Print Inspection: WDX3

The findings of the re-licensure survey conducted 9/28/21 through 9/30/21 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.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first re-visit to the re-licensure survey of 09/30/21, conducted 01/25/22, 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 revisit to the re-licensure survey of 9/30/21, conducted on 3/22/22, 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 Home and Community Based Services Regulations OARs 411 Division 004.

2. Resident 4 was admitted to the facility in 11/2018.

Resident 4's quarterly evaluation was not reflective in the following areas:

* Vision (Resident was legally blind);

* Hearing (Resident was hard of hearing);

* Weight loss (Resident had weight loss); and

* Resident self-administering vitamins/supplements.

The failure to ensure all areas in the quarterly evaluation were accurate was shared with Staff 2 (Director of Nursing/RN) and Staff 4 (Quality Coordinator) on 9/29/21. They acknowledged the findings.  

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (#3) and quarterly evaluations were reflective of care for 1 of 4 sampled residents (#4) whose evaluations were reviewed. Findings include, but are not limited to:

1. Resident 3's move-in evaluation, dated 5/19/21, lacked information regarding the following required elements:

* Spiritual/Cultural preferences; and

* Unsuccessful prior placements.

The move-in evaluation was reviewed with Staff 1 (Executive Director), Staff 2 (Director of Nursing /RN) and Staff 3 (Regional RN) on 9/29/21. They acknowledged the findings.

C252

1.Res # 3 - Move in evaluation was revised and does reflect questions regarding Spiritual/ Cultural preferences and unsuccessful prior placements. No action could be taken for this 2018 admission.

Res # 4 -A new  Quarterly evaluation will be completed to accurately reflect Residents status in all areas. Service plan will be updated as needed.

2.Move-in evaluation was updated to include Spiritual/ Cultural preferences and unsuccessful prior placements. The new move-in evaluation was distributed to all individuals that complete move in evaluations. It is currently in use for all new admissions.

3.All evaluations have been reviewed to ensure all regulatory areas are included in the evaluations. All evaluations meet regulatory requirements.

4.The DON will be responsible to ensure all actions are completed and monitored.

5.Compliance will be achieved by November 29, 2021.     

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 2 of 2 sampled residents (#s 7 and 10) whose evaluations were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 10's move-in evaluation, dated 12/19/21, lacked information regarding the following required elements:

* History of mental health treatments;

* Cognition - memory, confusion, decision making abilities;

* Personality;

* Housekeeping;

* Indicators of nursing needs;

* Complex medication regimen;

* History of dehydration or weight loss/gain;

* Unsuccessful prior placements;

* Elopement risk or history; and

* Environmental factors.

The move-in evaluation was reviewed with Staff 1 (Executive Director) and Staff 3 (Regional RN) on 01/25/22. They acknowledged the findings.

2. Resident 7's move-in evaluation, dated 12/24/21, lacked information regarding the following required elements:

* Visits to health practitioner, ER, hospital, nursing facility in the past year;

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

* History of mental health treatments;

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

* Non-pharmaceutical interventions for pain;

* Nutrition habits, fluid preferences;

* Indicators of nursing needs;

* Environmental factors that impact behaviors;

* Complex medication regimen;

* History of dehydration or weight loss/gain;

* Recent losses; and

* Unsuccessful prior placements.

The move-in evaluation was reviewed with Staff 1 (Executive Director) and Staff 3 (Regional RN) on 01/25/22. They acknowledged the findings.

C252

1. Community staff, including Regional RN, Resident Care Coordinator, and Quality Coordinator will ensure that all move-in evaluations address all required elements included in 411-054-0034 Resident Move-In and Evaluation.

Resident # 7 - Move in evaluation will be revised and to reflect questions regarding the following:

* Visits to health practitioner, ER,hospital, nursing facility in the past year;

* Vital signs if indicated by diagnosis,

health problems, or medications;

* History of mental health treatments;

* Personality, including how a person

copes with change or challenging

situations;

* Non-pharmaceutical interventions for

pain;

* Nutrition habits, fluid preferences;

* Indicators of nursing needs;

* Environmental factors that impact

behaviors;

* Complex medication regimen;

* History of dehydration or weight

loss/gain;

* Recent losses; and unsuccessful prior placements

Res # 10 -

Move in evaluation will be revised to reflect questions regarding the following:

* History of mental health treatments;

* Cognition - memory, confusion,

decision making abilities;

* Personality;

* Housekeeping;

* Indicators of nursing needs;

* Complex medication regimen;

* History of dehydration or weight

loss/gain;

* Unsuccessful prior placements; and

elopement risk or history;

2. The new comprehensive evaluation will be utilized for all pre-move in evaluations and quarterly evaluations

3.The revised evaluation will meet regulatory compliance.

