The findings of the re-licensure survey, conducted 02/28/22 through 03/01/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCCMemory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first re-visit to the re-licensure survey of 03/01/22, conducted 05/23/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the second re-visit to the re-licensure survey of 03/01/22, conducted 09/06/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCCMemory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the third re-visit to the re-licensure survey of 03/01/22, conducted 11/17/22 are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Based on observation, interview and record review, it was determined the facility failed to ensure the kitchen was kept clean and in good repair, and food was prepared and served in accordance with the Food Sanitation Rules OAR 333-150-00. Findings include, but are not limited to:

The facility consisted of three separate buildings. Meals were prepared in Building C (Ponderosa). Buildings A and B also had full kitchenettes but were used mainly for serving the meals and storing snacks and desserts.

1. During the Building C kitchen tour, on 02/28/22 from 10:30 am to 10:40 am, a one-compartment stainless sink was observed. The stainless sink contained two packages of raw meat in water. Staff 15 (Cook) was asked to check the water temperature and the water temperature indicated 71 degrees Fahrenheit.

On 02/28/22 at 10:35 am, the thawing process was discussed with Staff 15. Staff 15 stated there was not enough space in the refrigerator to defrost frozen meat. The surveyor informed Staff 15 of the need to discard the two packs of raw meat in the sink.

On 02/28/22 at 10:55 am, observation of the kitchen and the concern regarding the inappropriate thawing of the frozen raw meat was shared with Staff 1 (Executive Director) and Staff 2 (Regional Operation Specialist). They acknowledged the findings.

2. On 03/01/22 at 10:48 am, Staff 15 (Cook) was observed preparing lunch in Building C. Staff 15 prepared pureed diet food and desserts. Staff 15 stated she completed preparing the lunch meals. She was asked the food temperature of the lunch meals. She stated she did not check the temperature of the food.

On 03/01/22 at 10:55 am, the minimum required cooking temperature of food including meat and fish was discussed with Staff 15. She acknowledged the findings.

On 03/01/22 at 2:11 pm, during an interview with staff, the requirement to check food temperatures was shared with Staff 1 (Executive Director) and Staff 2 (Regional Operation Specialist). They acknowledged the findings.

3a. On 02/28/22, during a tour of the kitchen in Building C, the following areas were observed to be in need of cleaning or repair:  

* Kitchen door and door frame had splatters/drips and chips and exposed metal;

* Free-standing refrigerator door was sticky to the touch and had spillage and dried food matter inside;

* Inside and outside of the microwave had dried food matter and was sticky;

* Door and bottom of the oven were sticky with black and brown substances;

* Drawers and shelves of the prep table had brown matter inside, water damage on the bottom surface and chips with exposed raw materials around the perimeter of the drawer;

* Laminated countertop/prep table had chips in multiple areas;

* Walls throughout the kitchen had splatters, loose food debris, grease, dirt, dust and black matter and the wall near the entrance had multiple holes;

* Walls throughout the dry storage had a thick layer of dust and spider webs;

* Window and blinds had a thick layer of dust;

* Underneath the kitchen sink there was thick black matter, debris and food matter on the floor;

* Caulking around the kitchen sink and handwashing sink had black matter and cracks;

* The interior of the free-standing freezer, in the dry storage area, had spillage and dried food matter;

* The ceiling vent had accumulated dust;

* The dry storage doorframe was gouged; and

* The floor near shelves in the dry storage room, had food matter.

b. On 02/28/22 at 10:58 am, during a tour of the kitchen in Building A the following was observed to be in need of cleaning or repair:

* Kitchen door and door frame had splatters/drips, chipped paint and metal exposed;

* Free-standing refrigerator door was sticky to the touch and had spillage and dried food matter inside;

* Inside and outside of the microwave had dried food matter and was sticky to the touch;

* Door and bottom of the oven were sticky and had black and brown substances;

* Food warmer had dried food matter and was sticky to the touch;

* Laminated countertop/prep table had chips;

* Inside drawers underneath of the beverage area had brown matter;

* Drawers and shelves of the prep table had brown matter and water damage on the bottom surface;

* Walls throughout the kitchen had splatters, loose food debris, grease, dirt, dust and black matter;

* Walls throughout the dry storage had a thick layer of dust;

* Window and blinds above the kitchen sink area had a thick layer of dust;

* Underneath the kitchen sink there was thick black matter and food matter on the floor;

