The findings of the relicensure survey, conducted 03/28/22 through 03/31/22, 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 OARs 411 Division 004 for Home and Community Based Services Regulations.

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 re-visit to the initial survey of 03/31/22, conducted 10/31/22, 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.

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 initial survey of 03/31/22, conducted 04/14/23, 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 and OARs 411 Division 004 Home and Community Based Services Regulations.

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

Observations of the kitchen on 03/29/22 identified the following:  

*Multiple shelves, cupboards, and drawers in the kitchen were in need of clean and repair as a result of paint and finish being worn off to bare wood; and

*Facility staff was emptying flour and sugar in drawers, not in the original container or in a food safe container.

On 03/29/22, the need to ensure the facility kitchen was clean and in good repair and followed safe food handling practices was discussed with Staff 1 (Administrator) and Staff 2 (Food Service Coordinator). They acknowledged the findings.

To clean & repaint the exposed surfaces with upgraded Kitchen grade non-porous cleanable paint to cover all wood surfaces and ensure that a revised daily cleaning schedule is being monitored and followed.  

In addition, flour and sugar bags were updated at the time of survey and we continue to use the approved system for storage of these items.

Food Service Coordinator and/or Administrator will be responsible for monitoring of these actions.

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

During a tour of the environment on 10/31/22, drips, spills, splatters, and food matter were observed in/on multiple cabinet faces and in drawers. Multiple shelves had missing pieces of laminate with raw wood exposed.

On 10/31/22, the need to ensure the facility kitchen was clean and in good repair was discussed with Staff 12 (Interim Administrator) and Staff 10 (Team Lead/RCC). They acknowledged the findings.

OAR 411-054-0030 reviewed by Food Service Coordinator, Team lead/RCC and/or Administrator/Chief Operating Officer (COO). The CBC Annual Kitchen Inspection Power Point training and OAR was given to the Food Service Coordinator to review/educate self/kitchen staff on the requirements. The self-paced training will be completed by 12/15/22. The drips, spills, splatters and food matters on the cabinet faces and in drawers were cleaned on 11/1/22. They continue to be cleaned daily. The Food Service Coordinator has put together a new cleaning task sheet with specific days and shifts for tasks to be completed. The cleaning sheet is inspected for completeness by the Food Service Coordinator. All exposed wood on the cabinets will be sealed and/or laminate trim applied for high traffic surfaces. The COO will ensure the sealant and trim is completed by 12/15/22. Random weekly inspections will be conducted for cleanliness of the kitchen and task list completion. Food Service Coordinator,Team lead/RCC and/or Administrator are responsible for monitoring the cleanliness of the kitchen and task list completion by staff.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required components, were being conducted in person, and were dated with who was involved in the evaluation process, for 1 of 1 sampled resident (#1) who had recently moved in. Findings include, but are not limited to:

Resident 1 was admitted to the facility in March 2022.

1. Resident 1's move-in evaluation failed to address the following required components:

* Customary routines: eating and bathing;

* Spiritual, cultural preferences and traditions;

* List of current diagnoses;

* List of medications and PRN use;

* Visits to health practitioner(s), ER, hospital, and/or NF in the past year;

* Vital signs if indicated by diagnosis, health problems, or medications;

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

* Nutrition habits, fluid preferences & weight if indicated;

* List of treatments;

* Indicators of nursing needs including potential for delegated  nursing tasks;

* Complex medication regimen;

* History of dehydration or unexplained weight loss or gain; and

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

2. In an interview with Staff 1 (Administrator) and Staff 11 (RN), it was reported the move-in evaluation was not conducted in person.

3. The move-in evaluation failed to have documented evidence of who was involved in the evaluation process and date.

On 03/30/22, the need to ensure new move-in evaluations included all required topics, were conducted in person, and were dated with who was involved in the evaluation process was discussed with Staff 1 and Staff 11. They acknowledged the findings.

1.To address the following required components of all future Residents upon move-in evaluation Administrator will fill out every answer space on the evaluation/service planning evaluation form already being used. In addition, updating this form with all issues cited to be sure the correct and needed information is gathered in completion while working closely with the Facility RN.

2.  Administrator and Facility RN will perform ALL new Resident's evaluation/assessment in person.

3.  An additional information sheet has been added to our evaluation packet to include date of evaluation, location of evaluation and names/signatures of all involved in the evaluation.  

Administrator with assistance from Facility RN will be responsible to see that these changes are implemented.   