4.The DON will be responsible to ensure all actions are completed and monitored.

5.Compliance will be achieved by March 11, 2022

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 instructions for staff for 4 of 4 sampled residents (#s 3, 4, 5 and 6) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 11/2018 with diagnoses including diabetes. During the acuity interview on 9/28/21 the resident was identified to have a personal caregiver and to have a recent weight loss.

The service plan dated 7/22/21 was not reflective in the following areas:

* Weight loss and current interventions;

* Resident self-administering vitamins and supplements;

* Personal caregiver administering some medications as physician ordered; and

* Fall mats used when the Resident was in bed.

The need to ensure service plans were reflective of the resident's current status and provided clear instructions for staff was discussed with Staff 2 (Director of Nursing/RN) and Staff 4 (Quality Coordinator) on 9/29/21. They acknowledged the findings.

4. Resident 6's 9/3/21 service plan was reviewed, was not reflective and did not provide clear direction to staff in the following areas:

During observations and interviews with caregivers and Resident 6 on 9/29/21, it was reported s/he received all meals in the apartment, needed the help of one person for transfers and incontinence care daily. Resident 6 was able to respond to conversation but communication was inconsistent as there were times when s/he would not respond and appeared confused and unable to communicate needs.

* Dining preferences, receiving meals in apartment;

* Communication ability and needs;

* Mobility and need for assistance with transfers;

* Evacuation assistance needed; and

* Toileting ability and need for assistance.

The need to ensure service plans were reflective and included clear direction to staff was discussed with Staff 1 (Executive Director) and Staff 4 (Quality Coordinator) on 9/29/21. They acknowledged the findings.

2. Resident 3's service plan was reviewed. The service plan, dated 7/2/21, was not reflective of the resident's status and lacked clear instructions to staff in the following areas:

* Home health PT;

* Wheelchair use as a mobility device; and

* Mood disorder and interventions.

The need to ensure service plans were reflective and included clear direction to staff was discussed with Staff 1 (Executive Director) and Staff 2 (Director of Nursing/RN) on 9/29/21. They acknowledged the findings.

3. Resident 5 was admitted to the facility in September 2019 with diagnosis of edema. During the acuity interview on 9/28/21 the resident was identified as using PRN psychotropic medications.

Observations of resident ADL care on 9/28/21 through 9/30/21, interviews with staff, and review of the resident's current service plan and interim service plans were conducted during the survey.

The service plan dated 9/17/21 was not reflective of the resident's status and lacked clear instructions to staff in the following areas:

* Use of compression stockings;

* Use of psychotropic medications and non pharmacological interventions;

* Behaviors related to anxiety; and

* Instructions for incontinent care to be completed in bed.

The need to ensure service plans were reflective of the resident's current status and provided clear instructions for staff was discussed with Staff 1 (Executive Director), Staff 2 (Director of Nursing/RN), Staff 3 (Regional RN) and Staff 4 (Quality Coordinator) on 9/30/21. They acknowledged the findings.

C260

1.Res # 4 - Service plan was updated to include weight loss and interventions, self-administration of vitamins and supplements, personal caregiver administering some medication, and fall mats.

Res # 3 - Service plan was updated to include Home Health PT, W/C, and mood disorder and interventions

Res # 5 - Service plan was updated to include use of compression stockings, use of psychotropic meds and interventions, behaviors, anxiety, and instructions for incontinent care in bed.

Res # 6 - Service plan was updated to include Dining preferences, communication, Mobility, transfers, evacuation assistance, and toileting needs.

2.Service plans will be reviewed to ensure all care needs are reflected in the plan. Nursing staff will be in-serviced on service plans and ensuring plans are reflective of all needs and changes.

3.An audit will be conducted weekly on 4 Residents by the Quality Coordinator or designee to ensure compliance. Results of the audits will be reported to the Quality Council. The Council will review audit results for additional actions needed and determine the continued frequency of the audits until substantial compliance is reached and maintained.

4.The DON will be responsible to ensure all actions are completed and monitored.

5.Compliance will be achieved by 11/29/21.

Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 1 of 4 sampled residents (#5) whose orders were reviewed.  Findings include, but are not limited to:

Resident 5 was admitted to the facility in September 2019 with diagnosis including chronic kidney disease.

