resident's room and "the resident's face was red and resident was also shaky," s/he had diarrhea and vomited. The resident's family member stated to "call 911" and the resident was then sent to the emergency department and later admitted to the hospital and diagnosed with acute onset of chronic congestive heart failure. On 11/09/23 Resident 8 returned from the hospital and was put on alert charting for the return to the facility and medication changes, however there was no documented evidence the resident was evaluated, actions determined or communicated to staff related to the change of condition and referred to the facility nurse.In an interview on 12/06/23, Staff 29 (CG) reported Resident 8 needed more assistance with transfers, toileting, dressing and escorting to meals with a wheelchair because s/he "got short of breath easily and was weaker."An interview on 12/07/23 with Staff 23 confirmed that Resident 8 had not been evaluated upon return from the hospital and referred to the facility nurse. She acknowledged there was no documentation of resident-specific actions or interventions needed for the resident, communication of interventions to staff on all shifts and progress noted at least weekly through resolution following the exacerbation of CHF symptoms and hospitalization.Resident 8 experienced a change of condition related to symptoms of exacerbation of congestive heart failure. The facility failed to evaluate the resident, determine actions or interventions needed, refer to the facility nurse and monitor the resident resulting in hospitalization and a decline in ADL functioning. b. The following changes of condition lacked documentation of actions or interventions needed for the resident, communication of interventions to staff on all shifts, monitoring and progress noted at least weekly until resolution:* 10/21/23: Resident 8 was put on alert for loose stools following a medication error. Progress notes stated that Resident received a bisocodyl suppository (for constipation) instead of a hydrocortisone suppository (for rectal pain/itching); * 10/25/23: Resident 8 returned to the facility following a forearm fistula procedure with instructions for post-care. While the resident was placed on alert monitoring, there was no documented evidence the information was referred to the facility nurse; * 10/25/23: Following the fistula procedure Resident 8 was started on hydrocodone as needed (for pain); * 11/09/23: Upon return from the hospital, Resident 8 was started on losartan 25 mg once a day (for high blood pressure) and his/her torsemide 5mg changed from 1 to 2 tablets once a day (for edema); * 11/11/23: Resident 8 was put on alert for an injury fall and sustained two skin tears and his/her "arm was hot to the touch" and oxygen saturation was 74%; * 11/14/23: Resident 8 alerted staff that s/he had "some sores on his tailbone and above [his/her] bottom." There was no documented evidence the information was referred to the facility nurse; * 11/15/23: Progress notes stated "Blood pressure was low tonight and [s/he] was winded." On 11/29/23 progress notes indicated "Blood pressure was low when checked ..." and noted the blood pressure reading was 89/71 and oxygen saturation was 82%; * 11/27/23: Progress notes indicated "Resident is on alert charting for skin abrasion/skin tear. Resident was not sure what happened or how [s/he] got it"; * 11/28/23: Resident 8's family member reported to Staff 22 (ED) and Staff 23 that s/he had "gained 20 pounds since 11/24/23... due to [s/he] not being able to complete dialysis," and was put on alert. There was no documented evidence the information was referred to the facility nurse; and* 11/30/23: Resident 8 sustained a non-injury fall.The changes of condition and the need to evaluate the resident, refer to the facility nurse, document the change and update the service plan as needed was reviewed with Staff 22 and Staff 23 on 12/07/23 at 3:45 pm. They acknowledged the findings and no further information was provided.


2. Resident 12 was admitted to the facility in 07/2023 with diagnoses including cerebrovascular disease and gastroesophageal reflux disease.The resident's current service plan dated 01/18/24, Interim Service Plans (ISPs) dated 01/22/24 through 03/25/24, and progress notes dated 01/22/24 through 03/25/24 were reviewed. Observations of the resident and interviews with staff and the resident's family were completed between 03/25/24 and 03/28/24.a. The following short-term changes of condition lacked evaluation, documentation of actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, and progress noted, at least weekly through resolution:* 01/24/24 - Medication changes;* 01/25/24 - Discontinuation of compression stockings;* 01/26/24 - Difficulty swallowing pills;* 02/12/24 - Vomiting and nausea;* 02/16/24 - Change of hydromorphone from tablet to liquid; and* 03/14/24 - Medication changes.b. The following short-term change of condition lacked documentation of actions or interventions needed for the resident and communication of the determined actions or interventions to staff on all shifts:* 02/26/24 - Right heel skin breakdown. The need to ensure short-term changes of condition were evaluated with actions or interventions documented, communicated to staff on each shift and then monitored, at least weekly, through resolution was discussed with Witness 1 (Operations Specialist) on 03/28/24. She acknowledged the findings, and no additional documentation was provided.

Based on observation, interview, and record review, it was determined the facility failed to determine what resident-specific action or intervention was needed for a resident following a short-term change of condition, communicate the determined action or intervention to staff, and document progress until the condition resolved for 2 of 3 sampled residents (#s 11 and 12) who experienced changes of condition. This is a repeat citation. Findings include, but are not limited to:1. Resident 11 was admitted to the facility in 09/2020 with diagnoses including disorder of the white blood cells (WBC), bipolar disorder, major depressive disorder, and epilepsy.Clinical records, including the current service plan and observation notes from 01/22/24 through 03/24/24, were reviewed, and interviews with facility staff and the resident were conducted.The following short-term changes of condition lacked documentation the facility determined what resident-specific action or intervention was needed for the resident, communicated the determined action or intervention to staff, and documented weekly progress until the condition resolved:* 01/20/24 - "complained of meds not given last night";* 01/25/24 - "right shoulder itchy";* 01/25/24 - "difficult to arouse";* 02/01/24 - "diarrhea, has been refusing Miralax";* 02/06/24 - received vaccination;* 02/20/24 - received vaccination;* 02/24/24 - started new anti-seizure medication Lacosamide 50 mg three tablets orally twice daily;* 03/11/24 - pain in right knee; and* 03/18/24 - underwent urology outpatient procedure.The need to ensure the facility evaluated the resident and determined what resident-specific action or intervention was needed for the resident following a short-term change of condition, communicated the determined action or intervention to staff, and documented progress until the condition resolved was reviewed with Witness 1 (Operations Specialist) and Witness 2 (RN Consultant) on 03/27/24 and 03/28/24. They acknowledged the findings. No further information was provided.

Based on observation, interview and record review, it was determined the facility failed to ensure an RN assessment was completed and 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 01/2017 with diagnoses including right side hemiplegia, aphasia and cerebrovascular accident.Resident 2's service plan dated 03/28/23 noted the resident was assisted by his/her spouse for eating, required food to be cut up, and was dependent on staff assistance for wheelchair mobility.Resident 2's weight records were reviewed and revealed the following:* 03/10/23: 195.4 pounds;* 03/30/23: 195.2 pounds;* 05/18/23: 171.0 pounds;* 05/26/23: 171.6 pounds;* 06/02/23: 170.9 pounds;* 06/09/23: 171.6 pounds; and* 06/16/23: 170.5 pounds.Resident 2 was observed during lunch on 07/31/23 and 08/01/23. S/he required staff escort to the dining room, assistance from spouse with eating, and food to be cut up prior to serving. Resident 2 completed 50% of the meal on 07/31/23 and 100% of the meal on 08/01/23. In an interview on 08/01/23 at 1:10 pm, Resident 2's spouse reported s/he had not noticed any weight loss over the last six months, and Resident 2 had consistently had a good appetite. In an interview 08/01/23 at 1:56 pm, Staff 17 reported Resident 2 had no problems eating at all, had a great appetite, and was able to drink independently.From 03/10/23 to 06/09/23, Resident 2 had a weight loss of 23.8 pounds, or 12.2% of his/her body weight in three months. This change in weight was considered a severe loss and indicated a significant change of condition which required an RN assessment.On 08/01/23 at 11:30 am, an RN assessment for the significant change of condition was requested from Staff 2 (Health Services Director). On 08/02/23, Staff 2 provided charting notes, dated 02/17/23 through 08/01/23, which lacked documented evidence an RN assessment was performed.During an interview on 08/02/23 at 1:45 pm, Staff 2 confirmed an RN assessment was not completed.The need to ensure significant changes of condition were assessed by an RN and included findings, resident status, and interventions made as a result of the assessment was discussed with Staff 1 (Administrator) and Staff 2 on 08/02/23. They acknowledged the findings, and no additional documentation was provided.