* Caulking around the kitchen sink and handwashing sink had black matter and cracks;

* The interior of the free-standing freezer, in the dry storage area, had spillage and dried food matter; and

* Dry storage doorframe was gouged.

c. On 02/28/22 at 11:08 am, during a tour of the kitchen in Building B the following was observed to be in need of cleaning or repair:

* The interior of the free-standing cooler had spillage and dried food matter;

* Door and bottom of the oven were sticky and had black and brown substances;

* Drawers and shelves of the prep table had brown matter and water damage on the bottom surface;

* Food warmer had dried food matter;

* Inside drawers underneath the beverage area had brown matter;

* Multiple ants were observed in the kitchen area;

* The interior of the free-standing freezer, in the dry storage area, had spillage and dried food matter;

* Ice machine exterior was sticky to the touch;

* Laminated prep table had chips in multiple areas;

* Underneath the kitchen sink, there was thick black matter and food matter on the floor; and

* Caulking around the kitchen sink and handwashing sink had black matter and cracks.

On 02/28/22 at 11:50 am, the buildings were toured with Staff 1 (Executive Director) and Staff 2 (Regional Operation Specialist). They acknowledged the areas needed cleaning and repair.

1. The kitchens will receive a deep clean. Chipped paint,

gouges, and cracks will be repaired. The Food Temperature Log will be used at all meals prior to service.

2. The Dining Services Director and Cooks will receive additional training on Kitchen Cleaning Schedule Policy and Procedure, Food Temperature Logs, and Thawing meat practices.

3. The Dining Services Director will review weekly per the Quality Assurance Review Schedule - Dining Services.

4.The Executive Director will be responsible for ensuring corrections are completed and monitored.

Based on observation, interview and record review, it was determined the facility failed to ensure the kitchen was kept clean and in good repair, and food was prepared and served in accordance with the Food Sanitation Rules OAR 333-150-00.  This is a repeat citation. Findings include, but are not limited to:

The facility consisted of three separate buildings. Meals were prepared in Building C (Ponderosa). Buildings A and B also had full kitchenettes but were used mainly for serving the meals and storing snacks and desserts.

1. During the Building C kitchen tour on 05/23/22 at 9:15 am the following areas were observed to be in need of cleaning or repair:  

* Kitchen door and door frame had splatters/drips and chips and exposed metal;

* Drawers and shelves of the prep table had brown matter inside, water damage on the bottom surface and chips with exposed raw materials around the perimeter of the drawer;

* Laminated countertop/prep table had chips in multiple areas;

* Walls throughout the kitchen had splatters, loose food debris, grease, dirt, and dust and the wall near the entrance had multiple holes;

* Walls throughout the dry storage had of dust;

* Window and blinds were dusty;

* Underneath the kitchen sink debris and food matter on the floor;

* Caulking around the kitchen sink and handwashing sink had black matter and cracks.

b. On 05/23/22 at 9:30 am, during a tour of the kitchen in Building A the following was observed to be in need of cleaning or repair:

* Kitchen door and door frame had splatters/drips, chipped paint and metal exposed;

* Floor under rolling bin cracked and water damaged;

* Laminated countertop/prep table had chips;

* Inside drawers underneath of the beverage area had brown matter;

* Drawers and shelves of the prep table had brown matter and water damage on the bottom surface;

* Walls throughout the dry storage were dusty;

* Window and blinds above the kitchen sink area was dusty;

* Underneath the kitchen sink the cabinet doors were missing;

* Caulking around the kitchen sink and handwashing sink had black matter and cracks; and

* Dry storage doorframe was gouged.

c. On 05/23/22 at 9:30 am, during a tour of the kitchen in Building B the following was observed to be in need of cleaning or repair:

* Drawers and shelves of the prep table had brown matter and water damage on the bottom surface;

* Food warmer had dried food matter;

* Inside drawers underneath the beverage area had brown matter;

* The interior of the free-standing freezer, in the dry storage area, had spillage and dried food matter;

* Laminated prep table had chips in multiple areas;

* Underneath the kitchen sink, there was thick black matter and food matter on the floor; and

* Caulking around the kitchen sink and handwashing sink had black matter and cracks.

On 05/23/22, the buildings were toured with Staff 1 (Executive Director). She acknowledged the areas required repair, and the repairs had not yet been completed.

