The findings of the re-licensure survey, conducted 10/12/2021 through 10/14/2021, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004.

Abbreviations possibly used in this document:

ADL:activities of daily 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 following the re-licensure survey of 10/14/2021, conducted on 01/11/22 through 01/12/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004.

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 second re-visit following the re-licensure survey of 10/14/2021, conducted on 03/10/22, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Based on observation and interview, it was determined the facility failed to implement effective methods of infection control. Findings include, but are not limited to:

During the survey, conducted 10/12/21 through 10/14/21, Oregon Department of Human Services infection control guidelines, which were established to protect the facility staff and residents from the spread of COVID-19, and made available to all facilities, were not being followed by the facility.

Staff were observed in common areas and resident rooms to wear their masks below their noses, below their chins, or to be without a mask or eye protection.

The need to ensure staff appropriately and consistently used Personal Protective Equipment was discussed with Staff 1 (Administrator), Staff 2 (Assistant Administrator) and Staff 3 (RCC) on 10/14/21. They acknowledged appropriate infection control practices were not implemented.

1.) Mt.Scott will comply with OAR 411-054-0025 (4) (C 160) by conducting continual staff trainings and as needed corrections

2.) Management will do frequent walk throughs while on duty to ensure staff are wearing PPE appropriately, and will do pop-ups on swing and graveyard asleast once a week. Any staff needing frequent reminders r found in violation wwill require additional PPE training.

3.) Daily, Monthly during staff meetings, and as needed as violation occurs.

4.) HR Kellee Baxter and all management team

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (#4) whose move in evaluation was reviewed. Findings include, but are not limited to:

Resident 4 was admitted to the facility in April 2021. The resident's move-in evaluation failed to address the following elements:

* Spiritual, cultural preferences and traditions;

* Visits to health practitioners, ER, hospital or skilled care in the past year;

* Ability to manage medications;

* Ability to use call system;

* Fall risk or history;

* Complex medication regimen;

* History of dehydration or unexplained weight loss or gain;

* Recent losses;

* Unsuccessful prior placements;

* Smoking, ability to smoke safely; and

* Alcohol and drug use.  

The need to ensure all required elements were addressed on move-in evaluations was discussed with Staff 1 (Administrator), Staff 2 (Assistant Administrator), Staff 3 (RN) and Staff 4 (RCC) on 10/14/21. No additional information was provided.  

1.) Mt.Scott will comply with OAR 411-054-0034 (2-4) (Tag C 252) (please see attached assessment for resident 1 of 1 for which I failed to provide to surveyors during the mist of everything else going on) We will continue to complete new admissions assessments via eldermark

2.) All members of management will complete eldermarks webinar training titled "Service Minder Clinical: Assessments, this will provide training on how, where, when to acess assessment tab along with printing options, and an extensive change history done to each assessment/s.

3.) @ each new admissio, quarterly, an or PRN

4.) All management team members & R.N.

Based on observation, interview and record review, it was determined the facility failed to ensure the service plan was reflective, provided clear caregiving instruction, ensure that changes and entries made to the service plan were dated and initialed, and that the service plan was updated at least quarterly for 4 of 5 sampled residents (#s 2, 3, 5 and 6) whose service plans were reviewed. Findings include, but not limited to:

1. Resident 2 was admitted to the facility in February of 2019 with diagnosis including schizoaffective disorder. Resident 2's most recent service plan, created on 4/6/21, was not updated at least quarterly. The service plan was not reflective in the following areas:

* Use of bi-lateral side rails as an assistive device and instructions for staff;

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

* Environmental factors that impact the resident's behavior including, but not limited to: Noise, Lighting, Room temperature.

The need to ensure service plans were reflective of the resident's current condition, provided clear instruction, handwritten updates were initialed and the service plan was updated quarterly was discussed with Staff 1 (Administrator), Staff 2 (Assistant Administrator), Staff 3 (RN) and Staff 4 (RCC) on 10/14/21. They acknowledged the findings.   

2. Resident 3's most recent service plan, created on 8/24/21, was not reflective of:

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

* Environmental factors that impact the resident's behavior including, but not limited to: Noise, Lighting, Room temperature.

