Print Inspection: XD3K

The findings of the initial survey, conducted 08/29/22 through 08/30/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first re-visit to the re-licensure survey of 08/29/22, conducted 05/23/23 through 05/25/23, 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 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 08/30/22, conducted 11/29/23 through 12/01/23, are documented in this report. The survey was conducted to determine compliance with 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 third revisit to the re-licensure survey of 08/30/22, conducted 04/02/24 through 04/03/24, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Based on observation and interview, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety, or welfare of residents. Findings include, but are not limited to:

During the survey, 08/29/22 through 08/30/22, multiple staff were observed wearing masks below their noses or under their chins.

On 08/30/22, multiple visitors were observed not wearing masks.

The need to ensure all visitors who enter the building wear masks and all staff wear their masks properly to prevent the spread of COVID-19 was discussed with Staff 2 (RN) on 08/30/22. She acknowledged the findings.

1. Posted signs at all entrances indicate that masks are required upon entry and while present in community. If guests refuse, they are asked to vacate premises or conduct visits outside of the community.

Team Members are required to also wear masks while present in common areas or while in close contact with team members or residents as well as during food service. Corrective action is in place for those that violate this rule.

2. Supervisors will continue to provide guidance and direction to ensure compliance.

3. Daily evaluation will continue.

4. Responsible parties include all members of management; Campus Administrator, Wellness Director, Resident Care Coordinator, Memory Care Administrator, Dining Service Director, Life Enrichment Directors and Concierge.

Based on interview and record review, it was determined the facility failed to address all required elements on the move-in evaluation for 1 of 1 sampled resident (#2). Findings include, but are not limited to:

Resident 2 was admitted to the facility in 05/2022 with diagnoses including alcohol abuse, ocular laceration, and low back pain. Review of the resident's move-in evaluation, dated 05/05/22, identified the following elements which were not addressed:

* Interests, hobbies, social, leisure activities;

* List of current diagnoses;

* Visits to health practitioner(s), ER, hospital, or nursing facility in the past year;

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

* Pain: pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort;

* List of treatments: type, frequency, and level of assistance needed;

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

* Emergency evacuation ability;

* Complex medication regimen;

* History of dehydration or unexplained weight loss or gain;

* Recent losses; and

* Elopement risk or history.

The need to address all required elements in the move-in evaluation was discussed with Staff 2 (Wellness Director/RN) on 08/30/22. She acknowledged the findings.

1. Resident #2 shall be reevaluated as per OAR 411-054-0034 and administrator shall review for all elements.

2. Move In Evaluations will follow template that corresponds to OAR 411-054-0034. Evaluations will be reviewed by at least 1-2 other people (RCC, MCC, Wellness Director, Admin, or a delegate) to assure that all elements of the Evaluation have been completed.

3. Upon admission each residents evaluation and chart shall be reviewed by no less than two individuals to ensure completion. Quarterly chart reviews shall be completed to ensure all elements of OAR 411-054-0034 are met.

4. Responsibly parties include Wellness Director and Administrator to ensure compliance.

Based on observation, interview, and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements and were updated and modified during the 30 days following the resident's move-in for 1 of 1 sampled resident (#7) whose move-in evaluation was reviewed, and the facility failed to ensure quarterly evaluations were reflective of residents' current status and updated when a resident experienced a significant change of condition for 1 of 1 sampled resident (#9) whose evaluations were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 7 was admitted to the facility in April 2023 with diagnoses including osteoarthritis of the lumbar spine and depression.   

The move-in evaluation dated 03/31/23 lacked documentation relating to the following required elements:   

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

* History of dehydration;

* Emergency evacuation ability; and

* Elopement risk or history.

In an interview on 05/24/23, Staff 19 (Wellness Director, LPN) verified there were no updates made to the evaluation within the first 30 days from when the resident was admitted to the facility.

The need to ensure evaluations addressed all required elements and were updated as needed in the first 30 days of move-in was discussed on 05/25/23 with Staff 1 (Administrator), Staff 18 (RN), Staff 19, and Staff 20 (Assistant Wellness Director, LPN). They acknowledged the findings.

2. Resident 9 was admitted to the facility in August 2022 with diagnoses which included hypertension, cardiac arrhythmia, and cerebral infarction.

Observations, staff interviews and review of the record during the survey revealed s/he required full assistance with most ADLs and was currently receiving hospice services.

The most recent evaluation, dated 01/29/23, was not reflective of the resident's current health status and current needs in the following areas:

* Hospice admission;

* Recent losses;

* Use of hospital bed;

* Transferring;

* Dressing; and

* Toileting.

On 05/25/23, the need to ensure Resident 9's evaluation was reflective of his/her health status, current needs and was completed timely documenting change of condition updates was discussed with Staff 1 (Administrator), Staff 18 (RN), Staff 19 (Wellness Director, LPN) and Staff 20 (Assistant Wellness Director, LPN). They acknowledged the findings.

1. Residents #7 and #9 shall be re-evaluated as per OAR 411-054-0034 and administrator shall review for all elements.

2. Move In Evaluations, 30 Day Evaluations, and Quarterly Evaluations will follow a template that corresponds to OAR 411-054-0034. Evaluations will be reviewed by at least 1-2 other people (RCC, MCC, Wellness Director, Admin, or a delegate) to assure that all elements of the Evaluation have been completed. At the beginning of each month, Administrator and Wellness Director will pull a report from ECP that shows which residents are due for a re-evaluation.

3. Upon admission each resident's evaluation and chart shall be reviewed by no less than two individuals to ensure completion. Quarterly chart reviews shall be completed to ensure all elements of OAR 411-054-0034 are met.

4. Responsibly parties include Wellness Director and Administrator to ensure compliance.

Based on interview and record review, it was determined the facility failed to ensure initial evaluations addressed all required elements for 1 of 1 sampled resident (#10) whose initial evaluation was reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 10 was admitted to the facility in November 2023 with diagnoses including prostate cancer and type 2 diabetes.

The move-in evaluation, dated 11/09/23, lacked documentation relating to the required element of emergency evacuation ability.