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 (4) whose facility records were reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 4's new move-in evaluation did not address the following elements:

* Visits to health practitioner(s), ER, hospital, and/or NF in the past year;

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

* Mental health: History of treatment and effective non-drug interventions;

* Communication: Ability to understand and be understood and speech;

* Pain;

* Nutrition habits, fluid preferences & weight if indicated;

* History of dehydration or unexplained weight loss or gain; and

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

The need to ensure new move-in evaluations addressed all required elements was discussed with Staff 12 (Interim Administrator) and Staff 10 (Team Lead/RCC) and Staff 13 (Chief Operating Officer) on 10/31/22.  They acknowledged the findings.

OAR 411-054-0034 has been reviewed by Team lead/RCC/Administrator/RN. The move-in evaluation has been updated to address all the requirements in the OAR.  

The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations.

The evaluation worksheet was reviewed and updated.

Added sections to address:

Visits to health practitioner(s), ER, hospital, and/or NF in the past year; Personality including how the person copes with change or challenging situations; Mental health: History of treatment and effective non-drug interventions; Communication: Ability to understand and be understood by others and speech; Pain; Nutrition habits, fluid preferences & weight if indicated; History of dehydration or unexplained weight loss or gain: and Environmental factors that impact the resident's behavior including, but not limited to: noise, lighting, and room temperature. These changes have been completed on 11/7/22 and updated on 11/21/22.   

Team lead/RCC/Administrator/RN will be responsible for oversight each year for changing OAR requirements.

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

1. Resident 1 was admitted to the facility in March 2022 with diagnoses including history of Cerebrovascular accident.

In an interview with the Staff 1(Administrator) and Staff 11(RN) on 3/28/22, it was reported that outside providers were coming into the facility and providing home health services for physical therapy and occupational therapy.

The service plan, dated 03/07/22, failed to include a written description of what services home health would provide and when, how, and how often the services would be provided to the resident.

2. Resident 2 was admitted to the facility in March 2021 with diagnoses including COPD.

In an interview with Staff 8 (Universal Worker), it was reported the facility staff assisted the resident with a portable oxygen concentrator when going to meals in the dining room.

The service plan failed to provide clear direction and instruction to staff on how to operate the oxygen concentrator.

On 03/30/22, the need to ensure service plans were reflective of the residents' current care needs and included clear direction to staff was discussed with Staff 1 and Staff 11. They acknowledged the findings.

1. Service plan for Resident #1 has been updated with the information surrounding his additional services that home health is providing, when and how often the services are to be provided.  A separate area for additional services/equipment has been added to the evaluation form and service plan form to be sure that these services are included/reported.  Additional plan in place to receive direct intake information from these outside services.

2. Service plan for Resident #2 has been updated to give clear direction and instruction to staff on how to operate both the oxygen concentrator (room) and portable oxygen concentrator, as well as portable manual tanks.  A separate area for additional services/equipment has been added to the evaluation form and service plan form to be sure that these instructions are included.   

Administrator with assistance from Facility RN will be responsible to add and continue these two areas of evaluation & service plans.   

Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 1 of 1 sampled resident (#2) whose MARs and Controlled Substance Disposition logs were reviewed. Findings include, but are not limited to:

Resident 2 was admitted to the facility in April 2013. Resident 2 had signed physician orders for PRN oxycodone 10/325 mg as needed for pain.

Resident 2's Controlled Substance Disposition logs and MARS were reviewed from 3/1/22 - 3/28/22. The following deficiencies were identified:

* A 3/24/22 dose of oxycodone was documented as being removed from storage on the disposition log but was not documented as being administered on the MAR; and

* A 3/25/21 dose of oxycodone was documented as being removed from storage on the disposition log but was not documented as being administered on the MAR.

On 3/30/22, the need to ensure the narcotic disposition log and MAR were maintained and reflective for all controlled substances was discussed with Staff 1 (Administrator) and Staff 11 (RN). She acknowledged the findings.

All correct framework exists for this deficiency to be identified and corrected.  First action will be remedial training for entire medication staff and include specifically PRN medications, administration, & documentation.   Second action will be to have an additional set of eyes at shift change to review MAR/TAR at the completion of each shift prior to previous staff leaving facility.

Administrator with aide of Facility RN and newly appointed Medication Coordinator will be responsible for oversight.    

Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 1 of 1 sampled resident (#2 ) whose MARs and Controlled Substance Disposition logs were reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 2 was admitted to the facility in April 2013.

Resident 2 had signed physician orders to receive oxycodone PRN and scheduled for pain.