The need to ensure service plans were reflective of the resident's current condition, provided clear instruction, handwritten updates were initialed and the service plan was updated quarterly was discussed with Staff 1 (Administrator), Staff 2 (Assistant Administrator), Staff 3 (RN) and Staff 4 (RCC) on 10/14/21. They acknowledged the findings.

3. Resident 6 was admitted to the facility in May, 2019. The resident's service plan, dated 6/17/21, was reviewed and caregiving staff were interviewed.

The service plan was reviewed with Staff 11 (Resident Aide) on 10/14/21 at 10:15 am. The service plan was not reflective or lacked clear instruction in the following areas:

* Time needed with resident to encourage independence;

* Diabetic diet reflected on the service plan was not reflected in the instructions for kitchen staff;

* Bathing schedule;

* Nighttime smoking routine;

* Siderail use; and

* Activity interests.

There was one handwritten update that was not initialed and there was no documented evidence the service plan had been updated quarterly or as needed.

The need to ensure service plans were reflective of the resident's current condition, provided clear instruction, handwritten updates were initialed and the service plan was updated quarterly was discussed with Staff 1 (Administrator), Staff 2 (Assistant Administrator), Staff 3 (RN) and Staff 4 (RCC) on 10/14/21. They acknowledged the findings.   

4. Resident 5 was admitted to the facility in June 2020. Observations of the resident and interviews with staff from 10/12/21 to 10/14/21 and review of the service plan dated 9/26/21, showed the service plan was not reflective of the resident's current care needs, was not consistently followed by staff and/or did not provide clear direction to staff in the following areas:

The service plan stated that Resident 5 had dermatitis but did not give clear instructions on what signs or symptoms to watch for. There was one handwritten update that was not initialed that stated "rash on both legs ...staff to set up treatment" but did not provide instructions to staff on which treatment or how to proceed.

The need to ensure service plans were reflective of the resident's current condition, provided clear instruction, handwritten updates were initialed and the service plan was updated quarterly was discussed with Staff 1 (Administrator), Staff 2 (Assistant Administrator), Staff 3 (RN) and Staff 4 (RCC) on 10/14/21. They acknowledged the findings.   

1.) Mt.Scott will comply with OAR 411-054-0036 (1-4) please see attached evaluations for side rails for both res. 2 & 6. Additional components regarding Personality including how indiv. copes w/ change or challenging sit. & enviromental factors impacting resident behaviors will be addressed under current category mental status/ behaviors with resident input these compnents will be assressed and subsequent behaviors will be acknowledged.

2.) Evals/Assessments will be completed accordingly, see master service plan eval/assessment checklist which has been created to remind reviewal of all potential components on admission and atleast quarterly, or PRN (Master SP file created for RCC and training purposes moving forward for changesto RCC

3.) Upon admmission, quarterly, and PRN

4.) Service planning team: Including the resident (all members of management + RN)  

Based on interview and record review, it was determined the facility failed to ensure short-term changes of condition were evaluated, actions or interventions determined and communicated to staff and monitored through to resolution for 1 of 2 sampled residents (#5) who experienced a change of condition. Findings include, but are not limited to:

Resident 5 was admitted to the facility in June 2020 with diagnosis including diabetes.  

A progress note dated 08/30/21 revealed Resident 5 self-reported a rash to lower legs with skin that was very dry with scabs. Staff 2 (Assistant Administrator) documented in a progress note confirmation the resident's legs were dry with scratches and had yellow colored skin peeling off back of both legs.

In interview on 10/13/21 at 10:25 am Staff 4 (RN) stated that no evaluation or monitoring of the resident's skin had occurred.                             

There was no documented evidence the facility evaluated Resident 5's skin, determined what action or intervention may be required or monitored the resident's skin until resolution.  

Resident 5's change of condition, lack of action or interventions developed and failure to monitor changes through resolution was discussed with Staff 1 (Administrator), Staff 2 and Staff 3 (RCC) on 10/14/21. They acknowledged the findings.