The need to ensure initial evaluations addressed all required elements was discussed on 12/01/23 with Staff 25 (Campus Administrator), Staff 26 (Corporate RN), and Staff 31 (Regional Director of Operations). They acknowledged the findings.

1.Emergency evacuation ability has been add to the evaluation for resident 10.

2. The system will be corrected by training and auditing of evaluations (Growth and Wellness plans) with those directly initiating and updating the evaluations and service plan system.

3. Evaluations will be completed and reviewed at initial, 30-day, quarterly, and with significant change of condition.

4. RCC, Executive Director  

Based on interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current status and care needs for 1 of 5 sampled residents (#6). Findings include, but are not limited to:

Resident 6 was admitted to the facility in 04/2022 with diagnoses including Alzheimer's disease.

Review of the resident's 07/22/22 service plan, and interviews with staff and the resident, revealed the service plan was not reflective of the resident's current status related to the following:

* Communication abilities;

* Ability to use call light;

* Incontinence;

* Glasses;

* Recent loss of husband;

* Skin - red coccyx and perineal area;

* Hospice services; and

* Hospital bed.

The need to ensure the service plan was reflective of the resident's current status and care needs was discussed with Staff 2 (Wellness Director/RN) on 08/30/22. She acknowledged the findings.

1. Resident #6 shall be re-evaluated immediately to incorporate all elements identified in person-centered service plan as per OAR 411-004-0030.

2. Care plans shall be updated upon any Change of Condition as well as quarterly evaluations shall be completed and reviewed by service planning team quarterly.

3. A minimum of quarterly reviews shall be completed as well as upon change of condition based upon major life changes and feedback from care giving team.

4. Responsible parties include Wellness Director, Administrator and Caregiving Team.  

2. Resident 7 was admitted to the facility in April 2023 with diagnoses including osteoarthritis of the lumbar spine and depression.   

The resident's current service plan, dated 04/12/23, was reviewed, observations were made, and interviews were conducted between 05/23/23 and 05/25/23. Resident 7's service plan was not reflective and did not provide clear instruction to staff in the following areas:

* Routines, including preferred wake-up time and bedtime routine;

* Meal preferences including saving and warming up meals if s/he wakes up late;

* Mental health status including loneliness and social isolation;

* Increased confusion;

* Resistance to care;

* Mobility status;

* Level of assistance needed for ADLs;

* Toileting assistance including when the resident was independent and when s/he required assistance;

* Recent falls and interventions;

* The resident's ability to care for her/his dog; and

* Evacuation status.

The need to ensure resident service plans were reflective of current care needs, updated and provided clear direction to staff was reviewed with Staff 1 (Administrator), Staff 18 (RN), Staff 19 (Wellness Director, LPN), and Staff 20 (Assistant Wellness Director, LPN) on 05/25/23. 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' current status and care needs and provided clear instruction to staff for 2 of 3 sampled residents (#s 7 and 9) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 9 was admitted to the facility in August 2022 with diagnoses including hypertension, cardiac arrhythmia and cerebral infarction.

Interviews with care staff and observations of Resident 9 during the survey revealed s/he was incontinent, dependent on staff for ADL care, and had a change in marital status which impacted her/his care needs.  

Resident 9's current service plan, dated 01/29/23, failed to reflect the resident's care needs and lacked specific instruction to staff in the following areas:

* Bathing;

* Dressing;

* Grooming;

* Toileting; and

* Mobility.

The need to ensure service plans were reflective of the resident's current care needs and provided clear direction to staff was discussed with Staff 1 (Administrator), Staff 18 (RN), Staff 19 (Wellness Director, LPN) and Staff 20 (Assistant Wellness Director, LPN) on 05/25/23. They acknowledged the findings.

1. Residents #7 and #9 shall be re-evaluated immediately to incorporate all elements identified in person-centered service plan as per OAR 411-004-0030. Specific instructions for Care Staff will be added to the areas noted during survey.

2. Care plans shall be updated upon any Change of Condition as well as quarterly evaluations shall be completed and reviewed by a service planning team. Administrator and Wellness Director will review Service Plan to ensure clear and specific instructions are written into the Plan.

3. A minimum of quarterly reviews shall be completed as well as upon change of condition based upon major life changes and feedback from care giving team.

4. Responsible parties include Wellness Director, Administrator and Caregiving Team.  

Based on interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current status and care needs, provided clear instruction to staff, and were completed following the evaluation or assessment for 3 of 3 sampled residents (#s 11, 12, and 13) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 11 was admitted to the facility in July 2022 with diagnoses including hypertension.

Resident 11's significant change of condition assessment, dated 10/29/23, and service plan, dated 10/28/23, were reviewed. The service plan was signed as having been completed the day before the assessment.   

The need to ensure the assessment was completed prior to the development of the service plan was discussed with Staff 25 (Campus Administrator) and Staff 26 (Corporate RN) on 12/01/23. They acknowledged the findings.

2. Resident 13 was admitted to the facility in 08/2022 with diagnoses including Alzheimer's disease.

Review of the resident's current service plan, dated 08/31/23, revealed the following areas were not reflective and/or did not provide clear instruction to staff:

* Wheelchair versus walker for ambulation;

* Ability to stand;

* Transfer assistance needed;

* Meal assistance required; and

* Frequency of safety checks.

The need for the service plan to accurately reflect the resident's current care needs and status and to provide clear direction to staff for providing care was discussed with Staff 25 (Campus Administrator) and Staff 26 (Corporate RN) on 12/01/23. They acknowledged the findings.

3. Resident 12 was admitted to the facility in May of 2023 with diagnoses including dementia secondary to brain injury and history of prostate cancer.

The resident's current service plan dated 11/08/23 was not completed following the quarterly evaluation. The quarterly evaluation was completed 11/09/23.

On 12/01/23 the need to ensure resident service plans were completed following the quarterly evaluation was discussed with Staff 25 (Campus Administrator), Staff 26 (Corporate RN), and Staff 31 (Regional Director of Operations). They acknowledged the findings.

