Solomia Home Care LLC

The findings of the Change of Ownership survey, conducted 11/27/23 through 11/29/23, 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 livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day
The findings of the revisit to the re-licensure survey of 11/29/23, conducted on 03/20/24, 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.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans provided clear direction to staff which included a written description of who shall provide the services and what, when, how, and how often the services shall be provided, and were updated as needed for 2 of 2 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to:1. Resident 1 was admitted in 02/2022 with diagnoses including dementia, hypertension, and acute coronary syndrome.The resident's 08/01/23 service plan and Change of Care documents, dated from 10/13/23 through 11/20/23, were reviewed. Resident 1 was observed and staff were interviewed. The following areas were either not reflective on the resident's service plan or lacked clear direction to staff: * Weekly visits from HHPT; * Beverage preferences to maintain hydration; * Behaviors relating to showers and effective interventions; * Housekeeping; * Laundry; * Emergency evacuation instructions; * Pain, including non-drug interventions; * Instructions to staff if side rails were loose or in disrepair; * The use of compression socks; * Clear instruction on when to notify Staff 1 (Administrator) relating to "consistent" low blood pressure readings; and * Status on oral surgery after a crown fell out. The need to ensure service plans provided clear direction to staff which included a written description of who shall provide the services and what, when, how, and how often the services shall be provided and were updated as needed was discussed with Staff 1 on 11/29/23. She acknowledged the findings. 2. Resident 2 was admitted in 07/2023 with diagnoses including vascular dementia, kidney failure, and edema. The resident's 07/03/23 service plan and Change of Care documents, dated from 09/15/23 through 11/15/23, were reviewed. Resident 2 was observed and staff were interviewed. The following areas were either not reflective on the resident's service plan or lacked clear direction to staff: * Durable medical equipment such as a tilt-in-space wheelchair and an air overlay, pressure relieving mattress for the hospital bed; * Directions to staff if there were issues with the air overlay mattress;* Instructions to staff if side rails were loose or in disrepair; * Ability to walk with a walker; * Non-drug interventions for behaviors; * Instructions on who changes the filter and tubing on the resident's oxygen concentrator and how often the task was needed; * What services hospice provided and how often; * Housekeeping; * Laundry; * Pain, including non-drug interventions; * Emergency evacuation instructions; * Portable oxygen instructions including liter flow; * Leisure activities; * Instructions to staff relating to the care of compression stockings; * Beverage preferences; * Incontinent care needs including how the resident communicates s/he is in need of care and how often the resident needs to be checked on for assistance; * Bed time routine including the liter flow of oxygen and the blue wedge pillow placement; and* How often staff are to check on Resident 2 during the night. The need to ensure service plans provided clear direction to staff which included a written description of who shall provide the services and what, when, how, and how often the services shall be provided and were updated as needed was discussed with Staff 1 (Administrator) on 11/29/23. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to monitor and document what actions or interventions were needed for short-term changes of condition, including resident-specific instructions communicated to staff on each shift with weekly progress noted through resolution for 2 of 2 sampled residents (#s 1 and 2) who were reviewed for changes of condition. Findings include, but are not limited to: 1. Resident 1 was admitted in 02/2022 with diagnoses including dementia, hypertension, and acute coronary syndrome.Resident 1's medical chart was reviewed and the following changes of condition were identified: * 10/01/23 - "hard to transfer, very sleepy, leaning forward in chair, having [trouble sitting up];* 10/13/23 - "some changes in medication" (not specified); * 11/18/23 - return from the hospital after having a heart attack; * 11/20/23 - new medications added for aspirin (blood thinner), atorvastatin (lower cholesterol), clopidogrel (heart attack and stroke prevention), metoprolol (to treat high blood pressure); and * 11/20/23 - change in medications for mirtazapine (antidepressant) and risperidone (for agitation), both scheduled and PRN. There was no documented evidence the resident's short term changes of condition had actions or interventions determined and communicated to staff on each shift nor were the changes monitored weekly through resolution. The need to ensure residents who experienced short term changes of condition, had actions or interventions determined, the actions or interventions were communicated to staff on each shift, and weekly progress was noted was discussed with Staff 1 (Administrator) on 11/29/23. She acknowledged the findings.2. Resident 2 was admitted in 07/2023 with diagnoses including vascular dementia, kidney failure, and edema.Resident 1's medical chart was reviewed and the following changes of condition were identified: * 09/12/23 - staff documented the resident had a fever of 99.8; * 09/17/23 - staff "noticed a red spot on right buttcheek"; and * 10/08/23 - fall out of bed. On 11/29/23 at 10:12 am, Staff 3 (MT/CG) verified that Resident 2 had no current skin issues.There was no documented evidence the resident's short term changes of condition had actions or interventions determined and communicated to staff on each shift nor were the changes monitored weekly through resolution. The need to ensure residents who experienced short term changes of condition, had actions or interventions determined, the actions or interventions were communicated to staff on each shift, and weekly progress was noted was discussed with Staff 1 (Administrator) on 11/29/23. She acknowledged the findings.