1.) Mt.Scott will comply with OAR 411-054-0040(1-2) Skin assessment will be done. New CIC monitoring feature from eldermark- SBAR & WISDOMACT

2.) New monitoring of CIC features via eldermark currently being implemented, staff training to begin 11/17/21 go live date will also being 11/17/21.

We will continue to address training on this new feature/ topic atleast every 2 weeks

3.) Daily & as needed/ as CIC occur, are reported, found, and or acknowledged

4.) All members of Management & RN

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

Resident 6 admitted to the facility in May 2019 with diagnosis including hypertension. The resident's September 1 through October 13, 2021 MARs and physician orders were reviewed.

The resident had a physician's order for amlodipine besylate (for blood pressure) to be administered once a day and to be held for blood pressures that were less than 100/50 (either number) or a pulse that was under 50. The following was identified:

* On 9/3/21, the resident's pulse was recorded as 45 and the medication was administered;

* On five occasions, the medication was not administered due to the blood pressure machine "not working" or "not available;" and

* On four occasions, staff administered the medication without taking the resident's blood pressure or pulse.

The need to ensure non-licensed staff followed physician's orders was discussed with Staff 1 (Administrator), Staff 2 (Assistant Administrator), Staff 3 (RN) and Staff 4 (RCC) on 10/14/21. No additional information was provided.

1.) Mt.Scott will comply with OAR 411-054-0055 (1) (f-h) Additional order info implemented on physician orders sheet (see attached sample labeled Tag C 303)

2. See attached policy & procedure info implemented on Physicians order sheets

3.) N/A Only if providers specifies parameters and or required  b/p readings in order to administer b/p meds

4.) All members of management

Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused to consent to orders for 2 of 2 sampled residents (#s 5 and 6) who had documented medication refusals. Findings include, but are not limited to:

1. Resident 6 was admitted to the facility in May 2019 with diagnosis including hypertension, diabetes and peripheral vascular disease.

The resident's September 1 through October 13, 2021 MARs and physician orders were reviewed. Documentation showed the following refusals:

* Amlodipine besylate (for blood pressure);

* Boost Glucose Control (for blood glucose control and added protein);  

* Compression stocking (for blood flow);

* Lactulose (for bowel regularity);

* Metformin (for diabetes); and

* Vitamin B-12 (for vitamin deficiency).

There was no documented evidence the physician or practitioner was notified of the resident's refusal to consent to orders.

The need to ensure medication and treatment refusals were reported to the physician was discussed with Staff 1 (Administrator), Staff 2 (Assistant Administrator), Staff 3 (RN) and Staff 4 (RCC) on 10/14/21. No additional information was provided.

2. Resident 5 was admitted to the facility in June 2020 with diagnosis including diabetes.

The resident's September 1 through October 13, 2021 MARs and physician orders were reviewed. Documentation showed the following refusals:

* Hydrocortisone cream (for dermatitis);

* Ferrous Sulfate (for low iron);  

* Sea salt soak (for lower leg rash); and

* Compression stockings (for edema).  

There was no documented evidence the physician or practitioner was notified of the resident's refusal to consent to orders.   

The need to ensure medication and treatment refusals were reported to the physician was discussed with Staff 1 (Administrator), Staff 2, Staff 3 (RN) and Staff 4 (RCC) on 10/14/21. No additional information was provided.

1.) Mt.Scott will comply with OAR 411-054-0055 (1) (j) physician orders will be followed and physicians will be duly notified of missed/refused medications/tx.

2.) The following new systems are being implemented; New Form; Monthly notification of missed/refused/held medications & TX, and Completed/Faxed Missed med notifications Box in med room

3. Monthly- between 1st - 5th Noc med-aide will be alerted during nightly med passes to complete and attach last 30 days report of missed/refused/held meds/tx for all residents and fax to the provider.

4.) All members of management, R.N., & Med-Aides

Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused to consent to orders for 1 of 2 sampled residents (# 6) who had documented treatment refusals. This is a repeat citation. Findings include, but are not limited to:

Resident 6's 12/2021 and 01/01/22 through 01/11/22 MARs were reviewed and revealed the following:

Staff documented Resident 6 refused the order for lactulose on 27 occasions.

There was no documented evidence the facility notified Resident 6's physician of the refusals.