1. The community is installing new flooring, and cabinets/counters. Kitchen remodels will be completed following delivery of items from vendors. With current delays in product supply, we anticipate full completion on or before 8/30/22.

2. The kitchen cleaning schedule will be revised and maintained following the kitchen remodel.  

3. The Dining Services Director will review weekly per the Quality Assurance Review Schedule - Dining Services.

4.The Executive Director will be responsible for ensuring corrections are completed and monitored.  

2. Resident 2 moved into the facility in 02/2022.

The move-in evaluation failed to address the following areas:

* Effective non-drug interventions for mental health issues;

* Cognition including memory, orientation, confusion and decision making abilities;

* Personality, including how the person copes with change and challenging situations;

* Communication and sensory;

* Pain including pharmaceutical and non-pharmaceutical interventions;

* Skin condition;

* Nutrition habits, fluid preference;

* Complex medication regimen;

* History of dehydration or unexplained weight loss or gain;

* Elopement risk or history; and

* Environmental factors that impact the resident's behavior including but not limited to: noise, lighting, room temperature.

The need to ensure move-in evaluations included all required elements was discussed on 02/28/22 at 2:10 pm with Staff 1 (Executive Director) and Staff 2 (Regional Operation Specialist). They acknowledged the findings.

3. Resident 4's quarterly evaluation, dated 02/07/22, was reviewed and lacked evidence the evaluation had been updated in the following areas:

* Sensory including vision status and use of glasses;

* Toileting status including bowel management;

* Ability to use call system;

* Current preferred activities and activities ability;

* Fall risk including fall interventions; and

* Hydration status.

During an interview with Staff 2 (Regional Operation Specialist) on 02/28/22, she confirmed the quarterly evaluation had not been updated.

The need to ensure quarterly evaluations were reflective of resident's status was discussed on 03/01/22 at 2:11 pm with Staff 1 (Executive Director) and Staff 2 (Regional Operation Specialist). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure new move-in evaluations addressed all required elements for 1 of 1 sampled resident (# 2) who was recently admitted to the facility, and failed to ensure quarterly evaluations were completed timely and were updated for 2 of 3 sampled residents (#s 1 and 4) whose records were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 08/2014. The resident's most recent quarterly evaluation, dated 04/08/21 was reviewed and lacked evidence of being updated timely (quarterly), as required.

On 03/01/22 the need to ensure residents' evaluations were updated quarterly was discussed with Staff 1 (Executive Director) and Staff 2 (Regional Operation Specialist). They acknowledged the findings.

1. All resident service plans will be reviewed and updated, if needed, to meet all evaluation requirements.  

2. The Executive Director, Wellness Director(s) and Wellness Nurse will receive additional training on the Service Plan; Admissions policy and procedure.  

3.  The Executive Director and aforementioned department managers will review this area weekly per their individual Quality Assurance Review Schedules to ensure correction.

4.  The Executive Director will be responsible for ensuring corrections are completed and monitored.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current status and provided clear direction to caregiving staff regarding delivery of services for 2 of 3 sampled residents (#s 1 and 4) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 06/2020. The resident's current service plan, dated 05/24/21, and Interim Service Plans (ISPs) were reviewed and were not reflective of the resident's current status and care needs and failed to provide clear instruction in the following areas:

* Current fall status and interventions;

* Current preferred activities and the ability to participate in activities;

* Fluid preferences;

* Sensory including vision status and use of glasses;

* Changes in incontinence (bowel) and level of assistance required;

* Changes in dressing status and level of assistance required;

* Bathing status;

* Ability to use call system; and

* Use of compression stocking.

The need to ensure the service plan provided clear and accurate information was discussed with Staff 1 (Executive Director) and Staff 2 (Regional Operation Specialist) on 03/01/22. They acknowledged the findings.

2. Resident 1 was admitted to the facility in 08/2014 with diagnoses including dementia, hypertension, cardiomyopathy and macular degeneration. The resident's records were reviewed, including service plan (dated 04/08/21) interim service plans, progress notes, incident reports and outside provider notes.