Based on observation, interview, and record review, it was determined the facility failed to ensure an RN assessment was completed and included documented findings, resident status and interventions made as a result of the assessment for 1 of 1 sampled resident (#8) who experienced significant changes of condition. This is a repeat citation. Resident 8 experienced a reddened area that developed into an open wound. Findings include, but are not limited to:Resident 8 was admitted to the facility in 09/2023 with diagnoses including end stage renal disease and congestive heart failure. Resident 8 was dependent on renal dialysis. Review of clinical records, including the service plan dated 12/04/23, progress notes from 10/01/23 through 12/04/23, MAR/TARs dated for 11/01/23 through 12/07/23, and outside provider notes, revealed the following information:a. On 11/14/23 a progress note indicated Resident 5 "has some sores ...on [his/her] tailbone and above [his/her] bottom." There was no further documentation regarding the "sores". In an interview on 12/06/23 at 9:00 am, Resident 8 reported "what annoys me the most is the sore on my bottom when I sit in the chair." S/he stated that at night some staff will put a rolled up blanket "to help me stay on my side." On 12/06/23 at 9:00 am, Resident 8 was observed to be assisted by care staff to transfer from the wheelchair to the bed and positioned on his/her back. Care staff did not provide any intervention to alleviate pressure to his/her bottom.In an interview on 12/06/23 at 1:35 pm, Staff 29 (CG) stated "I have not seen the skin on [his/her] bottom," and was not aware of any special positioning.On 12/07/23 at 10:55 am, Staff 28 (MT) reported that initially, the sores were "open" and "I went in there with the nurse and we looked at it." Staff 28 stated recently the sores "had been healing up and looking great but it broke open again." There was no documentation of the nurse's reported visit or instructions of interventions for staff to follow.On 12/07/23 at 11:00 am, Staff 28 accompanied the surveyor and, with permission from Resident 8, observed the wound on the coccyx and confirmed there was an open area on the wound. Resident 8 experienced a significant change of condition related to redness and an open wound on his/her bottom. The facility failed to ensure an RN assessment was completed that documented findings, resident status and interventions made as a result of the assessment resulting in the development of a new open wound.b. The following significant changes of condition lacked evidence that the facility RN completed an RN assessment which included documentation of findings, resident status, and interventions made as a result of the assessment:* 10/25/23: Returned to the facility following a forearm fistula procedure with instructions for post-care; * 11/09/23: Returned from the hospital with a diagnosis of acute onset of chronic congestive heart failure; and * 11/28/23: Progress note documented a family member reported to Staff 22 (ED) and Staff 23 (RCC) that s/he had "gained 20 pounds since 11/24/23... due to [s/he] not being able to complete dialysis". A progress note dated 11/29/23 documented Resident 8 "went to dialysis today and they took some fluid off."On 12/05/23 and 12/07/23, documentation was requested from Staff 23 for RN assessments following the significant changes of condition regarding wounds, the fistula procedure, return from the hospital and weight gain. No further documentation was provided. The need to ensure an RN assessment was conducted for significant changes of condition was reviewed with Staff 22 and Staff 23 on 12/07/23 at 3:45 pm. They acknowledged the findings and no additional information was provided.
2. Resident 12 was admitted to the facility in 07/2023 with diagnoses including cerebrovascular disease.Review of the resident's progress notes dated 01/22/24 through 03/25/24 and interviews with staff revealed Resident 12 had a stage two wound on his/her left buttock. The open area was identified by a hospice care provider and communicated to the facility's RN on 03/14/24.The stage two wound constituted a significant change in condition for which an assessment by the facility RN was required. There was no documented evidence the facility RN conducted an assessment which included documentation of findings, resident status, and interventions made as a result of the assessment.During an interview on 03/28/24 at 11:56 am, Witness 2 (RN Consultant) acknowledged an RN assessment with all required components had not been completed for the wound.The need to ensure the facility RN conducted an assessment when a resident experienced a significant change of condition was reviewed with Witness 1 (Operations Specialist) on 03/28/24. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure an RN assessment was completed for 2 of 3 sampled residents (#11 and 12) who experienced a significant change of condition. This is a repeat citation. Findings include, but are not limited to:1. Resident 11 was admitted to the facility in 09/2020 with diagnoses including disorder of the white blood cells (WBC), bipolar disorder, major depressive disorder, and epilepsy.A review of the resident's clinical record dated between 01/22/24 and 03/24/24 identified the following:* A charting note on 03/24/24 stated "Alert monitoring initiated for open area on right buttocks"; and * An Interim Service Plan dated 03/24/24 for "open area on buttock."The noted skin impairment constituted a significant change in condition requiring an RN assessment. During the interview on 03/27/24, Witness 2 (RN Consultant) referred the surveyor to the charting note she entered on 03/25/24 at 5:45 pm, which stated "New area to open area [sic] stage 2 on right buttocks. EP [Elderplace Providence] called and will send a nurse out tomorrows to see resident." At the time the survey team exited the facility on 03/28/24, there was no documented evidence the facility RN conducted an assessment which included documentation of findings, resident status, and interventions made as a result of the assessment or the resident was assessed by an outside provider nurse.The need to ensure an RN assessment was completed for all residents who experienced a significant change of condition was reviewed with Witness 1 (Operations Specialist) and Witness 2 on 03/28/24. They acknowledged the findings. No further information was provided.

Based on interview and record review, it was determined the facility failed to ensure the delegation and supervision of special tasks of nursing care were completed in accordance with the Oregon State Board of Nursing (OSBN) Administrative Rules, for 1 of 1 sampled resident (#4) who received insulin injections by unlicensed facility staff. Findings include, but are not limited to:During the acuity interview on 07/31/23, Resident 4 was identified to receive insulin injections by unlicensed staff.a. Delegation records, reviewed on 08/01/23, lacked the required components in accordance with OSBN Division 47 Rules, in the following areas:* The RN took responsibility for delegating task and ensured supervision would occur. b. Staff 10's (MT) subsequent re-evaluation was due on 06/20/23 and was not completed. c. Staff 9 (MT), Staff 12 (MT), Staff 13 (MT) and Staff 14 (MT) lacked documented evidence subsequent re-evaluations included the following: * Individual observation and return demonstration of MT competence; and * Documentation of rationale, based on the competency of the MT, for how frequently the MT should be supervised and re-evaluated.The need to ensure all staff who administered insulin injections were appropriately delegated and supervised in accordance with OSBN Administrative Rules was discussed with Staff 1 (Administrator) and Staff 2 (Health Service Director) on 08/02/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure facility management or the licensed nurse were notified of the services provided by the outside providers and to ensure outside providers left written information in the facility that addressed the on-site services provided for 1 of 1 sampled resident (#3) who received home health physical therapy services. Findings include, but are not limited to:Resident 3 was admitted to the facility in 09/2020 with diagnoses including paraplegia and asthma.During the acuity interview on 07/31/23 the resident was identified as receiving home health physical therapy services.Interviews with Resident 3, and "Outside Provider Visit Notes" from 06/2023, and facility visitor sign-in logs, dated 06/2023 through 07/2023, were reviewed.Documentation for outside provider visits that occurred between 06/01/23 and 08/01/23 were requested on 08/02/23. The facility provided faxed documentation dated 08/02/23 at 2:00 pm from the HH PT provider that indicated a total of 13 visits occurred between 06/05/23 and 08/01/23. The facility had documentation of six PT visits that occurred in 06/2023. There was inconsistent documentation the facility's RN reviewed each "Outside Provider Visit Note." Additionally, the facility was unable to produce the "Outside Provider Visit Notes" for the remaining seven visits. The need to ensure the facility management or licensed nurse were notified of the services provided by outside providers and outside providers left written information in the facility that addressed the on-site services provided was discussed with Staff 1 (Administrator) and Staff 2 (Health Services Director) on 08/02/23. They acknowledged the findings.
2. Resident 7 was admitted to the facility in 06/2023 with diagnoses including vascular dementia and Type 2 diabetes. Resident 7's clinical record was reviewed and indicated the following: On 11/10/23, the resident was treated at the emergency department for right foot cellulitis, anorectal abscess and hyperglycemia. Instructions on the "After Visit Summary" provided to the facility included performing sitz baths four times daily to allow for ongoing drainage of the abscess. There was no documented evidence the discharge instructions were included in the resident's service plan or communicated to staff. The need to ensure the facility coordinated care with outside providers to ensure continuity of care was discussed with Staff 22 (Executive Director) and Staff 23 (RCC) on 12/07/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure information and interventions provided by outside service providers were communicated to staff and service plans adjusted if necessary for 2 of 2 sampled residents (#s 7 and 8) who received outside services. This is a repeat citation. Findings include, but are not limited to:1. Resident 8's current service plan and progress notes, which included outside provider documentation, dated 10/01/23 through 12/04/23, were reviewed and noted the following:* Progress note on 10/14/23 indicated a visit from the home health physical therapist (HHPT) on 10/03/23 "instructed [Resident 8] use a wheelchair/not walker to ride around on for safety." * Progress note on 10/31/23 indicated a visit from the HHPT on 10/24/23 stated Resident 8 was "unsteady, unsafe with gait when not using walker. Recommend ...using 4WW [four wheeled walker] for all gait."On 12/07/23, documentation was requested from Staff 23 (RCC) that staff were informed of the new interventions for Resident 8 and that the service plan was adjusted to reflect his/her current needs. Staff 23 was not able to provide additional information. The need to ensure the facility had protocols to ensure staff were informed of on-site, outside provider information and interventions and the service plan adjusted if necessary was reviewed with Staff 22 (ED) and Staff 23 on 12/07/23. They acknowledged the findings.