In an interview on 01/11/21, Staff 2 (Assistant Administrator) confirmed the facility had not followed instructions from the resident's physician directing the facility to inform the physician of Resident 6's medication refusals on the 1st of every month.

The need to ensure the facility notified prescribers of medication refusals was reviewed with Staff 1 (Administrator) and  Staff 2 on 01/12/22. They acknowledged the findings.

1.) Mt. Scott will comply with OAR 411-054-0055 (1) (j) physician orders will be followed and physicians will be duly notified of missed/refused medications/tx.

2.) The following new systems are being implemented; New Form; Monthly notification of missed/refused/held medications & TX, and Completed/Faxed Missed med notifications Box in med room

3. Monthly- between 1st - 5th Noc Med-Aide will be alerted during nightly med passes to complete and attach last 30 days report of missed/refused/held meds/TX for all residents and fax to the provider.

4.) All members of management, R.N., & Med-Aides

2. Resident 2 was admitted to the facility in February 2019 with diagnosis including schizoaffective disorder and pain. The resident's September 1 through October 13, 2021 MARs were reviewed and revealed the following:

* Multiple blanks on the MARs with no documentation of whether the medication was administered; and

* PRN Tramadol given on 10/13/21 but documented as 10/12/21.

The need to ensure resident MARs were accurate and included documentation of administration was discussed with Staff 1 (Administrator), Staff 2 (Assistant Administrator), Staff 3 (RN) and Staff 4 (RCC) on 10/14/21. They acknowledged the findings.  

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 2 of 5 sampled residents (#s 2 and 6) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 6 was admitted to the facility in May 2019 with diagnosis including peripheral vascular disease and osteoporosis. The resident's September 1 through October 13, 2021 MARs were reviewed and revealed the following:

* Multiple blanks on the MARs with no documentation of whether the medication was administered; and

* No results recorded for the administration of PRN acetaminophen (for pain) on 10/3/21.

The need to ensure resident MARs were accurate and included documentation of administration and effectiveness of medications was discussed with Staff 1 (Administrator), Staff 2 (Assistant Administrator), Staff 3 (RN) and Staff 4 (RCC) on 10/14/21. They acknowledged the findings.  

1.) Mt.Scott will comply with OAR 411-054-0055 (2) reviewal of systems, continual training and management supervision

2.) Medaides to review dashboard with daily shift audit and address any/all "not given" prior to leaving. Should be done during the alst 15 mins of there shift or during shift change.

3.) Daily as needed

4.) All management & Med-aides

Based on observation, interview and record review, it was determined the facility failed to ensure  supportive devices with restraining qualities were assessed by an RN, PT or OT prior to use, the device was service planned, and instruction was provided to caregivers on precautions and correct use of the device for 2 of 2 sampled residents (#s 2 and 6) who had a half-length side rail on their bed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in February of 2019 with diagnoses including schizoaffective disorder.

On 10/12/21 at 11:00 am, Resident 2's bed was observed to have bi-lateral half side rails in the raised position.  

There was no documented evidence the side rails had been assessed by an RN, PT or OT, or evidence CGs had been instructed on precautions and the correct use of the rails. The most current service plan, dated 4/6/21, did not include the use of side rails.

In an interview on 10/14/21 at 10:45 am, Staff 4 (RN) acknowledged an assessment had not been completed, and staff had not been instructed on side rail precautions and their correct use. In interview on on 10/14/21, Staff 1 (Administrator) and Staff 2 (Assistant Administrator) acknowledged the findings.

2. Resident 6 was admitted to the facility in May 2019 with diagnosis including peripheral vascular disease, abnormalities of gait and osteoporosis.

On 10/12/21 at 2:47 pm, a half side rail was observed in the raised position on the right side of the resident's bed.

On 10/13/21 at 10:12 am, a side rail assessment was requested from Staff 3 (RN). She stated there was no assessment of the side rail related to non-use. The side rail was observed in the raised position again on 10/13/21 at 10:17 am.

Resident 6's service plan, dated 6/17/21, was reviewed. There was no information relating to the use of the side rail.

