The findings of the Change of Ownership survey, conducted 07/18/22 through 07/20/22, 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 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 first revisit to the Change of Ownership survey of 07/20/22, conducted 10/19/22 through 10/20/22,  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 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 second re-visit to the change of ownership survey of 07/20/22, conducted 02/10/23, 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, OARs 411 Division 57 for Memory Care Communities, 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:

Observations were made in the MCC during the survey to determine adherence to universal precautions for infection control.

1. On 07/18/22 at 11:20 am, the surveyor obtained permission and observed a CG provide incontinent care to Resident 3. During the observation, the CG removed the wet brief and placed it on the bathroom floor. Additionally, the CG failed to change gloves after removing the soiled incontinent product and wiping urine from Resident 3's perineum. The CG touched the resident's hands, clothing and clean incontinent brief while wearing the same soiled gloves. After care was completed, the CG removed the gloves.

The above observation was discussed with Staff 1 (ED) and Staff 3 (Assistant ED) on 07/19/22 at 3:15 pm. They acknowledged appropriate infection control practices were not implemented.

2. During the survey, observations of staff and residents were made to determine compliance of proper infection control. On 07/19/22 at 10:23 am, a CG was observed wearing single-use gloves to adjust multiple unsampled residents' clothing, to move adaptive equipment, to transfer another unsampled resident to his/her room and then to deliver the morning snack to the residents. The CG did not change gloves or perform hand hygiene between providing personal care tasks or before delivering the morning snack.

This surveyor requested that the CG remove the soiled gloves and perform hygiene prior to passing food.

The need to ensure the facility exercised reasonable precautions against conditions that could threaten the health, safety or welfare of residents was discussed with Staff 1 (ED) and Staff 3 (Assistant ED) on 07/20/22 at 9:17 am. They acknowledged the findings.

Heritage House of Woodburn will implement the following:

1.All caregivers will be retrained on universal precautions and infection control.

2. Garbage cans have been put in all rooms with garbage bags for staff to place soiled items directly in there. Continued training throughout the year on universal precautions and infection control.

3.Caregivers will be monitored at least three times a week for correct universal precautions and infection control procedures.

Rooms will be checked weekly that trash cans and liners are still in place.

4. Executive Director and Assistant Executive Director will be responsible to seethat the corrections are completed/monitored.  

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:

Observation of the kitchen on 07/18/22 at 10:41 am revealed an accumulation of food spills, splatters, loose food debris, dirt and/or dust on or underneath the following:

* Interior shelving of standing refrigerator/freezer units;

* Exterior sides of standing refrigerators;

* Walls and outlets behind countertops;

* Blender;

* Coffee maker;

* Kettle;

* Baking pans;

* Countertops between standing refrigerators;

* Cabinet doors and shelving throughout the kitchen;

* Drawers throughout the kitchen;

* Floors under counters and near appliances;

* Lighting fixtures;

* Exterior edges of dishwashers;

* Stove vent;

* Control panel of stove; and

* Warming drawer of stove.

Cupboard shelves throughout the kitchen had exposed bare wood edges, and drywall under the microwave was gouged rendering the surfaces uncleanable.

The areas that required cleaning and repair were observed and discussed with Staff 3 (Assistant ED) on 07/19/22 at 1:19 pm. She acknowledged the areas that needed to be cleaned and repaired.

Heritage House of Woodburn will implement the following.

1. Staff retraining on cleaning the kitchen, task sheet made for staff to sign off on. Maintenance will fix areas to ensure all areas are cleanable.

2. Staff will clean spills as they happen, nightly cleaning task sheet to be followed nightly. Maintenance will fix exposed bare wood areas and drywall to ensure they are cleanable.

3. Weekly monitoring will be done.

4. The Assistant ED and/or Executive Director will be responsible for monitoring.

Based on observation, interview and record review, it was determined the facility failed to provide a daily activity program of social and recreational activities based on individual and group interests, physical, mental and psychosocial needs, and create opportunities for active participation in the community at large. Findings include, but are not limited to:

During the survey, the MCC was home to 13 residents.   