Review of these records, interviews with staff, and observations during survey indicated Resident 1's service plan was not reflective of the resident's current care needs or did not provide clear instructions to staff in the following areas:

*Visual impairment- The service plan stated Resident 1 had "no visual impairment", while the resident's list of diagnoses included glaucoma, cataracts and macular degeneration;

*Toileting needs- The service plan stated Resident 1 was "continent of bladder and bowel", but also documented the resident's need for an "incontinence package" (including gloves, wipes and briefs) and "total assistance" with toileting;

*Restraint device- The service plan stated Resident 1 "did not require any device with restraining qualities". However, siderails were observed on the resident's bed during survey, and staff presented the survey team with a documented assessment form for the use of siderails; and

*PRN oxygen- The service plan included no mention of oxygen or instructions to staff on maintenance and use of related equipment. However, an oxygen tank, regulators and tubing were observed in the resident's room, and the MAR listed oxygen as a PRN medication.

On 03/01/22 the need to develop service plans that reflected residents' current status and care needs, and provided clear instructions to staff was discussed with Staff 1 (Executive Director) and Staff 2 (Regional Operations Specialist). They acknowledged the findings.

1. All resident service plans will be reviewed to ensure the plans are reflective of resident needs and with clear instruction regarding delivery of service.

2.  The Executive Director, Wellness Director(s), and Wellness Nurse will receive additional training on the Service Plan Policy. All direct care staff will receive additional training on delivery of service.

3. The service plan schedule will be reviewed weekly per the Quality Assurance - Health Services Review Schedule.

4.  The Executive Director will be responsible for ensuring corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a service planning team that included the resident, the resident's legal representative if applicable, any person of the resident's choice, the Administrator or designee, and at least one other staff person who was familiar with or who was going to provide services to the resident for 2 of 3 sampled residents (#s 1 and 4) whose service plans were reviewed. Findings include, but are not limited to:

The most recent service plans for Residents 1 and 4 were reviewed during the survey. The records lacked documented evidence that the service plans were developed by a service planning team.

On 03/01/22 the need to ensure service plans were developed by a service planning team was discussed with Staff 1 (Executive Director) and Staff 2 (Regional Operation Specialist). They acknowledged the findings.

1. All resident service plans will be developed by a service planning team.  

2.  The Executive Director, Wellness Director(s), and Wellness Nurse will receive additional training on the Service Plan Policy, Pre-Service Plan Review, and the Service Plan Development and Meeting Notes.

3.  The Wellness Director(s) will review this area weekly per the Quality Assurance - Health Services Review Schedule.

4.  The Executive Director will be responsible for ensuring corrections are completed and monitored.

Based on observation, interview and record review, it was determined the facility failed to ensure short term changes of condition with resident specific interventions were determined and monitored for 1 of 3 sampled residents (# 4) in the areas of falls. Findings include, but are not limited to:

Resident 4 was admitted to the facility in 06/2020.

During the acuity interview, the resident was identified as having multiple falls in the last 90 days.

Observations from 02/28/22 through 03/01/22 revealed the resident ambulated in the room with a 4-wheeled walker independently and had discoloration/bruises on his/her face and neck area.

The resident's 05/24/21 service plan, 11/11/21 through 02/27/22 progress notes, Interim Service Plan(s) and incidents reports were reviewed and revealed the following:

* The resident's most recent plan of care indicated the resident was a "low fall potential" and no fall interventions were listed; and

* S/he experienced five falls including skin injury from the falls.

A review of the resident's record revealed the facility had not evaluated, implemented or monitored resident specific interventions related to falls.

The failure to evaluate the resident's status based on the evaluation and service planned needs was discussed with Staff 1 (Executive Director) and Staff 2 (Regional Operation Specialist) on 03/01/22. No further information was received.

1. All resident records will be reviewed to ensure all change of condition is identified with appropriate action (evaluation, intervention, service plan update, and resident monitoring).

2.  The Executive Director, Wellness Director(s) and Wellness Nurse will receive additional training on the Change of Condition policy.

3.  The Executive Director, Wellness Director(s), and Wellness Nurse will review this area daily per the Quality Assurance - Clinical Review Schedule.

4.  The Executive Director will ensure the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 1 of 3 sampled residents (# 4) whose orders were reviewed. Findings include, but are not limited to:

Resident 4 was admitted to the facility in 06/2020.

Resident 4 had a physician's order, dated 01/26/22, to apply Diaper Rash 10 % cream as directed and Nystatin powder twice daily.

Resident 4's 02/01/22 through 02/28/22 MAR revealed there was no indication these orders were transcribed to the MAR.

On 03/01/22, the physician orders and the MARs were reviewed with Staff 1 (Executive Director) and Staff 2 (Regional Operation Specialist). They acknowledged the findings.

