The findings of the change of ownership survey, conducted 01/03/22 through 01/05/22, 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 survey to the change of ownership survey of 01/05/22, conducted 06/27/22 through 06/28/22, 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

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 survey to the change of ownership survey of 01/05/22, conducted 09/06/22 through 09/08/22, 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

Findings of the third revisit to the re-licensure survey of 01/05/22, conducted 11/29/22, 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. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

Based on observation, interview, and record review, it was determined the licensee failed to provide effective oversight to ensure the quality and care of services rendered in the facility. Findings include, but are not limited to:

During the change of ownership survey, conducted 01/03/22 through 01/05/22, oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective, based on the number and severity of citations.

Refer to deficiencies in the report.

1.  All departments are staffed and working in their scope.  Facility will educate accordingly to ensure quality assurance and proper operations are conducted.    

2. Administrator and management team will meet weekly to discuss any issues that arise and areas will be of conerns will be addressed in a timely manner. Meeting minutes to be uploaded into CommuniCare.

3. Will be evaluated weekly.

4. Administrator

Based on observation and interview, it was determined the facility failed to ensure reasonable precautions were exercised against any condition which could threaten the health, safety, or welfare of residents, for 1 of 3 sampled residents (#1) related to infection control. Findings include, but are not limited to:

On 01/04/22 at 11:05 am, the surveyor obtained permission to observe Staff 11 (MT/CG) provide ADL care for Resident 1. The following was observed:

a. Staff 11 failed to change gloves after handling soiled bedding, clothing, and incontinence product. She touched the resident's wheelchair and provided perineal care while wearing the same soiled gloves.

b. Staff 11 failed to follow guidelines for proper personal protective equipment (PPE) use when she removed her face shield and placed it on the bathroom counter while providing care.

c. Staff 11 failed to follow universal precautions when she placed the resident's soiled clothing and bedding in a basket with other dirty laundry and left the basket in the resident's room.

The above observations and the need for staff to follow universal precautions for infection control and adhere to PPE guidelines while providing care to residents was discussed with Staff 1 (Administrator) and Staff 2 (RCC) on 01/05/22. They acknowledged the findings.

1. Immediate counseling was provided to the caregiver. Infection Control Concepts module has been assigned to the caregiver to reinforce teachings.

2.  All staff to be retrained at staff meeting on community's Infection Control procedures.  

3.  Staff to be observed randomly and on a weekly basis

4.  Administrator, RCC

Based on interview and record review, it was determined the facility failed to ensure all resident incidents were promptly investigated to rule out abuse and/or neglect and reviewed by the administrator, and to immediately investigate injuries of unknown cause and report to the local SPD office if abuse and/or neglect could not reasonably be ruled out and documented in a timely manner for 1 of 1 sampled resident (#1) who experienced a medication error, falls, and injuries of unknown cause. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 05/2021 with diagnoses including stroke.

A review of the resident's record, including progress notes, alert charting, incident investigations, hospital discharge paperwork, and physician after visit summaries, dated between 08/05/21 and 01/02/22, as well as interviews with staff and Witness 1 (Family Member), revealed the resident experienced the following:

* 11/07/21: Unwitnessed fall resulting in an "open area on right shoulder";

* 11/09/21: Medication error;

* 11/22/21: Unwitnessed fall with an injury to his/her right hand;

* 12/08/21: Bruise on left quad;

* 12/10/21: Skin tear on right forearm;

* 12/16/21: Skin tear on left shin and scratches on right calf; and

* 12/18/21: Bruises around stomach.

There were no investigations or documentation as to whether the facility ruled out abuse/neglect or, alternately, reported the injuries of unknown cause discovered by staff on 12/08/21, 12/10/21, 12/16/21, and 12/18/21.

The need to ensure all resident incidents and injuries were thoroughly investigated in a timely manner to rule out abuse and/or neglect, and reported to the local SPD if abuse and/or neglect could not reasonably be ruled out, was discussed with Staff 1 (Administrator) and Staff 2 (RCC) on 01/05/22. They acknowledged the findings.

The incidents which required reporting were self-reported by the facility per the survey team's request. Confirmation of the report was provided prior to survey exit.

1.  The Investigations mentioned in the SOD to be investigated to rule out abuse and to be reported to APS, if needed.

2.  The team to follow existing facility policy and procedure on Investigation Reporting to ensure abuse is ruled out in a timely manner.  

3.  Reporting and Investigations will be reviewed upon completion.  

4.  Administrator, RCC

Based on interview and record review, it was determined the facility failed to ensure resident move-in evaluations addressed all required elements for 1 of 1 sampled resident (#3) whose new move-in evaluation was reviewed. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 12/2021.

Review of the move-in evaluation, dated 12/02/21, revealed it failed to address the following required elements:

* History of treatment and effective non-drug interventions for mental health issues;

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

* History of dehydration and weight loss; and

* Environmental factors that impact the resident's behavior, including lighting and room temperature.

The need to ensure move-in evaluations addressed all required elements was discussed with Staff 1 (Administrator) and Staff 2 (RCC) on 01/05/22. They acknowledged the findings.

1.  The evaluation has been updated to reflect the deficiencies noted in the SOD.

2.  Administrator, RCC will collaborate to ensure the Pre-Admission evaluation is thorough and contains all required elements and accuratley reflects the prospects condition and needs.

3.  Evaluated prior to each admission

4.  Administrator, RCC

Based on interview and record review, it was determined the facility failed to ensure all required elements were addressed in move-in evaluations for 1 of 1 newly admitted resident (#9). This is a repeat citation. Findings include, but are not limited to:

Resident 9 was admitted to the facility in 06/2022 with diagnoses including high blood pressure and seizures.

The resident's Pre-Admission Evaluation, dated 06/01/22, was reviewed. There was no documented evidence the following required elements were addressed prior to the resident moving into the facility:

* Decision-making abilities;

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

* Recent losses; and

* Unsuccessful prior placements.

The need to ensure all required elements were addressed with residents prior to admitting them to the facility was discussed with Staff 1 (Administrator) on 06/28/22. She acknowledged the findings.

1.  The evaluation has been updated to reflect the deficiencies noted in the SOD.  Existing Pre-Admission Evaluation requirements will be reviewed.