Resident 2's Controlled Substance Disposition logs and MARS were reviewed from 10/01/22-10/31/22. The facility administered scheduled and PRN medications from the same card. The following deficiencies were identified:

* On 10/10/22, 10/28/22, 10/29/22,  oxycodone was documented as being removed from narcotic disposition log but was not documented as being administered on the MAR;

* On 10/12/22, oxycodone was documented as administered on the MAR, but not on the narcotic disposition log; and

* On 10/19/22: Five doses of oxycodone were documented as administered on the disposition log, but only four were initialed on the MAR.

On 10/31/22, the need to ensure the narcotic disposition log and MAR were maintained and reflective for all controlled substances was discussed with Staff 12 (Interim Administrator) and Staff 10 (Team Lead/RCC) and Staff 13 (Chief Operating Officer). They acknowledged the findings.

Facility RN given the OAR 411-054-0055 to review. Administrator had discussion with facility RN about the OAR cited to ensure staff training is completed with staff about all PRN medications that are given must be documented properly. On 11/14/22 remedial training was completed with staff who pass medications at an in-service. A 12 week safe medication administration training will take place weekly starting 12/8/22 that includes safe/accurate PRN and controlled medication administration (to be included by 12/15/22). Additional training through Relias (online training program) is assigned to staff whose job duty is to administer medications to complete by 12/15/22. The RN will provide oversite and support for staff that provide medication administration and check the narcotic log and MARs while onsite.

Starting 11/1/22, one staff member is counting out, the staff member coming on will also go over the MAR to ensure that we have initials, and any PRN's have follow ups. They will also check the narcotic disposition log and compare to the MAR and orders to ensure they are correct. Off going staff will not leave until all discrepancies are corrected and if unable to do so will call the designee in charge. Team lead/RR/ Administrator/RN will be responsible for oversight. RN is responsible to clarify PRN orders and monitor staff for proper medication administration weekly.    

Based on interview and record review, it was determined the facility failed to ensure signed provider orders were documented in resident's records for all medications the facility administered for 1 of 2 sampled residents (#1) whose orders were reviewed. Findings include, but are not limited to:

Resident 1's physician orders and the 03/01/22 through 03/28/22 MAR were reviewed.

The MAR indicated the facility had administered routine prednisone 20 mg on 03/27/22 and 03/28/22. There was no written, signed physician order in the resident's record for the medication.

On 03/30/22, the need to ensure physicians orders were documented in the resident record was discussed with Staff 1 (Administrator) and Staff 11 (RN). They acknowledged the findings.

This deficiency was created by a system not in place between ER and WCT when resident was sent home with medication from hospital dispensary.  The order was received prior to the end of survey.  In addition, contact has been made with Pioneer Memorial Hospital/ER CEO to put forms for orders to be filled out by ER physician to return to facility with Resident any time medication is ordered and sent home from their pharmacy and they are to no longer be hand written on release paperwork from ER.  

Administrator with aide of Facility RN and newly appointed Medication Coordinator will be responsible for oversight.    

Based on interview and record review, it was determined the facility failed to ensure residents' MARs were accurate for 2 of 2 sampled residents (#s 1 and 2) whose MARs were reviewed. Findings include, but are not limited to:

1. Review of Resident 1's 03/01/22 through 03/28/22 MAR, identified the following deficiencies:

* Prednisone 20 mg, once daily, failed to identify reason for usage;

* PRN Kaopectate 1 oz and PRN Milk of Magnesia 1 oz failed to identify route of administration;

* PRN Mylanta 1 oz was administered on 03/13/22. The facility failed to document the effectiveness of the PRN administration; and

* PRN Tylenol 325 mg was administered on 03/26/22. The facility failed to document time, reason, or effectiveness of the PRN administration.

2. Review of Resident 2's 03/01/22 through 03/28/22 MAR, identified the following deficiencies:

* Senna Plus, twice daily, lacked reason for use; and

* Potassium CHL 20 mg, once daily, lacked reason for use.

On 03/30/22, the need to ensure residents' MARs were accurate was discussed with Staff 1 (Administrator) and Staff 11 (RN). They acknowledged the findings.

All correct framework exists for this deficiency to be identified and corrected.  First action was to update all required information on the current/upcoming MAR/TAR that was completed by end of survey.  Second action will be remedial training for entire medication staff and include specifically PRN medications, administration, & documentation with correct and full entry onto MAR/TAR   Finally, having an additional set of eyes to review all MAR/TAR to confirm all entries are correct in entry and information.   

Administrator with aide of Facility RN and newly appointed Medication Coordinator will be responsible for oversight.    