2. Resident 2 was admitted to the facility in 01/2017 with diagnoses including right sided hemiplegia and aphasia. Interviews with staff during the survey identified s/he relied on staff for incontinence care. Observations made during the survey, 07/31/23 through 08/02/23, determined the facility failed to adhere to universal precautions for infection control in the following area:On 08/01/23 at 1:05 pm, Staff 15 (CG) and Staff 17 (CG) were observed providing ADL incontinence care for Resident 2. During the observation, Staff 15 donned gloves without performing hand hygiene and placed a gait belt on Resident 2. Staff 17 had gloves donned upon surveyor arrival to apartment. The caregivers transferred Resident 2 from wheelchair to the toilet. Staff 15 proceeded to remove the soiled incontinence brief, while Staff 17 was holding wipes. Staff 15 performed perineal care with wipes while wearing soiled gloves. Staff 15 failed to doff soiled gloves, perform hand hygiene and don clean gloves before touching the resident's body, placing clean incontinence products, and providing dressing assistance. The caregivers, while still wearing the soiled gloves, transferred Resident 2 from the toilet to the wheelchair, assisted Resident 2 with hand washing, and then transferred Resident 2 to a lift chair. After completing the transfer, the caregivers removed gloves and washed their hands.The need to establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment was discussed with Staff 1 (Administrator) and Staff 2 (Health Services Director) on 08/02/23. They acknowledged the findings.
Based on observation and interview, it was determined the facility failed to establish and maintain effective infection prevention and control protocols for 2 of 2 sampled residents (#s 1 and 2) during ADL care. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in 05/2021 with diagnoses including osteoarthritis of the knee. Observations and interviews with staff during the survey identified s/he was unable to bear weight during transfers and relied on staff for incontinence care needs. On 07/31/23 at 12:49 pm, the surveyor obtained permission from the resident and observed Staff 19 (CG) provide ADL incontinent care. During the observation, the caregiver donned gloves without performing hand hygiene. The caregiver removed the soiled incontinent brief. Staff 19 failed to doff soiled gloves, perform hand hygiene and don clean gloves before touching the resident's body and clean incontinent products. The caregiver then proceeded to cleanse the resident's perineum area and bottom while continuing to wear the same soiled gloves. The caregiver then assisted the resident with a toilet transfer to wheelchair, escorted the resident to his/her hospital bed, transferred the resident from the wheelchair to bed and covered the resident with blankets. Staff 19 continued to wear soiled gloves throughout the ADL care.The need to establish and maintain infection prevention and control protocols while performing ADL care was discussed with Staff 1 (Administrator) and Staff 2 (Health Services Director) on 08/01/23. They acknowledged the findings.
Based on observation and interview, it was determined the facility failed to designate an individual to be the facility's "Infection Control Specialist". Findings include, but are not limited to:In an interview on 03/25/24, Witness 1 (Operations Specialist) acknowledged the facility did not designate an individual to be the facility's "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The need to ensure the facility designated an individual to be the facility's "Infection Control Specialist", was reviewed with Witness 1 on 03/28/24. She acknowledge the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure adequate professional oversight of the medication and treatment administration systems. Findings include, but are not limited to:Administrative oversight of the medication administration system was found to be ineffective based on deficiencies identified in the following areas:C 282: RN Delegation and Teaching;C 302: Systems: Tracking Control Substances;C 303: Systems: Treatment Orders;C 305: Systems: Resident Right to Refuse;C 310: Systems: Medication Administration; C 315: Systems: Treatment Administration; andC 325: Systems: Self-Administration of Meds.The requirement to ensure adequate professional oversight of the medication administration system was discussed with Staff 1 (Administrator) and Staff 2 (Health Services Director) on 08/02/23. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure adequate professional oversight of the medication and treatment administration systems. This is a repeat citation. Findings include, but are not limited to:Administrative oversight of the medication administration system was found to be ineffective based on deficiencies identified in the following areas:C 302: Systems: Tracking Control Substances;C 303: Systems: Treatment Orders;C 310: Systems: Medication Administration; andC 325: Systems: Self-Administration of Medications.The requirement to ensure adequate professional oversight of the medication administration system was discussed with Staff 22 (ED) and Staff 23 (RCC) on 12/07/23. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure there was an effective system in place for tracking controlled substances for 1 of 1 sampled resident (#7) whose MARs and "Controlled Substance Disposition Logs" were reviewed. Findings include, but are not limited to:Resident 7 was admitted to the facility in 06/2023 with diagnoses including heart failure and vascular dementia. The resident's 07/01/23 - 07/31/23 MAR, current physician orders, and "Controlled Substance Disposition Log" entries were reviewed. The following was identified:* The resident had a physician order for oxycodone HCL 5 mg tablet, as needed, by mouth twice daily;* The MAR indicated one tablet was administered on 07/04/23 and one tablet on 07/28/23. However, the "Controlled Substance Disposition Log" documented two tablets were administered on each date; and* The MAR indicated two tablets were administered on 07/15/23; however, the medication administration was not documented on the "Controlled Substance Disposition Log."During an observation and interview on 08/01/23 at 1:30 pm, with Staff 13 (MT), the medication count was accurate. Staff 13 reported she believed the other MT wrote the wrong date on the disposition log for the two tablets that were administered on 07/15/23. The need to ensure MARs and "Controlled Substance Disposition Logs" matched was discussed with Staff 1 (Administrator) and Staff 2 (Health Services Director) on 08/01/23. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to have an effective system for tracking controlled substances for 1 of 1 sampled resident (#7) who was administered PRN narcotic medication. This is a repeat citation. Findings include, but are not limited to:Resident 7 was admitted to the facility in 06/2023 with diagnoses including vascular dementia and Type 2 diabetes.The resident had a physician's order for oxycodone IR 5 mg tablet, as needed, by mouth every four hours. Not to exceed three tablets a day.A review of Resident 7's 11/01/23 through 11/22/23 MAR and the Controlled Disposition Record revealed the following discrepancies:The medication was documented as having been administered on the MAR but was not documented in the Controlled Substance Disposition Record on 11/01/23, 11/20/23 and 11/21/23.The medication was signed out on the Controlled Substance Disposition Record but not documented as having been administered on the MAR on 11/05/23, 11/10/23, 11/11/23, 11/12/23, 11/17/23 twice, 11/18/23 twice and 11/19/23.An observation on 12/07/23 of the medication card showed the medication count was accurate. The need to ensure the facility had an effective system for tracking controlled substances was discussed with Staff 22 (Executive Director) and Staff 23 (RCC) on 12/07/23. They acknowledged the findings.

2. Resident 3 was admitted to the facility in 09/2020 with diagnoses including paraplegia and asthma.Resident 3's current physician orders and MAR, dated 07/01/23 through 07/30/23, were reviewed and revealed the following:The resident had physician orders for the following medications dated 07/06/23:* Armour Thyroid 120 mg - Take one tablet by mouth once daily (for thyroid);* Bisacodyl EC 5 mg - Take 10 mg by mouth daily (for constipation);* Duloxetine 20 mg - Take one capsule by mouth once daily for 14 days (for major depressive disorder);* Omeprazole 20 mg - Take 20 mg by mouth two times daily (for gastroesophageal reflux disease);* T3/T4 13.4/90 mcg - Take one capsule by mouth once daily (for thyroid); and* Venlafaxine 50 mg - Take 1.5 tablets by mouth two times daily for 14 days (for major depressive disorder).a. Resident 3's MAR had the following blanks:* Bisacodyl on 24 occasions because the medication was administered as PRN;* T3/T4 on one occasion; and* Omeprazole on 31 occasions because the medication was administered once daily.b. The following medications were documented as not received from the pharmacy:* Omeprazole on one occasion; and* Venlafaxine on one occasion.c. Duloxetine 20 mg was administered for 15 days not 14 days as prescribed.d. Armour Thyroid was not on the MAR or administered to the resident in 07/2023. A discontinuation order was requested on 08/01/23 at 9:54 am. No additional documentation was provided.On 08/01/23 at 10:02 am, Staff 10 (MT) and this surveyor reviewed the resident's medication supply and MAR. Staff 10 was unable to confirm whether the medications had been administered as prescribed.The need to ensure all medications were carried out as prescribed and written, signed physician orders were documented in the resident's facility record for all medications the facility was responsible to administer was reviewed with Staff 1 (Administrator) and Staff 2 (Health Services Director) on 08/02/23. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed and written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record for all medications and treatments the facility was responsible to administer for 2 of 4 sampled residents (#s 3 and 4) whose orders were reviewed. Findings include, but are not limited to:1. Resident 4 was admitted to the facility in 06/2018 with diagnoses including type 1 diabetes.Resident 4's MAR/TAR, dated 07/01/23 through 07/31/23, corresponding progress notes, and prescriber orders were reviewed and revealed the following:Resident 4 was receiving the following medications for diabetes:a. Tresiba 100-U/ml pen 3 ML: inject 12 units subcutaneously every night at bedtime. Hold if blood sugar below 100.* 07/10/23: Tresiba was administered when CBG was documented at 69; and* 07/25/23: There was no documented evidence that Tresiba was administered as prescribed, secondary to a blank on the MAR. b. Novolog 100-U/ML pen to be administered four times per day before meals and at bedtime. The amount of insulin administered was based on the resident's CBG level according to the following sliding scale:* 70 - 150: 0 units;* 151 - 200: 2 units;* 201 - 250: 3 units;* 251 - 300: 4 units;* 301 - 350: 5 units; * 351 - 400: 6 units; and* Above 400: 7 units and call provider.There was no documented evidence of the following:* 07/08/23: Provider being notified when CBG was 418; and * 07/25/23: Sliding scale insulin was administered as prescribed secondary to a blank on the MAR for the 8:00 pm dosage. c. Blood sugars: check blood sugars before each meal and at bedtime. Contact provider and facility RN if result below 75 or above 400. There was no documented evidence of the following: * 07/25/23: Blood sugars at 8:00 pm were checked as prescribed, secondary to a blank on the MAR; and * The provider was contacted on eight separate occasions in July when blood sugars were either below 75 or above 400.During an interview on 07/31/23 at 3:03 pm, Staff 9 (MT) was unable to locate any additional documentation regarding the 07/25/23 blanks on the MAR and provider notifications in the electronic MAR. The need to ensure physician's orders were carried out as prescribed was discussed with Staff 1 (Administrator) and Staff 2 (Health Services Director) on 08/02/23. They acknowledged the findings, and no additional information was provided.
Based on interview and record review, it was determined the facility failed to ensure orders were carried out as prescribed for all medications and treatments the facility was responsible to administer for 2 of 2 sampled residents (#s 7 and 8) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to:1. Resident 7 was admitted to the facility in 06/2023 with diagnoses including vascular dementia and type 2 diabetes.The resident's MAR, dated 11/01/23 through 12/05/23, and physician's orders were reviewed. Resident 7 had a physician's order to notify the primary care physician and RN if CBG was over 400.Between 11/04/23 and 11/30/23, Resident 7's CBG was over 400 on five occasions. There was no documented evidence the facility notified the primary care physician or RN.During an interview on 12/07/23 with Staff 24 (Delegation RN) confirmed s/he had not been notified of the CBGs over 400. The need to ensure physician's orders were carried out as prescribed was discussed with Staff 22 (Executive Director) and Staff 23 (RCC) on 12/07/23. They acknowledged the findings.