Random resident observations made on 07/18/22 and 07/19/22, review of the activity calendar, and interviews with staff revealed the following:

a. The July 2022 Memory Care Activity Program calendar provided during the entrance conference indicated the following activities would occur on 07/18/22:

* "Coffee & News;

* Daily Chronicle;

* Bake muffins;

* Puzzles; and

* Jeopardy on TV."

On 07/18/22, the only activity observed occurred at 10:00 am with one resident coloring at the dining table. Although music and television played sporadically, no other activities were observed between 9:30 am and 3:30 pm. Residents sat for long periods of time during waking hours in the common areas, outside or in their rooms with no activity.

b. On 07/19/22, the activity calendar noted the following activities would occur:

* "AM Exercise;

* Finish the line;

* Bingo;

* Gardening; and

* Write Cards."

The only activities observed between 8:30 am - 3:30 pm were "AM Exercise" and "Finish the line" between 10:20 am and 11:00 am. Music and television played, but no other activities were observed.

In an interview with a family member on 07/19/22, he stated he received a flyer in the mail for scheduled activities in May and believed he would get a flyer monthly. He had not received any additional activity flyers. He stated he visited often and had not seen any activities except for on 07/19/22.

Failure to provide a daily activity program of social and recreational activities based on individual and group interests, physical, mental and psychosocial needs, and create opportunities for active participation in the community at large was discussed with Staff 1 (ED) and Staff 3 (Assistant ED) on 07/19/22 at 3:15 pm. Staff 1 stated the facility scheduled a caregiver to conduct activities from 1:00 pm to 5:00 pm daily. However, if the facility had a "call out", then that person was pulled from activities to provide care. She added "it's a work in progress." Both acknowledged the lack of activities in the MCC.

Heritage House of Salem will implement the following:

1. Each resident's evaluation will include:

(i) Past and current interests;

(ii) Current abilities and skills;

(iii) Emotional and social needs and patterns;

(iv) Physical abilities and limitations;

(v) Adaptations necessary for the resident to participate; and

(vi) Identification of activities for behavioral interventions

2. Activity calendar will specify the time of day that the primary activities will take place. Additional activities, to be done as time allows, and will be listed as well.

3. An individual activity plan will be included in the evaluation.

4. The Universal Caregivers will be responsible for ensuring that the activities are done.

5. The Universal Caregivers will be responsible for completing the activity log and specifying who participated and who refused participation.

6. If the none of the Universal Caregivers are able to lead the activity due to emergency, resident care, etc. they will notify the Executive Director, Assistant Executive Director and/or designated supervisor so that they can arrange for coverage and/or perform the activity.

7. All staff will be trained at the next in-service on the new procedures for implementing and tracking activities.

8.The Executive Director  and/or Assistant Executive Director will be responsible for reviewing the activity logs weekly.

3. Resident 3 was admitted to the MCC in 07/2019 with diagnoses which included dementia.

Interviews with care staff and observations of Resident 3 during the survey revealed s/he was incontinent, dependent on staff for ADL care, did not use a call light to summon assistance, had ½ bilateral side rails, was on a pureed diet and needed meal assistance.

Resident 3's service plan, dated 04/23/22, revealed it was not reflective of the resident's needs and lacked clear direction regarding the delivery of services in the following areas:

* Ability to communicate;

* Phone use;

* Independent ambulation;

* Television use;

* Use of fall mat;

* Meal assistance;

* Side rail use;

* Dining chair with arms;

* Bowel and bladder incontinence;

* Use of barrier creams;

* Use of grab bars in bathroom;

* Bed placement; and

* Crushed medications.

The need to ensure the service plan was reflective of Resident 3's current care needs and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 3 (Assistant ED) on 07/19/22 at 2:10 pm. 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 residents' current care needs, provided clear direction to staff regarding the delivery of service and followed for 3 of 3 sampled residents (#s 1, 2 and 3) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 09/2019 with diagnoses including dementia. Resident 2 was observed in bed most of the time and relied on staff for all ADL care.