Resident 5 had a signed physician order, dated 7/28/21, to administer polyethylene glycol powder (Miralax) every other day at 8:00 am.

The MAR, dated 8/28/21 through 9/27/21, showed Resident 5 was administered the medication daily.

The need to ensure orders were carried out as prescribed was discussed with Staff 1 (Executive Director), Staff 2 (Director of Nursing/RN), Staff 3 (Regional RN) and Staff 4 (Quality Coordinator). They acknowledged the findings.

C303

1.Res # 5 - The order for Miralax was changed to correctly reflect the physicians order.

Current orders will be reviewed for accuracy. Corrections will be made as necessary.

2.Med Techs will be in-serviced on order processing and triple check process.

3.An audit will be conducted weekly on 4 Residents to ensure compliance. Results of the audits will be reported to the quality council. The council will review for additional actions needed and determine the continued frequency of the audits until substantial compliance is reached and maintained.

4.The DON will be responsible to ensure all actions are completed and monitored.

5.Compliance will be achieved by 11/29/21.

Based on observation, interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed for 1 of 3 sampled residents (#7) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 7 was admitted to the facility in January 2022 with diagnoses including end stage renal disease, type 2 diabetes and bilateral lower extremity amputation.

Resident 7's signed physician orders, dated 01/04/22, and MAR dated 01/01/22 through 01/24/22, were reviewed and showed the following inaccuracies:

a. The following prescribed treatments had not been added on the MAR/TAR and were not being administered as prescribed:

* Check fistula on left arm every shift; and

* Enter weight post dialysis upon return three times per week.

b. During an interview and review of the medication blister pack for Sevelamer Carbonate (phosphorus binder), on 1/25/22, with Staff 17 (CG/RA), showed the following routine medication was not administered:

* On 01/12/22 at 5:00 PM Sevelamer Carbonate was still in the blister pack and was not administered.

The need to ensure orders were carried out as prescribed was discussed with Staff 1 (Executive Director) and Staff 3 (Regional RN) on 01/25/22. They acknowledged the findings.

C303

1.Res # 7- The orders were present from a skilled care admission and inadvertently missed being discontinued. The physician has been faxed to discontinue the two cited orders.

2. Admission orders will be reviewed by the DON or RCC prior to admit and orders not performed in our setting will be discontinued. Missed medications will be checked 5 days a week and followed up by the DON or RCC. Med Techs will be in-serviced on preventing missed meds by the DON.   

3.An audit will be conducted weekly on new admits  to ensure compliance with physician orders. Missed medications reviewed 5 days a week by RCC and audited weekly by the DON. Results of the audits will be reported to the quality council. The council will review for additional actions needed and determine the continued frequency of the audits until substantial compliance is reached and maintained.

4.The DON will be responsible to ensure all actions are completed and monitored.

5.Compliance will be achieved by 03/11/22.

4. Resident 4 was admitted to the facility in 11/2018 with diagnoses that included diabetes and was legally blind.

Resident 4's 9/1/21 through 9/28/21 MARs were reviewed and revealed the following inaccuracies:

a. Medications scheduled to be given routinely, but did not identified if staff, private caregiver, or resident was responsible for administering them:

* Dorzolamide - Timolol eye drop (for glaucoma);

* Latanoprost eye drops (for glaucoma); and

* Prednisone eye drops (anti-inflammatory).

The need to ensure residents' MARs had correct information as to who was responsible for administration and administration times for medications including insulin was discussed with Staff 2 (Director of Nursing/RN) and Staff 3 (Regional RN) on 9/28/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure residents' MARs were accurate for 4 of 4 sampled residents (#3, 4, 5 and 6) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 6's 9/1/21 through 9/28/21 MAR was reviewed and revealed the following inaccuracies:

* A 8/31/21 physician's order for Onadesteron (anti-nausea medication) directed to take 1 tablet by mouth every 6 hours as needed for nausea. The MAR instructed staff to administer 1 tablet by mouth every 8 hours as needed for nausea; and

* Lacked clear parameters for staff to follow related to when to administer Polyethylene Glycol OTC powder (bowel care medication) which instructed staff to give the medication every day as needed for bowel care.

The need to ensure accuracy of MAR documentation and provide clear parameters to staff was discussed with Staff 1 (Executive Director), Staff 3 (Regional RN) and Staff 4 (Quality Coordinator) on 9/29/21.  They acknowledged the findings.