2. Resident 8 was admitted to the facility in 09/2023 with diagnoses including end stage renal disease and congestive heart failure.Resident 8's 11/01/23 through 12/05/23 MARs, corresponding progress notes and current physician's orders were reviewed.Records revealed the following medications were not given as prescribed on the following dates, with documentation stating the medication was "not here from the pharmacy":* Losartan (for blood pressure) four times a week - 11/12/23, 11/13/23, 12/05/23 and 12/07/23;* Metoprolol ER 25 mg (for blood pressure) four times a week - 12/02/23, 12/03/23 and 12/05/23;* Rosuvastatin 20 mg (for heart failure) - 12/02/23 and 12/03/23;* Clopidogrel 75 mg (blood thinner) - 12/02/23 and 12/03/23;* Amiodarone 200 mg (for congestive heart failure) - 12/02/23 and 12/03/23;* Renal caps 1 mg (supplement) - 11/14/23;* Calcium acetate 1334 mg (supplement) three times a day - 11/13/23 for noon and 8 pm doses; and * Desitin 13% cream (for reddened or excoriated perineal area) - 11/11/23.During an interview on 12/07/23 at 9:50 am, Staff 19 (MT) was asked about the process for reordering medications and stated some medications are automatically renewed and some required the MT to reorder. Staff 19 was unable to state when medications would be reordered. The need to ensure physician orders were carried out as prescribed was discussed with Staff 22 (ED) and Staff 23 (RCC) on 12/07/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure orders were carried out as prescribed for all medications and treatments the facility was responsible to administer for 3 of 3 sampled residents (#s 11, 12 and 13) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to:1. Resident 13 was admitted to the facility in 12/2022 with diagnoses including Type 2 diabetes and idiopathic cardiopathy.The resident's MAR, dated 03/01/24 through 03/25/24, corresponding progress notes and current physician orders were reviewed.The MAR was blank for the following medications or treatments: * CBG checks and Insulin Lispro 100 unit/ ML on three occasions.On 03/26/24 at 10:40 am, the surveyor and Staff 19 (MT) reviewed the MAR and were unable to verify if the above orders had been followed.The need to ensure physician orders were carried out as prescribed was discussed with Witness 1 (Operations Specialist) on 03/28/24. She acknowledged the findings.
3. Resident 12 was admitted to the facility in 07/2023 with diagnoses including chronic hypoxic respiratory failure and gastroesophageal reflux disorder.Resident 12's MAR dated 03/01/24 through 03/24/24, corresponding progress notes, and current physician's orders were reviewed. The resident had the following prescriber orders:* Hydromorphone (for pain) - one mL by mouth two times daily in the morning and evening;* Levothyroxine 112 mcg (for thyroid) - take one tablet by mouth every morning;* Prochlorperazine 10 mg (for nausea) - Give 0.5 tablet by mouth three times daily; and* Call hospice if oxygen saturation drops below 88%.a. The MAR was blank for the following medications: * Levothyroxine 112 mcg (for thyroid) on one occasion; and* Prochlorperazine 10 mg (for nausea) on two occasions.On 03/26/24 at 10:54 am, the surveyor and Staff 19 (MT) reviewed the MAR and medication supply. Staff 19 was unable to verify if the above orders had been followed.b. The MAR indicated the resident did not receive the prescribed dosage of hydromorphone on 03/23/24 and 03/24/24 because the "med not here." On 03/26/24, Staff 19 confirmed the medication was not administered as prescribed.c. On 03/11/24 the MAR indicated the resident received 0.5 mL of hydromorphone, or half the prescribed dose, because "that was all med that was in bottle." d. On 02/12/24 and 02/13/24, the resident's oxygen saturation levels were documented as 82% and 83% respectively. During an interview on 03/28/24, Witness 2 (RN Consultant) confirmed the facility had no documentation hospice was notified of Resident 12's oxygen saturation levels dropping below the prescribed parameter.The need to ensure physician orders were carried out as prescribed was discussed with Witness 1 (Operations Specialist) on 03/28/24. She acknowledged the findings.

2. Resident 11 was admitted to the facility in 09/2020 with diagnoses including disorder of the white blood cells (WBC), bipolar disorder, major depressive disorder, and epilepsy.Resident 11's current physician orders, signed 12/27/23, and MARs from 03/01/24 through 03/25/24 were reviewed. Interviews with facility staff and the resident were conducted. The following was revealed:* Fluticasone 50 mcg nasal spray was ordered to be administered two sprays by nasal route daily and may be kept in the resident's room to self-administer;* Ipratropium Bromide 0.06% solution was ordered two sprays under the tongue every two hours as needed for excessive saliva and may be kept in resident's room to self-administer; and* Nitroglycerin 0.4 mg was ordered one tablet under the tongue every five minutes as needed for chest pain and may be kept in room to self-administer.During the interview with the resident on 03/26/24 at 12:35pm, s/he stated all the medications were being administered by the facility staff, and no medications for self-administration were in the apartment.Staff 13 (MT) on 03/26/24 and Staff 32 (MT) on 03/27/24 confirmed all the resident's medications were administered by facility staff, and none of Fluticasone, Ipratropium Bromide or Nitroglycerin were available on the med cart.The need to ensure physician or other legally recognized practitioner orders were carried out as prescribed was reviewed with Witness 1 (Operations Specialist) and Witness 2 (RN Consultant) on 03/28/24. They acknowledged the findings. No further information was provided.

Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused consent to an order for 1 of 1 sampled resident (#3), who had documented medication refusals. Findings include, but are not limited to:Resident 3 was admitted to the facility in 09/2020 with diagnoses including paraplegia.The resident's MAR, dated 07/01/23 through 07/30/23, was reviewed and revealed facility staff documented Resident 3 refused the following orders: * Polyethylene glycol (for constipation) on five occasions.There was no documented evidence the facility notified Resident 3's physician of the refusals.On 08/02/23, the need to notify the physician/practitioner when a resident refused consent to orders was discussed with Staff 1 (Administrator) and Staff 2 (Health Services Director). They acknowledged the findings. No additional information was provided.

Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was kept for all medications that were ordered by a legally recognized provider and administered by the facility for 1 of 3 sampled residents (#1) whose MARs were reviewed. Findings include, but are not limited to:Resident 1's 06/01/23 through 07/31/23 MARs were reviewed during the survey. The following deficiencies were identified:a. Resident 1 was prescribed Artificial Tears eye drops as needed. The MAR indicated "ok to leave at bedside and self administer." The resident did not choose to self-administer the medication, therefore the information on the MAR was inaccurate. b. Resident 1 was prescribed fluticasone nasal spray, 1-2 sprays in each nostril. There was no parameter instructing unlicensed staff when to administer one spray verses two sprays. c. The MARs were missing initials of the person who administered medications or treatments as follows:* Behavior monitoring on seven occasions; and* Levothyroxine on three occasions. The need to ensure MARs were reviewed for accuracy was discussed with Staff 1 (Administrator) and Staff 2 (Health Services Director) on 08/01/23. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure residents' MARs were accurate and provided medication-specific instructions and parameters for administration of PRN medications for 2 of 2 sampled residents (#s 7 and 8) 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 06/2023 with diagnoses including vascular dementia and Type 2 diabetes.A review of the resident's 11/01/23 through 12/05/23 MAR and current physician orders showed the resident had an order for a continuous glucose monitoring device. The MAR contained no information to indicate how to operate the device. There were no specific instructions on the MAR to staff on how to insert the sensor or how often the sensor needed to be replaced. In an interview on 12/07/23, Staff 24 (Delegation RN) confirmed the MAR contained no information related to the continuous glucose monitoring device.The need to ensure the facility's MAR included medication-specific instructions was discussed with Staff 22 (Executive Director) and Staff 23 (RCC) on 12/07/23. They acknowledged the findings.
2. Resident 8 was admitted to the facility in 09/2023 with diagnoses including end stage renal disease and congestive heart failure.The resident's 11/01/23 through 12/05/23 MARs and physician's orders were reviewed. The following PRN medications lacked resident specific parameters or instructions to direct non-licensed staff on which medication should be administered and in what order: * Senna and milk of magnesia were prescribed for constipation; and* Acetaminophen and hydrocodone were prescribed for pain.During an interview on 12/07/23, Staff 19 (MT) confirmed she was not sure which medication to give first if the resident was having constipation.The need to ensure resident's MAR was accurate and included resident specific parameters and instructions for PRN medications was reviewed with Staff 22 (ED) and Staff 23 (RCC). They acknowledged the findings.


Based on interview and record review, it was determined the facility failed to ensure MARs included resident-specific parameters and instructions for PRN medications for 1 of 3 sampled residents (#12) whose MARs were reviewed. This is a repeat citation. Findings include, but are not limited to:Resident 12 moved into the facility in 07/2023 with diagnoses including chronic hypoxic respiratory failure and gastroesophageal reflux disorder.Resident 12's MAR/TAR dated 03/01/24 through 03/25/24 was reviewed during survey and revealed the following:The following PRN medications and treatments lacked resident-specific parameters or instructions to staff:* Albuterol sulfate 0.083% nebulizer (for wheezing);* Antac+sim 200-200-20 mg/5mL (for upset stomach);* CPAP (for respiratory failure);* Haloperidol 2mg/mL (for agitation, hallucinations, nausea); and* Lorazepam 0.5 mg (for restlessness or anxiousness).During an interview with Witness 2 (RN Consultant) on 03/28/24, she confirmed the PRN medications lacked resident-specific parameters or instructions for unlicensed staff.The need to ensure PRN medications included resident-specific parameters and instructions to unlicensed staff was discussed with Witness 1 (Operations Specialist) on 03/28/24. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to maintain an accurate treatment record of all treatments ordered by a legally-recognized practitioner and administered by the facility for 1 of 1 sampled resident (#1) for whom the facility provided treatments. Findings include, but are not limited to:Resident 1 was admitted to the facility in 05/2021 with diagnoses including type 2 diabetes mellitus.Review of Resident 1's signed physician order dated 06/21/23, instructed staff to apply a warm compress two-to-four times per day until better. Review of the 06/01/23 through 07/31/23 TAR identified the following deficiencies:* Resident 1's TAR lacked initials of the person who had administered the treatment on seven occasions; and* The TAR lacked treatment instructions, including location to apply compress and when to call the prescriber or nurse.The need to ensure the TAR included treatment instructions and unlicensed staff initialed the TAR for all treatments the facility was responsible to administer was reviewed with Staff 1 (Administrator) and Staff 2 (Health Services Director) on 08/01/23. They acknowledged the findings.

