Fox Hollow Independent and Assisted Living Community

Based on observation and interview, it was determined the facility failed to ensure food was handled, and the kitchen was maintained, in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: Observations of the facility kitchen, food storage areas, food preparation, and food service with Staff 2 (Dining Room Supervisor) on 01/24/25 revealed splatters, spills, drips, and debris noted on:   - Stand mixer; - Reach in refrigerators; - Ice cream freezer; - Exterior sides and knobs of the gas range and oven; - Walls throughout the kitchen; - Flooring and cove base throughout the kitchen; - Fans of walk-in refrigerator and freezer; - Dry storage area flooring beneath shelving; - Stainless steel and metal rack shelving surfaces, legs, and feet; - Can opener blade and casing; - Interior of cupboards and drawers in kitchen and dining room beverage station; - Bakery racks; - Underneath shelving and equipment throughout kitchen; - Dishwashing area including flooring, drains, walls, sinks, caulking, exhaust vent, and equipment; - The clean side of the dish washing area had visible debris; - Garbage can lids and sides; and - Hand washing areas including walls and equipment. * A package of raw hamburger was stored above other foods. * Boxes of food were stored on the floor in the walk in refrigerator and freezer. * Multiple dented cans were found in the dry storage. * Scoops were left in containers of food; * Packages of food were left open in the dry storage. * There were undated, uncovered, and unlabeled opened packaged and prepared foods in all refrigerators. * Expired foods were identified in the refrigerators. * The wire racks of the reach in refrigerator were chipped and corroded. * Tray line cutting boards were stained and deeply scored. * The coffee station cupboards and drawers were damaged creating un-cleanable surfaces. * Testing strips were not available to ensure the sanitizing solution was at the correct ratio. Sanitizer towels were not submerged in the sanitizing solution. * There was no evidence of monitoring of temperatures of refrigerators, the ware wash machine, or foods. * A broom and dustpan were stored leaning on a wire rack of clean dishes. * Dish racks were stored directly on the floor. * Dietary staff were observed without beard restraints. * Staff preparing food were observed to not change gloves between tasks. * A staff preparing plates and serving residents was observed with long painted nails not using gloves. The areas in need of cleaning and repair, and the food handling and storage findings were reviewed with Staff 1 (Executive Director) on 01/25/24. She acknowledged the findings.

1. All areas identified in the Statement of Deficiencies have been cleaned and sanitized. Dented cans were removed and team was educated on not accepting or storing dented cans. Cabinet faces underneath the coffee machine are being replaced. New cutting boards, wire racks for reach in and dishmachine racks for storage have been ordered. 2. Dining Services Director and Dining Room Manager retrained the team on cleaning, temp logs, food handling and storage. Dining Services employees are being retrained on proper handwashing, glove and hairnet/beard restraint wearing according to Oregon Basic Food Handlers Course Guide and taking the Pre-Service Infection Prevention and Control for Community-Based Care course.  Dining Services employees are being educated on how food is to be properly labeled, dated, and stored. 3.Dining Services Director and Dining Room Manager will audit kitchen daily for cleanliness and to ensure all food items are covered, labeled, dated and stored appropriately.   4. Dining Services Director and Dining Room Manager are responsible to carry out the cleaning and systems corrections. Executive Director will inspect kitchen at least weekly at random times.

The findings of the kitchen inspection, conducted 01/25/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the revisit to the kitchen inspection of 01/25/24, conducted 04/10/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was maintained in a clean and sanitary manner and that food was prepared in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: Observation of the kitchen on 09/28/22 revealed the following: * Food crumbs, dust, and debris on the surface of the dishwasher; * Multiple food items in the refrigerator were not covered; * Multiple food items in the refrigerator were not labeled or dated; * The shelf below the food prep area, that held clean dishes, had food and debris on it; * Multiple severely dented cans; * Cook not utilizing proper hand hygiene when handling food; and * A carton of vegetables was stored on the ground. The need to ensure the facility prepared food in accordance with the Food Sanitation Rules OAR 333-150-000 was discussed with Staff 1 (ED) on 09/28/22. She acknowledged the findings.