2.  Administrator, RCC, Nurse will collaborate to ensure the move in admission evaluation is complete and reflects an accurate discovery process of the  prospects condition and needs.

3.  Evaluated prior to each admission date and during the first 30 days of residency.  Further review will be conducted on a quarterly basis.

4.  Administrator, RCC, Nurse  

3. Resident 2 was admitted to the facility in 11/2017 and had a diagnosis of lower extremity edema.

Review of the resident's 08/06/21 service plan and interviews with staff and the resident revealed the service plan was not reflective of the resident's current status and care needs and did not provide clear direction to staff in the following areas:

* Edema;

* Assistance with tubigrip stockings on legs (for compression);

* Flow rate of supplemental oxygen;

* Discontinuation of home health RN for wound care.

The need to ensure the service plan was reflective of the resident's current status and care needs and provided clear direction to staff was discussed with Staff 1 (Administrator) and Staff 2 (RCC) on 01/05/22. They acknowledged the findings.

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

1. Resident 4 was admitted to the facility in 06/2021 with diagnoses including hypertension.

Review of Resident 4's records indicated the service plan, dated 10/13/21 was not reflective of the resident's current care needs in the following areas:

* Hospice services;

* Fall risk, history, and interventions;

* History of dehydration and weight fluctuations; and

* History of suicidal statements.

The need to ensure service plans were reflective of residents' current status and care needs was discussed with Staff 1 (Administrator) and Staff 2 (RCC) on 01/05/21. They acknowledged the findings.

2. Resident 1 was admitted to the facility in 05/2021 with diagnoses including stroke.

The resident's current service plan, dated 10/13/21, progress notes and alert charting documentation dated 08/05/21 through 01/02/22, incident investigations, and hospital discharge and after visit summaries were reviewed, and interviews were conducted with staff, the resident, and Witness 1 (Family Member).

Resident 1's service was not reflective of his/her current status and care needs and did not provide clear direction to staff regarding the delivery of care in the following areas:

* Fall risk, history, and interventions;

* Cellulitis;

* Level of ADL assistance needed;

* Transfer assistance required; and

* Evacuation status.

The need to ensure service plans were reflective of residents' current status and care needs and provided clear direction to staff was discussed with Staff 1 (Administrator) and Staff 2 (RCC) on 01/05/22. They acknowledged the findings.

1.  The Service Plan's will be updated to address the deficiencies noted in the SOD.

2.  A copy of the current Service Plan will be provided to all staff for feedback and comment on each resident for the residents 30 day and quarterly review to ensure the care needs are captured and reflected on the service plan.

3.  Evaluation of Service Plan to be done prior to completion.

4.  Admininstrator, RCC

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 the resident, for 3 of 3 sampled residents (#s 1, 2 and 4). Findings include, but are not limited to:

Resident 1, 2 and 4's most recent service plans lacked evidence that a service planning team reviewed and participated in the development of the service plans.

The need to ensure service plans were developed by a service planning team was discussed with Staff 1 (Administrator) and Staff 2 (RCC) on 01/05/21. No further information was provided.

1.  Resident service plans to be reviewed by the resident or legal representative, the Administrator and RCC and to be documented on the signature page.

2.  The Service Planning team to follow existing facility policy and procedure on service planning.  

3.  Service plan signatures will be reviewed upon completion of the initial, 30 day, quarterly and with change of condition.

4.  Administrator, Office Manager, RCC

2. Resident 4 was admitted to the facility in 06/2021, with diagnoses including hypertension.

a. Review of Resident 4's records, interviews, and observations indicated the following:

Resident 4's service plan, dated 10/13/21, noted the resident was independent with transfers, ambulation, and most ADLs.

During an interview on 01/04/22, Resident 4 stated that s/he would use the call light if s/he really needed assistance but s/he tried not to "bug staff with little things that I can do on my own." During the interview, Resident 4 was observed independently walking and getting snacks from the cabinets in his/her apartment.

During an interview on 01/04/22, Staff 12 (MT) stated Resident 4 was usually independent with most ADLs but sometimes required reminders to attend meals in the dining room. Staff 12 stated the resident did have a wheelchair in his/her room, which had been provided by hospice, but s/he adamantly refused to use it.

Progress notes and incident investigations dated 10/01/21 through 01/02/22 indicated the following:

* 11/14/21 - Staff reported hearing a "huge crash" coming from upstairs and found Resident 4 on his/her back on the floor of his/her bathroom. Staff noted the resident had a small skin tear on the lower right arm. The resident stated "yes" when asked if s/he hit their head, but refused  to have emergency medical services called or go to the emergency room for further evaluation when the staff tried (multiple times) to persuade him/her to do so. The investigation included an intervention of "perhaps a slip proof mat on the bathroom floor in front of the toilet." There was no documented evidence the intervention had been implemented or communicated to staff, or monitored for effectiveness.

* 11/15/21 - Staff reported hearing Resident 4 yell for help from his/her apartment and found him/her lying on the floor behind the recliner. Staff noted a skin tear to Resident 4's left forearm. The resident declined to go to the emergency department for further evaluation and stated s/he felt fine and had just lost balance. There was no documented evidence the facility determined and documented interventions needed in response to the fall.

* 11/16/21 - Staff reported Resident 4 was sent to the hospital related to falls on 11/14/21 and 11/15/21, ongoing unsteadiness, and complaints of hearing loss. On 11/18/21 a Health Assessment, completed by an RN, stated the resident returned to the facility with a diagnosis of dehydration and failure to thrive/weakness and a referral for hospice services. There was no documented evidence the facility determined and documented interventions needed in response to the new diagnoses and the resident's status.

* 12/14/21 - Staff reported Resident 4 stated s/he fell near his/her bed and had a hard time getting back up. Staff indicated the resident did not use the call light and they were unaware the resident had fallen. Staff noted the resident had a bruise on the left side, near his/her ribs. There was no documented evidence the facility determined and documented interventions needed in response to the fall.

There was no documented evidence the facility monitored the resident's risk for falls, skin tears to the right and left arms, bruise on the left side, or return from hospital with new diagnoses of dehydration and failure to thrive/weakness.

b. Review of Resident 4's December 2021 MAR/TAR and physician orders indicated the facility received orders for staff to administer two anti-fungal medications, Diflucan 100 mg daily for seven days and Lotrimin cream three times daily as needed, for the treatment of a rash. There was no documented evidence the facility monitored the rash or monitored the resident for adverse reactions to the medication.