Observations of the resident, interviews with staff, review of the current service plan and clinical records during the survey, from 04/30/22 through 07/13/22, revealed Resident 2's service plan was not reflective of his/her status, did not provide specific directions to staff, and staff did not follow the plan in the following areas:

* Use of a cushion;

* Use of catheter;

* Diet status;

* Vision status;

* Outside provider status; and

* Wound status on coccyx area.

On 07/20/22, the service plan was discussed with Staff 1 (ED) and Staff 3 (Assistant ED). They acknowledged the service plan was not reflective of the resident's status, did not provide clear direction and staff did not follow the plan.

2. Resident 1 was admitted to the facility in 03/2020 with diagnoses including Alzheimer's dementia.

Review of the most current service plan dated 06/10/22 and observations and interviews conducted between 07/18/22 and 07/20/22, revealed Resident 1's service plan was not reflective, did not provide clear instruction to staff and/or was not followed in the following areas:  

* Sleeping routine;

* Bathing;

* Toileting;

* Dressing;

* Grooming/Hygiene;

* Food preferences;

* Communication;

* Communication assistive devices;

* Medications;

* Fall History; and

* Evacuation status.

The need to ensure service plans were reflective of the identified needs and preferences of the resident, provided clear direction to staff and were followed by staff was discussed with Staff 3 (Assistant ED) on 07/19/22 at 1:49 pm. She acknowledged the findings.

Heritage House of Woodburn will implement the following:

1. All residents assessments/evals and service plans will be entered into our new system, Point Click Care utilizing the new assessment/evaluation form that addresses all necessary requirements of the OAR's.

2. Caregivers will be responsible for reviewing, signing and following the care plans. They will also be trained on signing off on the tasks after they've completed them.

3. All staff will receive additional training at the next in-service on how to read the care plans and to notify management if any of the residents care needs have changed.

4. Task Manager will be implemented by September 18th.

5. The Executive Director and/or Nurse will review and monitor to ensure that the care plans are being reviewed and signed and that the proper care is being delivered. The Executive Director and/or Assistant Executive Director will pull reports to ensure that tasks are signed off on each week

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

Resident 1 and 2's clinical records and service plans were reviewed during the survey. There was no documented evidence the service plans were developed by a Service Planning Team.

During an interview with a member of Resident 1's family, conducted on 07/19/22 at 2:04 pm, it was reported that s/he had not been involved in a service plan review meeting and did not receive a copy of the service plan.

On 07/19/22 and 07/20/22, the facility's system for ensuring resident service plans were developed by a service planning team was discussed with Staff 1 (ED) and Staff 3 (Assistant ED). They acknowledged the findings.

Heritage House of Woodburn will implement the following:

1. Careplan review letters will be sent out to POA/Guardian, case manager as applicable, to meet to review careplans every 90days and as needed.

2. Executive Director and/or Assistant Executive director will send out invitation letter at least two weeks prior to meeting date.

3. Executive Director and/or assistant Executive director will evaluate monthly for the following month.

4. Executive Director and/or Assistant Executive Director will be responsible to see that correction is completed and monitored.  

2. Resident 3 was admitted to the MCC in 07/2019, was on hospice services, and had a history of falls.

Resident 3's clinical record and progress notes, reviewed from 04/06/22 through 07/18/22, revealed the following:

a. Resident 3 started a new medication on 04/21/22. The facility initiated short-term monitoring the same day. However, no monitoring until resolution was documented for the short-term change in condition.

b. The resident fell on 04/08/22, 04/20/22, 05/16/22 and 05/29/22. Review of the record revealed no documented evidence the facility monitored and documented on the progress of the resident's condition at least weekly until resolved. Additionally, the facility failed to consistently evaluate if service-planned interventions were implemented, were effective, or if new interventions were needed.

c. Resident 3 sustained minor injuries when s/he fell on 05/16/22 and 05/29/22. There was no documented monitoring of the injuries until resolution.

Additional information was requested on 07/19/22.

On 07/19/22 at 3:15 pm, Staff 1 (ED) and Staff 3 (Assistant ED) reported they reviewed the resident's record and concluded the short-term changes in condition had not been monitored until resolved, and the facility failed to consistently evaluate if service-planned interventions for falls were implemented, were effective, or if new interventions were needed. No further information was provided.