1. Resident 11 and 12 service plans have been signed and updated after the evaluation was completed.

Resident 13 service plan will be updated to ensure clear instructions are provided for wheelchair versus walker for ambulation, ability to stand, transfer assistance needed, meal assistance required, and frequency of safety checks

2. The system is corrected by providing additional training on processes and procedures pertaining to evaluation completed, then the service plan creation. Audit of all service plans to ensure clear and accurate instructions.

3. Service plans will be completed and reviewed at initial, 30-day, quarterly, or with any significant change of condition.

4. RCC and Executive Director

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team which included the resident, the resident's legal representative if applicable, any person of the resident's choice, the Administrator or designee, and at least one other staff person who was familiar with or who was going to provide services to the resident for 5 of 5 sampled residents (#s 1, 2, 4, 5, and 6) whose service plans were reviewed. Findings include, but are not limited to:

Current service plans for Residents 1, 2, 4, 5, and 6 were reviewed during the survey. There was no documented evidence a Service Planning Team participated in and reviewed the development of the service plans.

On 08/30/22 the need to ensure service plans were developed by a Service Planning Team was discussed with Staff 2 (Wellness Director/RN). She acknowledged the findings.

1. For residents #1, #2, #4, #5 and #6 a Service Planning Team to be established for any re-evaluations to be completed upon Change of Condition or at a minimum Quarterly. This action also applies to any other residents of The Landing.

2. Service Planning Team will be gathered to develop Care Plans after Change of Condition or Quarterly reviews. The team will consist of Resident and/or Representative, Residents Physician, Member of Wellness Team and Administrator or delegate.

3. Quarterly evaluations to be completed and documented that Service Planning Team is in place.

4. Responsible parties include Wellness Director and Administrator.

Based on observation, interview and record review, it was determined the facility failed to ensure residents who had short-term changes of condition were evaluated, resident-specific instructions or interventions were developed, interventions were evaluated for effectiveness, and the condition was monitored at least weekly to resolution for 5 of 5 sampled residents (#s 1, 2, 4, 5, and 6) who experienced changes of condition. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 11/2021 with diagnoses including osteoarthritis.

Observations of the resident, interviews with staff, review of the service plan dated 05/27/22, temporary service plans, incident investigations, and progress notes dated 05/24/22 through 08/28/22 identified the following:

a. Progress notes dated 07/09/22 revealed Resident 4 had an assisted fall and sustained a fracture to the right fibula (lower leg) and left radius (lower arm).

Staff 2 (Wellness Director/RN) reported on 08/29/22 the resident required increased assistance with ADLs, and was unable to walk for a few weeks after the fall.

Resident 4 was observed during survey to be wearing a splint to the left lower arm/ hand, and was able to walk independently with the use of a walker.

There was no documented monitoring at least weekly of the resident's condition and decreased mobility, resident-specific directions to staff, service plan update related to the fractures, or the increased assistance required as a result of the injuries.

The need to ensure short-term changes of condition had documentation to reflect monitoring at least weekly to resolution, provided clear, resident-specific directions to staff, and interventions were evaluated for effectiveness was discussed with Staff 2 (Wellness Director/RN) on 08/30/22. She acknowledged the findings.

b. During the entrance conference on 08/29/22 it was reported Resident 4 had chronic leg ulcers.

The resident was observed on 08/29/22 to have multiple fluid-filled blisters on the lower legs, and stated the blisters at times popped and left wounds.

There was no documented monitoring of the leg blisters and/or wounds at least weekly through resolution.

The need to ensure short-term changes of condition had documentation to reflect monitoring at least weekly to resolution was discussed with Staff 2 (Wellness Director/RN) on 08/30/22. She acknowledged the findings.

2. Resident 5 was admitted to the facility in 02/2022 with diagnoses including non-Hodgkin's lymphoma and chronic leg ulcers.

Observations of the resident, interviews with staff, review of the service plan dated 08/18/22, temporary service plans, and progress notes dated 05/24/22 through 08/28/22 revealed the following:

During the entrance conference it was reported Resident 5 had chronic leg ulcers and was currently being treated for cellulitis of the legs.

Resident 5 was observed on 08/29/22 with dressings to both lower extremities, around and just above the ankles.

There was no documented monitoring of the leg ulcers and cellulitis at least weekly until resolution.

The need to ensure short-term changes of condition were monitored and progress was documented at least weekly through resolution was discussed with Staff 2 (Wellness Director/RN) on 08/30/22. She acknowledged the findings.

3. Resident 6 was admitted to the facility in 04/2022 with diagnoses including Alzheimer's disease.

Review of the 05/29/22 through 08/29/22 progress notes and skin sheets revealed there was no documented evidence the facility had determined and documented what actions and interventions were needed for the resident or monitored the resident at least weekly through resolution for the following short-term changes of condition:

* 06/22/22 - Non-injury fall;

* 06/16/22 - Husband passed away;

* 06/14/22 - Red perineal and coccyx areas.

The need to determine and document what actions and interventions were needed for residents when they experienced short-term changes of condition, and to monitor the changes at least weekly through resolution, was discussed with Staff 2 (Wellness Director/RN) on 08/29/22. She acknowledged the findings.

4. Resident 1 was admitted to the facility in 02/2022 with diagnoses including diabetes.

The resident's clinical record, including progress notes dated 05/25/22 through 08/27/22, were reviewed, and staff and the resident were interviewed. Several short-term changes of condition were identified in the progress notes:

* 6/9 - there was redness "under breast and stomach" and a "laceration/opening" under the stomach on the right side;

* 6/23 - resident returned from a dental appointment "with gauze and instruction to replace for continued bleeding" and to only eat soft foods for three days;

* 6/25 - the facility received a faxed communication stating to "follow post operative instructions given to resident" [there was no indication who sent the fax];

* 6/26 - resident had a rash from his/her "feet to below the knees";

* 7/29 - during a shower, resident "was really week [sic] and could hardly move";

* 8/4 - resident had a "red raw rash under abdominal skin fold";

* 8/5 - there was an open area on the resident's "backside"; and

* 8/27 - resident experienced high systolic blood pressure of 151, which went up to 159 an hour later.

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

An interview with Staff 2 (Wellness Director/RN) verified the lack of documented monitoring for the resident's changes of condition.

The need for staff to document monitoring of resident changes of condition at least weekly was discussed with Staff 2 on 08/30/22. She acknowledged the findings.