2. Resident 2 was admitted to the facility in 01/2017 with diagnoses including right side hemiplegia and aphasia.Review of Resident 2's physician's orders and MAR, dated 07/01/23 through 07/31/23, revealed the resident self-administered two medications.During an interview on 08/01/23, Resident 2's spouse stated s/he assisted Resident 2 in self-administering two medications. The medications were observed and determined to have corresponding orders to self-administer: * Carboxymethyl 0.5% ophthalmic solution (for dry eyes); and* Fluticasone 50 mcg nasal spray (for allergy relief).Resident 2 and his/her spouse's quarterly self-administration evaluations were requested and received on 08/01/23. Resident 2 was evaluated on 01/16/23, and his/her spouse was evaluated on 04/13/23. During an interview on 08/02/23 at 1:45 pm, Staff 2 (Health Services Director) confirmed there were no updated quarterly evaluations for the self-administration of medications for Resident 2 or his/her spouse. The need to ensure residents who chose to self-administer medications were evaluated at least quarterly was discussed with Staff 1 (Administrator) and Staff 2 on 08/02/23. They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to ensure residents who chose to self-administer their medications were evaluated at least quarterly to assure ability to safely self-administer medications for 2 of 3 sampled residents (#s 2 and 5) who administered their own medications. Findings include, but are not limited to:1. Resident 5 was admitted to the facility in 07/2018 with diagnoses including seizure disorder and history of brain aneurysm. The service plan dated 04/17/23 indicated Resident 5 administered their own medications. However, the resident's 07/01/23 through 07/31/23 MAR indicated Resident 5 was partially self-administering medications and treatments, and the facility staff was also administering some medications and treatments.Review of the self-medication evaluation dated 04/19/23 was not updated quarterly and was not accurate to include information regarding what medications and treatments the resident was able to safely administer. The need to complete evaluations of a resident's ability to self-administer medications at least quarterly was discussed with Staff 1 (Administrator) and Staff 2 (Health Services Director) on 08/01/23. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure residents who chose to self administer medications had an evaluation completed at least quarterly to determine their ability to self administer medications for 1 of 1 sampled resident (#10) reviewed for self administration. This is a repeat citation. Findings include, but are not limited to:Resident 10 was admitted to the facility in 06/2021 with diagnoses including chronic obstructive pulmonary disease and Type 2 diabetes. During record review of Resident 10, it was determined the resident self-administered his/her own medications. The resident's 10/02/23 through 12/05/23 charting notes, evaluations, physicians orders and the 11/01/23 through 12/05/23 MARs were reviewed.The last self administration evaluation was completed on 05/06/22. Staff 23 (RCC) confirmed there was no more recent evaluation of the resident's ability to self administer his/her medications. The need to ensure residents who self administered their medications were evaluated at least quarterly was discussed with Staff 22 (Executive Director) and Staff 23 on 12/07/23. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure supportive devices with potentially restraining qualities were evaluated quarterly and the devices were included in the resident's service plan for 2 of 2 sampled residents (#s 1 and 2) who had side rails. Findings include, but are not limited to: 1. Resident 2 was identified during the acuity interview on 07/31/23 to have side rails on his/her bed. The resident's clinical record was reviewed and staff were interviewed.A half-length side rail was observed on the left side of the resident's hospital bed in the up position on 08/01/23. On 08/02/23, Staff 2 (Health Services Director) confirmed the most recent evaluation of the side rail was completed on 01/16/23. The need to ensure a quarterly evaluation was completed was discussed with Staff 1 (Administrator) and Staff 2 during the survey. They acknowledged the findings.
2. Resident 1 was identified during the acuity interview on 07/31/23 to have side rails on his/her bed. Bilateral half-length side rails were observed on the resident's hospital bed in the up position on 08/01/23. Review of the "Supportive Devices with Restraining Qualities Assessment," dated 01/13/23, and the resident's current service plan, dated 04/03/23, lacked documentation of the following:* The 01/13/23 evaluation lacked documentation the resident specifically requested or approved of the device; * The use of the supportive device was not evaluated on a quarterly basis; and * The supportive device with restraining qualities wasn't included in the resident's service plan.The need to ensure an evaluation for the use of side rails was completed quarterly and included all required documentation was discussed with Staff 1 (Administrator) and Staff 2 (Health Services Director) on 08/01/23. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure a thorough RN, PT, or OT assessment was completed prior to the use of a supportive device with restraining qualities, document other less restrictive alternatives were evaluated prior to the use of the device, instruct caregivers on the correct use and precautions related to the use of the device and include it in the service plan for 1 of 1 sampled resident (# 8) who used a supportive device with restraining qualities. This is a repeat citation. Findings include, but are not limited to: Resident 8 was admitted to the facility in 09/2023 with diagnoses including end stage renal disease and congestive heart failure.Observations of the resident and an interview with staff indicated the resident had a quarter-length side rail on the left side of his/her bed in the up position and another on the right side in the down position. The side rail was in good repair and flush with the mattress. The resident's service plan dated 12/04/23, contained no information regarding the side rail.On 12/06/23, an evaluation for the side rail was requested. An evaluation for the side rail, dated 12/07/23 and completed by Staff 24 (Delegation RN) was provided on 12/07/23, after the start of the survey. The need to ensure supportive devices with restraining qualities were assessed by an RN, PT, or OT and were included in the resident's service plan was discussed with Staff 22 (ED) and Staff 2 (RCC) on 12/07/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to update the acuity-based staffing tool (ABST) no less than quarterly for 4 of 7 sampled residents (#s 1, 2, 4 and 5) and multiple unsampled residents whose ABST was reviewed. Findings include, but are not limited to:On 08/01/23 at 2:46 pm, the ABST was reviewed with Staff 3 (Business Office Manager) and revealed the following:a. Resident 1 was admitted to the facility in 05/2021 and his/her ABST had not been reviewed and updated quarterly since 04/03/23. b. Resident 2 was admitted to the facility in 01/2017 and his/her ABST had not been reviewed and updated quarterly since 03/28/23.c. Resident 4 was admitted to the facility in 06/2018 and his/her ABST had not been reviewed and updated quarterly since 04/20/23.d. Resident 5 was admitted to the facility in 07/2018 and his/her ABST had not been reviewed and updated quarterly since 04/17/23.e. The ABST for 26 unsampled residents had not been reviewed or updated quarterly.The need to ensure the facility's ABST was updated no less than quarterly was reviewed with Staff 1 (Administrator) and Staff 2 (Health Services Director) on 08/02/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to develop a staffing plan to meet the scheduled and unscheduled needs of the residents based on care minutes calculated by their ABST tool. This is a repeat citation. Findings include, but are not limited to:The facility's ABST tool calculations, resident ABST data entries and the facility's staffing plan were reviewed on 12/06/23 and 12/07/23.Review of the total number of weekly minutes generated by the ABST were discussed with Staff 22 (ED) and Staff 23 (RCC). They were unable to determine how the weekly minutes were used to determine staffing levels on the three shifts and acknowledged the ABST was not used to develop the current staffing plan. The need to ensure an ABST was used to develop and implement a staffing plan to meet resident needs was discussed with Staff 22 on 12/07/23. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 3 of 4 newly-hired staff (#s 13, 18 and 21) completed all required pre-service orientation training prior to beginning their job responsibilities. Findings include, but are not limited to:Staff training records were reviewed with Staff 3 (Business Office Manager) on 08/01/23. The following deficiencies were identified:* Staff 13 (MT) hired on 01/17/23 did not complete training related to strategies for addressing social needs of persons with dementia and engaging them with meaningful activities;* Staff 18 (CG) hired on 06/08/23 did not complete required pre-service infectious disease prevention training, training related to the dementia disease process and understanding, communicating and responding to distressful behavioral symptoms; and * Staff 21 (Dietary Aide) hired on 03/02/23 did not complete required pre-service infectious disease prevention training prior to beginning their job responsibilities.The need to ensure newly-hired staff completed all required pre-service orientation training was discussed with Staff 1 (Administrator) and Staff 3 on 08/01/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff (#s 27, 28, 29, and 30) completed all required pre-service orientation training prior to beginning their job responsibilities. This is a repeat citation. Findings include, but are not limited to:Staff training records were reviewed with Staff 22 (ED) and Staff 23 (RCC) on 12/07/23. The following were identified:* Staff 27 (MT), hired on 10/26/23, had no documented evidence of having completed abuse reporting or infectious disease prevention training, or any evidence of having completed the required pre-service dementia training;* Staff 28 (MT), hired on 10/17/23, had no documented evidence of having completed resident rights and values of CBC care, abuse reporting, or infectious disease prevention training, or any evidence of having completed the required pre-service dementia training;* Staff 29 (CG), hired on 11/03/23, had no documented evidence of having completed abuse reporting or infectious disease prevention training, or portions of pre-service dementia training including the dementia disease process including progression, strategies for addressing social needs and engaging them in meaningful activities, and specific aspects of dementia including addressing pain, providing food/fluids, preventing wandering, and use of person-centered approach; and* Staff 30 (Cook), hired on 10/16/23, had no documented evidence of having completed abuse reporting, infectious disease prevention training, Oregon food handler's certification and having received a written job description.The need to ensure newly hired staff completed all required pre-service orientation training was discussed with Staff 22 and Staff 23 on 12/07/23. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure documented evidence all pre-service orientation and pre-service dementia training was completed prior to beginning job duties for 2 of 3 newly hired staff (#s 43 and 35) whose training records were reviewed. This is a repeat citation. Findings include, but are not limited to:Training records were reviewed on 03/26/24. The following were identified: * Staff 43 (Cook), hired on 01/22/24, had no documented evidence of having completed resident rights and values of community-based care (CBC), abuse reporting requirements, infectious disease prevention, fire safety and emergency procedures and having received a written job description.* Staff 35 (MT), hired on 02/19/24, had no documented evidence of having completed resident rights and values of CBC care, and fire safety and emergency procedures or portions of pre-service dementia training including strategies for addressing social needs and engaging them in meaningful activities, and specific aspects of dementia including addressing pain, providing food/fluids, preventing wandering, and use of person-centered approach.The need to ensure newly hired staff completed all required pre-service orientation training was discussed with Witness 1 (Operations Specialist) on 03/28/24. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly-hired direct-care staff (#s 13, 16 and 18) 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 08/01/23 with Staff 3 (Business Office Manager) and revealed the following:* Staff 13 (MT), Staff 16 (CG) and Staff 18 (CG), hired on 01/17/23, 06/08/22 and 03/02/23 respectively, lacked documented evidence of completing the required training on changes associated with normal aging; and * Staff 16 (CG) and Staff 18 (CG) lacked demonstrated competency of First Aid/abdominal thrust training within 30 days of hire. The need to ensure newly-hired staff completed training and demonstrated competency in all assigned duties within 30 days of hire was discussed with Staff 1 (Administrator) and Staff 3 on 08/02/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired direct-care staff (#s 27, 28 and 29) demonstrated satisfactory performance in all assigned duties within 30 days of hire. This is a repeat citation. Findings include, but are not limited to:On 12/07/23 review of staff training records and interview with Staff 22 (ED) and Staff 23 (RCC) indicated the following:Staff 27 (MT), hired 10/26/23, lacked documented evidence of demonstrated satisfactory performance in the following required areas within 30 days of hire:* Role of service plans in providing individualized care;* Changes associated with normal aging;* Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition;* Conditions that require assessment, treatment, observation and reporting;* General food safety, serving and sanitation; * Competency with medication pass duties; and* First aid, abdominal thrust.Staff 28 (MT), hired 10/17/23, lacked documented evidence of demonstrated satisfactory performance in the following required areas within 30 days of hire:* Role of service plans in providing individualized care;* Changes associated with normal aging;* Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition;* Conditions that require assessment, treatment, observation and reporting;* General food safety, serving and sanitation; * Competency with medication pass duties; and* First aid, abdominal thrust.* Staff 29 (CG), hired 11/03/23, lacked documented evidence of demonstrated satisfactory performance in the following required areas within 30 days of hire:* Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition;* Conditions that require assessment, treatment, observation and reporting;* General food safety, serving and sanitation; and* Abdominal thrust.During the survey, Staff 27 and Staff 28 were provided supervision while performing their duties until competency with the medication pass was demonstrated and documentation completed.The need to ensure newly hired staff completed training and demonstrated competency in all assigned duties within 30 days of hire was discussed with Staff 22 and Staff 23 on 12/07/23. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure 2 of 2 newly hired direct-care staff (#s 40 and 35) demonstrated satisfactory performance in all assigned duties within 30 days of hire. This is a repeat citation. Findings include, but are not limited to:Training records were reviewed on 03/26/24. The following deficiencies were identified: Staff 40 (CG), hired 02/09/24, lacked documented evidence of demonstrated satisfactory performance in the following required areas within 30 days of hire:* Role of service plans in providing individualized care;* Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition; and* Conditions that require assessment, treatment, observation and reporting.Staff 35 (MT), hired 02/19/24, lacked documented evidence of demonstrated satisfactory performance in the following required areas within 30 days of hire:* Role of service plans in providing individualized care;* Changes associated with normal aging; and* General food safety, serving and sanitation. The need to ensure newly hired staff completed training and demonstrated competency in all assigned duties within 30 days of hire was discussed with Witness 1 (Operations Specialist) on 03/28/24. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure long-term employees completed a minimum of 12 hours of annual in-service training on topics related to the provision of care for persons in a community-based care setting, including six hours of in-service training on dementia care, for 3 of 3 long-term staff (#s 8, 9 and 17). Findings include, but are not limited to: Staff training records were reviewed on 08/01/23. The records lacked documented evidence that Staff 8 (MT), Staff 9 (MT) and Staff 17 (CG) hired 02/11/20, 11/11/21 and 05/16/22 respectively, completed at least 12 hours of annual training on provision of care in a community-based care setting, including at least six hours of dementia training. On 08/02/23 the need to ensure all annual training requirements were completed by care staff based on anniversary dates of hire was discussed with Staff 1 (Administrator) and Staff 3 (Business Office Manager). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure long-term employees completed a minimum of 12 hours of annual in-service training on topics related to the provision of care for persons in a community-based care setting, including six hours of in-service training on dementia care. This is a repeat citation. Findings include, but are not limited to: On 12/07/23 Staff 22 (ED) and Staff 26 (Business Office Manager) were asked to explain the facilities process for providing annual in-service training to staff. Staff 22 and Staff 26 stated the facility had not yet developed a process for tracking annual employee training and was not able to provide any additional documentation.On 12/07/23, the need to ensure all annual training requirements were completed by care staff based on anniversary dates of hire was discussed with Staff 22. Staff acknowledged the facility had not developed and implemented a plan to provide in-service training to staff as required.