Based on interview and record review, it was determined the Administrator failed to show documented evidence of a current Residential Care Facility Administrator license. Findings include, but are not limited to:On 11/27/23, the facility was asked to provide documentation of the Residential Care Facility Administrator license. There was no documented evidence Staff 1 (Administrator) had a Residential Care Facility Administrator license that met the department's requirements. The need to ensure the facility's administrator had a Residential Care Facility Administrator was discussed with Staff 1 on 11/28/23. She acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to develop an acuity-based staffing tool (ABST) that included the 22 required components, reflected an accurate time frame needed for each component, and was updated with significant changes of condition and at least quarterly to generate an accurate staffing plan. Findings include, but are not limited to:The facility's ABST was reviewed with Staff 2 (Administrative Assistant) on 11/28/23. The following was identified:a. The facility's ABST did not include the following required components:* If multiple staff are required to assist with transferring and completing tasks, how much additional time is needed;* Providing non-drug interventions for pain management;* Providing treatments (e.g. skin care, wound care, antibiotic treatments); and* Completing resident specific housekeeping performed by care staff (laundry was addressed on the facility's tool).b. The minutes assigned to the components were not reflective of the time it would take to complete the task. Examples include:* Five minutes a day to complete laundry services for each resident;* Five minutes a day, per resident, to respond to call lights in a 24 hour period; * Forty minutes a day for supervising, cueing, or supporting while eating three meals and two snacks in a 24 hour period.Per observation, not all seven of the residents were being supervised, cued, or supported while eating breakfast, lunch, and a snack between the hours of 8:45 am and 3:15 pm. However, all seven residents were assigned 40 minutes per day for this activity. When asked how long it would take staff to assist a resident to the bathroom after the resident used their call light, Staff 2 agreed the assistance needed would take longer than five minutes each time.c. It was confirmed by Staff 2 on 11/28/23 at 12:10 pm that the ABST was not updated with significant changes of condition or quarterly.The need to ensure the facility included all 22 required components in their ABST, the minutes were reflective of the time needed to complete each task, and was updated with significant changes of condition and at least quarterly was discussed with Staff 1 (Administrator) on 11/29/23 and Staff 2 on 11/28/23. Staff 2 asked for resources relating to using the state's ABST, which the survey team provided.

Based on observation and interview, it was determined the facility failed to ensure all interior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) were kept in good repair. Findings include, but are not limited to:The facility's environment was toured on 11/28/23 and the following was observed:* Room two had a deep gouge in the wall behind a recliner;* The door leading into the hall where the residents' units were had paint chipping; * There were multiple areas where paint was chipping down the hallway where the resident units were located; and * Multiple door frames down the resident units hall were observed with splintering wood and/or chipped paint.The need to ensure the facility's interior environment was kept in good repair was discussed with Staff 1 (Administrator) who acknowledged the findings.

Based on record review and interview, it was determined the facility failed to ensure residents who lived in the facility were provided a key to their units. Findings include, but are not limited to:Review of records for Residents 1 and 2 revealed no documented evidence the residents had been provided keys to their rooms or had been evaluated for the ability to manage keys to their rooms.On 11/29/23 at approximately 11:15 am, Staff 1 (Administrator) confirmed the residents had not received a key to their room nor had they been evaluated for the ability to manage a key. The need to ensure all residents were provided keys to their units was discussed with Staff 1 on 11/29/23. She acknowledged the findings.

The findings of the re-licensure survey, conducted 4/14/21 through 4/15/21, 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 Home and Community Based Services Regulations OARs 411 Division 004.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day
The findings of the first re-visit to the re-licensure survey of 5/14/21, conducted 8/17/21, 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. Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day

The findings of the second revisit to the re-licensure survey of 5/14/21, conducted 11/03/21, 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.