The facility's failure to determine, document, communicate and monitor interventions and the residents' status when they experienced changes of condition was discussed with Staff 1 (Administrator) and Staff 2 (RCC) on 01/05/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure residents who experienced changes of condition were evaluated and referred to the RN for further assessment as indicated; necessary actions or interventions were determined, documented, and communicated to staff; and the resident's condition, including effectiveness of interventions, was monitored weekly through resolution, for 2 of 3 sampled residents (#s 1 and 4) who had documented changes of condition. Resident 1 experienced severe, ongoing weight loss, repeated falls with injuries, and a wound which became infected. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 05/2021 with diagnoses including stroke.

Resident 1's facility record, including the current service plan, dated 10/13/21, progress and alert charting notes dated 08/05/21 through 01/02/22, 09/01/21 through 12/31/21 MARs, physician orders, hospital discharge orders and after visit summaries, and weight records from 06/05/21 through 01/04/22 were reviewed. Staff, the resident, and Witness 1 (Family Member) were interviewed. The resident experienced multiple changes of condition.

a. Weight records revealed the resident's weight was:

* 06/05/21 - 202 lbs.;

* 07/21/21 - 184.4 lbs.; and

* 09/2021 - 179.8 lbs.

Between 06/05/21 and 07/21/21 Resident 1 lost 17.6 lbs., or 8.71% of his/her total body weight in one month, which is considered severe.

Between 06/05/21 and 09/2021 the resident lost 22.2 lbs., or 10.99% of his/her total body weight in three months, which is considered severe.

There was no documented evidence the resident's severe weight loss was evaluated and referred to the RN, interventions were developed, implemented, communicated to staff, and monitored for effectiveness, or the resident's change of condition was monitored through resolution.

On 01/04/22 the surveyor requested a current weight for Resident 1. Staff 2 (RCC) reported the resident weighed 198.6 lbs., a gain of 18.7 lbs. from his/her 12/2021 weight of 179.9 lbs, or 10.39% of his/her total body weight in one month, which represented a severe gain.

Resident 1 was interviewed on 01/04/22 and reported s/he didn't always like the food served and would ask for "mush" [oatmeal] instead. The resident indicated s/he had never asked for food outside of meal and snack times, but was sure the facility would provide food if requested.

In an interview on 01/05/22, Witness 1 (Family Member) indicated the resident was eating the same amount of food s/he had been eating when living at home and had snacks available in his/her apartment. Witness 1 reported the resident had a difficult time chewing because s/he had lost their dentures, but stated s/he had no concerns about the resident's eating habits or diet.

The lack of interventions and monitoring resulted in ongoing severe weight loss, after which there was a severe weight gain. This constituted a risk to the health, safety, and welfare of the resident.

During the survey, the facility RN was unavailable for an interview.

b. Resident 1 experienced seven falls between 08/05/21 and 12/20/21, as follows:

* 08/05/21 - non-injury unwitnessed fall in the bathroom after a shower;

* 10/27/21 - unwitnessed fall in the hallway outside of the kitchen, with a bruise appearing on the right hip one week later;

* 11/07/21 - unwitnessed fall in his/her bedroom resulting in an "open area" on the right shoulder;

* 11/22/21 - unwitnessed fall in the shower with an injury to the right hand;

* 11/24/21 - witnessed fall in bedroom without injury;

* 11/27/21 - witnessed fall in bedroom resulting in hitting his/her head and bruises on the left side of the back; and

* 12/20/21 - unwitnessed fall in bedroom resulting in hitting his/her head. The resident was sent to the emergency department. Staff documented in alert charting notes for this incident they provided wound care for the "front of [his/her] leg," the resident's bottom and head, and "many sores and bruises."

The facility documented possible interventions in progress notes, alerting charting, and/or investigations:

* 08/05/21 - put a dry towel or bathmat "outside the shower";

* 10/27/21 - encourage resident to use his/her "pendant or any call light nearby"; and

* 11/24/21 - "perhaps no more hot showers at night."

There was no documented evidence those interventions were implemented, communicated with staff on all shifts, and/or monitored for effectiveness. The resident continued to fall and sustained multiple injuries, causing a serious risk to the health, safety, and welfare of the resident.

During the survey, the facility RN was unavailable for an interview.

c. On 09/15/21, staff documented in a progress note the resident had "what looks like a pressure ulcer on the outside of [his/her] left ankle." On 09/22/21, staff documented the resident went to urgent care on 09/21/21, where it was discovered the "abrasion" on his/her left ankle had become infected.

There was no documented evidence this change of condition was evaluated and referred to the RN for assessment. Subsequently, the wound became infected, which posed a serious risk to the health, safety, and welfare of the resident. Additionally, the facility failed to monitor the wound through resolution per their alert charting instructions.

The resident was prescribed cephalexin (an antibiotic) 500 mg four times a day for 10 days, a total of 40 doses. The medication was first administered on 09/23/21 and was discontinued on 10/01/21 after the first dose of the day. On 09/28/21, a progress note indicated the resident's ankle "was becoming infected again."

During the survey, the facility RN was unavailable for an interview.

d. A progress note dated 12/29/21 indicated the resident was sent to the emergency department on 12/28/21. The emergency department "After Visit Summary" indicated the resident was seen for "extremity weakness." The resident was diagnosed with "swelling due to blockage of lymphatic flow" [lymphedema] and "bacterial infection of leg."