Based on interview and record review, it was determined the facility failed to conduct fire drills every other month in accordance with the Oregon Fire Code (OFC) and failed to provide fire and life safety instruction to staff on alternate months. Findings include, but are not limited to:The previous six months of fire drill and fire and life safety training records were reviewed on 08/01/23 with Staff 1 (Administrator) and Staff 6 (Environmental Services Director). The following deficiencies were identified:a. Fire Drills:* Fire drills were only conducted on 02/27/23 and 07/31/23, not every other month as required.* The facility was not relocating residents from the simulated fire area. Therefore, there was no documentation of: - The escape route used; - Problems encountered, comments relating to residents who resisted or failed to participate in the drills; - Evacuation time-period needed; and - Number of occupants evacuated.b. Fire and life safety training for staff:* The facility was not providing fire and life safety training for staff on alternate months as required.The need to ensure fire drills and fire and life safety training was conducted per the rules was reviewed with Staff 1 and Staff 6 on 08/01/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted and documented every other month per the Oregon Fire Code (OFC) and fire and life safety instruction to staff was provided on alternate months. This is a repeat citation. Findings include, but are not limited to:On 12/05/23, fire drill and fire and life safety training records for staff were requested for the time period of 10/01/23 through 12/04/23. Staff 22 (ED) stated the facility had not conducted any fire drills or provided any fire and life safety training to staff during that time period.The need to ensure fire drills and fire and life safety training was conducted per the rules was reviewed with Staff 22 and Staff 25 (Environmental Services Director) on 12/07/23. They acknowledged no drills or training had been conducted.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted and documented every other month per the Oregon Fire Code (OFC) and fire and life safety instruction to staff was provided on alternate months. This is a repeat citation. Findings include, but are not limited to:On 03/27/24, fire drill and fire and life safety training records for staff were requested for the time period of 01/22/24 through 03/25/24. Staff 41 (Maintenance Director) stated the facility had not conducted any fire drills or provided any fire and life safety training to staff during that time period.The need to ensure fire drills and fire and life safety training was conducted per the rules was reviewed with Witness 1 (Operations Specialist) on 03/28/24. She acknowledged no drills or training had been conducted.

Based on interview and record review, it was determined the facility failed to ensure residents were instructed within 24 hours of admission and re-instructed at least annually in general safety procedures, evacuation methods, responsibilities during fire drills and designated meeting places outside the building or within the fire safe area in the event of an actual fire. Findings include, but are not limited to:On 08/01/23, Staff 1 (Administrator) was asked to explain the facility's process for providing fire safety training to residents upon admission and annually. Staff 1 stated she did not know the facility's process and did not think the facility was providing the training as required. No further documentation of resident training was provided.The need to ensure residents were trained in fire safety procedures upon admission and at least annually was reviewed with Staff 1 and Staff 6 (Environmental Services Director) on 08/01/23. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure the relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to C240, C252, C260, C270, C280, C290, C302, C303, C310, C325, C340, C361, C370, C372, C374, C420, C613, C615 and C630.
Based on observation, interview, and record review, it was determined the facility failed to ensure their first re-visit survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include, but are not limited to:Refer to C240, C260, C262, C270, C280, C303, C310, C370, C372, C420, and C613.