5. Resident 2 was admitted to the facility in 05/2022 with diagnoses including alcohol abuse, ocular laceration, and low back pain.

A review of the resident's progress notes, incident reports and investigations, interim service plans, and Task Administration Records, dated 06/06/22 through 08/28/22, as well as interviews with staff and the resident, revealed the following short-term changes of condition:

* 06/06/22: A witnessed fall in which the resident hit his/her head and refused to go to the emergency room;

* 07/09/22: Demonstrated confusion and was attempting "to give someone a drink that was not there." The same day the resident was found sitting on the toilet holding an alcoholic beverage. When staff discovered him, he asked to be put to bed;

* 08/09/22: The resident was unresponsive after a shower. Later the same day, the resident was found on the floor in his/her apartment. S/he sustained a skin tear to the left arm and had redness on the forehead and chin; and

* The resident experienced significant weight fluctuations between 06/30/22 and 08/30/22, losing an overall 14 pounds in two months.

There was no documented evidence the resident's changes of condition were evaluated and referred to the RN if indicated, actions or interventions were developed and communicated with staff on all shifts, interventions were monitored for effectiveness, and/or staff consistently monitored changes through resolution, with at least weekly documentation.

The need to evaluate changes, refer changes to the RN if indicated, develop actions or interventions and communicate them with staff, monitor the interventions for effectiveness, and document the resident's progress at least weekly through resolution was discussed with Staff 2 (Wellness Director/RN) on 08/30/22. She acknowledged the findings.

1. Residents #1, #2, #4, #5 and #6: Current/Identified COCs will be documented and monitored per 24 Hour Log Book. Staff will be notified of COCs and trained on how to care for the resident with accepted interventions and how to identify any complications that may arise due to COC. Weekly progress notes will be documented by the Wellness Director.

2. The Wellness Director will be responsible for evaluating and documenting COCs. COCs will be communicated to the Wellness Team using a 24 hour log, which will also track the monitoring of COCs. Wellness Director and/or RCC will train the Team how to identify complications and what interventions should be used for COCs. The Wellness Director will monitor and document weekly findings.

3. The process being used for COCs will be evaluated initially on a monthly basis until the Administrator and Wellness Director both feel the process is working and in compliance with OAR 411-054-0040. After the initial monthly evaluations, the process will be evaluated quarterly.

4. Responsible Party: Wellness Director

1. Resident 7 was admitted to the facility in April 2023 with diagnoses including osteoarthritis of the lumbar spine and depression.   

A review of the resident's progress notes from 04/12/23 through 05/22/23, and staff interviews identified the resident experienced the following short-term changes of condition related to falls:

* 04/16/23 Resident had a fall and sustained a skin tear to his/her arm;

* 04/19/23 Resident had a fall while taking his/her dog out for a walk; and

* 05/10/23 Resident had a fall and hit the back of his/her head;

There was no documented evidence the facility consistently evaluated the resident, determined what resident specific actions or interventions were needed following each fall, communicated the actions and interventions to staff on all shifts and updated the service plan as needed.

The need to ensure resident specific actions or interventions were developed after a fall, and they included resident specific instructions for staff was discussed with

Staff 1 (Administrator), Staff 18 (RN), Staff 19 (Wellness Director, LPN) , and Staff 20 (Assistant Wellness Director, LPN) on 05/25/23. They acknowledged the findings.

2. Resident 9 was admitted to the facility August 2022 with diagnoses including hypertension and cerebral infarction.  

Resident 9's progress notes and facility records dated 04/01/23 through 05/23/23 were reviewed and revealed the following changes of condition:

* Began antibiotic for UTI on 04/11/23;

* Loss of spouse on 04/19/23;

* New medication (escitalopram) on 04/25/23;

* Return from hospital with fractured hip on 05/01/23;

* New medications (tramadol and potassium chloride ER) on 05/05/23;

* Dosage change (Lexapro) on 05/11/23;

There was no documented evidence the facility consistently evaluated the resident, determined actions or interventions specific to each change of condition, updated the service plan as needed, or monitored and documented on the progress of the condition at least weekly until resolved.

The need to ensure changes of condition were evaluated, interventions were determined, implemented, and communicated to staff and monitored at least weekly until resolved was discussed with Staff 1 (Administrator), Staff 18 (RN), Staff 19 (Wellness Director, LPN) and Staff 20 (Assistant Wellness Director) on 05/25/23 at 3:15 pm. The findings were acknowledged.  

Based on interview and record review, it was determined the facility failed to determine what actions or interventions were needed, communicate information to staff on all shifts, monitor effectiveness of interventions, and document weekly through resolution for 2 of 3 sampled residents (#s 7 and 9) who experienced short-term changes of condition. This is a repeat citation. Findings include but are not limited to:

1. Current/Identified COCs for Residents #7 and #9 will be documented and monitored per 24 Hour Log Book. Staff will be notified of COCs and trained on how to care for the resident with accepted interventions and how to identify any complications that may arise due to COC. Weekly progress notes will be documented by the Wellness Director and/or Registered Nurse.

2. The Wellness Director and Asst. Wellness Director will be responsible for Short-term COCs. The RN will be responsible for evaluating and documenting Significant COCs. COCs will be communicated to the Wellness Team using a 24 hour log, which will also track the monitoring of COCs. Wellness Director and/or RCC will train the Team how to identify complications and what interventions should be used for COCs. The Wellness Director and/or RN will monitor and document weekly findings and document resolution of COC.

3. The process being used for COCs will be evaluated quarterly to ensure compliance with OAR 411-054-0040.

4. Responsible Parties: Wellness Director and RN

Based on interview and record review, it was determined the facility failed to evaluate changes of condition, refer to the facility RN if needed, determine and document interventions needed, communicate the interventions to staff, and/or document monitoring of progress at least weekly through resolution for 1 of 3 sampled residents (#13) who experienced short-term changes of condition. This is a repeat citation. Findings include, but are not limited to:

Resident 13 was admitted to the facility in 08/2022 with diagnoses including Alzheimer's disease.