Based on interview and record review, it was determined the facility failed to ensure all required elements were addressed in residents' evaluations for 1 of 1 sampled resident (# 2) whose move-in evaluation was reviewed and 1 of 1 sampled resident (# 1) who lacked a quarterly evaluation. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in March 2021 with diagnoses including vascular dementia.Resident 2's move-in evaluation, dated 2/25/21 was reviewed. There was no documented evidence the following required elements were addressed prior to move-in:* Mental health: history of treatment;* Personality, including how the person copes with change or challenging situations;* Pain: including how a person expresses pain or discomfort;* Skin condition;* List of treatments, including type, frequency and level of assistance needed;* Complex medication regimen;* Elopement risk or history; and* Environmental factors that impact the resident's behavior, including, but not limited to noise, lighting and room temperature.The facility's failure to address all required elements prior to resident's admission to the facility was discussed with Staff 1 (Owner) on 5/14/21. She acknowledged the findings.2. Resident 1 was admitted to the facility in December 2020 with diagnoses including a history of recurrent urinary tract infections.Resident 1's current evaluation, dated 12/27/20, was not updated quarterly as required. The facility's failure to document a resident quarterly evaluation was discussed with Staff 2 (Med Tech) on 5/13/21. No additional information was provided.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of the resident's current health status and care needs and provided clear direction to staff for 1 of 2 sampled resident (# 2) whose service plans were reviewed. Findings include, but are not limited to:Resident 2 was admitted to the facility in March 2021 with diagnoses including vascular dementia, chronic kidney disease and a fractured clavicle. On 5/13/21 and 5/14/21, the most recent service plan (no date), physician's orders and chart notes were reviewed. Observations and interview with the resident and staff revealed the service plan was not reflective or lacked clear direction for staff in the following areas:* How and when to use the Hoyer lift for transfers, air mattress and arm sling;* Use of side rails on the bed;* Precautions related to clavicle fracture;* Pain and interventions;* Behaviors including interventions when refusing care;* Activity preferences;* Mood indicators and history of depression, including interventions to be tried;* History of weight loss, meal preferences and interventions to be tried; and* Hospice services.The requirement to ensure service plans were reflective of the resident's needs and preferences and provided clear direction to staff was discussed with Staff 1 (Owner) on 5/14/21. She acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of resident's current needs and status, provided clear direction to staff and were followed for 1 of 2 sampled residents (#4) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:Resident 4 was admitted to the facility in 1/2021. Review of the resident's service plan, dated 8/12/21, interviews with Staff 7 (MT/CG) and Staff 2 (Administrator), and observations of the resident and his/her apartment indicated the following deficiencies: Resident 2's service plan was not reflective, lacked clear instruction to staff or was not implemented in the following areas:*Pain issues and management;*Fall mat next to the resident's bed;*Use of toothettes (oral swabs);*Puree diet (physician orders on 8/13/21 changed diet from "mechanical soft" to puree, but service plan was not reflective); and*"Honey-thick" liquids (orders on 8/13/21 called for "honey-thick", but the service plan still stated "nectar-thick").On 8/17/21 the need to ensure service plans were reflective of residents current status, provided clear direction to staff and were followed was discussed with Staff 1 (Owner) and Staff 2. They acknowledged the findings. No further documentation was provided.

Based on interview and record review, the facility failed to have written policies to ensure a resident monitoring and reporting system was implemented 24-hours a day with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action. The facility failed to have written communication of a resident's change of condition, and any required interventions, for caregivers on each shift and documentation of staff instructions or interventions that were resident specific and made part of the resident record with weekly progress noted until the condition resolved for 1 of 1 sampled residents (# 1 ) who required monitoring. Findings include, by are not limited to:Resident 1 was admitted to the facility in December 2020 with diagnoses including a history of recurring urinary tract infections. A review of chart and outside provider notes revealed the following: a. On 3/5/21, a care plan change form was completed stating the resident was seen by their physician for "ongoing rash". A new ointment was ordered BID and a patch was ordered to be changed every 7 days. Outside provider notes from home health/RN were reviewed. On 3/29/21, there was no mention of the resident's skin condition. On 4/6/21, the home health RN documented the resident "continues to scratch arm and back". On 4/29/21, the RN instructed facility staff to "please put lotion within reach of pt...complaining of itching..., and skin is overall improved."The record lacked evidence of weekly progress notes on the skin conditions until resolved and there was no instruction to staff on monitoring of the new medication. b. A physician's order, dated 1/24/21, indicated Oxybutynin would be started for control of bladder spasms and cephalexin (Keflex) for treatment of a urinary tract infection (UTI). Home health notes on 3/29/21 noted "dark hematuria, [resident] reports increased urinary spasms, burning". The home health RN recommended increased "H2O" and indicated they administered the residents' B12 injection. On 4/29/21, home health notes requested facility staff "note color of urine daily and report increased blood, blood clots." The record lacked evidence the resident's bladder spasms and UTI were monitored and interventions provided until resolved and there was no instruction to staff on monitoring of the new medications.During an interview with Staff 2 (Med Tech) on 5/13/21 and Staff 1 (Owner) on 5/14/21, it was determined the facility did not have a clear process for monitoring and reporting changes of condition. The need to ensure a monitoring and reporting system was in place with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action and the need to document evidence of monitoring of changes in condition weekly until resolved was discussed with Staff 1 (Owner) on 5/14/21. No additional information was provided.

