Print Inspection: S3FO

The findings of the re-licensure survey, conducted 08/01/22 through 08/03/22, 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 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 first re-visit to the re-licensure survey of 08/03/2022, conducted 12/27/22 through 12/29/22, 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 and OARs 411 Division 004 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 to the re-licensure survey of 08/03/22, conducted on 05/03/23, 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

MCCMemory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the third re-visit to the re-licensure survey of 08/03/22, conducted on 07/18/23, 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 was clean and in good repair, in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:

On 08/01/22 at 10:00 am, the facility kitchen was observed to need cleaning and repair in the following areas:

a. Food spills, splatters, debris, dirt and black matter was observed on or underneath the following:

* Wall and pipes underneath the three-compartment sink;

* Shelves and wheel castors of multiple rolling carts;

* Interior ceiling of the microwave;

* Industrial floor fan;

* Wall to right of kitchen entrance;

* Floor perimeter and underneath appliances;

* Electrical outlet next to the grill; and

* Pipes and wall behind steamer.

b. The following areas needed repair:

* Entrance and exit doors had scraped door jambs.

The areas that required cleaning and repair were observed and discussed with Staff 4 (Food Service Director) on 08/01/22. The findings were acknowledged.

1.  Walls and pipes underneath the three compartment sink have been cleaned, shelves and wheel castors on rolling carts have been cleaned, interior ceiling of microwave oven has been cleaned, industrial floor fan has been removed from the kitchen, kitchen walls have been scrubbed down and cleaned, floor perimeter and under appliances has been deep cleaned, the electrical outlet next to the grill and the pipes and wall behind steamer have been cleaned.  The entrance and exit door jams have been touched up and repainted.

2. A sanitation and environmental audit will be completed weekly by the Food Services Director and reported to the Administrator.

3. Audit will be completed weekly and reports will be presented at quarterly QA meeting.

4. Food Services Director to ensure compliance.

Based on interview and record review, it was determined the facility failed to communicate what actions or interventions were needed for a resident to staff, monitor and document on the progress of the condition at least weekly until resolved, refer a significant change of condition to the facility nurse and monitor each resident consistent with his or her evaluated needs and service plan, for 5 of 6 sampled residents (#s 1, 2, 3, 4 and 5) who experienced short term and significant changes of condition. Findings include, but are not limited to:

1a. Resident 4 was admitted to the facility in 2021 with diagnoses including diastolic heart failure.

The record indicated the resident had a fall on 06/23/22, after which the resident required increased assistance with transfers, ambulation, showering, dressing, toileting and tray service in his/her room.

After monitoring the resident's status for several weeks, Staff 7 (Service Plan Coordinator) determined the need for continued increased assistance represented a significant change of condition, and completed an evaluation of the change and updated the resident's service plan.

In an interview on 08/02/22, Staff 7 acknowledged she was unsure of whether she had notified one of the nurses that had been working with the facility of the significant change of condition. In an interview on 08/02/22, Staff 15 (RN) stated she had not received notice of Resident 4's significant change of condition.

b. The resident had a fall and developed bruising on the top of the left foot. The facility failed to document on the progress of the condition at least weekly between 06/24/22 and 07/13/22 when the condition was documented as resolved.

The need to ensure the facility had a process for informing the facility RN of significant changes of condition and documented on the progress of changes of condition at least weekly until resolved was discussed with Staff 1 (Administrator), Staff 2 (Consultant RN), Staff 3 (Service Plan Coordinator), Staff 6 (Resident Care Coordinator), Staff 7, Staff 15 and Staff 16 (Consultant RN) on 08/03/22. They acknowledged the findings.

2. Resident 3 was admitted to the facility in 2015 with diagnoses including mild dementia, irritable bowel syndrome and heart disease. The record also noted the resident experienced periodic back pain.

The service plan indicated Resident 3 was at risk for weight loss due to declining intake. The facility had implemented interventions which included encouraging dining in a supervised table in the facility dining room, tray service if the resident declined to come to the dining room and health shakes between meals.

There was no documented evidence the facility monitored whether the service-planned interventions were effective or whether other interventions needed to be developed.

The requirement of monitoring service-planned interventions for effectiveness was discussed with Staff 1 (Administrator), Staff 2 (Consultant RN), Staff 3 (Service Plan Coordinator), Staff 6 (Resident Care Coordinator), Staff 7 (Service Plan Coordinator), Staff 15 (RN) and Staff 16 (Consultant RN) on 08/03/22. They acknowledged the findings.