The need to ensure side rails were assessed and added to the resident's service plan with clear caregiving instruction was discussed with Staff 1 (Administrator), Staff 2 (Assistant Administrator), Staff 3 and Staff 4 (RCC) on 10/14/21. They acknowledged the findings.

1.) Mt.Scott will comply with OAR 411-054-0060 Restraints and supportive devices. Please see attached evaluations for side rails for both res. 2 & 6. 2.) see master service plan eval/assessment checklist which has been created to remind reviewal of all potential components on admission and atleast quarterly, or PRN (Master SP file created for RCC and training purposes moving forward for changesto RCC

3.) Upon admmission, quarterly, and PRN

4.) Service planning team: Including the resident (all members of management + RN)   

Based on interview and record review, it was determined the Executive Director failed to have 20 hours of documented Department approved continuing education credits each year. Findings include, but are not limited to:

On 10/13/21 Staff 1 (Administrator) stated that he had not completed any continuing education credits in two years and revealed he did not have the required 20 hours of Division - approved training.

During an interview on 10/14/21, Staff 1 acknowledged he had not completed the required continuing education training.

1.) Mt.Scott will comply with OAR 411-054-0065 (3-4) Admin requirements. Admin will complete quired training hours.

2.) Admin will complete required training hours by the required due date moving forward

3.) As required annually

4.) Administrator

Based on interview and record review, it was determined the facility failed to provide documentation that fire drills included all required components and were conducted every other month and fire life safety training was conducted on alternating months. Findings include, but are not limited to:

Fire and life safety records for February 2021 through June 2021 were reviewed and lacked the following components:

* Alternate escape routes were being used during the fire drills; and

* There was no documented evidence fire life safety training was conducted on alternating months of fire drills.

The need to ensure the facility was in compliance with all required fire drill components and fire and life safety instruction was discussed with Staff 1, Staff 4 (RCC), Staff 10 (Resident Aide - Interpreter) and Staff 12 (Facilities Manager) on 10/13/21 and 10/14/21. They acknowledged the findings.

1.) Mt.Scott will comply with OAR 411-054-0090 (1) (a-d) See attached documents (w/ Tag #)

2.) Implemented Fire safety inservice form,&  monthly following each fire drill maint. will be required to review issues with fire drill an correct issues. and monthly during staff meetings

3.)Monthly during staff meetings and monthly following fire drills

4.) Maintenance, all members of management, & R.N.

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements were conducted according to the Oregon Fire Code (OFC). Findings include but are not limited to:

Fire and life safety records were reviewed on 10/13/21 and revealed the facility lacked documented evidence of fire and life training was provided to residents annually.

The need to ensure all fire drills were conducted in accordance to the OFC and fire and life safety training for all residents was conducted annually was discussed with Staff 10 (Resident Aide - Interpreter) and Staff 12 (Facilities Manager) on 10/13/21. Staff 12 acknowledged the findings.

1.) Mt.Scott will comply with OAR 411-054-0090 (1(e-h) - (2-5) See attached documents (w/ Tag #)

2.) Will be reviewed upon admission and annually there after, or as needed

3.) quarterly during service plan evaluation

4.) Maintenance, all members of management, & R.N.

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

Refer to C 305 and C 510.

1.) Mt. Scott will comply with OAR 411-054-0105 (2-3)

Weekly/ as needed follow up/ follow through from ANY/ALL management staff

2.) Reviewal of follow-up/follow through actions will be addressed during out daily morning management meetings, and any and all issues, and or interventions not currently working to resolve issues can be addressed and approached with alternative means. (See POC for C305 correction to prevent reoccurence.)

3.) (POC C455) Daily during morning management meetings if/when issues arise/ until issues are effectivey resolved then ideally would be as needed

POC C305 Monthly- This will also pop up on the med dashboard under the held/missed medications which is monitored daily by assist. admin

4.) Maintanence personnell, Management, RN, & Med- Aides

Based on observation and interview, it was determined the facility failed to ensure all exterior pathways were made of hard, smooth material and maintained in good repair. Findings include, but are not limited to:

On 10/14/21 at 10:25 am a tour of the facility revealed an uneven exterior concrete pathway, with cracks up to four inches wide, was observed in the front entry courtyard leading to the ramp for entry into the building.