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 07/31/23 at 11:03 am. The following areas were in need of cleaning or repair:* Doors and door frames for resident rooms 006, 112, 201 and 216 had scuffs, damaged paint or black marks;* Third floor Activity Room door frame had gouges; * Multiple bench seats on all three floors were soiled;* The seat material was deteriorating on four chairs in the first floor common area; * Handrails on the third floor between rooms 201 and 212 had gouges; and* There was refuse and lint behind the row of washers in the third floor resident laundry room.The building was toured and areas needing cleaning or repair were discussed with Staff 3 (Business Office Manager) and Staff 6 (Environmental Services Director) on 08/01/23. 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 12/05/23 and 12/06/23. The following areas were in need of cleaning:* Fabric benches located in corridors and common areas were soiled/stained; and* PTAC (Packaged Terminal Air Conditioner) unit vents/filters in resident apartments had a layer of dust/dirt/debris.The following was in need of repair:* Door frames to resident apartments, including but not limited to apartments 213, 216, and 219, had scuffs, damaged paint, or black marks; * Handrails between rooms 201 - 212 and 217 - 230 had gouges; * Cabinet baseboard in the laundry room was detached; and * Walls throughout the facility had scuffs, gouges, damaged paint and black marks. The areas needing cleaning and repair were reviewed with Staff 22 (ED) and Staff 23 (RCC) on 12/07/23. They acknowledged the findings.
Based on observation and interview, it was determined the facility failed to ensure all interior materials and surfaces were kept in good repair. This is a repeat citation. Findings include, but are not limited to:The interior of the facility was toured on 03/25/24 and 03/28/24. The following areas were in need of repair:* Doors and door frames to resident apartments had scuffs, gouges, damaged paint, or black marks, including but not limited to apartments 213, 216, 219, and 220; * Handrail joint near apartment 203; and * Walls throughout the facility had scuffs, gouges, damaged paint and black marks. The areas needing repair were reviewed with Witness 1 (Operations Specialist) and Staff 41 (Maintenance Director) on 03/28/24. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure operable resident windows with sill heights lower than 36 inches and above the first floor were designed to prevent accidental falls. Findings include, but are not limited to:The interior of the facility was toured on 07/31/23 at 11:00 am. Resident units and common areas had vertically-opening windows with sill heights of less than 36 inches. Multiple windows were inspected and lacked any kind of device which limited how much the window could open to prevent accidental falls. During the environmental tour on 08/01/23 at 1:38 pm, Staff 6 (Environmental Services Director) explained residents frequently removed the limiting devices he had installed on all the window frames.The need to ensure second floor resident windows were designed to prevent accidental falls was reviewed with Staff 3 (Business Office Manager) and Staff 6 on 08/01/23. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure operable resident windows with sill heights lower than 36 inches and above the first floor were designed to prevent accidental falls. This is a repeat citation. Findings include, but are not limited to:The interior of the facility was toured on 12/05/23. Resident units and common areas above the first floor, including but not limited to the dining room and activity room, had vertically opening windows with sill heights of less than 36 inches. Multiple windows were inspected and lacked any kind of device which limited how much the window could open to prevent accidental falls.The need to ensure windows above the first floor were designed to prevent accidental falls was reviewed with Staff 22 (ED), Staff 23 (RCC) and Staff 25 (Environmental Services Director) on 12/07/23. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure washing machines had a minimum rinse temperature of 140 degrees Fahrenheit or used a chemical disinfectant when washing soiled linens and clothing. Findings include, but are not limited to: The facility laundry room was inspected on 07/31/23 at 11:00 am. In an interview on 07/31/23, Staff 19 (CG) stated the facility used a powder sanitizer for laundering soiled items "but we are out." On 07/31/23 at 2:50 pm, Staff 6 (Environmental Services Director) stated he did not know the current detergent lacked a sanitizing chemical component. The need to ensure soiled laundry was properly disinfected was discussed with Staff 3 (Business Office Manager) and Staff 6 on 08/01/23. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure washing machines had a minimum rinse temperature of 140 degrees Fahrenheit or used a chemical disinfectant when washing soiled linens and clothing and laundry was arranged in a way to provide one-way flow of soiled linen and clothing from the soiled area to the clean area. This is a repeat citation. Findings include, but are not limited to:On 12/05/23 and 12/06/23, the facility laundry area was observed and multiple interviews with staff were conducted. The following deficiencies were identified:a. Interviews with Staff 17, 31, 33 and 34 (all CGs who laundered soiled resident linens and clothing) indicated the CGs did not consistently use a chemical disinfectant when laundering soiled linens and clothing.b. Observations during the survey indicated both staff and residents were unclear about where to leave and how to designate soiled laundry so that it wouldn't be co-mingled with non-soiled laundry.The need to ensure soiled laundry was properly disinfected and handled was discussed with Staff 22 (ED), Staff 23 (RCC) and Staff 25 (Environmental Services Director) on 12/07/23. They acknowledged the findings.

The findings of the on-site investigation, conducted 07/11/23 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 livingCBG: capillary blood glucose or blood sugar CG: caregiverCS: Compliance Specialistcm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMT: Medication TechMAR: Medication Administration RecordMCC: Memory Care CommunityOT: Occupational TherapistPT: Physical TherapistPRN: as neededRCC: Resident Care CoordinatorRN: Registered Nurse

Based on interview and record review, conducted during a site visit on 07/11/23, it was confirmed the facility failed to carry out medication orders as prescribed for 1 of 1 sampled residents (#1). Findings include, but not limited to:Resident 1's signed physician orders, dated 12/01/22 revealed the resident had an order for calcium carbonate 500 mg 1 tab by mouth two times a day with meals. Resident 1's progress notes for 06/01/23 through 06/30/23 revealed the family brought in calcium citrate 500 mg and s/he received that medication from 05/30/23 through 06/07/23.During an interview, Staff 1 (Executive Director) stated Resident 1's family brought the medication in as it was less expensive for them to get at the store, than it was through the facility's pharmacy. Staff 1 stated, the wrong supplement was administered unnoticed for several days.The findings were reviewed with and acknowledged by Staff 1 on 07/11/23.It was confirmed the facility failed to carry out medication and treatment orders as prescribed.Verbal plan of correction: Staff 1 to provide education to staff when a medication was received on creating a progress note to document medication name, dose, and verifying medication matches order when receiving a medication from a resident's family member. Staff 1 and nurse will observe all MTs complete a med pass one time per week beginning within the next 30 days to provide any needed education, and audit for skills. Based on interview and record review, conducted during a site visit on 07/11/23, it was confirmed the facility failed to document orders in the resident's record for all medications and that the facility is responsible to administer for 1 of 1 sampled resident (#2). Findings include, but not limited to:During interview on 07/11/2022, Staff 1 (Executive Director) stated Resident 2's hospice nurse was in facility on 05/24/23 and discussed a change in Resident 2's narcotic pain medication. Staff 1 further stated Hospice sent the medication, it was entered into the narcotic book. Staff 1 further stated MTs were doing the shift end count on it daily however, staff did not give the medication and did not follow up to request an order for it. A review of Resident 2's signed physician orders noted the narcotic pain medication was ordered by the hospice RN on 05/24/23 and signed by the provider on 05/30/23. There was no documented evidence the medication was given from 05/24/23 to 06/02/23 or that facility staff attempted to contact hospice to get an order. The findings were reviewed with and acknowledged by Staff 1 by phone on 07/25/23.The facility failed to document orders in the resident's facility record for that pain medication the facility is responsible to administer. Plan of correction: Staff 1 completed a role play/in-service with all MTs on what they would do in that situation. Executive Director to provide education to staff when a medication is received on creating a progress note to document medication name, dose, etc and verifying medication matches order. Staff 1 and nurse would observe all MTs complete a med pass one time per week beginning within the next 30 days to provide any needed education and audit for skills. Based on interview, and record review, conducted during a site visit on 07/11/23, it was confirmed the facility failed to carry out medication orders as prescribed for 3 of 3 sampled residents (#s 3, 4 and 5). Findings include, but not limited to:1. A review of Resident 3's March 2023 MAR indicated Resident 3 had an order for psychoactive medication : Take 1 tab by mouth nightly. A review of the narcotic sign out sheet revealed a dose of that medication was noted to be missing on 3/19/23.During an interview on 07/11/23, Staff 2 (RN) stated swing shift MT gave Resident 3 their 10:00 pm medication on 03/19/23. Staff 2 stated resident 3 forgot and asked Staff 5 (MT) for it on night shift. Staff 5 gave Resident 3 another dose of psychotropic medication without checking if that medication was already administered. 2. A review of Resident 4's June 2023 MAR indicated Resident 4 had an order for pain medication take two tablets by mouth every six hours as needed.In an interview on 07/11/23 Staff 2 stated on 06/07/23, Resident 4 asked Staff 5 for one pain pill instead of the ordered two and Staff 5 gave him/her one, not realizing they could not halve the dose.3. A review of Resident 5's May 2023 MAR revealed resident 5 had an order for pain medication take 1 tab three times by mouth at 10:00 am, 4:00 pm and 10:00 pm as well as an order for pain medication take 1 tab by mouth nightly at 2:00 am.In an interview on 07/11/23, Staff 2 stated Swing MT gave Resident 5 his/her 10:00 pm pain medication on 05/09/23. Resident 5 didn't remember and asked Staff 5 for it on night shift. Staff 5 gave another 10:00pm dose and then held the 2:00 am dose without consulting anyone. Staff 1 (Executive Director) and Staff 2 said that Staff 5 was removed from the medication cart after multiple attempts to re-educate. S/he resigned after being removed from the med cart and was no longer employed by the facility.The findings were reviewed with and acknowledged by Staff 1 and 2 on 07/11/23.It was confirmed the facility failed to carry out medication orders as prescribed.Verbal plan of correction: Staff 1 and Staff 2 will observe all MTs complete a med pass one time per week beginning within the next 30 days to provide any needed education and audit for skills. MT responsible for those errors was removed from the med cart and resigned from his/her position and was no longer employed by the company.

Based on interview and record review, it was confirmed the facility failed to meet the staffing hours needed according to the acuity-based staffing tool (ABST). Findings include, but not limited to:A review of the facility's ABST revealed four days of the previous week were short of their ABST needs:On 07/08/23, the facilities staffing hours needed were 87.56, and the facility was staffed with 74.26 hours;On 07/07/23, the facilities staffing hours needed were 87.56, and the facility was staffed with 62.10 hours;On 07/05/23, the facilities staffing hours needed were 87.36; and the facility was staffed with 85.22 hours; and On 07/04/23, the facilities staffing hours needed were 87.36, and the facility was staffed 82.65.During interview, Staff 1 (Executive Director) stated, they do occasionally have problems with staffing.The findings were reviewed with and acknowledged by Staff 1 on 07/11/23.It was confirmed the facility failed to meet the staffing hours needed according the ABST.Facility plan of correction: Staff 1 stated, she was attempting to recruit and hire new staff. Staff 1 stated, she would educate the business office manager to verify all hours worked when doing the daily ABST verification.

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 04/04/2023. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified:Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

Based on interview and record review, it was confirmed that the facility failed to document the investigation of abuse. Findings include but not limited to:During a joint interview, Staff #1-Staff #2 (S1-S2) stated:*Resident #2 (R2) 's family called to notify that R2 indicated that Staff #6 had hit R2.*S2 attempted to interview R2 at that time.*They did not document the investigation.The facility was unable to produce any documentation of an investigation for this incident.These findings were reviewed with and acknowledged by S1 on 04/04/2023 who was in agreement.Plan of Correction: CS to provided ODHS abuse reporting and investigation guide. Facility RN and Resident Care Coordinator (RCC)have now been trained on how to complete incident reports. Facility to ensure any reported/suspected abuse is reported within 24 hours and investigated.