3. Resident 5 was admitted to the facility in December 2019 with diagnoses including diabetes and congestive heart failure.

The resident's 05/08/22 through 08/01/22 progress notes, skin care progress sheets, and physician communications were reviewed. The resident experienced the following change of condition related to wounds without documented monitoring at least weekly until resolution:

Resident 5 had chronic pressure ulcers to the right and left buttocks.  There was no documented evidence of monitoring the progress of the wounds after 06/02/22 through 7/29/22.

The need to monitor short term changes weekly to resolution was discussed with Staff 2 (Consultant RN) on 08/02/22. She acknowledged the findings. Staff 1 (Administrator) reported being aware of the findings and had no questions.

4. Resident 1 was admitted to the facility in February 2020 with diagnoses including diabetes mellitus and chronic kidney disease.

The resident's 04/30/22 through 08/01/22 progress notes, skin care progress sheets, outside provider notes and physician communications were reviewed. The resident experienced the following changes of condition related to wounds without documented monitoring by the facility nurse at least weekly until resolution:

* 06/11/22 onset of chronic pressure wound to the right buttock. There was no documented evidence of monitoring the progress of the wounds after 06/11/22 through 7/13/22; and

* 12/2021 onset of chronic pressure wounds to both heels. There was no documented evidence of monitoring of the progress of the wounds after 05/31/22 through 07/14/22.

5. Resident 2 was admitted to the facility in January 2014 with diagnoses including atrial fibrillation.

The resident's 04/29/22 through 08/01/22 progress notes, temporary service plans and the current service plan, dated 06/27/22, were reviewed. The resident experienced the following change of condition related to weight loss without evidence that new interventions were communicated to staff to follow:

* On 07/01/22, an RN assessment was completed related the resident's recent weight loss. Interventions were identified to address the weight loss, including providing the resident with persistent encouragement at meals, snacks and menu items of choice, offering health shakes and obtaining weekly weights. There was no documented evidence the interventions were communicated to staff and the interventions had not been implemented.

The need to monitor short term changes at least weekly to resolution and ensure interventions were communicated to staff was discussed with Staff 1 (Administrator) and Staff 2 (Consultant RN) on 08/02/22. They acknowledged the findings.

1. Resident 4 has had a change of condition assessment completed by the RN. Resident 4 bruising on foot has been resolved. Resident 3 has discharged. Resident 5 wounds are continuing to be monitored weekly and documented on. Resident 1 wounds are conituing to be monitored weekly and documented upon. Resident 2 interventions will be put in place and communicated with staff and documented accordingly.

2. Changes in resident condition will be monitored and identified through the 24 hour chart review and follow up process.  Changes in resident condition will also be discussed at morning stand up. Nursing staff have been in-serviced on assessing/evaluating skin concerns on a weekly basis until the issue is resolved/healed.

3. Monthly audits will be completed by Director of nursing to ensure that monitoring of any new change of conditions have been completed and that all skin checks have been completed timely and interventions put in place and communicated to staff. Audit details to be reported at quarterly QA meeting.

4. Director of nursing to ensure compliance  

3. Resident 3 was admitted to the facility in 2015 with diagnoses including mild dementia, irritable bowel syndrome and hemorrhoids.

The resident received hospital discharge orders dated 05/31/22 that included an order to increase routine senna (for constipation) from one 8.6 mg tablet BID to two 8.6 mg tablets BID.

Review of the MAR between 06/01/22 and 07/31/22 indicated the facility did not implement the new order for the increased dosage until 07/29/22.

The facility's failure to ensure medication orders were carried out as prescribed was reviewed with Staff 1 (Administrator), Staff 2 (Consultant RN), Staff 3 (Service Plan Coordinator), Staff 6 (Resident Care Coordinator), Staff 7 (Service Plan Coordinator), Staff 15 (RN) and Staff 16 (Consultant RN) on 08/03/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to follow physician orders as prescribed for 5 of 6 sampled residents (#s 1, 2, 3, 5 and 6) whose MARS and physician orders were reviewed. Findings include, but are not limited to:

1. Resident 5 was admitted to the facility in December 2019 with diagnoses including diabetes and hypothyroidism.

Resident 5's 07/01/22 through 07/31/22 MARs and signed physicians orders were reviewed and identified the following:  

* Blood sugar checks (CBG's) were ordered before meals and at bedtime (for diabetes). The physician was to be notified of any CBG less than 80 or greater than 400.  On 07/10/22 at 11:00 am and 8:00 pm, Resident 5's blood sugar levels were greater than 400.  There was no documented evidence the facility notified the physician of the blood sugars greater than 400.