Based on interview and record review, it was determined the facility failed to monitor and evaluate for falls and document weekly progress until the condition resolved for 2 of 2 sampled residents (#s 2 and 3) reviewed for change of conditions. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 09/2019 with diagnoses including dementia.

Resident 2's clinical records were reviewed during the survey and revealed the following:

* 05/06/22 - New dose of Trazodone (medication to treat depression);

* 06/03/22 - Received a COVID booster injection; and

* 06/07/22 - New dose of Trazodone.

There was no documented evidence the resident's changes of condition were monitored, at least weekly, through resolution.

On 07/19/22 and 07/20/22, the above information was shared with Staff 1 (ED) and Staff 3 (Assistant ED). They acknowledged the findings.

Heritage House of Woodburn will implement the following:

1. All residents will be placed on alert charting for any changes in conditions, medications or incidents. Monitoring will continue each shift until resolved and closed by Executive Director or nurse.

2. Executive Director and Assistant Executive Director will both check that alert chartings were opened with all new orders, incidents and changes in condition. The Executive Director and Nurse will close alerts when resolved.

3. Executive director and/or Assistant Executive Director will check at least three times a week  that staff are completing alert charting each shift.

4. Executive Director and Assistant Executive Director will be responsible to see that the corrections are completed and monitored.  

3. Resident 3 was admitted in 07/2019 with diagnoses which included dementia and received a pureed diet during the survey.

In an interview with Staff 6 (Med Aide) on 07/19/22 at 1:30 pm, she stated staff crushed Resident 3's medications prior to administering them to him/her.

Review of the clinical record revealed no physician order authorizing staff to crush the medications.

In an interview on 07/19/22 at 3:10 pm, Staff 1 (ED) and Staff 3 (Assistant ED) confirmed the facility had no order to crush Resident 3's medications. Staff 1 stated they would contact the physician to obtain an order.

Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 3 of 3 sampled residents (#s 1, 2 and 3) whose orders were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 09/2019 with diagnoses including dementia.

a. Resident 2 had a physician's order, dated 06/03/22, to administer Milk of Magnesia 30 ml orally if there was no bowel movement in three days.

Resident 2's 07/01/22 through 07/18/22 bowel record was reviewed and revealed the resident had no bowel movement from 07/04/22 to 07/09/22 (six days).

Resident 2's 07/01/22 through 07/18/22 MAR revealed the medication was not administered on those days as ordered.

b. Resident 2's 06/03/22 physician orders and 07/01/22 through 07/18/22 MAR were reviewed during the survey. The following prescribed medications were not administered as prescribed on 07/13/22:

* Ativan 0.25 mg daily to treat anxiety.

On 07/19/22 and 07/20/22, the above findings were shared with Staff 1 (ED) and Staff 3 (Assistant ED). They acknowledged the findings.

2. Resident 1 was admitted to the facility in 03/2020 with diagnoses including Alzheimer's dementia.

Resident 1's MARs dated 07/01/22 through 07/18/22 and current physician's orders were reviewed and revealed the following:

a. Resident 1 had a physician's order for lorazepam (for anxiety) 1 mg tablet by mouth every eight hours as needed for severe agitation.

b. Lorazepam was administered three times between 07/01/22 and 07/18/22 in the following doses:

* 07/05/22 - .25 mg for shower;

* 07/09/22 - .50 mg for shower; and

* 07/12/22 - .25 mg for shower.

The need to ensure that medication orders were carried out as prescribed was discussed with Staff 3 (Assistant ED) on 07/19/22 at 1:49 pm. She acknowledged the findings.

Heritage House of Woodburn will implement the following:

1. Retraining of med caregiver, 1:1 training by Executive Director and Assitant Executive Director with emphasis on, following MARS, monitoring bowel records and giving PRN as directed as well as double checking dosages and notifying Executive Director and/or Assistant Executive Director of any issues taking/swollowing meds.