2. Resident 3's 9/1/21 through 9/28/21 MAR was reviewed and revealed the following inaccuracies:

* An 8/25/21 physician's order was to discontinue a prescription for Estradiol cream. The medication continued to be on the MAR;

* Stated a range of times for administration of medications but did not contain documentation of the time medications were given;

* Resident 3 was prescribed two PRN bowel care medications - Bisacodyl and Docusate sodium. The MAR lacked clear parameters for staff regarding when to administer each medication;

* Resident 3 was prescribed three PRN medications to treat pain - Acetaminophen, Lidocaine patch and Tramadol (a narcotic pain med). The MAR lacked parameters for staff regarding when to administer each medication.

The need to ensure accuracy of MAR documentation and provide clear parameters to staff was discussed with Staff 1 (Executive Director), Staff 3 (Regional RN) and Staff 4 (Quality Coordinator) on 9/29/21. They acknowledged the findings.

3. Resident 5 was admitted to the facility in September 2019 with diagnoses of chronic kidney disease and frequent urinary tract infection.

Review of Resident 5's MAR dated 8/28/21 through 9/27/21 identified the following inaccuracies:

* The entry for monthly weight was not documented on 9/4/21; and

* Self administering Estradiol cream was not accurate information.

On 9/30/21, the need to ensure an accurate MAR was kept for all medications and treatments was discussed with Staff 1 (Executive Director), Staff 2 (Director of Nursing/RN), Staff 3 (Regional RN), and Staff 4 (Quality Coordinator). They acknowledged the findings.

C310

1.Res # 6 - Ondansetron order was corrected to every 6 hours.

Res # 3 - Estradiol cream was discontinued. Bowel meds and pain meds have clear parameters as to when to administer. The administration time for Levothyroxine was changed to 0600. Actual administration times can always be seen in the electronic MAR.

Res # 5 - No action can be taken for the missing weight.  The monthly weight was refused. Her service plan has been updated to reflect her periodic refusals of monthly weights. The Estradiol cream instructions have been updated to include staff providing the cream for her to self-administer.

Res # 4 - The person who will administer the 3 medications has been identified on the orders.

2.Med Techs will be in-serviced on order processing and the triple check process. All medication times will be reviewed to ensure meds that have time specific parameters related to pharmacy standards are not scheduled during a range of time but have a specific time assigned. Medications given for the same purpose will be reviewed to ensure specific parameters are present.

3.A random audit will be conducted weekly by the DON or designee on new orders received to ensure compliance. Issues will be corrected and additional education provided to staff involved. Results of the audits will be reviewed at the monthly quality council. The council will determine if additional actions are required and the continued frequency of the audit until substantial compliance is achieved and maintained.

4.The DON will be responsible to ensure all actions are completed and monitored.

5.Date of compliance: 11/29/21

Based on interview and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities was assessed thoroughly by an RN, PT or OT prior to use for 2 of 2 sampled residents (#s 1 and 5) who had bilateral half-length side rails on their bed.  Findings include, but are not limited to:

a. Resident 1 was admitted to the facility in 9/2021 with diagnoses including cerebral infarction and history of falls.

Interviews with staff, and review of the resident's current service plan and interim service plans were conducted during the survey.

Review of a bed rail evaluation, dated 9/28/21, had been completed by Staff 2 (Director of Nursing/RN). The evaluation lacked the following documentation:

* Instruction to caregivers on the correct use and precautions related to the use of the device; and

* Documentation of the use of the side rail on the service plan.

b. Resident 5 was admitted to the facility in September 2019. During the acuity interview on 9/28/21, Resident 5 was identified as using side rails.

Interviews with staff and a review of the current service plan and interim service plans were conducted during the survey.

Review of a bed rail evaluation dated 7/8/21, lacked the following documentation:

* Less restrictive alternatives evaluated prior to the use of the device; and

* Instruction to caregivers on the correct use and precautions related to use of the device.

The need to ensure the use of side rails were thoroughly evaluated was discussed with Staff 1 (Executive Director), Staff 2 (Director of Nursing/RN), Staff 3 (Regional RN) and Staff 4 (Quality Coordinator) on 9/30/21. They acknowledged the findings.

C340

1.Res # 1 - Service plan has been updated with staff instructions and use of the side rail. A new bed rail assessment has been completed that includes less restrictive alternatives tried and instructions to caregivers on correct use.

Res # 5 - A new bed rail assessment has been completed with less restrictive alternatives tried and instructions given to caregivers.

2.All nursing staff will be in-serviced on the use and precautions related to bed rails. Bed rail assessments and corresponding service plans will be reviewed and revised as needed.