* Orders for Humalog insulin (for diabetes) was scheduled to be administered three times a day with meals, and included instructions to hold the insulin for CBG's less than 120.  On 07/19/22 at 0800 Resident 5's CBG was 107. The Humalog insulin was administered when it should have been held as ordered.

* Orders for Lantus Solostar insulin (for diabetes) was scheduled to be administered twice daily, and included instructions to hold the insulin for CBG's less than 120.  On 07/04/22, 07/19/22 and 07/31/22 Resident 5's CBG was less than 120. The insulin was administered on each of the three occasions when it should have been held as ordered.

* Levothyroxine 112 mcg was ordered to be administered daily before breakfast for hypothyroidism. On 07/16/22 the facility failed to administer the medication.  

Following physician orders as prescribed was discussed with Staff 2 (Consultant RN) on 08/02/22. She acknowledged the findings. Staff 1 (Administrator) reported he had been informed of the findings and had no questions.

2. Resident 6 was admitted to the facility in December 2019 with diagnoses including hypothyroidism.

Resident 6's 07/01/22 through 07/31/22 MARs and signed physicians were reviewed and identified the following:  

* Levothyroxine 150 mcg was ordered to be administered daily on an empty stomach for hypothyroidism. On 07/16/22 and 07/18/22 the facility failed to administer the medication.

Following physician orders as prescribed was discussed with Staff 2 (Consultant RN) on 08/02/22. She acknowledged the findings. Staff 1 (Administrator) reported he had been informed of the findings and had no questions.

4. Resident 1 was admitted to the facility in February 2020 with diagnoses including diabetes mellitus and chronic kidney disease.

Resident 1's 07/01/22 through 07/31/22 MARs, vital signs logs and signed physician orders, dated 08/01/22, were reviewed and identified the following:  

* The physician's order for Carvedilol (for blood pressure control) twice per day included parameters to "take blood pressure before giving medication" and to "hold [the medication] for systolic blood pressure < (less than) 100";

* On 07/23/22 and 07/26/22, the resident had a systolic blood pressure reading below 100, and staff administered the medication when it should have been held; and

* The vital signs log showed staff did not consistently obtain the resident's blood pressure prior to each administration of the medication.  

5. Resident 2 admitted to the facility in January 2014 with diagnoses including atrial fibrillation.

Resident 2's 07/01/22 through 07/31/22 MARs and signed physician orders, dated 07/08/22, were reviewed and identified the following:  

* The physician's order for Prednisone 10 mg (for upper respiratory infection) for 5 days was not administered.

On 08/03/22, Staff 2 (Consultant RN) confirmed the order had not been transcribed to the MAR.

The need to ensure physician's orders were followed was discussed with Staff 1 (Administrator) and Staff 2 on 08/02/22. They acknowledged the findings. Staff 2 added the vital signs to the electronic MAR system prior to the survey exit.

1. Resident 5, the physician was made aware of the blood sugars that were greater than 400 in the last 30 days, notified of insulin that was given and should have been held and the one time thyroid medication was not given as ordered. Resident 6 physician was made aware of the missed thyroid medication on two occasions. Resident 3 has discharged. Resident 1 MAR was corrected so the med aide would be able to record/document the residents blood pressure prior to giving as ordered. Resident 2 physician was made aware that the prednisone that was ordered was not implemented and the order was discontinued.

2. In-service provided to med aides on following physician orders, monitoring blood pressure, notifying physician when blood sugars are below or above specified parameters that have been ordered and reviewing new orders when a resident returns from the hospital or appointment.

3. Daily audits of the EMAR will be conducted each morning by LN on duty to ensure orders were followed, physicians were notified, parameters were met. Audit results will be reported to the Director of nursing. Audit details to be reported at quarterly QA meeting.