C240 Resident Services Meals, Food Sanitation Rule 1. All areas identified in the Statement of Deficiencies have been cleaned and sanitized. Dented cans were removed and team was educated on not accepting or storing dented cans.   2. Dietary Manager will educate team on the Daily Cleaning Checklist. The Dining Services team is also being retrained on proper handwashing. 3. Dietary Manager will audit kitchen daily for cleanliness and to ensure all food items are covered, labelled, dated and stored appropriately. Executive Director will inspect kitchen at least once a week at random times. 4. Dietary Manager and Executive Director are responsible to carry out the corrections.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and provided clear direction to staff regarding care and services for 2 of 5 sampled residents (#s 2 and 3). Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 09/2018 with diagnoses including dementia. Observations of the resident, interviews with staff and review of the care plan dated 09/09/22, showed the care plan was not reflective of the resident's current care needs and/or did not provide clear direction to staff in the following areas: * Agitation and distressed behaviors; * Air overlay use; * Gait belt use and transfer pole; * Toileting assistance; * Weight monitoring; and * Ambulation and wheelchair propelling. The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (ED), Staff 2 (Wellness Director/RN) and Staff 14 (Regional RN) on 09/29/22. They acknowledged the findings. 2. Resident 3 was admitted to the facility in 01/2017 with diagnoses including anxiety and urinary incontinence. The resident's 09/21/22 service plan, Kardex (the document caregivers used), MAR dated 09/01/22 through 09/28/22 and progress notes dated 06/01/22 through 09/28/22 were reviewed. The resident was interviewed on 09/28/22 at 2:15 pm and Staff 16 (Agency CG) was interviewed on 09/29/22 at 10:50 am. The service plan was not reflective and lacked clear caregiving instruction in the following areas: * Self management of liter flow use while using an oxygen concentrator; * Assistance needed for portable oxygen use and which liter the oxygen should be set at; * Self administration of an inhaler and multiple over the counter medications; * Behavior intervention of sitting and talking with the resident; * Preferred sleeping and waking times being variable; * Incontinent assistance; * Bed mobility assistance; * Once weekly escorts to the Beauty Shop; * Safety checks; and * Signs and symptoms of when the resident may be getting a urinary tract infection. The need to ensure resident service plans were reflective of current care needs and provided clear caregiving instruction was discussed with Staff 1 (ED), Staff 2 (Wellness Director/RN) and Staff 14 (Regional RN) on 09/29/22. They acknowledged the findings.

C260 Service Plan: General 1.  Resident 2's service plan was updated to reflect all current needs and provide clear direction to staff regarding care and services. Resident 3's service plan was updated to reflect all current needs and provide clear direction to staff regarding care and services.All Assisted Living resident service plans will be updated to reflect resident specific care needs with clear direction for care staff. This will be completed by date certain. 2. Moving forward,  Resident evaluations will be completed at move-in, 30 days, and every 90 days there after. Re-evaluation will also occur with change of condition. 3. Residents will be evaluated at move-in, 30 days and every 90 days therafter. 4. Wellness Director will be responsible to assure corrections are completed.