1. All Medication Administration Records will be reviewed to ensure signed physician orders are in place and medication or treatment orders are followed.    

2.  The Executive Director, Wellness Director(s), and Wellness Nurse will receive additional training on the Orders Policy and Procedure.

3. The Wellness Director(s) and Wellness Nurse will review daily per the Quality Assurance - Health Services Review Schedule.

4.  The Executive Director will ensure the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate for 2 of 3 sampled residents (#s 3 and 4) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 11/2021 with diagnoses including Alzheimer's disease.

The resident's 02/01/22 through 02/28/22 MARs were reviewed during the survey and lacked resident specific instructions for the following:

* PRN Tylenol tablets versus PRN Tylenol suppository for fever greater than 100 degrees;

* PRN morphine versus PRN Tylenol for pain;

* PRN Lorazepam versus PRN morphine for shortness of breath; and

*PRN Milk of Magnesia versus PRN polyethylene glycol for constipation.

On 03/01/22, the need for the facility to ensure MARs provided clear instruction to unlicensed staff was discussed with Staff 1 (Executive Director) and Staff 2 (Regional Operations Specialist). They acknowledged the findings.

2. Resident 4 moved into the facility in 06/2020.

Resident 4's MARs, reviewed from 02/01/22 - 02/28/22, revealed the following inaccuracies:

* To apply PRN Lidocaine 4 % patch 1- 2 patches for pain without clear instruction including when to apply 1 or 2 patches.

* Staff documented they administered all medications to the resident on 02/18/22 and staff documented the resident's evening medications were "sitting popped out in the clear medication box" and documented the resident was not able to wake up to administer the medications.

On 03/01/22, the need to maintain an accurate MAR for all medications administered by the facility and to ensure MARs were accurate and provided clear instruction to unlicensed staff was discussed with Staff 1 (Executive Director) and Staff 2 (Regional Operation Specialist). They acknowledged the findings.

1. All Medication Administration Records will be reviewed to ensure resident specific instructions are available to staff for PRN (as needed) medications.  

2.  The Executive Director, Wellness Director(s), and Wellness Nurse will receive additional training on the Orders Policy and Procedure.

3.  The Wellness Nurse will review daily per the Quality Assurance - Health Services and Clinical Review Schedule.

4.  The Executive Director will ensure the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure new hires had the required abdominal thrust and First Aid training for 2 of 3 newly hired staff (#s 8 and 9).  Findings include, but are not limited to:

During the survey, training records were reviewed for Staff 8 (MT) hired 12/21/21, and Staff 9 (MT) hired 12/30/21.

Staff 8 and 9 did not have documented evidence they had received first aid and abdominal thrust training.

The need to ensure staff were trained in first aid and abdominal thrust was discussed with Staff 1(Executive Director) and Staff 2 (Regional Operations Specialist) on 03/01/22. They acknowledged the findings.

1. All employee records will be reviewed to ensure documented evidence of completion of first aid and abdominal thrust are present.

2. The Executive Director and Business Office Director will receive additional training on required training within first 30 days for Direct Care Staff.  

3. The Business Office Director will review weekly per the Quality Assurance - Business Office Review Schedule.

4.The Executive Director will ensure the corrections are completed and monitored.  

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

Fire and life safety records, reviewed between 09/2021 and 01/2022, revealed the following:

* No fire and life safety instruction had been completed during the six-month time frame.

On 03/01/22 at 10:28 am, Staff 1 (Executive Director) confirmed there was no staff in-service on fire and life safety for the last six months.

The requirements regarding fire and life safety instruction for staff was reviewed with Staff 1 (Executive Director) and Staff 2 (Regional Operation Specialist) on 03/01/21 at 2:11 pm. They acknowledged the findings. No further information was provided.

1. The community will complete fire drills life safety instruction at least every other month.

2. The Executive Director and Mainteance Director will receive additional training on the Fire Life Safety Training & Drill Flow Chart and the Fire Drill Checklist.

3. The Maintenance Director will review monthly per the Quality Assurance - Maintenance Review Schedule.

4.  The Executive Director will ensure the corrections are completed and monitored.  

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

Refer to C 240 and C 510.

1. The needed repairs will be completed to obtain compliance with citations regarding C240 and C510.

2. The Executive Director received additional training on requesting an extension when contractors are not able to complete work within plan of correction timeframe.