4. Director of nursing to ensure facility compliance.

Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) that met the regulation for 5 of 5 sampled residents (#s 1, 2, 3, 4 and 5) whose records were reviewed. Findings include, but are not limited to:

There was no documented evidence the facility was using an ABST that would determine a staffing plan that was reflective to meet the 24-hour scheduled and unscheduled needs of residents and included all the required ABST elements.

The requirements of the ABST were discussed with Staff 1 (Administrator) and Staff 17 (Staffing Coordinator) on 08/02/22. They acknowledged the current acuity tool the facility was using did not include all the required information. The facility started transitioning to using the Department tool prior to the survey exit.

1. Facility will adopt and utilize state ABST tool for all residents residing in Assisted Living.

2. Service Plan Coordinators have input all residents and established minutes to ensure that facilities staffing plan would be reflective to meet the 24 hour scheduled and unscheduled needs of residents included in all the required ABST elements.

3. ABST tool will be updated on a monthly, quarterly basis or if a significant change of condition occurs for a resident.

4. Service plan coordinators will update monthly, quarterly or if a significant change of condition occurs and report to Administrator and Staffing Coordinator   

Based on interview and record review, it was determined the facility failed to ensure pre-service dementia training was completed prior to beginning work in the facility for 1 of 3 sampled staff (#12) whose training records were reviewed. Findings include, but are not limited to:

Staff training records were reviewed on 08/01/22.

* Staff 12 (Med Aide), hired 06/29/22, lacked documented evidence of having completed pre-service dementia training.

The need for staff to complete all required pre-service dementia training before working with residents was reviewed with Staff 1 (Administrator) on 08/01/22 at 4:00 pm. He acknowledged the findings. No further information was provided.

1. Staff #12 will complete pre-service Dementia training. Training will be placed in training folder.

2. All new staff hired will be required to complete their pre-service dementia training prior to being scheduled  for on the floor training. HR Director and Staffing Coordinator will coordinate and establish a training plan to ensure that all new hires meet their pre-educational requirements prior to being allowed to do hands on training. A training folder will be created to make audits easy to track.

3. A training audit will be completed on all new staff prior to them being scheduled with a trainer on the floor.

4. Human Resource Director and Staffing Coordinator will ensure these trainings are completed on a ongoing basis.

Based on interview and record review, it was determined the facility failed to ensure 1 of 3 caregiving staff (#12) demonstrated satisfactory performance in all job duties within 30 days of hire and completed First Aid certification and abdominal thrust training. Findings include, but are not limited to:

Training records were reviewed on 08/01/22.

There was no documented evidence Staff 12 (Med Aide), hired 06/29/22, had demonstrated competency in all required areas and within 30 days of hire including:

* 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 and observation and reporting; and

* General food safety, serving and sanitation.

Additionally, there was no documented evidence Staff 12 had completed First Aid certification and abdominal thrust training.

The need to ensure staff had demonstrated competence in all job duties within 30 days of hire and completed First Aid certification and abdominal thrust training was reviewed with Staff 1 (Administrator) on 08/01/22 at 4:00 pm. He acknowledged the findings. No further information was provided.

1. Staff #12 will complete trainings on:

 *Role of service plans in providing individualized care

 *Providing assistance with ADL's

 * Changes associated with normal aging

 *Identification, documentation, and reporting of

   change of condition

  *Conditions that require assessment, treatment and

    observation and reporting

  *General food safety, serving and sanitation.

Staff #12 will also complete and provide certificate for First aid and abdominal thrust.

2. A training program and audit tool has been created utilizing a separate training binder and spread sheet to ensure all trainings and certificates are recieved and filed away in the employees training folder.  

3. A training binder audit will be completed monthly with findings being reported to the Administrator and StaffingCcoordinator.  These finding will also be reported on Quarterly QA meetings.

4. The Human Resource Director in collaboration with the Staffing Coordinator will be responsible to ensure that all trainings are completed timely or staff member will be removed from the schedule until such trainings have been completed.              

Based on interview and record review, it was determined the facility failed to have documented evidence that 12 hours of annual in-service training, including six hours related to the care of the dementia resident, was completed for 3 of 3 long-term staff (#s 10, 11 and 13) whose training records were reviewed. Findings include, but are not limited to:

a. Staff 10 (CG), hired 06/27/19, failed to have documented evidence of completing six hours of annual in-service training related to provision of care, between 06/2021 and 06/2022.

b. Staff 11 (MT), hired 03/31/17, failed to have documented evidence of completing six hours of annual in-service training related to provision of care, between 03/2021 and 03/2022.

c. Staff 13 (MT), hired 06/24/05, failed to have documented evidence of completing six hours of required annual in-service training related to the care of the dementia resident, between 06/2021 and 06/2022.