Based on interview and record review, the facility failed to have a health services system in place which included an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation. The facility failed to provide an adequate number of nursing hours relevant to the census and acuity of the resident population and that the facility nurse was provided as stated in disclosure material. Findings include, but are not limited to:During interviews on 5/13/21 - 5/14/21, Staff 1 (Owner) and Staff 2 (Med Tech) confirmed the facility did not currently have an RN that was scheduled for regular on-site duties and available for phone consultation as needed.The need to provide a system of health services which included a facility RN was discussed with Staff 1 on 5/14/21. No additional information was provided.
Based on interview and record review, it was determined the facility failed to ensure an RN assessment was performed timely following a significant change of condition for 1 of 1 sampled resident (#4) who experienced a significant change. This is a repeat citation. Findings include, but are not limited to:Resident 4 was admitted to the facility in 1/2021. Review of the resident's service plan, dated 8/12/21, progress notes, dated 7/14/21 to 8/17/21, incident reports and hospital discharge summaries indicated the following:On 8/7/21 Resident 4 was transported to the hospital after falling three times during the night and exhibiting "stroke-like" symptoms, including slurred speech, facial droop and left side deficits. At the hospital Resident 4 was diagnosed with cerebrovascular accident (stroke) with left-sided weakness, and returned to the facility on 8/7/21. The resident's deficits persisted, and s/he was subsequently admitted to hospice. This incident constituted a significant change of condition.There was no documented evidence that a facility RN assessment was performed following the resident's return from the hospital, significant changes in care needs related to the stroke and admit to hospice.In an interview on 8/17/21 Staff 1 (Owner) stated Staff 8 (RN) was not available at the time of the event, and acknowledged the facility RN assessment was not performed. Staff 8 was not available for interview during the revisit. On 8/17/21, a copy of ODHS Change of Condition and Monitoring Compliance Guidelines was provided and discussed with Staff 2 (Administrator).On 8/17/21 the need to ensure facility RN assessments were performed for all residents who experienced significant changes of condition was discussed with Staff 1 and Staff 2. They acknowledged the findings. No further documentation was provided.

Based on interview and record review, it was determined the facility failed to ensure residents' MARs provided clear instructions and parameters for administration of PRN medications for 2 of 2 sampled residents (#s 1 and 2) whose MARs were reviewed. Findings include, but are not limited to:1. Resident 1's 5/1/21 through 5/13/21 MARs were reviewed and revealed the following orders:* Acetaminophen three times daily as needed for pain; and* Tramadol every eight hours as needed for moderate to severe pain. The MAR lacked clear direction and instruction to staff regarding which medication to administer first and parameters as required.2. Resident 2's 5/1/21 through 5/13/21 MARs were reviewed and revealed the following orders:* Acetaminophen every four hours as needed for pain; * Morphine every hour as needed for pain; and* Oxycodone every six hours as needed for pain. * Haldol every two hours as need for nausea/vomiting; and* Lorazepam every two hours as needed for nausea/vomiting.* Bisacodyl as needed for constipation; and* Miralax as needed for no BM in three days.The MAR lacked clear direction and instruction to staff regarding which medications to administer first, and other parameters as required.The need to ensure MARs included clear parameters and direction to staff for medication administration was discussed with Staff 1 (Owner) on 5/14/21. She acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities was assessed by an RN, PT or OT prior to use for 1 of 1 sampled resident (# 2) who had a side rails. Findings include, but are not limited to:Resident 2 was admitted to the facility in March 2021 with diagnoses including a clavicle fracture.During an observation on 5/13/21, Resident 2's hospital bed was observed to have full side rails on both sides of the bed. There was no documented evidence a side rail assessment had been completed by an RN, PT or OT which included:* Informing the resident of the risks and benefits associated with the device;* The facility documented other less restrictive alternatives evaluated prior to the use of the device;* The facility had instructed caregivers on the correct use and precautions related to the use of the device; and* Documenting the use of the side rail on the service plan.The need to ensure supportive devices with potentially restraining qualities were assessed prior to use was discussed with Staff 1 (Owner) on 5/13 and 5/14/21. No additional information was provided.