2. Resident 1 was admitted to the facility in 03/2022 with diagnoses including congestive heart failure and restless leg syndrome. Observations of the resident, interviews with staff, review of the service plan dated 08/19/22 and progress notes dated 06/01/22 through 09/28/22 were reviewed. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness and/or lacked resident-specific directions to staff in the following areas: * Medication changes; * Emergency room; * Loose stools and vomiting; and * Fall and pelvic fracture . The need to ensure short-term changes of condition had documentation to reflect monitoring at least weekly to resolution and provided clear, resident-specific directions to staff was discussed with Staff 1 (ED), Staff 2 (Wellness Director/RN) and Staff 14 (Regional RN) on 09/29/22. They acknowledged the findings. 3. Resident 2 was admitted to the facility in 09/2018 with diagnoses including Multiple Sclerosis and osteoarthritis. Observations of the resident, interviews with staff, review of the service plan dated 09/09/22 and progress notes dated 06/10/22 through 09/28/22 were reviewed. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness and/or lacked resident-specific directions to staff in the following areas: * Medication changes; * Behaviors and agitation; * Skin breakdown; * Eye infection and antibiotic use; and * Falls. The need to ensure short-term changes of condition had documentation to reflect monitoring at least weekly to resolution and provided clear, resident-specific directions to staff was discussed with Staff 1 (ED), Staff 2 (Wellness Director/RN) and Staff 14 (Regional RN) on 09/29/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to document monitoring of short term changes of condition until resolution and failed to document monitoring of residents consistent with their evaluated needs for 4 of 4 sampled residents (#s 1, 2,  3 and 4) who experienced short term changes of condition. Findings include but are not limited to: 1. Resident 4 was admitted in 08/2022 with diagnoses including dementia and was evaluated as a fall risk and dependent for care needs. a. Resident 4's service plan included interventions to reduce falls. Resident 4's clinical record revealed s/he fell nine times between 08/07/22 and 09/20/22. There was no documented evidence all service planned fall interventions were monitored and reviewed to determine effectiveness with each incident. b. Resident 4's clinical record revealed: * 08/07/22 - black eye and cut to nose from a fall; * 09/2/22 - abrasions to right shoulder and knee from a fall; * 09/03/22 - abrasions to both shoulders from a fall; and * 09/20/22 - abrasion to left shoulder from a fall. There was no documented evidence the injuries had been monitored at least weekly until resolved. The need to monitor residents per their evaluated needs and to monitor changes in condition to resolution was discussed with Staff 1 (ED) and Staff 2 (Wellness Director/RN) on 09/29/22. They acknowledged the findings. 4. Resident 3 was admitted to the facility in 01/2017 with diagnoses including anxiety and chronic obstructive pulmonary disease. The resident's records were reviewed and revealed the following: On 07/19/22, the facility faxed Resident 3's physician stating the resident "overused" an "inhaler", which the resident was administering independently, and requested permission for the facility to administer it from that date forward. The physician signed and returned the fax on 08/03/22, providing permission for the facility to take over the administration of the inhaler. There was no documented evidence the "overuse" of the inhaler was monitored through resolution or the facility determined and documented what interventions were needed for the resident.   On 09/21/22 the physician signed an order for the resident to "trial" the inhaler again. There was no documented evidence of what the staff should be monitoring for, how long the resident needed to be monitored or interventions implemented and monitored for the "trial" use of self administering the inhaler. The need to ensure short term changes of condition were monitored at least weekly through resolution, the facility determined and documented what interventions were needed for the resident, and the interventions were monitored for effectiveness was discussed with Staff 1 (ED), Staff 2 (Wellness Director/RN) and Staff 14 (Regional RN) on 09/28/22. They acknowledged the findings.

C270 Change of Condition and Monitoring 1. Resident's 1, 2, 3, and 4 changes are now documented appropriately. Assisted Living resident changes of condition will be documented timely using Interim Service plans and skin assessments.    2. Staff to receive training on monitoring and reporting changes in condition to Wellness Nurse. Facility to train all staff to use the "Clinical Alerts" in PCC to notify Wellness Nurse of potential changes in condition. Significant change procedure reviewed and step by step outline of expected actions available to staff. 3. Changes of condition will be discussed in weekday meetings. Wellness Nurse will notify Executive Director  any time a resident experiences a significant change of condition. Interim service plans will be utilized to monitor short-term changes in condition. 4. Executive Director and Wellness Nurse are responible for corrections.