The diagnosis of lymphedema represented a significant change of condition. There was no documented evidence the change of condition was evaluated and referred to the RN for assessment. In addition, there was no documented evidence interventions specified in the "After Visit Summary" were implemented and shared with all staff or the resident's status was monitored per the facility's alert charting instructions.

e. The following short-term changes of condition, documented in the progress notes or the alert charting notes, were not monitored per the facility's alert charting instructions, and/or not monitored through resolution:

* 09/22/21 - urinary tract infection (UTI), prescribed cephalexin (an antibiotic);

* 09/23/21 - rash on the right side of the groin;

* 10/05/21 - extremely low blood pressure (95/53) and pulse (71);

* 10/29/21 - "needing more care than usual";

* 11/09/21 - "still has groin rash";

* 11/09/21 - dizziness and weakness "due to high amounts of [his/her] dipyridamole" (a blood thinner). The progress note states s/he was administered a total of 450 mg of the medication on 11/07/21 and a total of 375 mg on 11/08/21. The prescribed dose was a total of 300 mg per day;

* 11/11/21 - wound on right shoulder re-opened;

* 11/19/21 - rash was now under the stomach and on both sides of the groin, "medium pink" and "tender to touch";

* 11/27/21 - a "very red and angry looking groin rash" which was "sore to the touch" and extended from under the "apron area" of the stomach "almost all the way" to the anus;

* 12/01/21 - bruise on left buttock;

* 12/08/21 - bruise on left quad which was "red and purple";

* 12/09/21 - "raspy voice";

* 12/10/21 - skin tear on right forearm;

* 12/16/21 - skin tear on left shin and "what looks like scratches" on right calf;

* 12/18/21 - bruises around stomach and "leg issues";

* 12/26/21 - wound on lower right of back and middle of back;

* 01/02/22 - resident sent to the hospital 01/01/22, due to his/her face being "droopy, and swollen a little bit," swollen hands, and slurred speech, and returned to the facility with diagnoses including weakness, debility, accumulation of fluid in tissues, and a popliteal cyst behind the right knee, as well as a recommendation for a higher level of care.

The facility was unable to provide documentation of each change of condition being evaluated and referred to the RN if indicated; having interventions developed, implemented, communicated to staff on all shifts, and monitored for effectiveness; and/or being monitored per alert charting instructions through resolution.

During the survey, the facility RN was unavailable for an interview..

The need to ensure all changes of condition were evaluated and referred to the RN If indicated; had interventions developed, implemented, communicated to staff on all shifts, and monitored for effectiveness; and were monitored per the facility's alert charting instructions through resolution was discussed with Staff 1 (Administrator) and Staff 2 (RCC) on 01/05/22. They acknowledged the findings.

1.  Retraining of all staff on reporting change of condition to RCC and RN.

2.  All staff to be retrained on Stop and Watch procedure.  This will allow swift determination of change of condition and implementation of interventions in order to monitor residents health, safety and welfare.

3.  Monitored daily by Medication Aide and RCC.

4.  Admin/RCC/Nurse

Based on observation, interview and record review, it was determined the facility failed to determine and document what actions and interventions were needed for residents when they experienced short-term changes of condition, communicate them to staff on all shifts, monitor the changes at least weekly through resolution, and evaluate interventions for effectiveness for 2 of 2 sampled residents (#s 6 and 8) reviewed with changes of condition. This is a repeat citation. Findings include, but are not limited to:

1. Resident 6 was admitted to the facility in 04/2020 with diagnoses including Parkinson's disease.

Review of 03/06/22 through 06/27/22 progress notes, alert charting notes, incident investigations, facility health assessments, the 03/20/22 service plan, and interviews with staff and the resident revealed the following:

Resident 6's 03/20/22 service plan indicated s/he had a history of falls and non-compliance with the use of his/her walker.

The resident had 17 documented falls between 03/06/22 and 06/27/22, including multiple with skin injuries.

There was no documented evidence the facility consistently determined and documented what actions and interventions were needed for the resident when s/he experienced the short-term changes of condition, evaluated fall prevention interventions for effectiveness, communicated fall prevention interventions identified on the health assessments to staff on all shifts, and monitored the short-term changes of condition at least weekly through resolution.

During an interview with Resident 6 on 06/27/22, s/he stated, "I take care of myself."

The need to determine and document what actions and interventions were needed for the resident, communicate them to staff on all shifts, evaluate the interventions for effectiveness, and monitor the resident at least weekly through resolution of the short-term change of condition was discussed with Staff 1 (Administrator) and Staff 14 (RCC) on 06/28/22. No further information was provided.

2. Resident 8 was admitted to the facility in 11/2021 with diagnoses including fractures of neck and right femur, spondylosis, and glaucoma.

Review of the resident's facility record, including progress notes, alert charting, and health assessments from 03/06/22 through 06/27/22, as well as interviews with the resident and staff, revealed the following:

* On 04/07/22 the resident was put on alert due to a wound on his/her right heel.

* There was no documented evidence the facility monitored the wound from 04/07/22 through 05/02/22.

The need to monitor short-term changes of condition with weekly progress noted until the condition was resolved was discussed with Staff 1 (Administrator) and Staff 14 (RCC) on 06/28/22. No additional information was provided.

1.  Retraining of medication aides on the process of alert charting when a change of condition occurs.

2.  Residents to be placed on alert charting when a Change of Condition occurs. The resident to remain on alert until condition has resolved to ensure thorough monitoring.

3.  Monitored daily by Medication Aide and RCC. Admin/Nurse to review weekly.

4.  Admin/RCC/Nurse

2. Resident 4 was admitted to the facility in 06/2021 with diagnoses including hypertension.

Review of Resident 4's records indicated the following:

* Resident 4's service plan, dated 10/13/21, noted the resident was independent with transfers, ambulation, and most ADLs.

* A progress note dated 11/16/21, revealed Resident 4 was sent to the hospital related to falls on 11/14/21 and 11/15/21, ongoing unsteadiness, and complaints of hearing loss. A progress note, dated 11/17/21 revealed facility staff spoke with hospital staff, who reported Resident 4 was requiring a two-person assist for transfers.

* A Health Assessment completed by an RN on 11/18/21 noted the resident returned to the facility with diagnosis of dehydration and failure to thrive/weakness and a referral for hospice services. The Health Assessment did not include information related to the resident's current status and did not provide interventions related to the resident's new diagnoses and admission to hospice services. Additionally, there was no documented evidence the resident's service plan had been updated.

The need to ensure residents who experienced significant changes of condition were thoroughly assessed by an RN, include finding of the resident's status, and interventions developed as a result of the assessment, and the resident's service plan was updated was discussed with Staff 1 (Administrator) and Staff 2 (RCC) on 01/05/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure a significant change of condition assessment was completed by the RN, which included findings, resident status, and interventions, for 2 of 3 sampled residents (#s 1 and 4) who experienced significant changes. Resident 1 experienced ongoing, severe weight loss, repeated falls with injuries, and a wound that became infected. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 05/2021 with diagnoses including stroke.