The need to ensure staff completed required annual in-service training, based on anniversary dates of hire, was reviewed with Staff 1 (Administrator) on 08/01/22 at 4:00 pm. He acknowledged the findings. No further information was provided.

1. Staff 10 and 11 will complete 6 hours of training related to provision of care. Staff 13 will complete 6 hours of training related to the care of the dementia resident.

2. Staff training will be audited and placed in a training binder, an audit tool has been created and spread sheet to ensure all trainings and certificates are completed timely and filed in the employees training folder.  

3. An audit will be completed monthly on the training binder.  The findings will be reported to the Administrator and Staffing Coordinator for us to follow up on.  These findings will also be reported in Quarterly QA meetings.

4. The Human Resource Director in collaboration with the Staffing Coordinator will be responsible to ensure that all trainings are completed timely or staff member will be removed from the schedule until such trainings have been completed.              

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted every other month, included required components on fire drill records, and provided fire life safety instruction to staff on alternating months. Findings include, but are not limited to:

On 08/01/22, fire drill and fire/life safety training records for the previous six months were requested.

Review of the documentation provided identified the following:

* One fire drill had been completed during the six-month time frame reviewed;

* Fire drill records lacked the following components:

- Escape route used;

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

- Evacuation time-period needed;

- Number of occupants evacuated; and

- Evidence alternate routes were used during fire drills.

* Fire and life safety instruction was not provided to staff.

The requirements regarding fire drills and fire and life safety instruction for staff were reviewed with Staff 1 (Administrator) and Staff 5 (Maintenance Manager) on 08/01/22 at 2:20 pm. The findings were acknowledged.

1. A fire drill will be completed on a monthly basis moving forward. Fire drill records will include the following components moving forward: Escape route used, problems encountered (with comments relating to residents who resisted or failed to participate), the evacuation time period needed, the number of occupants evacuated, and evidence that alternative routes were used during drill.  Fire and life safety instruction will also be provided to staff.

2. Maintenance Director and Administrator will execute monthly fire drills ensuring that all shifts participate and are trained over a three month time period and that all components to the drill will be completed and documented. This will be recurring throughout the year.

3. Drill will be executed monthly. Monthly fire drill reminders will be placed in the TELS system as a reminder to Maintenance Director to assure compliance that this is getting done monthly. Findings of drill will be reported at quarterly QA meeting

4. Maintenance Director and Administrator will ensure compliance

Based on observation, 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 613.

The carpet and vinyl will be replaced on the first and second floors including the stairs in the front lobby area, sitting areas, corridor's, in front of the Business office Mgr's office, common areas adjacent to the front desk.

The first floor laundry room vinyl will be replaced around the drain and in the whole room.

The Maintenance Director will conduct weekly facility walk through's to audit where the carpets need cleaned, and repaired.

Facility walk through's and audits will be completed weekly by the Maintenance Director and discussed with the Administrator.

The Maintenance Director is responsible in auditing this weekly; the Administrator is responsible to assure compliance.

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

Observations of the inner courtyard surfaces and pathways on 08/01/22 and 08/02/22 showed the following:

* Uneven surfaces were noted where the concrete had cracked and separated or was broken; and

* Multiple drop-offs of 2-4 inches along several pathway edges.

The need to ensure pathways did not have potential tripping hazards was discussed with Staff 1 (Administrator) on 08/01/22 and Staff 14 (Owner/Management) on 08/02/22. The findings were acknowledged.

1. Facility will repair or replace any uneven surfaces where concrete was cracked or seperated. Areas along pathway edges will be filled with either: soil and seed, barkdust, or river rock to ensure there are no drop offs exceeding 2 inches.

2. Maintenance team and Administrator will do facility ground walks to ensure areas remain even, uncracked, and drop offs do not exceed two inches.

3. Rounds will be completed weekly. Findings will be reported at quarterly QA Meeting

4. Maintenance Director and Administrator will ensure compliance.

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

In interview on 12/29/22, Staff 1 (Administrator) acknowledged the findings and confirmed the facility had been granted an extension until 03/15/23 to complete maintenance and replacement of the cement patio surfaces and pathways.