Based on observation and interview, it was determined the facility failed to ensure it consistently complied with masking requirements as prescribed in OAR 333-019-1011. Findings include, but are not limited to: Per Oregon Administrative Rule 333-019-1011(6), (8) and (10), persons employed in an assisted living or residential care facility are required to wear a face mask while they are in the facility except when the employee is alone in a closed room. Observations of staff during the survey revealed multiple instances where staff failed to wear their face mask properly, exposing their nose, or nose and mouth. The need to ensure staff consistently wore a face mask was reviewed with Staff 1 (ED), Staff 2 (Wellness Director/RN) and Staff 14 (Regional RN) on 09/28/22. They acknowledged the findings.

C295 Infection Prevention & Control - masking mandate 1. All employees are being reminded of the requirement to properly wear a face mask, while in the facility, except when the employee is alone in a closed room. Mask must be worn so that nose and mouth are covered. 2. Employees will be trained on proper mask wearing, reminded, and then corrective action will occur should repeat violations of not properly wearing a face mask occur. 3. Executive Director and management team to check that masks are worn properly randomly each day. 4. Executive Director and supervisors are responsible to enforce that all employees are properly wearing face masks.

2. Resident 1 was admitted to the facility in 09/2018 with diagnoses including Multiple Sclerosis. The resident's 06/10/22 through 09/28/22 progress notes, 08/02/22 physician orders and the 09/01/22 through 09/28/22 MAR/TAR was reviewed. a. The MAR reflected administration instructions for the following medications: * Cholecalciferol 1000u, one tab daily; * Milk of Magnesia 30ml prn for constipation if no bowel movement in 3 days; * Mylanta 200-200-20 mg/5ml, give 30 ml by mouth every 4 hours prn for gastrointestinal upset; * Risamine Ointment 0.44-20.625% apply prn for redness/skin breakdown; * Senna tablet 8.6 mg, take one tablet prn for bowel management; * Tylenol ES tablet 500 mg, give one tablet by mouth every 6 hours prn for pain or fever; and * Glycerin Adult Suppository, give 1 suppository prn if MOM not affective if no bowel movement for 3 days. There were no signed physician orders onsite at the facility for the listed medications and treatments. b. There was a signed physician's order for staff to check the resident's oxygen saturation levels every shift and titrate oxygen use between 2-8 liters to keep oxygen saturation levels greater than 90%. The order was not reflected on the MAR and staff were not monitoring oxygen saturation levels. In an interview on 09/29/22, Staff 2 (Wellness Director/RN) indicated a fax was sent to the physician for clarification and signature regarding the medications and treatments with no signed orders. The need to ensure the facility had orders for all medications and treatments administered was discussed with Staff 1 (ED), Staff 2 and Staff 14 (Regional RN) on 09/29/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed, and signed physician orders were documented in the resident's record for all medications and treatments the facility was responsible to administer, for 2 of 4 sampled residents (#s 1 and 3) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 01/2017 with diagnoses including anxiety. The resident's 09/01/22 through 09/28/22 MAR, physician's orders and progress notes dated 06/01/22 through 09/28/22 were reviewed. There were four entries on the MAR dated 09/06/22 through 09/09/22 stating, "Other / See Nurse Notes" relating to the administration of venlafaxine (for anxiety). There was no documented evidence of corresponding nurse notes for those days. On 09/28/22 at approximately 3:00 pm, Staff 2 (Wellness Director/RN) stated the facility was waiting for the medication delivery and confirmed the resident had not received the medication during those four days. The need to ensure the facility carried out physician's orders as prescribed was discussed with Staff 1 (ED), Staff 2 and Staff 14 (Regional RN) on 09/29/22. They acknowledged the findings.