Based on interview and record review, it was determined the facility failed to employ a full-time administrator scheduled to be on-site at least 40 hours per week. Findings include, but are not limited to:During the entrance conference conducted 5/13/21, Staff 2 ( Med Tech) stated the former administrator of record was no longer employed. She further stated she had completed the 40 hour administrator training course, but had not yet submitted the paperwork to the department for review. She revealed she was currently working at the facility providing caregiving and Med Tech duties. In an interview on 5/14/21, Staff 1 (Owner) acknowledged the previous administrator had left "some time ago" and there was no current certified administrator. Staff 1 reported that Staff 2 was working on getting the required documents to submit to the department.The need to ensure the facility employed a full-time administrator scheduled to be on-site at least 40 hours per week was reviewed with Staff 1 on 5/14/21. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 newly hired caregiving staff (#s 4 and 5) demonstrated satisfactory performance in all required areas within 30 days of hire. Findings include, but are not limited to:Training records were reviewed and interview with Staff 2 (MT) on 5/14/21 revealed the following:1. There was no documented evidence Staff 4 (MT) hired 1/29/21 and Staff 5 (MT) hired 4/1/21 had demonstrated competency in all required areas within 30 days of hire including:* Role of service plans in providing individualized care;* Providing assistance with ADL's;* Changes associated with normal aging;* Identification, documentation and reporting of changes of condition;* Conditions that require assessment, treatment and observation and reporting; and* Staff 4 and 5 also had responsibilities including administering medications, had no documented evidence of demonstrated competency in medication administration.2. Training records for Staff 4 lacked documented evidence First Aid and abdominal thrust training was completed within 30 days of hire.The above areas were verified during the record review with Staff 1 (Owner) on 5/14/21.

Based on interview and record review, it was determined the facility failed to ensure documented evidence of the required 12 hours of annual in-service training, including six hours of dementia care training, was completed for 1 of 1 long-term staff (# 3) whose training records were reviewed. Findings include, but are not limited to:Annual in-service training records were requested on 5/13/21. Staff 3 (MT), hired 2/16/18, lacked documentation of a minimum of 12 hours annual in-service training, which included six hours of dementia care training for the period between 2/16/20 and 2/16/21.The need to ensure long term staff had 12 hours of annual in-service training, including six hours of dementia care training and be able to provide documentation of the training, was discussed with Staff 2 (MT) on 5/14/21. No additional information was provided.

Based on interview and record review, it was determined the facility failed to ensure all requirements were met for Fire and Life Safety preparedness, instruction and documentation. Findings include, but are not limited to:On 5/14/21, fire drill records were requested. The records from March 2021 to May 2021 were reviewed and lacked the following documentation:* Evidence the facility was providing fire and life safety instruction to staff on alternating months from fire drills;* Location of simulated fire origin* Escape route used;* Problems encountered and comments relating to residents who resisted or failed to participate in the drills;* Evacuation time period needed;*Staff members on duty and participating; and* Number of occupants evacuated.On 5/14/21 the above areas were reviewed with Staff 1 (Owner) and Staff 2 (MT). No further information was received.

Based on interview, it was determined the facility failed to instruct residents within 24 hours of admission, and re-instruct residents at least annually, 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. Findings include, but are not limited to:On 5/14/21, the facility's process and documentation for instructing residents on basic safety procedures were review with Staff 1 (Owner). Staff 1 stated the facility did not have a process for providing instructions to residents upon admission and at least annually in fire and life safety procedures. The surveyor reviewed the rule with Staff 1 and provided a copy of a form with the accompanying information. Staff 1 stated she understood the requirements and would be able to implement a procedure for providing instruction to residents and determine whether the evacuation standard for residents could be met.

Based on observation, interview and record review, it was determined the facility failed to ensure their relicensure survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include, but are not limited to:Refer to C260 and C280.