3.A random audit will be performed weekly by the DON or designee on bed rail assessments and corresponding service plans. Results of the audits will be reviewed at the monthly quality council. The council will determine if additional actions are required and the continued frequency of the audit until substantial compliance is achieved and maintained.

4.The DON will be responsible to ensure all actions are completed and monitored.

5.Date of compliance: 11/29/21.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired caregiving staff (#s 10, 11 and 15) demonstrated satisfactory performance in all job duties within 30 days of hire. Findings include, but are not limited to:

Training records were reviewed on 9/29 and 9/30/21.

There was no documented evidence Staff 10 (CG/Resident Assistant), hired 5/16/21, Staff 11 (CG/Resident Assistant), hired 7/12/21 and Staff 15 (CG/Resident Assistant), hired 8/25/21 had demonstrated competence in the following required areas within 30 days of hire:

* Role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Identification, documentation and reporting of changes of condition;

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

* Staff 10 lacked documented evidence of medication administration competency.

The need to ensure staff had documentation of demonstrated competence in all job duties within 30 days was reviewed with Staff 1 (Executive Director) on 9/30/21. He acknowledged the findings.

C372

1.All new direct care associates will receive the necessary training required within 30 days of hire. This training will include, but not be limited to, the role of service plans; providing assistance with activities of daily living; changes associated with normal aging; identification of resident changes in functioning ability and documentation and reporting changes of condition; resident conditions that require assessment, treatment, observation, and reporting, and medication administration competency.

2. All new and recently hired direct care associates that have not completed required training within 30 days of hire will complete the required training.

3.The Executive Director and Human Resources associates will monitor and provide all needed associate training within 30 days of hire and as needed.

4.The Executive Director, DON, and Human Resources associates.

5.Compliance will be achieved by 11/29/21.

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 residents with dementia, was completed for 2 of 3 long-term staff (#s 12 and 16) whose training records were reviewed. Findings include, but are not limited to:

The annual in-service training records were reviewed on 9/29 and 9/30/21.

Staff 12 (CG/Resident Assistant), hired 8/21/16, and Staff 16 (CG/Resident Assistant), hired 9/26/18, failed to have documented evidence of completing 12 hours of required in-service training.

The need to ensure staff completed 12 hours of on-going training, including 6 hours related to dementia, was reviewed with Staff 1 (Executive Director) on 9/30/21. He acknowledged the findings.

C374

1.All associates will receive a minimum of 12 hours of in-service training, including six hours of training related to the care of residents with dementia. Training will include a combination of online and in-person learning.

2.Associate training will be tracked and monitored via an electronic spreadsheet and various learning certificates. These mediums will be compiles and tracked by our Human Resources representative.

3.A quarterly audit will be performed on each associate file to determine if compliance is achieved or if any trainings topics need to be completed. If needed, required trainings will be provided by our Human Resources associates.

4.The Executive Director, DON, Human Resources representative, and any other associate supervisor will monitor ongoing compliance.

5.Compliance will be achieved by 11/29/21.

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

On 9/29/21, review of facility fire drill and fire and life safety instruction records, from 4/2021 through 9/2021, and interviews with staff indicated the facility was not documented;

* The escape route used;

* Number of occupants evacuated;

* Problems encountered and comments related to residents who resisted or failed to participate in the drills was not documented; and

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

On 9/30/21, the need to ensure fire and life safety instruction was provided to staff on alternate months and residents were relocated during fire drills was discussed with Staff 1 (Executive Director) and Staff 5 (Maintenance Director). They acknowledged the findings.

C420

1.Facility fire drills will occur every other month at different times of the day, and include all shifts.  Fire drills will also include, but not be limited to the escape route used, number of occupants evacuated, and problems encountered and residents who refused to participate. Furthermore, fire and life safety education will be provided to associates on alternate months.

2.Executive Director will work with the Plant Operations Director to ensure compliance with all required elements of our monthly fire drills. Executive Director will also incorporate fire and life safety education during alternating all staff meetings (scheduled monthly).

3.A quarterly audit of community fire drills and associate training records will be conducted to ensure compliance.

4.The Executive Director, Plant Operations Director, and Human Resources representative will be responsible for maintaining ongoing compliance.

5.Compliance will be achieved by 11/29/21.

Based on interview and record review, it was determined the facility failed to provide Fire and Life Safety instruction to residents annually.  Findings include, but are not limited to:

Fire drill records, from 4/2021 through 9/2021, were reviewed on 9/29/21 with Staff 1 (Executive Director).