C303 Systems: Treatment Orders 1. Residents 1 and 3 MARs are current per MD orders. If med is refused, or unavailable, RN will be notified immediately. A Med Aide meeting will be held to review medication administration to include the 6 rights which will go over right resident , right dose, right drug, right time, right route, right documentation, ensuring that parameters are followed.The meeting will also include what to do if a resident refuses a medication or if a medication is not available to administer. 2. Med Aide meetings will be held every other month. 3. The Resident Care Coordinator will conduct MAR audits weekly and report any issues to Wellness Director for follow-up. All new orders will be checked by 3 people; the Med Tech, the RCC and the WD to verify they are correct. 4. Wellness Director will assure audits and training occurs.

Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused to consent to orders for 1 of 2 sampled residents (#3) who had documented medication and treatment refusals. Findings include, but are not limited to: Resident 3 was admitted to the facility in 01/2017 with diagnoses including chronic obstructive pulmonary disease (COPD). The resident's 09/01/22 through 09/28/22 MAR, physician's orders and progress notes dated 06/01/22 through 09/28/22 were reviewed. There was documentation of the following refusals: * Inhaler (for COPD) was documented as refused in the progress note on 08/05/22; * Polyethylene glycol powder (for constipation) on 09/07/22, 09/08/22 two times, 09/09/22, 09/24/22 two times and 09/28/22; and * Pulmicort flexhaler (for COPD) on 09/01/22, 09/02/22, 09/04/22 through 09/07/22, 09/08/22 two times, 09/09/22 two times, 09/16/22 and 09/20/22. On 09/28/22 at 3:42 pm, Staff 2 (Wellness Director/RN) confirmed there was no documented evidence the facility notified the prescriber of the refusals. The need to ensure the physician/prescriber was notified when a resident refused to consent to orders was discussed with Staff 1 (ED), Staff 2 and Staff 14 (Regional RN) on 09/29/22. They acknowledged the findings.

C305 Systems: Resident Rights to Refuse 1. If Resident 3 refuses a medication, both RN and MD will be notified immediately. Med Aide training will occur regarding notification of the physician/practitioner when a resident refuses consent to an order. 2. Daily, the Wellness Director and Resident Care Coordinator will review "not administered medication passes" in Point Click Care and will follow-up with any medication or treatment refused or not administered to assure physician/practitioner was notified. 3. Daily when Wellness Director and Resident Care Coordinator are present. 4. Wellness Director will assure audit occurs.

Based on observation, interview and record review, it was determined the facility failed to evaluate a resident's ability to safely self-administer specific medications for 1 of 3 sampled residents (#3) who were reviewed for self-administering medications. Findings include, but are not limited to: Resident 3 was admitted to the facility in 01/2017 with diagnoses including chronic obstructive pulmonary disease (COPD) and history of urinary tract infections. The resident's electronic chart was reviewed, which included all evaluations, progress notes and physician's orders. a. In a fax to Resident 3's physician on 07/19/22, it was reported the resident had "overused" an inhaler that s/he self administered. On 08/03/22 the physician faxed the facility directing staff to administer the inhaler. On 09/21/22 the resident's physician signed an order for the resident to start a "trial" of self administering an inhaler. There was no documented evidence the resident had been evaluated to assure the ability to safely self-administer the inhaler prior to 07/19/22 or on 09/21/22. b. On 09/09/22, Resident 3 returned to the facility from urgent care with the diagnosis of a urinary tract infection. Urgent care sent Cipro (an antibiotic to treat the infection) with the resident for him/her to self administer. There was no documented evidence the resident had been evaluated to assure the ability to safely self-administer the antibiotic on 09/09/22. c. During an interview with Resident 3 on 09/28/22 at 2:15 pm, there were multiple over the counter (OTC) medications observed. Due to the resident not being evaluated to assure the ability to self-administer prescribed medications, it was unknown if self-administering OTCs was contraindicated. The need to ensure residents were evaluated to assure ability to safely self-administer medications was discussed with Staff 1 (ED), Staff 2 (Wellness Director/RN) and Staff 14 (Regional RN) on 09/29/22. They acknowledged the findings.