Resident 1's facility record, including the current service plan, dated 10/13/21, progress and alert charting notes dated 08/05/21 through 01/02/22, 09/01/21 through 12/31/21 MARs, physician orders, hospital discharge orders and after visit summaries, and weight records from 06/05/21 through 01/04/22 were reviewed. Staff, the resident, and Witness 1(Family Member) were interviewed. The resident experienced multiple changes of condition.

a. Weight records revealed the resident's weight was:

* 06/05/21 - 202 lbs.;

* 07/21/21 - 184.4 lbs.; and

* 09/2021 - 179.8 lbs.

Between 06/05/21 and 07/21/21 Resident 1 lost 17.6 lbs., or 8.71% of his/her total body weight in one month, which is considered severe.

Between 06/05/21 and 09/2021 the resident lost 22.2 lbs., or 10.99% of his/her total body weight in three months, which is considered severe.

These represented significant changes of condition for which an RN assessment was required. There was no documented evidence an RN completed an assessment of these severe weight losses. The severe, ongoing weight loss represented a serious risk to the health, safety, and welfare of the resident.

During the survey, the facility RN was unavailable for an interview.

b. Review of the resident's current service plan and progress notes did not indicate falls prior to 08/05/21 and did not identify the resident as a fall risk. Resident 1 experienced seven falls between 08/05/21 and 12/20/21, as follows:

* 08/05/21 - non-injury unwitnessed fall in the bathroom after a shower;

* 10/27/21 - unwitnessed fall in the hallway outside of the kitchen, with a bruise appearing on the right hip one week later;

* 11/07/21 - unwitnessed fall in his/her bedroom resulting in an "open area" on the right shoulder;

* 11/22/21 - unwitnessed fall in the shower with an injury to the right hand;

* 11/24/21 - witnessed fall in bedroom without injury;

* 11/27/21 - witnessed fall in bedroom resulting in hitting his/her head and bruises on the left side of the back; and

* 12/20/21 - unwitnessed fall in bedroom resulting in hitting his/her head. The resident was sent to the emergency department. Staff documented in alert charting notes for this incident they provided wound care for the "front of [his/her] leg," the resident's bottom and head, and "many sores and bruises."

The increase in falls represented a significant change of condition for which an RN assessment was required. There was no documented evidence an RN had assessed the resident's falls or of interventions being implemented. The resident continued to fall and sustained multiple injuries, causing a serious risk to the health, safety, and welfare of the resident.

During the survey, the facility RN was unavailable for an interview..

c. A 09/15/21 progress note indicates the resident had "what looks like a pressure ulcer on the outside of [his/her] left ankle." On 09/22/21 staff documented the resident went to urgent care on 09/21/21, where it was discovered the "abrasion" on his/her left ankle had become infected.

Staff's documentation of a "pressure ulcer" represented a significant change of condition for which an RN assessment was required. There was no documented evidence the RN assessed the wound; subsequently, the wound became infected. That posed a serious risk to the health, safety, and welfare of the resident.

During the survey, the facility RN was unavailable for an interview.

d. A progress note dated 12/29/21 indicated the resident was sent to the emergency department on 12/28/21. The emergency department after visit summary indicates the resident was seen for "extremity weakness." The resident was diagnosed with "swelling due to blockage of lymphatic flow" [lymphedema] and "bacterial infection of leg."

The diagnosis of lymphedema constituted a significant change of condition. There was no documented evidence of an RN assessment of the resident's change of condition.

During the survey, the  facility RN was unavailable for an interview.

The need to ensure all significant changes of condition were assessed by an RN, with documented findings, resident status, and interventions made as a result of the assessment, was discussed with Staff 1 (Administrator) and Staff 2 (RCC) on 01/05/22. They acknowledged the findings.

Refer to C270, examples 1a through 1d.

1. Assessments have been completed to relfect change of condition for those residents outlined in SOD.

2.  All staff to be retrained on Stop and Watch procedure.  This will allow swift determination of change of condition and implementation of interventions in order to monitor residents health, safety and welfare.

3. MA and RCC to review Stop and Watches daily

4. Admin, RCC, RN

Based on interview and record review, it was determined the facility failed to ensure written, signed physician orders were documented in the resident's record for all medications and treatments administered by the facility and orders were carried out as prescribed for 1 of 3 sampled residents (#1) whose MARs and physician orders were reviewed. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 05/2021 with diagnoses including stroke.

The resident's current service plan, dated 10/13/21, progress and alert charting notes dated 08/05/21 through 01/02/22, 09/01/21 through 12/31/21 MARs, and physician orders were reviewed, and staff, the resident, and Witness 1 (Family Member) were interviewed.

a. The resident was identified to have a chronic rash in the groin area and other skin issues related to falls and injuries of unknown cause.

Between 09/14/21 and 12/27/21, staff documented treating the resident's skin issues 50 times. There was no physician order for any type of skin treatment in the resident's facility record.

b. On 12/30/21 the facility began administering cephalexin (an antibiotic) 500 mg twice per day to the resident, for a bacterial infection of the resident's leg, per the after visit summary from an emergency department visit on 12/28/21. The after visit summary was not signed by a physician. There was no documented evidence of a signed physician order for the cephalexin in the resident's record.

c. On 09/21/21 the resident was prescribed cephalexin (an antibiotic), 500 mg four times daily for 10 days. The facility began administering the medication on 09/23/21 and discontinued the medication after the first dose on the ninth day. There was no documented evidence of a signed physician order to discontinue the medication.

The need to have signed physician orders for all medications and treatments provided to the resident by the facility, and to follow physician orders as prescribed, was discussed with Staff 1 (Administrator) and Staff 2 (RCC) on 01/05/22. They acknowledged the findings.

1. Counseled and retrained Medication Aides on requirement to have signed Physician's Orders prior to providing treatment.

2.  Medication Aides have been counseled and will be retrained on the facility procedure for reviewing new orders to ensure transcription is correct.  