* Staff 1 stated the facility was not providing or documenting annual instruction for residents in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire.

* The facility was not using alternate routes during fire drills.

The requirements for Fire and Life Safety instruction for residents were reviewed with Staff 1 on 9/29/21. He acknowledged the findings.

C422

1.Residents will receive fire and life safety instructions upon admission and annually upon the anniversary of their move in date. Instruction will include general safety procedures, evacuation methods, responsibility during fire drills, and designated meeting places.

2.Both resident trainings will be conducted and recorded separately. The training upon move in will be conducted individually by our Move-In Coordinator and Plant Operations Director. Annual trainings will either be provided during monthly Resident Council meetings or individually as needed.

3.Records of the move in fire and life safety instructions, and annual instructions will be evaluated quarterly.

4.The Executive Director, Move-In Coordinator, and Plant Operations Director will be responsible for maintaining ongoing compliance.

5.Compliance will be established by 11/29/21.

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

Refer to C 252, C 303 and C 613.

1. New flooring for the entire ground floor corridor has been ordered with a projected arrival date of 03/11/2022

2. Installation of the new flooring is projected to be completed by 03/31/2022

3. An extention of the citation was approved by DHS and the alledged compliance date is 03/31/2022

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

Observations on 9/28/21 revealed multiple drop-offs of 2-4 inches along pathway edges and sitting areas in the patio, garden areas and walkways.

Additionally, several walkways were obstructed with branches, over-grown plants and garden hoses that posed a potential tripping hazard.

The need to ensure pathways did not have potential safety hazards was discussed with Staff 1 (Executive Director) and Staff 5 (Maintenance Director) on 9/29/21. They acknowledged the findings and stated a delivery of landscaping material had been ordered and would be installed.

C610

1.The general building exterior, including drop offs along pathway edges, will be corrected to ensure safety. Additionally, all tripping hazards will be removed from walkways.

2.Community staff will be responsible for removing tripping hazards, while the uneven pathways will be corrected by a preferred vendor.

3.Once completed, pathway edges and exterior walkways will be monitored as needed.

4.The Executive Director and Plant Operations Director will be responsible for ensuring the corrections are completed and monitored.

5.Compliance will be achieved by 11/29/21.

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

Observations of the facility on 9/28/21 and 9/29/21 showed the following areas in need of cleaning or repair:

* Multiple areas of the carpet in the corridors and entry ways throughout the ground floor of the facility had black stains and worn areas; and

* Rooms 120 and 226 had multiple dark stains on the carpets.

The areas in need of cleaning and repair were discussed with Staff 1 (Executive Director) and Staff 5 (Maintenance Director) on 9/29/21. They acknowledged the findings.

C613

1.Ground floor common area carpeting will be replaced to ensure compliance with OAR 411-054-0300.

2.Executive Director will work with a preferred contractor regarding the removal and replacement of ground floor common area carpeting.

3.Once replaced, the new carpeting will be cleaned as needed by community staff and routinely by professional cleaners.

4.The Executive Director, Plant Operations Director, and Housekeeping Director.

5.Compliance will be achieved by 11/29/21.

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

Observations of the facility on 01/25/22 showed the following areas in need of cleaning or repair:

* Multiple areas of the carpet in the corridors and entry ways throughout the ground floor of the facility had black stains and worn areas; and

* Rooms 120 and 226 had multiple dark stains on the carpets.

The areas in need of cleaning and repair were discussed with Staff 1 (Executive Director) and Staff 5 (Maintenance Director) on 01/25/22. They acknowledged the findings. An extension was granted until 03/21/22.

1. All outstanding tags will be in compliance on or before the date the facility alleges compliance.

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

The building was toured on 9/29/21 with Staff 5 (Maintenance Director). Observations and interviews with staff confirmed the doors by which residents could exit the facility did not have a working alarm or other acceptable system to alert staff when residents left the building. Some of the exit doors had an alarm installed, however, the audible chime was not sufficient to alert staff when the door was opened.

On 9/29/21, the need to ensure exit doors were equipped with an alarming device to alert staff when residents exited the building was discussed with Staff 1 (Executive Director).  He acknowledged the findings.

C655

1.All exit doors will be equipped with an alarming device to provide security and alert staff when residents are exiting the building.

2.The violation will not reoccur once all doors are equipped with the necessary alarming device.

3.Quarterly and as needed

4.Executive Director and Plant Operations Director

5.Compliance will be achieved by 11/29/21