C325 Systems: Self-Administration of Meds 1.  Identified resident, #3 will be evaluated for safety of self-administration by date certain 2. Moving forward after date certain,  Residents who choose to self-administer medications will be evaluated upon move-in and at least quarterly to assure ability to safely self-administer medications.   3. Every 90 days and with change of condition after resident moves in. 4. Wellness Director will be responsible to assure corrections are completed.

Based on interview and record review, it was determined the facility failed to ensure all pre-service training was completed prior to beginning job duties for 2 of 2 newly hired direct care staff (#s 11 and 12) and infectious disease training for 1 of 2 long term staff  (#4) whose training records were reviewed. Findings include, but are not limited to: The facility's training records were reviewed on 09/28/22. Staff 11 (CG), hired on 08/30/22, and Staff 12 (MT), hired on 08/31/22, lacked documented evidence that the pre-service orientation, infectious disease training and pre-service dementia training were completed prior to beginning their job duties. Staff 4 (Community Relations Director) had no documented evidence of completing infectious disease prevention training. The need to ensure staff completed all components of the pre-service training was discussed with Staff 1 (ED) on 09/28/22. No additional information was provided.

C370 Staffing Requirements and Training: Caregiver Requirements 1. Newly hired direct care staff, including employee #11 and 12, will receive infectious disease training, as will long term staff member #4. Employee files will be audited to see which trainings are missing. Employees will be scheduled to complete any identified trainings by date certain. 2. Business Office Manager will inform supervisor once pre-service trainings, including infectious disease training, have been completed by new hire. New hire cannot be scheduled to shadow until all pre-service trainings have been completed. 3. Business Office Manager will review pre-service training status of new hires with Executive Director and department supervisors  weekly. 4. Business Office Manager will be responsible to assure corrections are completed and monitored going forward.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 newly hired staff (#s 9 and 10) had documented demonstration of competency in all required areas within 30 days of hire. Findings include, but are not limited to: Review of the facility's training records on 09/28/22 indicated the following: Staff 9 (MT), on hired 06/17/22, and Staff 10 (MT), hired on 08/24/22, lacked documented evidence that competencies were demonstrated within the first 30 days of hire in the following areas: * The role of service plans in providing individualized resident care; * Providing assistance with the activities of daily living; * Changes associated with normal aging; * Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition; * Conditions that require assessment, treatment, observation and reporting; * General food safety, serving and sanitation; and * Medication pass and treatments administered. On 09/28/22, the facility ensured demonstrated competencies were documented for current staff on shift and would be documented for all additional MTs prior to performing any additional medication passes. The need to document demonstrated competency in job duties within 30-days of hire was discussed with Staff 1 (ED) and Staff 2 (Wellness Director/RN). They acknowledged the findings.

C372 Training within 30 days: Direct Care Staff 1. Newly hired staff members #9 and 10 demonstrated competencies in all required areas with the RN Wellness Nurse. Employee files will be audited to see which documented competencies are missing. Employees will be scheduled to complete any identified competencies by date certain. 2. Business Office Manager will assign new employee training and track completion using matrix. Wellness Director will document evidence that competencies were demonstrated within the first 30 days of hire and will be maintained on file. 3. Wellness Director  and/or designee will complete competency verification with new care staff within 30 days of hire. Business Office Manager will review training status with Executive Director and Wellness Director weekly. 4. Wellness Director and Business Office Manager are responsible for corrections.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 long term staff (#s 8 and 12) completed the minimum required 12 hours of annual in-service training, including six hours of dementia training. Findings include, but are not limited to: Facility training records were reviewed on 09/28/22 and revealed the following: Staff 6 (MT), hired on 10/11/10, and Staff 8 (MT), hired on 05/17/16, did not have documented evidence for the completion of the required 12 hours of annual in-service training, including six hours of dementia training. The need to ensure all required in-service training hours and requirements were completed annually was reviewed with Staff 1 (ED) and Staff 2 (Wellness Director/RN) on 09/28/22. They acknowledged the findings.