Review of the resident's clinical record, including progress notes dated 09/03/23 through 11/29/23, temporary service plans, and monitoring documentation was completed, and staff were interviewed.

a. Documentation identified the resident had an unwitnessed fall on 09/25/23. There was no documented evidence fall interventions were reviewed for effectiveness or new interventions were implemented.

b. In a progress note dated 11/14/23, staff documented the resident had a rash between his/her buttocks which was "open and painful." There was no documented evidence the resident's rash was monitored, with documentation at least weekly, until resolution.

In an interview on 11/30/23, Staff 26 (Corporate RN) confirmed there was no documentation of skin monitoring related to the rash documented on 11/14/23.

There was an additional note on 11/29/23 which indicated an incident report had been created for a skin concern. The facility provided a copy of the report that indicated staff observed "redness to resident's groin area" and a MT applied barrier cream.

On 12/01/23 the need to determine and document interventions, communicate interventions to staff, and to monitor through resolution, with at least weekly documentation, all short-term changes of condition experienced by residents was discussed with Staff 25 (Campus Administrator) and Staff 26. They acknowledged the findings. No additional information was provided.

1. Resident 13: Develop and implement new fall prevention strategies for fall identified on 9/25/23. Create ISP and alert charting. Nursing to assess rash in groin identified 11/14/23.

2. Clinical meetings to include review of alert charting, ISP review, incident reports.

3. Daily

4. Nurse, RCC, Executive Director

2. Resident 4 was admitted to the facility in 11/2021 with diagnoses including osteoarthritis and Parkinson's disease.

During the entrance conference on 08/29/22, staff reported the resident had a recent assisted fall and sustained a fracture to the left radius (lower arm) and right fibula (lower leg).

Staff 2 (Wellness Director/RN) reported after the fall with injuries Resident 4 required increased assistance in ADL tasks and was unable to walk.

The fall with fractures and increased assistance required in multiple areas of care and mobility constituted a significant change in condition. There was no documented evidence a significant change of condition assessment was completed by the RN which included findings, resident status, and interventions made as a result of the assessment.

The need to ensure an RN assessment was completed after a significant change of condition, to include review of and update to the service plan and instruction to staff, was discussed with Staff 2 on 08/30/22. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure an RN assessment was completed for significant changes in condition for 2 of 2 sampled residents (#s 2 and 4) who experienced significant changes. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 05/2022, with diagnoses including alcohol abuse, ocular laceration, and low back pain.

The resident's clinical record was reviewed, including 06/06/22 through 08/28/22 progress notes and weight records, and interviews were conducted with staff and the resident. The following weight changes were identified:

* 06/30/22: 174 pounds;

* 07/13/22: 151.2 pounds. This was a 22.8 pound loss; and

* 08/30/22: At the request of the surveyor, the resident was weighed and was 160 pounds. This was an 8.8 pound gain from 07/13/22 and a loss of 14 pounds from 06/30/22.

There was no documented evidence the RN completed an assessment to determine if the resident had experienced a significant change of condition.

In an interview with the resident on 08/30/22, s/he stated they did not like the food the facility served and usually ate a "couple of bites" of lunch and dinner. The resident indicated they had health shakes in their refrigerator and ate all meals in their apartment. The resident also acknowledged residents can request anything they want to eat from the kitchen.

The facility RN, in an interview on 08/30/22, stated she had not completed an assessment to determine if the resident's weight changes represented a significant change of condition.

The need for all significant changes to be assessed by an RN in a timely manner was discussed with Staff 2 (Wellness Director/RN) on 08/30/22. She acknowledged the findings.

1. Resident # 2: Monthly weights will be documented. RN will assess for Significant COC if there is a signficant change in weight. RN will follow all procedures outlined for COCs and update the Service Plan accordingly.

Resident 4: RN will document any Significant COCs, following all COC procedures and update Service Plan.

2. RN will complete an assessment following a Significant COC and update the Care Plan accordingly. All COC procedures will be followed, including: documenting in 24 hour log, communicating to staff about interventions and things to look for, etc.

3. This process will initially be evaluated on a monthly basis until the Admin and Wellness Director both feel the processes are working and in compliance with the corresponding OARs. After the initial monthly evaluations, the process will be evaluated quarterly to ensure compliance and that we are meeting the needs of the residents.

4. Responsible Party: Wellness Director

Based on interview and record review, it was determined the facility failed to ensure significant changes of condition were assessed by an RN in accordance with their conditions, findings documented and interventions developed and implemented as a result of the assessment for 1 of 1 sampled resident (#9) who experienced significant changes of condition. This is a repeat citation. Findings include, but are not limited to:

Resident 9 was admitted to the facility in August 2022 and had diagnoses which included cerebral infarction.

During the entrance conference on 05/23/23, staff stated the resident had recently been admitted to Hospice services and had a recent fall which resulted in a fractured hip.

Review of the resident's clinical record including progress notes dated 04/01/23 through 05/23/23 and resident weight history of 03/08/2023 through 05/11/2023 revealed the following significant changes of condition for which an assessment by the facility RN was required:

a. Review of the progress notes revealed that on 05/01/23 Resident 9 returned from the hospital following a fall which resulted in a fractured right hip.

b. A progress note dated 05/10/23 stated that Resident 9 had been admitted to Hospice services.

c. Resident 9's monthly weight history was reviewed and noted a weight on 04/20/23 of 160.9 lbs. On 05/11/23 Resident 9 had a documented weight of 183.4 lbs constituting a 13.98% weight gain.  During an interview on 05/24/23 at 9:05 am, Staff 18 (RN) was unaware of the significant weight gain for Resident 9.

This surveyor requested Resident 9 be re-weighed, which was done on 05/25/23 at 2:10 pm by Staff 7 (RCC). The re-weigh confirmed Resident 9's weight was 183.2 and included the weight of the wheelchair which was 36 lbs.  The weight subtracting the wheelchair was 147.4 lbs. It was concluded the weight from 04/20/23 to 05/11/23 was actually a significant weight loss of 13.5 lbs constituting an 8.39% loss.     

During an interview on 05/24/23 at 9:05 am, Staff 18 was unable to provide documentation of an RN assessment for the above changes of condition.