The need for exterior pathways to be made of hard smooth material  maintained in good repair was discussed with Staff 1 (Administrator), Staff 2 (Assistant Administrator) and Staff 3 (RCC) on 10/14/21, they acknowledged the findings.

1.) Mt.Scott will comply with OAR 411-0540200 (3) Temporary repairs already completed, due to time of year once weather allows permanent repairs will follow.

2.) Maintenance to perform daily walk throughs and address such issues with management for how to repair. Employee's report safety concerns/issues on maintanence clip board

3. Daily, as needed. Monthly during our staff meetings and safety committee reviews topics

4.) Maintenance, All employees

Based on observation and interview, it was determined the facility failed to ensure facility grounds were free of litter. This is a repeat citation. Findings include, but are not limited to:

On 01/11/22, a tour of the facility's exterior courtyards and pathways identified the following deficiency:

*Cigarette butts and other garbage littered the porch and walkways of the smoking area.

The need to keep facility grounds orderly and free of litter and refuse was discussed with Staff 1 (Administrator) and Staff 2 (Assistant Administrator) during a tour on 01/12/22. They acknowledged the findings.

1.) Mt. Scott will comply with OAR 411-054-0200 (3) by continuing to monitor the upkeep of the grounds regularly. Facility grounds have been picked up and are free from trash littering the porch and walk ways, and cigarette butts.

2.) We have implemented daily sweeps of the facility grounds to our housekeepers, maintanence man, and all staff

3.) Daily atleast twice in the AM & PM, and as visible trash and or cigarette butts seen by any staff.

4.) All staff, but management will enforce when needed.

Based on observation and interview, it was determined the facility failed to ensure the environment was kept clean and in good repair. Findings include, but are not limited to:

Observations of the facility between 01/11/22 and 01/12/22 revealed the following:

a. Interior

* Carpets throughout the facility in hallways and common areas had black stains in multiple areas:

* Laminate flooring in the common television area had spills on it and was sticky to the touch;

* The floors in the laundry room had areas of exposed sub-flooring where the laminate was missing and damaged making it an un-cleanable surface;

* The ceiling in the hallway, near the exit door to the side porch, was open. The ceiling beams and insulation were exposed. The walls near the open area had new drywall that was not painted; and

* The ceiling above a water fountain in the hallway near room 11 had a brown stain and was buckling and peeling away from the ceiling.

b. Exterior

* The tent on the porch of the smoking area had multiple holes in it;

* Multiple plastic chairs and tables in the smoking area were dirty;  

* The exit door and door frame to the smoking area had chipped paint, black and brown build-up and a hole at the bottom (right side) creating a possible entry for pests.

The environment was toured with Staff 1 (Administrator) on 01/12/22 and the need to maintain all interior and exterior surfaces in clean and good repair was discussed. He acknowledged the findings.

1.) Mt. Scott will comply with OAR 411-054-0200 (4) (d-i) Due to E.O. causing restrictions to regular services such as monthly carpet cleanings from outside vendor will resume in Feburary. Laminate floors are getting waxed and striped to remove the sticky build up. Exposed flooring is being addressed an repaired. The opening in the ceiling has been closed and is being painted and the buckling/stained ceiling will get repaired.

3.) Daily walk throughs Mon - Fri, and review maintaince repair log for reported issues

4.) Maintainence man, All of management

Based on observation and interview, it was determined the facility failed to ensure all doors that exited to the interior courtyards were equipped with operational alarming devices or other acceptable systems to alert staff when residents exited the building. Findings include, but are not limited to:

A tour of the facility on 10/14/21 revealed there were no exit door alarms to alert staff when the doors were opened.  

During interview on 10/14/21 at 2:15 pm, Staff 1 (Administrator), Staff 2 (Assistant Administrator) and Staff 3 (RCC) verified there were no exit door alarms. They acknowledged the findings.

1.) Mt.Scott will comply with OAR 411-054-0200 (11-13) Door alarms will be installed on all exit doors

2.) Continual functioning of alarms checked monthly and as needed by maintenance

3.) Monthly as needed

4.) Maintenance/  Safety Committee/ All employees