3. This area will be reviewed with each plan of correction.

4. The Executive Director is responsible ensuring compliance.

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:

Refer to C 510.

Refer to C 510.

Based on observation and interview, it was determined the facility failed to maintain all exterior pathways to the common-use areas in good repair. Findings include, but are not limited to:

The exterior grounds, courtyard areas and walkways of the building were toured on 02/28/22 at 10:45 am. There were multiple sections of the sidewalk with drop-offs of up to two inches, measured from the concrete surface to the bark dust beds. These drop-offs represented tripping/fall risks for residents.

On 02/28/22 the drop-offs were reviewed with Staff 1 (Executive Director) and Staff 2 (Regional Operation Specialist). They acknowledged the findings and stated plans to have additional bark dust spread.  

1. The community will fill in the drop offs along the sidewalks.   

2.  The Executive Director and Maintenance Director will receive additional training on the QA - Quarterly Building Inspection.

3.  The Executive Director and Maintenance Director will review this area quarterly per the Quality Assurance Master Review Schedule to ensure correction.

4.  The Executive Director will ensure the corrections are completed and monitored.   

Based on observation and interview, it was determined the facility failed to maintain all exterior pathways to the common-use areas in good repair. This is a repeat citation. Findings include, but are not limited to:

The exterior grounds, courtyard areas and walkways of the building were toured on 05/23/22 at 9:46 am. There were multiple sections of the sidewalk with drop-offs of up to two inches, measured from the concrete surface to the barkdust beds. These drop-offs represented tripping/fall risks for residents.

On 05/23/22 the drop-offs were reviewed with Staff 1 (Executive Director). She acknowledged the findings and stated she had ordered barkdust and mulch that would be delivered in four to six weeks.

1.The community had barkdust installed along the sidewalks on 6/17/22.   

2.  The Executive Director and Maintenance Director will receive additional training on the QA - Quarterly Building Inspection.

3.  The Executive Director and Maintenance Director will review this area quarterly per the Quality Assurance Master Review Schedule to ensure correction.

4.  The Executive Director will ensure the corrections are completed and monitored.   

Based on observation and interview, it was determined the facility failed to maintain all exterior pathways to the common-use areas.  This is a repeat citation. Findings include, but are not limited to:

The exterior grounds, courtyard areas and walkways of the building were toured on 09/06/22. The following was identified:

*The courtyard in cottage "Alpine" was observed with a concrete sidewalk below the adjacent concrete pad and there was an approximate 4 inch deep drop off between the surfaces.  The sidewalk represented tripping/fall risks for the residents.

On 09/06/22 the drop-offs and sunken concrete were reviewed with Staff 1 (Executive Director). She acknowledged the findings.

1. The identified section of the sidewalk is being removed and repoured in order to remove the approximate 4 inch deep drop off between the surfaces.

2. Audits will be completed using the QA- Quarterly Building Inspection form.

3. The Executive Director and Maintenance Director will review this area quarterly per the Quality Assurance Master Review Schedule.

4. The Executive Director will ensure the corrections are completed and monitored.

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to C240, C372, C420 and C510.

Refer to C240, C372, C420 and C510

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:

Refer to C 240 and C 510.

Refer to C240 and C510

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:

Refer to C 510.

Refer to C 510.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 long term staff (#s 11, 12 and 13) completed the required number of hours of annual in-service training. Findings include, but are not limited to:

Staff training records were reviewed on 03/01/22 and revealed the following:

* Staff 11 (CG) hired 08/30/20, Staff 12 (CG) hired 07/12/05 and Staff 13 (CG) hired 10/17/17 had no documented evidence they had completed a total of 16 hours of annual in-service training related to the provision of care, including a minimum of six (6) hours related to dementia care.

The need to ensure staff completed all required training in a timely manner was discussed with Staff 1 (Executive Director) and Staff 2 (Regional Operations Specialist) on 03/01/22. They acknowledged the findings.

1. All employee records will be reviewed to ensure documented annual continuing education is completed.

2. The Executive Director and Business Office Director will receive additional training on continuing education totalling a minum of 16 hours per year (with a minimum of 6 hours related to dementia care).

3. The Business Office Director will review monthly per the Quality Assurance - Business Office Review Schedule.

4. The Executive Director will ensure the corrections are completed and monitored.   

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to C252, C260, C262, C270, C303 and C310.

Refer to C252, C260, C262, C270, C303 and C310