3.  Medication orders will be reviewed daily by Medication Aides and weekly by RCC.

4.  Administrator, RCC, Nurse

Based on interview and record review, it was determined the facility failed to ensure physician orders were followed as written for 1 of 2 sampled residents (#8) whose physician orders were reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 8 was admitted to the facility in 11/2021 with diagnoses including fractures of neck and right femur, spondylosis, and glaucoma.

The resident's 06/01/22 through 06/27/22 MAR and physician orders signed 04/26/22 were reviewed. The following was identified:

Three PRN medications were discontinued by the physician on 04/26/22:

* Acetaminophen (a pain reliever) 325 mg, give two tabs every six hours as needed for mild discomfort or temperature greater than 99.5 degrees Fahrenheit;

* Oxycodone (a narcotic pain reliever) 5 mg/5 ml solution, give 2.5 ml every four hours as needed for pain; and

* Senna-Time (a stool softener) 8.6 mg, give two tabs (17.2 mg) nightly as needed every night that oxycodone is given for pain.

These medications were on the 06/01/22 through 06/27/22 MAR as current as-needed medications.

In an interview with Staff 1 (Administrator) on 06/27/22, she stated she would discontinue the orders on the MAR.   

An interview with Staff 15 (MT) on 06/28/22 revealed the resident's prescribed oxycodone was still in the medication cart and in the controlled substance disposition log.

The need to follow physician orders as written was discussed with Staff 1 and Staff 14 (RCC) on 06/28/22. They acknowledged the findings.

1. The resident's medication administation record was correct at survey to reflect the current Physician's order.

2.  Medication Aides have been counseled and will be retrained on the facility procedure for reviewing new orders to ensure transcription is correct.  If an error has been found in the pharmacy's transcription, the Medication Aide is to contact the pharmacy immediately and then notify the RCC/Nurse.

3.  Medication orders will be reviewed daily by Medication Aides and weekly by RCC/Nurse to ensure new orders are reflected on the Medication Administation Record.

4.  Administrator, RCC, Nurse

Based on interview and record review, it was determined the facility failed to ensure there was a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications and that residents were evaluated quarterly to assure their ability to safely self-administer medications for 1 of 1 sampled resident (#2) who self-administered their medication. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 11/2017 and had a diagnosis of congestive heart failure.

During the acuity interview on 01/03/21, Resident 2 was identified as self-administering all of his/her medications.

Review of the resident's facility record revealed there was no documented evidence a quarterly self-administration evaluation had been completed, and there was no current signed physician's order for the resident to self-administer medications.

The need to complete evaluations quarterly and to have a current signed physician's order for self-administration in the resident's chart was discussed with Staff 1 (Administrator) and Staff 2 (RCC) on 01/05/22. They acknowledged the findings.

The resident's ability to self-administer medication was evaluated by the facility on 01/05/21 and a copy was provided to survey prior to exit.

1. The resident's quarterly self medication assessments were completed and in their electronic file at time of survey.  They were printed and placed in resident paper chart. The physician was faxed for an updated signed order.

2. The self medication assessments will continue to be completed on a quarterly basis and with change of condition. They will be printed and filed in resident paper chart.

3. Quarterly

4.  Administrator, RCC

Based on interview and record review, it was determined the facility failed to ensure the administrator completed the required 20 hours of documented annual continuing education units (CEUs). Findings include, but are not limited to:

Prior to the acuity interview on 01/03/22, Staff 1 (Administrator) was provided with the entrance conference checklist and asked to provide copies of the listed documents. Upon review of the information provided by Staff 1, it was determined she had only six hours of documented annual CEUs.

In interviews on 01/04/22 and 01/05/22, Staff 1 stated she had completed the required hours of training and had been required to provide proof of the training to receive her administrator's license in 11/2021. Staff 1 reported she had requested copies of her CEU documentation, but had not yet received the information.

The need to ensure the Administrator completed 20 hours of documented annual CEUs was discussed with Staff 1 and Staff 2 (RCC) on 01/05/22. They acknowledged the findings.

1.  The Administrator has been counseled on requirement of Continuing Education hours and is in process of obtaining training certifications.

2.  Continuing Education certificates to be printed after each course and scanned into employee file for ease of access.  

3.  Continuing Education will be audited monthly   

4.  Office Manager

Based on interview and record review, it was determined the facility failed to have a sufficient number of caregivers to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to:

During the assisted living change of ownership survey, conducted 01/03/22 through 01/05/22, interviews with staff and Witness 1 (Family Member) were conducted and staffing schedules were reviewed.

In an interview on 01/05/22, Staff 7 (CG) stated they had experience working on all shifts at the facility. Staff 7 stated staffing levels on the overnight shift could be difficult, because there was only one staff scheduled for assisted living and one for memory care; if help was needed on assisted living, staff called the person working on the memory care unit for assistance. Staff 7 indicated Resident 1 frequently requested help during the overnight shift and was sometimes a two-person transfer.

Witness 1, during an interview on 01/05/22, corroborated Staff 7's statement that only one staff was scheduled to work the overnight shift for assisted living and one staff for memory care. Witness 1 stated they expressed concern about the staffing level on graveyard shift to Staff 1 (Administrator) and were assured "the staffing ratio was where it should be at night." Witness 1 reported Resident 1 was "easily" a two-person transfer when s/he was feeling weak and was frequently awake and out of bed between 10:00 pm and 6:00 am.

Staffing schedules for the weeks of 11/28/21, 12/12/21, 12/19/21, 12/26/21, 01/02/22 revealed one direct care staff was scheduled for assisted living and one direct care staff was scheduled for memory care on the overnight shift.

The facility's failure to ensure it had a sufficient number of caregivers to meet the 24-hour scheduled and unscheduled needs of residents was discussed with Staff 1 and Staff 2 (RCC) on 01/05/22. Staff 1 stated she would be requesting permission from the owner to schedule additional staff for the overnight shift.

1.  Resident service plans will be reviewed to ensure accurate care is accounted for and will then base staffing needs off of resident acuity.