C374 Annual Training & Other Requirements 1. All staff will receive infectious disease training on an annual basis. All direct care staff will be educated on the 12 hours of annual inservice training requirement, including 6 hours of dementia care and the balance related to the provision of care for persons in a community-based care setting, including training on chronic diseases in the facility population.  Relias and/or Oregon Care Partners will be used as needed to complete required training. 2. Business Office Manager will assign courses and notify Executive Director and department supervisors of the status of their staff's training every month. 3. The Business Office Manager will track staff completion of required trainings and report progress monthly to Executive Director and department supervisors. 4. Business Office Manager and Executive Director are responsible for corrections.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted and documented every other month and fire and life safety instruction to staff was provided on alternate months. Findings include, but are not limited to: Fire drill records and fire and life safety training records from 04/01/22 through 09/28/22 were reviewed. The following deficiencies were identified: a.  The facility's fire drill form lacked the following documentation: * Problems encountered and comments relating to residents who resisted or failed to participate in the drills; and * Number of occupants evacuated. b. There was no documented evidence the facility was providing fire and life safety instruction to staff on alternating months. The requirements regarding fire drills and fire and life safety instruction for staff was reviewed with Staff 1 (ED) on 09/28/22. Staff 1 acknowledged the facility was not relocating or evacuating residents during fire drills and the facility was not providing fire and life safety instruction to staff .

C420 Fire & Life Safety 1. The Fire & Life Safety Drill and Staff Training Record form has been updated to include Problems encountered and comments relating to residents who resisted or failed to particpate in the drills, as well as the number of occupants evacuated. This form will be used, by the Maintenance Director and Executive Director each month going forward. 2. The Fire & Life Safety Drill and Staff Training Record form will be used to provide documented evidence that staff were provided fire and life safety instruction on alternating months going forward. The training provided will be specified and staff signatures on this form will reflect that each staff member received this training. 3. The Maintenance Director, and Executive Director, will use this form to ensure that drills and training are provided, and documented, each month. 4. Maintenance Director and the Executive Director are responsible for corrections.

Based on interview and record review, it was determined the facility failed to ensure fire and life safety instruction was provided to residents upon move in and at least annually. Findings include, but are not limited to: Fire drill records and fire and life safety training records from 04/01/22 through 09/28/22 were reviewed on 09/28/22. The records lacked documented evidence that residents had received training within 24 hours of admission and were re-instructed annually in the following areas: * General safety procedures; * Evacuation methods; * Responsibilities during fire drills; and * Designated meeting places inside or outside the building. A written record of fire safety training, including content of the training sessions and the residents attending was not maintained by the facility. The need to ensure residents received fire and life safety training on admission and were re-instructed annually was discussed with Staff 1 (ED) on 09/28/22. She acknowledged the findings.

C422 Fire & Life Safety: Training for Residents 1. A Fire & Life Safety Resident education will occur with all current residents as part of annual training. This training will be conducted by the Executive Director and Maintenance Director by date certain. 2. A Fire & Life Safety information packet will be provided to residents upon move in, and annually, for this training. The Resident Acknowledgement page will be kept on file for each resident as documentated evidence of fire and life safety training for residents upon move in, and annually. 3. The Community Relations Director and Executive Director will review new resident move in documentation monthly to ensure Acknowledgement page of this training is on file. 4. The Executive Director and Maintenance Director are responsible for holding annual resident training. The Community Relations Director and Executive Director are responsible to ensure that this training is completed upon resident move into community.

The findings of the re-licensure survey, conducted  09/28/22  through  09/29/22 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the revisit to the re-licensure survey of 09/29/22, conducted 01/04/23 through 01/05/23, are documented in this report. It was determined the facility was in compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home, and Community Based Services Regulations OARs 411 Division 004.