2. All med caregivers are being retrained 1:1 with Executive Director and/or Assistant Executive director and group training with Nurse.

3. Assistant Executive Director will do MAR audits at least twice a week to check orders are being followed and follow up as needed.

4. Executive Director and/or Assistant Executive Director are responsible to see that the corrections are completed/monitored.

2. Resident 2 was admitted to the facility in 09/2019 with diagnoses including dementia.

Resident 2's record indicated s/he had an order for Ativan for "agitation and anxiety" as needed.

Resident 2's 07/01/22 through 07/18/22 MAR was reviewed during the survey and revealed the following:

* The as needed Ativan was administered on one occasion, 07/07/22; and

* No documented evidence non-drug interventions had been attempted with ineffective results prior to administering the medication.

On 07/19/22 and 07/20/22 Resident 2's record was reviewed with Staff 1 (ED) and Staff 3 (Assistant ED) who acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure PRN psychotropic medications used to treat a resident's behavior had resident specific parameters and staff documented that non-pharmacological interventions had been tried with ineffective results prior to administering the medications for 2 of 2 sampled residents (#s 1 and 2) who were prescribed PRN psychotropic medications. Findings include, but are not limited to:

1. Resident 1 moved into the facility in 03/2020 with diagnoses including Alzheimer's dementia.

Review of the resident's service plan, physician's orders and 07/01/22 through 07/18/22 MARs revealed the following:  

Resident 1 was prescribed lorazepam 1 mg (for anxiety) one tablet every eight hours PRN for severe agitation.

The facility failed to ensure the resident's MARs and clinical record included the following required information:

* Resident specific parameters regarding use of lorazepam for showers; and

* Staff administered the PRN lorazepam on three occasions for showers without documentation that non-pharmacological interventions were attempted prior to administration of the medication.

The need to ensure the required information for PRN psychotropic medications was documented in the MARs or clinical record was discussed with Staff 3 (Assistant ED) on 07/19/22 at 1:49 pm. She acknowledged the findings. No further documentation was provided.

Heritage House of Woodburn will implement the following:

1. Retraining of med caregivers, 1:1 training by Executive Director and Assitant Executive Director with emphasis on, following PRN parameters and trying and documenting alternatives tried before giving PRN.

2. All med caregivers being retrained 1:1 with Executive Director and/or Assistant Executive director and group training with Nurse.

3. Assistant Executive Director will do MAR audits at least twice a week to check orders are being followed and follow up as needed.

4. Executive Director and/or Assistant Executive Director are responsible to see that the corrections are completed/monitored.

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

Fire drills and fire and life safety training records for the previous six months were requested during the survey.

Review of the documentation provided identified the following:

* There was no documented evidence fire and life safety instruction to staff was provided every other month.

On 07/19/22 and 07/20/22, the requirement regarding fire and life safety instruction for staff was reviewed with Staff 1 (ED) and Staff 3 (Assistant ED). They acknowledged the findings.

Heritage House of Woodburn will implement the following:

1. Individual fire life safety trainings have been completed with all employees.

2.Fire life training will be completed every other month at monthly staff meeting by the Executive Director and/or Assistant Executive Director.

3. Executive Director and /or Assistant Executive Director will evaluate monthly that fire life safety trainings are being completed every other month alternating with the fire drills.

4. Executive Director and Assistant Executive Director will be responsible to see the corrections are completed and monitored.  

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

Refer to C513.

Heritage House of Woodburn will implement the following:

1.Executive Director will fill out an exception if we are not in compliance of our compliance date.

2.Executive Director will monitor and make sure compliance is being completed by compliance date.

3.Correction will be evaluated weekly.

4.Executive Director will be responsible of making sure corrections are in compliance of the date.

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

Observations of the facility on 07/18/22 and 07/19/22 revealed the following:

* The common bathroom (near Room 6) had a broken towel rod, and the edge of the door had scraped areas;

* Room 6 had a scraped door;

* The television room carpet had several large red stains. A white loveseat had stains, food matter and urine odors on the cushions;

* Cushions of a green loveseat in the piano room had a urine odor;  

* The outdoor patio furniture had several tears in multiple cushions;

* Carpet in Room 11 had multiple stains throughout; and

* Room 2 had a urine odor and a broken toilet paper holder with no toilet paper available.