2.  Service plans updated as required. Acuity/staffing data will be reviewed monthly for accurate staffing.

3.  Monthly and as needed  

4.  Administrator, RCC

Based on interview and record review, it was determined the facility failed to ensure pre-service orientation in all required topics, including pre-service dementia training, was completed prior to providing services to residents for 2 of 2 newly hired direct care staff (#s 10 and 13) whose training records were reviewed. Findings include, but are not limited to:

Staff training records were reviewed on 01/05/22.

a. Staff 10 (CG), hired 11/16/21, lacked documented evidence of having completed pre-service dementia training and the following required orientation training:

* Resident rights and values of CBC care;

* Abuse reporting requirements;

* Standard precautions for infection control; and

* Fire safety and emergency procedures.

b. Staff 13 (MT), hired 10/01/21, lacked documented evidence of having completed pre-service dementia training.

The need for staff to complete all required pre-service orientation and dementia training before working with residents was reviewed with Staff 1 (Administrator) and Staff 2 (RCC) on 01/05/22. They acknowledged the findings.

1. Staff have been assigned required trainings as defined in SOD and have been removed from staff schedule until completed.  Per Company policy, new employee files will remain in open status until all required pre-employment trainings are completed.

2.  Per Company policy, new employee files will remain in open status until all required pre-employment trainings are completed prior to being placed on staff work schedule.

3. Training records will be reviewed prior to being added to staff schedule.

4.  Administrator, Office Manager

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 newly hired staff (#s 10 and 13) demonstrated competency in their job duties within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed on 01/05/22.

a. Staff 10 (CG) was hired 11/16/21. There was no documented evidence Staff 10 demonstrated competency in their job duties within 30 days of hire in the following areas:

* The role of service plans in providing individualized care;

* Providing assistance with ADLs;

* 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

* First aid/abdominal thrust.

b. Staff 13 (MT) was hired 10/01/21. There was no documented evidence Staff 13 demonstrated competency in their job duties within 30 days of hire in the following areas:

* 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;

* First aid/abdominal thrust; and

* Other duties as applicable - medication administration.

The surveyor informed Staff 1 (Administrator) and Staff 2 (RCC) at 1:15 pm, Staff 13 could not administer medications until demonstrated competency in MT duties was documented. They both acknowledged the findings. Staff 1 and Staff 2 indicated they would ensure there was documentation of Staff 13 demonstrating competency in her job duties before she administered medications.

The facility's failure to ensure staff completed all required training within 30 days of hire and prior to working independently was discussed with Staff 1 and Staff 2 on 01/05/22. They acknowledged the findings.

1.  Staff #10 and #13 will be assigned required trainings as outlined in SOD.

2.  Per Company policy new employee files will remain in open status until all required trainings have been completed and documented.

3.  Training records will be reviewed within 30 days of hire.

4.  Administrator, Office Manager

Based on interview and record review, it was determined the facility failed to provide fire and life safety instruction to staff on alternating months and include all required components on fire drill records. Findings include, but are not limited to:

Review of June 2021 through December 2021 fire and life safety records revealed the following:

a. There was no documented evidence fire and life safety instruction was consistently provided to staff on alternating months.

b. Fire drill records lacked the following components:

* Escape route used;

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

* Evacuation time period needed; and

* Number of occupants evacuated.

The need to ensure fire and life safety instruction was provided to staff on alternating months and fire drill records addressed all required components was discussed with Staff 1 (Administrator) on 01/05/22. No further information was provided.

1. Educate safety committee and facility staff in monthly staff meetings and orientation of new employees as to proper fire drill protocols to include potential problems and barriers to overcome, relative escape routes to use based on fire locations, evacuation time tracking, and occupant evacuee participation;

2. In each monthly staff meeting (as well as direct feedback to staff upon conclusion of each fire drill), review the most recent fire drills discussing timely responses by staff, problems and barriers observed, escape route utilization; time management to successful evacuation and occupant participation;

3. In each unannounced fire drill on rotating shifts, the maintence director will monitor the drill at the site of designated fire to evaluate and then document findings of drill;

4. Administrator and Maintenance supervisor.

Based on interview and record review, it was determined the facility failed to include all required elements in fire drill documentation in accordance with the Oregon Fire Code (OFC). This is a repeat citation. Findings include, but are not limited to:

Fire and life safety records dated 03/2022 through 05/2022 were reviewed.

Fire drill documentation was lacking the following required elements:

* Escape route used;

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

* Evacuation time period needed; and

* Number of occupants evacuated.

The need to include all required elements when documenting fire drills was discussed with Staff 1 (Administrator) on 06/28/22. She acknowledged the findings.

1. Educate safety committee and facility staff in monthly staff meetings and orientation of new employees as to proper fire drill protocols to include potential problems and barriers to overcome, relative escape routes to use based on fire locations, evacuation time tracking, and occupant evacuee participation;

2. In each monthly staff meeting (as well as direct feedback to staff upon conclusion of each fire drill), review the most recent fire drills discussing timely responses by staff, problems and barriers observed, escape route utilization; time management to successful evacuation and occupant participation;

3. In each unannounced fire drill on rotating shifts, the maintence director will monitor the drill at the site of designated fire to evaluate and then document findings of drill;

4. The safety Committee will review the evaluation for improvements; the Administrator shall ensure effectivness of drills.

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements were being met. Findings include, but are not limited to:

Fire and life safety records for July 2021 through December 2021 were provided. Review of the records revealed a lack of documented evidence related to the following required elements:

* Alternate evacuation routes used during fire drills;

* Documentation of interventions and/or resolution for resident evacuation concerns identified during fire drills; and

* Annual fire and life safety training provided to residents

Multiple staff interviewed during the survey reported they were unsure where the point of safety was.

The need to have all components of fire and life safety training documented was discussed with Staff 1 (Administrator) on 01/05/22. She acknowledged the findings.

1. Educate facility staff in monthly staff meetings and orientation of new employees as to proper Fire and Life Safety drill protocols to include potential problems and barriers to overcome, relative escape routes to use based on fire locations, evacuation time tracking, and occupant evacuee participation;

2. In each monthly staff meeting (as well as direct feedback to staff upon conclusion of each evacuation drill), review the most recent fire drills and evacuation drills discussing timely responses by staff, problems and barriers observed, escape route utilization; time management to successful evacuation and occupant participation;

3. In each unannounced fire drill on rotating shifts, the maintence director will monitor the drills at the site of designated fire and evacuaton and document findings of drill;

4. Administrator and Maintenance supervisor.

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

Fire and life safety records for 03/2022 through 05/2022 were reviewed on 06/28/22.

There was no documented evidence the facility provided annual fire and life safety training for residents.