Based on interview and record review, the facility failed to have specific parameters for staff administering PRN medications for 1 of 2 sample residents (#4) whose records were reviewed. This is a repeat citations. Findings include, but not limited to:

Residents 4's physician orders and MARs were reviewed from 10/2/22 through 10/22/22 and revealed the following:

The resident had orders for PRN Tylenol 325 mg by mouth four time a day for pain, and oxycodone 10/325 by mouth one time a day for pain. There were no directions for unlicensed staff which pain medication to administer first.

The need to ensure there were clear parameters for staff when administering multiple PRN medications for the same condition was discussed with Staff 12 (Interim Administrator),  Staff 10 (Team Lead/RCC) and Staff 13 (Chief Operating Officer) on 10/3122.  They acknowledged the findings.

Facility RN given the OAR 411-054-0055 to review. Administrator had discussion with facility RN about the OAR cited to ensure all PRN medications are clarified. When a resident has a duplicated PRN the RN will clarify the order on the MAR.

On 11/14/22 remedial training was completed with staff who pass medications at an in-service with the facility RN and Administrator. A 12 week safe medication administration training will take place weekly starting 12/8/22 that includes safe/accurate PRN (to be included by 12/15/22). Additional training through Relias (online training program) is assigned to staff whose job duty is to administer medications to complete by 12/15/22.

The RN will provide oversite and support for staff that provide medication administration and check the PRN medications and follow-up while on site.  

Starting 11/1/22, one staff member is counting out, the staff member coming on will also go over the MAR to ensure that staff initials are present, and any PRN's have follow ups. Off going staff will not leave until all discrepancies are corrected and if unable to do so will call the designee in charge.

Team lead/RR; Administrator/RN will be responsible for oversight.

RN is responsible to clarify PRN orders weekly.  

Based on interview and record review, it was determined the facility failed to ensure 1 of 1 newly hired staff (#7) had demonstrated competency in all required areas within 30 days of hire. Findings include, but are not limited to:

Review of the facility's training records on 03/20/22 indicated Staff 7 (Universal Worker) lacked documented evidence of demonstrated competency in:

*Role of service plans in providing individualized care;

*Providing assistance with ADL's;

*Changes associated with normal aging;

*Identification, documentation and reporting of changes of condition;

*Conditions that require assessment, treatment, observation and reporting;

*General food safety, serving and sanitation; and

*Other duties as applicable (Medication and Treatment Pass).

On 03/29/22, the need to ensure staff had documented evidence of competency demonstration in assigned duties, within 30 days of their hire date, was discussed with Staff 1 (Administrator) She acknowledged the findings.

Noted Universal Worker's documentation was completed prior to the end of survey.  

This area of deficiency is being addressed by creation of new hire tracking/sign off sheet and a more aggressive detailed 30-day training plan.  Weekly review and sign off for competency will be required from the new hire's FTA/KTA (Floor Training Associate/Kitchen Training Associate).  

Administrator with aide of newly appointed Training Coordinator will be responsible for oversight.    

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 sampled newly-hired staff (#s 14, 15 and 17) completed all required training within 30 days of hire. This is a repeat citation. Findings include, but are not limited to:

Staff training records were reviewed with Staff 10 (Team Lead/RCC) on 10/31/22.

The following deficiencies were identified:

Staff 14 (Universal Worker), hired on 8/2/22, Staff 15, Universal Worker, hired on 8/12/22, and Staff 17, Universal Worker, hired on 8/22/22, lacked documented evidence of demonstrated competency in the following areas within 30 days of hire:

* Changes associated with normal aging;

* Identification of changes in the resident's physical; emotional and mental functioning and documentation and reporting on the resident's changes of condition.

* Conditions that require assessment, treatment, observation and reporting;

* General food safety, serving and sanitation; and

* Trained in the use of the abdominal thrust and First Aid.

The need to ensure documentation of competency and Fist Aid training within 30 days of hire was reviewed Staff 12 (Interim Administrator) and Staff 10 (Team Lead/RCC) and Staff 13 (Chief Operating Officer) on 10/31/22. They reported they would address the lacking competencies, and ensure training completion timely in the future.

The training requirements in OAR 411-054-0070. A training spreadsheet is being created to track all of the staff training requirements. This spreadsheet will include the training requirements, due dates, and date of completion. All new hires will be added the spreadsheet to track. A record of all required staff training will be kept in their file. Employee's training will be inspected each month for completion. Training will include, online, in person and self-paced models.

Employees will be given their personal yearly education/training plans with instructions on how to complete and the due dates.

All employee training will be in compliance by 12/15/22.  

The team lead/RCC/Administrator and RN will ensure all required training will be completed within the time frame allowed.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 long-term staff (#s 4 and 5) completed the required minimum 12 hours of in-service training annually. Findings include, but are not limited to:

Staff training records were reviewed on 03/29/22.