The surveyor toured the environment with Staff 3 (Assistant ED) on 07/19/22 at 12:25 pm. She acknowledged the findings.

Heritage House of Woodburn will implement the following:

1. Maintenance will replace the toilet paper holder in room 2, the towel rod in the shower room, outdoor patio furniture cushions will be replaced, carpets, recliners and loveseats will be cleaned and areas replaced if unable to be cleaned. Doors and framing scratched will be painted.

2. Will use chair pads on furniture to change out and wash frequently. Maintenance will do monthly walk through to check for scratches and touch up painting. Executive Director and Assistant Executive Director will do weekly walk through to monitor for any environmental concerns. Staff will notify Executive DIrector and Assistant Executive Director of any environmental concerns right away when found.

3. Weekly monitorning of the environment will be completed.

4. Executive Director and Assistant Executive Director will be responsible to ensure corrections are completed and monitored.

Based on observation, interview and record review, it was determined the facility failed to ensure the environment was maintained in clean and good repair. This is a repeat citation. Findings include, but are not limited to:

Observations of the facility on 10/19/22 and 10/20/22 revealed the following:

The carpet in the living room, hallways and resident rooms 8 and 9 had multiple areas of dark and light discoloration and stains.

The surveyor discussed the carpet with Staff 1 (Administrator) and Staff 2 (Assistant ED) on 10/19/22 and 10/20/22. They acknowledged the findings and stated the carpet was scheduled to be replaced.

Heritage House of Woodburn will implement the following:

1. Carpets will be cleaned or replaced if carpet is unable to get cleaned. New Patio furniture will be ordered and comply with weight regulations to prevent residents from picking up or use to elope.

2. Maintenance will do monthly walk throughs and Executive Director will do weekly walk throughs to monitor the carpets for any stains or smells. Will make sure patio furniture still comply with weighted regulations  

3. Executive Director will be responsible in making sure corrections is implemented.

4. Regional will be responsible to ensure 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 C 160, C 240, C 242, C 420 and C 513.

Refer to C160, C240, C242, C,420 and C515

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 C513.

Refer to C 513  

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 C 260, C 262, C 270, C 303 and C 330.

Refer to C260, C262, C270, C303 and C330

Based on observation and interview, it was determined the facility failed to ensure furniture in the outdoor recreation area was of sufficient weight and design and maintained to prevent resident injury or aid in elopement. Findings include, but are not limited to:

On 10/19/22 and 10/20/22, observations of the facility's outdoor area revealed the following:

Furniture in the outdoor recreation area was not of sufficient weight. Several patio chairs had been modified with 10 pound dumbbell/hand weights, attached underneath the seat and on the back of the chairs. The weights were attached to the chairs with utility tape and metal brackets (underneath the utility tape) which had sharp metal edges and exposed screws and hardware.  

The need to ensure furniture in the outdoor recreation area was of sufficient weight and design and maintained to prevent resident injury was discussed with Staff 1 (Administrator) and Staff 2 (ED in training) on 10/20/22. They acknowledged the findings.

Refer to C 513

Based on observation and interview, it was determined the facility failed to individually identify residents' rooms to assist residents in recognizing their room. Findings include, but are not limited to:

The MCC was toured on 07/18/22 and 07/19/22. Resident rooms 6, 9 and 10 lacked any means of identifying the rooms for the residents. All of these residents had resided in the facility for more than four weeks.

The need to ensure each resident room was identified to assist the resident was reviewed with Staff 3 (Assistant ED) on 07/19/22. She acknowledged the findings.

Heritage House of Woodburn will implement the following:

1. All resident rooms will have identifier posted.

2. Executive Director and/or Assistant Executive Director will check weekly that all room identifiers are still posted for each room.

3. Weekly walk through to evaluate posting is in place.

4. Executive Director and/or Assistant Executive Director is responsible to ensure correction is completed and monitored.