The need to ensure residents were trained annually on fire and life safety topics was discussed with Staff 1 (Administrator) on 06/28/22. She acknowledged the findings.

1. Educate facility residents in monthly Council meetings and orientation of new residents as to proper Fire and Life Safety drill protocols to include potential problems and barriers to overcome, relative escape routes to use based on fire locations, evacuation time tracking, and occupant evacuee participation;

2. In each monthly Residents Council meeting (as well as direct feedback to residents upon conclusion of each evacuation drill), review the most recent fire drills and evacuation drills discussing timely responses by residents, problems and barriers observed, escape route utilization; time management to successful evacuation and occupant participation;

3. In each unannounced fire drill on rotating shifts, the maintence director will monitor the drills at the site of designated fire and evacuaton and document findings of drill;

4. The managements will review the evaluation for improvements; the Administrator shall ensure effectivness of drills.

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. This is a repeat citation. Findings include, but are not limited to:

Refer to C252, C270, C303, C420, C422 and C610.

1) All management team will work together to comply with all OAR's

2) Management team will plan accordingly and discuss reglarly in meetings.

3) Management team will manage this in quarterly QUAPI meetings as a group

4) Administrator and RCC will manage this

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. This is a repeat citation. Findings include, but are not limited to:

Refer to C 610.

1. Management team will work together to monitor any further physical plant safety concerns going forward. Management team will re-train staff on bringing any concerns to the attention of supervisors.

Any and all safety concerns brought to the attention of the management team will be addressed in safety and management meetings and addressed as soon as possible to mitigate risk.

Physical plant safety concerns will be addressed during monthly safety meetings or weekly management meetings, or more frequently as needed.

Facility Safety Supervisors: The Maintenance Supervisor and Administrator will monitor this.

Based on observation and interview, it was determined the facility failed to ensure perimeter walkway surfaces were maintained in good repair. Findings include, but are not limited to:

Observations of the concrete walkways along the perimeter of the building on 01/04/22 showed there were multiple drop-offs of 2-6 inches along pathway edges, and the concrete pad by the stairs was not level with the adjacent pad. Those issues created potential tripping hazards for residents.

The need to ensure the pathways were maintained in good repair and did not have potential safety hazards was discussed with Staff 1 (Administrator) on 01/04/22. She acknowledged the findings.

1. General Building Exterior requiremetns have been reviewed and will be addressed based on SOD.

2. Maintenance supervisor to walk the ground to ensure the pathways are in good repair.

3. Maintence director will monitor monthly.

4. Administrator and Maintenance supervisor.

Based on observation and interview, it was determined the facility failed to ensure there were no drop-offs along perimeter pathways which could present a tripping hazard for residents. This is a repeat citation. Findings include, but are not limited to:

Observations of the concrete pathways along the perimeter of the building on 06/27/22 revealed there were multiple drop-offs of two to eight inches.

The need to ensure there were no drop-offs along perimeter pathways was discussed with  Staff 1 (Administrator) on 06/27/22. She acknowledged the findings.

1. General Building Exterior requiremetns have been reviewed and will be done based on SOD information immediately.

2. In each monthly maintenance meeting (as well as direct feedback to staff upon conclusion of safety committee), review the most recent concerns.

3. Maintence director will monitor monthly and manage accordingly and in timely manor for safety.

4. The safety Committee will review the evaluation for improvements; the Administrator shall ensure effectivness of drills.

Based on observation and interview, it was determined the facility failed to ensure all exterior pathways were maintained in good repair and pathway edges were free from drop-offs, which could present a tripping hazard for residents. This is a repeat citation. Findings include, but are not limited to:

Observations of the concrete pathways along the perimeter of the building, on 08/06/22, revealed there were multiple drop-offs of two to eight inches.

The need to ensure there were no drop-offs along pathway edges was discussed with Staff 1 (Administrator) and Staff 16 (Regional Maintenance Director) on 09/06/22. They acknowledged the findings.

Regional Maintenance Director cordinated with contractor for wall to be started by 9-29-22.  Paperwork/signed contract for work was provided to Survey team at time of visit.

Retaining wall is a permanent solution to this concern.

Routine walk through with maintenance to be sure retaining wall is secure and safe will be done at weekly walk through with safety and maintenance team.

Facility Safety Supervisors: The Maintenance Supervisor and Administrator will monitor this.

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

A tour of the environment was conducted on 01/04/22. The following areas were in need of cleaning and repair:  

a. Laundry Room:

* There was chipped paint on the wall;

* There were gouges in the drywall behind the washer/dryer;

* The cabinet/counter had exposed raw wood;

* There were cracks in the laminate floor by the drain;

* There was a broken soap dispenser by the hopper;

* There was a build-up of gray matter on the window sill;

* There was an accumulation of brown/black matter in the utility sink;

* There was a build-up of black matter and smudges in the corners of the floor and at the base of the washers and dryers;

* There was dirty laundry in the hopper;

* The coved flooring had pulled away from the wall near the hopper; and

* There were pieces of debris and trash on the floor.

b. The first floor common area bathroom had cracked caulking at the base of the toilet and chipped paint on the door.

The environment was toured with Staff 1 (Administrator) on 01/05/22. The need to ensure the environment was kept clean and in good repair was discussed at that time. She acknowledged the findings.

1.  All items on SOD to be addressed

2.  Staff will let housekeeping and maintenance know if repairs need done or areas are in need of cleaning in timely manor to ensure facility remains clean and in good repair.

3.  Monitored weekly with maintenance and housekeeping walkthrough.

4.  Administrator and Maintenance supervisor.

Based on observation and interview, it was determined the facility failed to ensure all exit doors were equipped with an alarm or other acceptable security system to alert staff when residents exited the facility. Findings include, but are not limited to:

During a tour of the facility with Staff 1 (Administrator), she reported the exit doors off the dining room and second floor balcony did not have alarms to alert staff when residents were exiting the building.

On 01/05/22, the need to ensure exit doors were equipped with an alarming device or other acceptable system was discussed with Staff 1. She acknowledged the findings.

1. Exterior door alarms have been ordered and will installed upon arrival.

2. Alarms to be installed.

3.  Monitored monthly by maintenance.

4.  Administrator and Maintenance supervisor.