Based on observation, interview and record review it was confirmed that the facility failed to complete resident service plans quarterly, failed to have service plans be reflective of needs, failed to provide clear directions and failed to have resident service plans readily available to staff. Findings include but not limited to:During an unannounced site visit on 04/03/2023 CS observed service planning binders stored in the locked medication room.Compliance Specialist (CS) reviewed Resident #1(R1) and Resident #4-Resident #6 (R4-R6) service plan which revealed two of four service plans had not been updated in the last quarter. R6's service plan stated that R6 is occassionally incontinent of bladder. Shower days are not listed.During separate interviews, Staff #1 (S1) and Staff #3 (S3) stated:*They have been working to update and complete service plans.*S3 just received more training in March 2023 on how to update service plans.*R6 has a catheter.These findings were reviewed with and acknowledged by S1 on 04/04/2023 who was in agreement. Plan of Correction: Facility to ensure that all service plans are current within 30 days. Resident Care Coordination (RCC) and RN to complete service plans within 30 days and submit to Executive Director (ED) for review. S1 to relocate service plan binders to an area accessible by caregivers by end of day 04/04/2023.

Based on record review and interview, it was confirmed that the facility failed ensure adequate professional oversight of the medication and treatment administration system. Findings include but not limited to: During an unannounced site visit on 04/04/2023 Compliance Specialist (CS) reviewed Resident #2 (R2)'s progress notes and Medication Administration for April 2022 and incident report dated 4/7/2022 which revealed that R2 received the wrong medication on 4/1/2022. A review of medication error report dated 3/19/23 Resident #3's progress notes for March 2023 and a Facility self-report form dated 3/20/2023 revealed that R3 received a double dose of a medication on 3/19/2023. A review of narcotic count verification sheets for March 2023 and December 2022 revealed 21 instances in which narcotic counts were not signed off on as verified. A review of an incident report and investigation worksheet for an incident that occurred 12/24/2022-12/25/2022 revealed that a Medication Technician (MT) lost a pill off the medication cart and the pill was found by another MT on 12/31/2022. A review of the facility's Narcotic Count policy dated 06/08/2017 revealed that narcotics are to be counted at the beginning and end of every shift.During interview, Staff #3 (S3) stated that the MT on 3/19/2023 had pre-popped a narcotic for R3 which lead to the medication error and that they provided education on administering narcotics after the incident. S3 stated that they thought the medication from the 12/24/2022 incident had been lost but was later found by another MT in the cart.These findings were reviewed with and acknowledged by Staff #1 (S1) on 04/04/2023 who was in agreement.Plan of Correction: Resident Care coordinator to audit narcotic logs five days/week.Facility to provide Medication Technician Training in partnership with Consonus pharmacy by end of month and continuing monthly. Facility to offer additional training called " How to avoid medication errors " through Relias.

Based on record review and interview, it was confirmed that the facility failed to implement a system for tracking controlled substances. Findings include but not limited to:During an unannounced site visit on 04/04/2023, Compliance Specialist (CS) reviewed narcotic correct count verification sheets for March 2023 and December 2022 which revealed 21 instances in which narcotic counts were not signed off on as verified. A review of an incident report and investigation worksheet for an incident that occurred 12/24/2022-12/25/2022 revealed that a Medication Technician (MT) lost a pill off the medication cart and the pill was found by another MT on 12/31/2022.A review of the facility's Narcotic Count policy dated 06/08/2017 revealed that narcotics are to be counted at the beginning and end of every shift.During interview Staff #3 (S3) stated that they thought the medication had been lost but was later found by another MT in the cart.These findings were reviewed with and acknowledged by Staff #1 (S1) on 04/04/2023 who was in agreement.Plan of Correction: Resident Care coordinator to audit narcotic logs five days/week.

Based on record review and interview, it was confirmed that the facility failed to carry out medication and treatment orders as prescribed. Findings include but not limited to:During an unannounced site visit on 04/04/2023 Compliance Specialist (CS) reviewed Resident #2 (R2)'s progress notes and Medication Administration for April 2022 and an incident report dated 4/7/2022 which revealed that R2 received the wrong medication on 4/1/2022. A review of medication error report dated 3/19/23 Resident #3 (R3)'s progress notes for March 2023 and a Facility self-report form dated 3/20/2023 revealed that R3 received a double dose of a medication on 3/19/2023.During interview, Staff #3 (S3) stated that the MT on 3/19/2023 had pre-popped a narcotic for R3 which lead to the medication error and that they provided education on administering narcotics after the incident.These findings were reviewed with Staff #1 (S1) on 04/04/2023 who was in agreement.Plan of Correction: Facility to provide Medication Technician Training in partnership with Consonus pharmacy by end of month and continuing monthly. Facility to offer additional training called " How to avoid medication errors " through Relias.

Based on interview and record review, it was confirmed that the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include but not limited to:During an unannounced site visit on 04/04/2023, Compliance Specialist (CS) reviewed the facility's staff schedule for April 2023 which revealed that on 04/02/2023 two Medication Technicians (MTs) and two Caregivers (CGs) were scheduled on day shift. A review of the facility's posted staffing plan revealed the need for two MTs and three CGs on day shift. A review of Resident #5 (R5)'s Individual Account Report (call light log) for 04/02/2023-04/04/2023 revealed seven instances when R5's call light was on for more than 30 minutes, including one incident that lasted 1:43:49 and one that lasted 3:11:57.During interview, Staff #1 (S1) stated that staff are expected to respond to call lights within 15 minutes.During separate interviews, Resident #1 (R1), R5 and Resident #7 (R7) stated:*They have been left in the bathroom for up to three hours.*Their average wait time for a response to their call light is an hour and a half.*There is not enough staff.*The call light doesn't always get a response.*They were short handed yesterday (04/03/2023).These findings were reviewed with (S1) by phone on 04/05/2023.Plan of Correction: S1 declined to provide a plan of correction and stated they would reach out to their corporate office for input.

Based on record review and interview, it was confirmed that the facility failed to fully implement an Acuity-Based Staffing Tool (ABST). Findings include but not limited to:During an unannounced site visit on 04/04/2023, Compliance Specialist (CS) reviewed the facility's ABST for 04/03/2023 which revealed:*The ABST included 15 Activities of Daily Living (ADL) categories. *18 residents ABST profiles have not been updated in the last quarter.*They needed 95.6 hours of care.A review of the facility's staff schedule for April 2023 revealed 11 employees scheduled on 04/03/2022 including two Medications Technicians (MTs) and two Caregivers (CGs) scheduled on day shift. A review of the facility's posted staffing plan revealed the need for two MTs and three CGs on day shift. A review of Resident #5 (R5)'s Individual Account Report (call light log) for 04/02/2023-04/04/2023 revealed seven instances when R5's call light was on for more than 30 minutes, including one incident that lasted 1:43:49 and one that lasted 3:11:57.During interview Staff #1 (S1) stated:*The facility has 8 hour shifts so 95.6 / 8 = 11.95 staff so they need 12 staff per day.*They do not take into account a half hour lunch for each employee.*Staff are expected to respond to call lights within 15 minutes.During separate interviews, Resident #1 (R1), R5 and Resident #7 (R7) stated:*They have been left in the bathroom for up to three hours.*Their average wait time for a response to their call light is an hour and half.*There is not enough staff.*The call light doesn't always get a response.*They were short handed yesterday (04/03/2023).These findings were reviewed with and acknowledged by S1 on 04/04/2023 who was in agreement.Plan of Correction: Facility to ensure that all care plans, which feed their ABST, are current within 30 days. Facility is not tracking all 22 ADLs and will discuss with their regional/corporate staff. Facility to request permission from corporate to use agency staff when not staffed to level required by ABST.

The findings of the kitchen inspection, conducted on 9/22/2022, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.
The findings of the first revisit to the kitchen inspection survey of 09/22/22, conducted 11/08/22 are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and following appropriate sanitation protocols, in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to:On 9/22/2022 at 10:50 am, the facility kitchen was observed and the following areas were noted: *The refrigerator storing food items such as juice, milk and produce had a temperature of 47 degrees F. It also contained uncovered food items which included jello, peaches and cottage cheese. Staff 1 (Administrator) indicated the temperature would be addressed promptly.*The dairy refrigerator had the following food items unlabeled and not dated: open bag of shredded cheese, meat patties, pickles, oatmeal, mandarin oranges, peanut butter and diced peaches. The following food items were not sealed, dated or labeled: hot dogs, sliced meats, lettuce and sausage. *Dry storage area food bins (flour and salt) had scoops in them. The bin covers were covered in food particles, debris and were sticky to touch. A cardboard box of foam cups and two gallon containers of cooking wine were sitting directly on the floor. *The prep area near the coffee making area and eye wash sink had a crate and two cardboard boxes sitting directly on the floor containing potatoes. On the counter in the same area a container of powdered sugar had a cup in it. *The bread freezer had uncovered/unlabeled serving containers of ice cream.*The dishwasher had a data plate indicating both high and low temperatures. Staff 2 and Staff 3 (kitchen staff) were unsure what the temperature should be. Gauges indicated 150 for wash and 180 for rinse. Observations of wash temperature only reached 142 degrees F. Staff 1 was informed and stated they would have machine checked promptly. *In the dish room the wall behind the sink with the sprayer was covered in food splatters and the top of the dishwasher had food debris and dust. *Three garbage cans in the food prep areas were uncovered.*The salad cart had food debris on the shelves. *Vents above the stove had debris/grease. Pipes leading to the stove hood above the handwashing sink had a layer of dust/debris.The findings above were discussed with Staff 1 on 9/22/2022. The findings were acknowledged.