There was no documented evidence Staff 4 (Universal Worker), hired 03/18/20, and Staff 5 (Universal Worker), hired 11/20/20, had completed a minimum of 12 hours of annual in-service training related to the provision of care, at least six of which needed to relate to dementia care.

The need to ensure all required in-service training hours were completed annually was reviewed with Staff 1 (Administrator). She acknowledged the findings.

Noted Universal Workers are working toward getting current on all required education.  

This area of deficiency is being addressed by creating a yearly in-service training plan to include pre-assigned education to be planned and continued as staff enters second year and each subsequent year to include all required training to include 6 hours of 12 in Dementia.  Individual training binders with those training plans will be added to the training process at Willow Creek Terrace for better tracking and documentation of those in-service requirements.  

Administrator with aide of newly appointed Training Coordinator will be responsible for oversight.   

Based on interview and record review, it was determined the facility failed to provide documentation that fire drills were being conducted every other month and all required components of fire drills were documented. Findings include, but are not limited to:

Review of fire drill records on 03/29/22, for September 2021 through March 2022, showed the facility failed to conduct fire drills every other month and failed to document escape routes used.

On 03/29/22, the need to ensure documentation that fire drills were being conducted every other month and all required components of fire drills were documented was discussed with Staff 1 (Administrator). She acknowledged the findings.

This area of deficiency is being adressed by creating an updated schedule and documentation of fire drills to be conducted following the guidance of OFC to include all information required as per that research and to update reporting forms with those required updates including fire escape routes used.  

Administrator with aide of newly appointed Team Leader will be responsible for oversight.    

Based on interview and record review, it was determined the facility failed to conduct fire drills according to the Oregon Fire Code (OFC). This is a repeat citation. Findings include, but are not limited to:

Fire drill and life safety records were reviewed on 10/31/22. The facility failed to evacuate and/or relocate residents during monthly fire drills. Therefore, documentation was incomplete in the following areas:

* Problems encountered, comments relating to residents who resisted or failed to participate in the drills;

* Evacuation time-period needed; and

* Number of occupants evacuated.

The requirements for conducting fire drills and maintaining completed fire drill records was discussed with Staff 12 (Interim Administrator) and Staff 10 (Team Lead/RCC) and Staff 13 (Chief Operating Officer) on 10/31/22. They acknowledged the findings.

The fire drill and life safety requirements in OAR 411-054-0090 were reviewed by the Administrator. Monthly fire drills are now scheduled with the new Health and Safety Coordinator at MCHD. A meeting and site visit has been conducted. A new plan is in place for fire drills that include evacuation to be conducted every other month with documentation of problems encountered, comments relating to residents who resisted or failed to participate in the fire drills; evacuation time-period needed; and number of occupants evacuated. Training from Understanding Fire Drills and Fire Life Safety Training (2021) provided to Health and Safety Coordinator/Team Lead-RCC/Administrator.  Residents will be trained on fire drills OR life safety each month and documented in their chart.

The fire drills and life safety trainings will be scheduled by the Health and Safety Coordinator. Documentation will be completed each month. Compliance by 12/15/22.

The Team-lead/RCC and Administrator will ensure these are accomplished each month and that the documentation is completed and available every month.

Based on interview and record review, it was determined the facility failed to provide evidence that alternating evacuation routes were used during fire drills and resident evacuation levels were met. Findings include, but are not limited to:

Review of Fire and Life Safety Records on 03/29/22, for September 2021 through March 2022, identified the facility lacked documented evidence of the following:  

* Alternate exit routes were used during fire drills; and

* A written record of fire safety training, including content of the training sessions and the residents attending.

On 03/29/22, the need to ensure alternate exit routes were used during fire drills and fire and life safety instruction was provided to residents upon admission and at least annually was discussed Staff 1 (Administrator). She acknowledged the findings.

This area of deficiency is being addressed by assigning different escape routes to be used during fire drills and to include a written record of fire safety information at Resident move-in and by adding an additional section to our Fire Drill manual to include a written record of yearly fire safety training with documentation of Residents attending and training content.

Administrator with aide of newly appointed Team Leader will be responsible for oversight.    

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

Refer to C 240, C 252, C 302, C 310, C 374, and C 420.

A written plan of correction is completed by 11/22/22. All actions on the plan of correction will be implemented and in place by 12/15/22. Ongoing daily/weekly/monthly evaluation/monitoring will be put in place to ensure the corrections are completed and repeat violations are avoided.

The RN/Team-lead/RCC/Administrator are responsible for this.