1. Facility will repair or replace any uneven surfaces where concrete was cracked or seperated. Areas along pathway edges will be filled with either: soil and seed, barkdust, or river rock to ensure there are no drop offs exceeding 2 inches.

2. Maintenance team and Administrator will do weekly walking rounds to ensure areas remain even, uncracked, and drop offs do not exceed two inches.

3. Rounds will be completed weekly. Findings will be reported at quarterly QA Meeting

4. Maintenance director and Administrator will ensure compliance.

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

Observations of the facility on 08/01/22 revealed the following:

* Rooms 308, 326, 330, 432, 434, elevators, and fire doors had scraped doors and/or jambs;

* Carpet stains were observed in common areas near the Business Office Manager's office, first floor elevator, hallways near Rooms 321, 351, 407, 429 and first floor sitting area adjacent to the front desk;

* A first-floor laundry room was missing vinyl from around the floor drain;

* Stairs located in the front lobby had edges with thread bare carpet;

* A white gazebo had pillars with chipped paint and loose wood on the lower sections; and

* A rust colored gazebo had an accumulation of moss on the lattice and interior seating, sections of the lattice were loose, and several areas of wood on the interior and exterior were missing paint.

The surveyor toured the environment with Staff 1 (Administrator) on 08/01/22. He acknowledged the findings.

1. Rooms 308, 326, 330, 432, 434, elevators, and fire doors will be cleaned and paint will be touched up. Carpet will be replaced in the Assisted living side of the building. Vinyl from around 1st floor laundry room drain will be replaced, Stairs carpet will be replaced, white gazebo will be repaired and repainted, and rust colored gazebo will be removed from the area.

2. Environmental walk around the facility grounds will be completed weekly with Maintenance director and Administrator.

3.Environmental Walks around the facility grounds will be completed weekly. Audits of findings will be brought to quarterly QA meeting.

4. Maintenance Director and Administrator ensure compliance.

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

In interview on 12/29/22, Staff 1 (Administrator) acknowledged the findings and confirmed the facility had been granted an extension until 03/15/23 to complete maintenance and replacement of the facility carpet.

1. Rooms 308, 326, 330, 432, 434, elevators, and fire doors will be cleaned and paint will be touched up. Carpet will be replaced in the Assisted living side of the building. Vinyl from around 1st floor laundry room drain will be replaced, Stairs carpet will be replaced, white gazebo will be repaired and repainted, and rust colored gazebo will be removed from the area.

2. Environmental walking rounds will be completed weekly with Maintenance director and Administrator.

3. Walking rounds will be executed weekly. Audits of findings will be brought to quarterly QA meeting.

4. Maintenance director and Administrator ensure compliance.

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

Observations of the facility on 05/03/23 identified the following:

* Carpet stains were observed in common areas near the Business Office Manager's office, corridors throughout the facility and first floor sitting area adjacent to the front desk;

* Stairs located in the front lobby had edges with thread bare carpet; and

* A first-floor laundry room was missing vinyl from around the floor drain.

The surveyor toured the environment with Staff 21 (Administrator) on 05/03/23. She acknowledged the findings.

Refer to C455

Based on observation and interview, it was determined the facility failed to provide an exit door alarm or other acceptable system to alert staff when residents exited the ALF. Findings include, but are not limited to:

The first floor of the Assisted Living area of the building included the main entrance and additional side doors by which residents could exit the building.

The facility was toured on 08/02/22. There was no system in place which alerted staff when a resident exited the ALF building.

The need to have a system which alerted staff when residents exited the building was discussed with Staff 1 (Administrator) on 08/02/22. He acknowledged there were no door alarms or other system in place to alert staff when a resident exited.

1. Door alarms have been ordered and will be installed on all exit doors of the first floor of the Assisted Living area.

2. Door alarms will be tied to call system and audits will be run quarterly to ensure equipment is functioning properly.

3. Door alarms reports will be run monthly by Maintenance Director, to assure they are continuing to work and see if there are any concerns with the system and doors. Maintenance Director will discuss findsing with Administrator and correct any necessary corrections needed. A reminder will be placed in TELS systems for monthly reminders. Findings reported at quarterly QA meeting.

4. Maintenance director will ensure compliance.