The need to complete an RN assessment for significant changes of condition, to include findings, resident status and interventions, was discussed with Staff 1 (Administrator), Staff 18, Staff 19 (Wellness Director, LPN) and Staff 20 (Assistant Wellness Director, LPN) on 05/25/23. They acknowledged the findings.

1. Monthly weights for Resident #9 will be documented. RN will assess for Significant COC if there is a signficant change in weight. RN will also perform an assessment on any future Sig COCs in a timely manner; Wellness Director or Asst Wellness Director will do so for Short-term COCs. Wellness Director and/or RN will follow all procedures outlined for COCs and update the Service Plan accordingly.

2. Wellness Director and/or RN will complete an assessment following all COCs (short-term or significant) and update the Care Plan accordingly. All COC procedures will be followed, including: documenting in 24 hour log, communicating to staff about interventions and things to look for, weekly nurse notes will be documented through to resolution.

3. This process will be evaluated quarterly by the Wellness Director to ensure compliance and that we are meeting the needs of the residents.

4. Responsible Parties: Wellness Director and RN

Based on interview and record review, it was determined the facility failed to ensure a RN assessment was completed for 1 of 2 sampled residents (#12) who experienced a significant change of condition. This is a repeat citation. Findings include, but are not limited to:

Resident 12 was admitted to the facility in May of 2023 with diagnoses including dementia secondary to brain injury and history of prostate cancer.

Review of the resident's monthly weight records from 06/15/23 through 11/06/23 showed the following:

The resident experienced a 13.8 pound weight gain from 10/06/23 to 11/06/23, which constituted an 8.6% weight gain in one month. The resident weighed 160 pounds on 10/06/23 and 173.8 pounds on 11/06/23.

On 11/30/23 the resident was observed to eat 100% of his/her lunch. The resident weighed 170.2 pounds on 12/1/23, in a weight taken at the request of the Surveyor.

Staff 26 (Corporate RN) stated in an interview on 11/30/23 she could not find a RN assessment from the previous RN for this significant change of condition.

On 12/01/23 the need to ensure the facility RN completed an assessment for all residents who experienced a significant change of condition was discussed with Staff 25 (Campus Administrator), Staff 26, and Staff 31 (Regional Director of Operations). They acknowledged the findings.

1. Resident 12: Significant change of condition for weight change will be completed by the RN and documented in a chart note.

2. RN will assess and doucment significant change of conditions weekly. A log will be implemented to keep track of significant changes. Weights will be completed at least monthly, reviewed, and any significant changes reported to the RN. Training to be provided to care staff on significant change of condition versus short-term change of condition.

3. Log will be reviewed and updated during daily clinical meeting and as needed by the RN.

4. RN, Executive Director

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

Resident 4 was admitted to the facility in 05/2021 with diagnoses including major depressive disorder and Parkinson's disease.

Resident 4's MARs and current physician orders, dated 07/01/22 through 08/28/22, were reviewed and revealed the following:

* Losartin 100 mg was ordered on 06/13/22 to be administered at bedtime daily for 30 days. The facility continued to administer the Losartin daily after the 30 days were completed.

* Melatonin 10 mg was ordered on 07/01/22 to be administered every evening. The melatonin was not added to the 07/2022 or 08/2022 MAR and was not administered. Staff were unable to locate a discontinuation of the order.

Resident 4's MARs and orders were reviewed with Staff 2 (Wellness Director/RN)  on 08/30/22. She acknowledged staff failed to ensure orders were carried out as prescribed.

1. Resident #4: Current Medication orders will be reviewed and Medication Systems will be updated to reflect current orders. Parameters and Adverse Effects will be included on all Medication Administration Records.

2. New, Discontinued, Updated Medication Orders will be triple checked for accuracy by Med Tech, RCC, and Wellness Director. Parameters and Adverse Effects will be included.

3. This process will be evaluated for every Medication addition/change/discontinuation for every resident on an ongoing basis- Triple Check.

4. Responsible Party: Wellness Director and Administrator

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included adverse side effects as indicated, effectiveness of PRN medications, and parameters for the administration of PRN medications for 4 of 4 sampled residents (#s 1, 4, 5, and 6). Findings include, but are not limited to:

1. Review of the 08/01/22 through 08/29/22 MAR for Residents 1, 4, 5, and 6 revealed there were no adverse side-effects of PRN medications listed.

2. Resident 6 was admitted to the facility in 04/2022 with diagnoses including Alzheimer's disease.

Review of the 06/15/22 physician orders and the 08/01/22 through 08/29/22 MAR revealed the following:

a. The resident's current physician orders included PRN alprazolam and lorazepam to treat anxiety/agitation. Alprazolam was administered once and lorazepam was administered nine times between 08/01/22 and 08/29/22. The facility failed to consistently document why the medication was given or whether it was effective.

b. The resident had physician orders for multiple PRN medications to treat constipation, pain, anxiety/agitation, and "air hunger." There were no parameters listed on the MAR related to the sequence in which to administer the medications.

c. The resident had an order to administer 0.5 mg to 1 mg of lorazepam PRN for anxiety/agitation, but did not list parameters under which staff should administer the different doses.

The need to ensure the MAR was accurate and included adverse side effects for medications as indicated and parameters for the administration of PRN medications was discussed with Staff 2 (Wellness Director/ RN) on 08/30/22. She acknowledged the findings.

1. Resident 1,4,5,6: Adverse Side Effects and Parameters for PRN Medications have been added to the MAR. Triple Check Process was used for accuracy.

2. An audit will be completed on all Resident Medication Administration Records. Adverse Effects and Parameters for PRN Medications will be added to the MAR for all residents. Non-Medicinal Interventions will be documented. Reason for giving PRN will be documented as well as effects of PRN medications. Triple Check Process will be used to ensure accuracy - Med Tech, RCC, Wellness Director.

3. This process will be continually evaluated as medications are added to the MAR for each Resident. Triple Check Process - Med Tech, RCC, Wellness Director.

4. Responsible Party: Wellness Director and Administrator

Based on interview and record review, it was determined the facility failed to ensure residents who chose to self-administer their medication were evaluated to determine their ability to safely do so, upon move-in and at least quarterly thereafter, for 2 of 2 sampled residents (#s 2 and 3) who self-administered their medication. Findings include, but are not limited to:

Facility records for Residents 2 and 3 were reviewed during survey, and the RN was interviewed. There was no documented evidence, which the RN confirmed, an evaluation of the residents' ability to safely self-administer their medication had been completed.

The need for an evaluation of the resident's ability to safely self-administer medication, at the time of admission to the facility and at least quarterly thereafter, was discussed with Staff 2 (Wellness Director/RN) on 08/30/22. She acknowledged the findings.

1. Residents #2, #3: Evaluations for Self Administration of Medication will immediately be completed on all Residents who Self Administrate by the RN.

2. Before move in and/or upon receipt of doctor's orders that allow for Self Administration of Medication, RN will perform an evaluation to ensure that the Resident is capable of administering their own medication. The RN will also perform a quarterly evaluation of residents to ensure they can continue to Self Adminster.

3. This process will be evaluated quarterly to make sure all Self Administrating Residents are still able to do so.

4. Responsible Party: Wellness Director

Based on interview and record review, it was determined the facility failed to document non-pharmacological interventions were attempted unsuccessfully prior to the administration of PRN psychotropic medications and failed to document how the resident expressed anxiety/agitation for 1 of 1 sampled resident (#6.) Findings include, but are not limited to:

Resident 6 was admitted to the facility in 04/2022 with diagnoses including Alzheimer's disease.

Review of the 06/15/22 physician orders, the 07/22/22 service plan, and the 08/01/22 through 08/29/22 MAR revealed the following:

The resident's current physician orders included both alprazolam and lorazepam to treat anxiety/agitation. Alprazolam was administered once and lorazepam was administered nine times between 08/01/22 and 08/29/22. There was no description of how the resident expressed anxiety/agitation and no documented evidence non-pharmacological interventions were identified or attempted prior to administration of the medications.

The need to document how the resident expressed anxiety/agitation, and identify/implement non-drug interventions without success prior to the administration of psychotropic medications was discussed with Staff 2 (Health Services Director/RN) on 08/30/22. She acknowledged the findings.

1) Resident 6: Med Techs will be trained on proper procedures, non-drug interventions and how to use them. A description of how the resident is expressing anxiety will be documented. Non-drug interventions used will also be documented. These steps will take place before the use of psychotropic medications.

2) For each resident prescribed PRN psychotropics, Med Techs will be trained on proper procedures, non-drug interventions and how to use them. A description of how the resident is expressing the potential need for the prescribed medication will be documented. Non-drug interventions used will also be documented. These steps will take place before the use of psychotropic medications.

3) This process will be evaluated during the initial order of PRN psychotropics and quarterly for each resident who is prescribed PRN psychotropics.

4) Responsible Party: Wellness Director and Administrator

Based on interview and record review, it was determined the facility failed to ensure an assessment was completed by the facility RN, PT, or OT prior to the use of a supportive device with restraining qualities and the device was included in the service plan for 1 of 1 (#6) sampled resident. Findings include, but are not limited to:

Resident 6 was admitted to the facility in 04/2022 with diagnoses including Alzheimer's disease.

The resident was identified to have a bed rail during the acuity interview. The bed rail was observed on the resident's bed on 08/29/22.

There was no documented evidence an assessment had been completed by an RN, PT, or OT prior to use of the bed rail. Review of the 07/22/22 service plan revealed it lacked information related to the use of the device.

The need to ensure supportive devices with restraining qualities were assessed prior to use and included in the resident's service plan was discussed with Staff 2 (Wellness Director/RN) on 08/30/22. She acknowledged the findings.

1) Resident 6: A bed rail assessment will be completed immediately by the Wellness Director and will be added to the Resident's Care Plan.

2) Upon receiving an order for use of supportive devices with restraining qualities from either PCP, Hospice, or Home Health, the Wellness Director will perform an assessment pertaining to the use of the device per the individual needs. The assessment will be documented and the Resident's Care Plan will be adjusted accordingly.

3) This process will be evaluated for each instance and quarterly to make sure compliance is maintained.

4) Responsible Party: Wellness Director

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff completed all pre-service orientation and dementia training prior to performing job duties. Findings include, but are not limited to:

Staff training records were reviewed on 08/29/22.

1. There was no documented evidence Staff 6 (CG), Staff 7 (MT/CG), Staff 11 (MT/CG), or Staff 17 (CG), hired 07/18/22, 07/26/22, 05/23/22, and 05/27/22, respectively, completed one or more of the following required pre-service orientation topics:

* Resident rights and values of CBC care;

* Abuse reporting requirements;

* Infectious disease prevention;

* Fire safety and emergency procedures; and

* A signed job description.

2. There was no documented evidence Staff 6 and Staff 7 completed the required pre-service dementia training prior to performing job duties.

The need for new hires to complete all pre-service orientation and dementia training prior to performing any job duties was discussed with Staff 1 (Campus Administrator) on 08/29/22. He acknowledged the findings.

1) Staff 6,7,11,17: All trainings will be reviewed and all missing training will be completed immediately.

2) All Pre-Service Orientation Training (Resident Rights, Abuse Reporting, Infectious Disease Control, Fire/Life Safety, Signed Job Description, etc) will be completed, documented, and filed in an organized fashion before all new hires are allowed to perform job duties. Oregon Care Partners Pre-Service Dementia Course will be used for any Direct Care Staff to meet state requirements for Pre-Service Dementia training. Certificates of completion for all Trainings will be kept in triplicate: Employee's File, Training Binder, and Admin's Master Binder.

3) This process will be evaluated during the New Hire process and quarterly to ensure compliance.

4) Responsible Party: Administrator

Based on interview and record review, it was determined the facility failed to ensure 3 of 4 newly hired staff demonstrated competency in all assigned job duties within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed on 08/29/22.

1. There was no documented evidence Staff 7 (CG), Staff 11 (MT/CG), or Staff 17 (CG), hired 07/26/22, 05/23/22, and 05/27/22, respectively, demonstrated competency in one or more of the following areas:

* 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 which require assessment, treatment, observation, and reporting;

* General food safety, serving, and sanitation; and

* First Aid/abdominal thrust.

The need to ensure all new hires demonstrated competency in all assigned job duties within 30 days of hire was discussed with Staff 1 (Campus Administrator) on 08/29/22. He acknowledged the findings.

1) Staff 7,11,17: Competency/Skills Checks have been performed on all employees that were missing this documentation in their file. Competency/Skills Checks include: Service Plans, ADLs, COCs, Documentation, Food Safety, Sanitation, First Aid/Abdominal Thrust.

2) Competency/Skills Checks will be completed and signed during Floor Training/Orientation. The Trainer and New Hire will both sign off on all skills, including all state requirements. The New Hire will not be allowed to work the floor alone until all skills have been signed off.

3) This process will be evaluated for each New Hire and quarterly to ensure compliance.

4) Responsible Party: Administrator

Based on interview and record review, it was determined the facility failed to ensure 1 of 1 long-term staff completed the required number of annual in-service training hours. Findings include, but are not limited to:

Staff training records were reviewed on 08/29/22.

There was no documented evidence Staff 16 (CG), hired 07/26/20, completed the required 12 hours of annual in-service training, to include a minimum of six hours of dementia care training.

The need for long-term staff to complete the required number of hours of annual in-service training was discussed with Staff 1 (Campus Administrator) on 08/29/22. He acknowledged the findings.

1) Staff 16: To date, Staff 16 has completed 6 hours of dementia training and will complete the other required hours of training before the compliance deadline. As competency/skills check has also been performed. Documentation of all training and skills checks will be kept in triplicate: Employee File, Training Binder, and Admin Master Binder.

2) Annual Training and Competency/Skills Checks will be tracked in our Training Binder and an Excel Spreadsheet that identifies when Annual Trainings are due (employee anniversary date). All Staff Meeting Training will be documented with times for each training. Employees who have not completed the required training will be written up or pulled off the floor until all training and skills checks have been completed.

3) This process will be evaluated quarterly to ensure compliance.

4) Responsible Party: Administrator

Based on interview and record review, it was determined the facility failed to conduct fire drills and to provide fire and life safety instruction to staff on alternating months, in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to:

Review of facility records on 08/30/22 with Staff 4 (Maintenance Director) and Staff 5 (Maintenance Assistant) identified the following deficiencies:

* There was no documented evidence fire drills were conducted every other month as required; and

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

On 08/30/22 the need to conduct regular fire drills, and to provide fire and life safety instruction to staff, in accordance with the OFC was discussed with Staff 2 (Wellness Director/RN), Staff 4, and Staff 5. They acknowledged the findings.

1) Fire Drills and Fire Training have been scheduled for the months of September and October. They will be performed on alternating months thereafter. Documentation will be kept in the appropriate places.

2) Fire Drills and Fire Training will be scheduled to alternate every other month. Fire Drills will be documented using forms provided by the Oregon Fire Marshall. Fire/Life Safety Trainings will be chosen from a list provided by the Oregon Fire Marshall that is specific to Assisted Living. Trainings will be documented using forms provided by the Oregon Fire Marshall. Administrator and Maintenance Director will coordinate drills to be performed on different work shifts using different routes and scenarios. Documentation for Drills and Training will be kept in the Fire/Life Safety Log, Employee Files, and Admin Master Binder.

3) This process will be evaluated quarterly to ensure compliance.

4) Responsible Party: Maintenance Director and Administrator

Based on interview and record review, it was determined the facility failed to provide fire and life safety instruction to residents within 24 hours of admission and at least annually, in accordance with the Oregon Fire Code (OFC).  Findings include, but are not limited to:

Review of facility records on 08/30/22 identified the following deficiencies:

* There was no documented evidence residents were instructed on general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places inside or outside the building in the event of an actual fire within 24 hours of admission; and

* There was no documented evidence annual training on fire safety was provided to residents.

On 08/30/22 the need to provide and document fire and life safety instruction for residents, within 24 hours of admission and at least annually, in accordance with the OFC was discussed with Staff 2 (Wellness Director/RN), Staff 4 (Maintenance Director), and Staff 5 (Maintenance Assistant). They acknowledged the findings.

1) Fire/Life Safety Training for Current Residents will be held in a group setting to catch up on compliance. Residents who cannot attend the Group Training will be trained on an individual basis. Documentation of the training will be kept in Resident Files, Fire/Life Safety Binder, and Admin Master Binder.

2) Fire/Life Safety Training will take place during Contract Signing or on the date of Move-In. Community is developing a video that will walk Residents through procedures, routes, and scenarios. Residents will then be able to ask questions. Annual Training will take place on an individual basis on or before Resident's Anniversary date. Resident and Trainer will document the Training, which will be kept in Resident Files, Fire/Life Safety Binder, and Admin Binder.

3) This process will be evaluated during every training and once a semester to ensure compliance.

4) Responsible Party: Maintenance Director and Administrator

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

Refer to C252, C260, C270 and C280.

Based on observation, interview, and record review, it was determined the facility failed to ensure the 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, C260, C270, and C280.

Refer to C252, C260, C270, and C280.

Campus Administrator is responsible for implementing, monitoring and ensuring completion of the POC.

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

During a tour of the environment on 08/29/22, multiple drop-offs of up to three inches from the concrete to the planting surface were observed along the perimeter and courtyard pathway edges.

The need to ensure facility pathways did not have drop-offs which posed a potential safety risk for residents was discussed with Staff 1 (Campus Administrator) on 08/29/22. He acknowledged the findings.

1) To date, an estimate has been received by Landscapers to bring the Bark Mulch level with Walking Paths. A date will be scheduled for this maintenance ASAP, but at a minimum before compliance deadline.

2) Paths will be inspected by Maintenance Director and Administrator regularly during "rainy season" and at a minimum of quarterly to ensure compliance. Maintenance Director will perform necessary maintenace to ensure compliance. If more bark mulch needs to be added, landscapers will be notified and necessary work will be completed.

3) This process will be evaluated regularly during "rainy season" and at a minimum of quarterly to ensure compliance.

4) Responsible Party: Maintenance Director and Administrator