The findings of the relicensure survey, conducted 07/31/23 through 08/02/23, 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 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 08/02/23, conducted 11/13/23 through 11/14/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.

3. Resident 4 was admitted to the facility in 12/2022 with diagnoses including diabetes.

Observations of the resident, resident and staff interviews, review of the service plan available to staff dated 05/16/23 and TSPs (Temporary Service Plans) showed the service plan was not reflective of the resident's current care needs or did not provide clear direction to staff in the following areas:

* Use of air mattress;

* Ambulation status;

* Outside service provider;

* Use and managing of hearing aids; and

* Use and managing glasses.

The need to ensure Resident 4's service plan was reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (ED), Staff 2 (LPN) and Staff 5 (Chief Operating Officer) on 08/02/23 at 12:40 pm. They reviewed the service plan and acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction to staff regarding the delivery of services, and were implemented by staff for 3 of 4 sampled residents (#s 2, 3, and 4). Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 08/2022 with diagnoses including history of intracranial hemorrhage, osteoporosis, cardiac pacemaker and repeated falls.  

Observations of the resident, interviews with staff, and review of the service plan, dated 05/09/23, showed the service plan was not reflective of the resident's current care needs, did not provide clear direction to staff and/or was not implemented by staff in the following areas:

* Toileting needs;

* Dietary needs and preferences including mechanical soft diet and use of clothing protector when eating;

* Use of sling for right arm;

* Ambulation ability;

* Use of glasses; and

* Non-medication interventions for pain.

The need to ensure service plans were reflective of current care needs, provided clear direction to staff and were implemented by staff was discussed with Staff 1 (ED), Staff 2 (LPN), and Staff 5 (Chief Operating Officer) on 08/02/23. They acknowledged the findings.

2. Resident 3 was admitted to the facility in 11/2019 with diagnoses including hypertension and muscle weakness and was identified in the acuity interview as experiencing a recent weight loss with dysphagia (difficulty swallowing) and speech therapy services from an outside provider.

Observations of the resident, resident and staff interviews, review of the most recent service plan dated 07/12/23, and TSPs (Temporary Service Plans) showed the service plan was not reflective of the resident's current care needs or was not implemented by staff in the following areas:

* Outside service providers; and

* Weekly weights.

The need to ensure service plans were reflective and implemented was discussed with Staff 1 (ED), Staff 2 (LPN) and Staff 5 (Chief Operating Officer) on 08/02/23 at 11:40 am. They acknowledged the findings.

1- Action taken to correct rule/violation

Resident 2- Service plan was updated to reflect current care needs and preferences with clear instructions how to perform required tasks.  

Resident 3- Service plan was updated to reflect current care needs including weekly weights and outside providers.

Resident 4- Service plan was updated to reflect current care needs, Preferences and clear instructions how to perform tasks.

2- System correction- Inservice to be held with Health Service team covering state requirements for service plans, ensuring they are person centered.

3-Completed service plans to be reviewed by HSD, and ED to make sure they are detailed, with clear instructions, preferences and preson centered.

4-Reponsible party- RCC, HSD, ED

2. Resident 4 was admitted in 12/2022 with diagnoses including diabetes. Resident 4 required a wheelchair for mobility.

Resident 4's clinical record and charting notes, reviewed from 04/03/23 through 07/27/23, showed the following changes of condition:

* 05/29/23: On a new anti-depressant medication;

* 06/04/23: Emergency visit due to signs of depression and lethargy;

* 06/13/23: Returned from a one week hospital stay;

* 06/15/23: Started on a pureed diet; and

* 06/19/23: Started on a new scheduled pain medication.

The facility initiated short-term monitoring. However, there was no documented evidence the changes were monitored at least weekly through resolution.  

Additional information was requested on 08/02/23. On 08/02/23 at 11:00 am, Staff 2 (LPN) reported she reviewed the resident's record and concluded the short-term changes in condition had not been monitored weekly until resolved.

The need to ensure short term changes of condition were monitored with weekly progress noted until resolution was reviewed with Staff 1 (ED), Staff 2 and Staff 5 (Chief Operating Officer) on 08/02/23 at 12:40 pm. They acknowledged the findings. No further information was provided.

Based on interview and record review, it was determined the facility failed to ensure short-term changes of condition were monitored through resolution, with progress noted weekly, for 2 of 4 sampled residents (#s 3 and 4) reviewed with changes of condition. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 11/2019 with diagnoses including hypertension and muscle weakness, and was identified in the acuity interview as having a recent weight loss with dysphagia (difficulty swallowing).

Interviews with the resident and staff, a review of the service plan dated 07/12/23, and progress notes dated 07/12/23 through 07/31/23 were reviewed.

Progress notes, dated 07/12/23, documented a significant weight loss of 9.27 pounds and a temporary service plan was created. The facility initiated monitoring; however there was no documented evidence of weekly progress noted through resolution.

During an interview on 08/02/23, Staff 2 (LPN) and Staff 3 (RN) confirmed the change of condition had not been monitored weekly until resolution.

The need to ensure changes of condition were monitored at least weekly until resolution was discussed with Staff 1 (ED), Staff 2 and Staff 5 (Chief Operating Officer) on 08/02/23. They acknowledged the information.

1- Immediate Action Taken-

Resident 3- Change of Condition Assessment was updated.

Resident 4- Change of Condition documentation was updated

2- System Correction- HSD to create a "Change of Condition" log. She and RN will both monitor the log weekly, ensuring follow-up and documentation is occuring.

3- On-going Evaluation- HSD and RN will go over Change of Condition log weekly

4- HSD, RN

Based on observation, interview and record review, it was determined the facility failed to ensure a safe medication system and failed to ensure adequate professional oversight of the medication and treatment administration systems. Findings include, but are not limited to:

1. Administrative oversight of the medication and treatment administration system was found to be ineffective, based on deficiencies in the following areas:

C 302: Systems: Tracking Controlled Substances

C 303: Systems: Medication and Treatment Orders

C 305: Systems: Resident Right to Refuse

C 310: Systems: Medication Administration

C 325: Systems: Self-Administration of Medications

2. Review of the MAR for 3 of 3 sampled residents (#s 1, 2 and 4) who received medication administration from facility staff indicated the facility used non time-specific ranges for medication administration. The MAR included administration times of "AM Ra", "PM Ra" and "HS Ra".

The facility's medication administration policy was requested and received on 08/01/23. Review of the document revealed the facility lacked a policy for determining medication administration times not otherwise directed by the physician or other legally recognized practitioner. The document did not include information on how "AM Ra, PM Ra or HS Ra" was determined for each medication and was not resident-specific.

During an interview on 08/01/23 at 11:11 am, Staff 5 (Chief Operating Officer) confirmed there was no policy for training medication aides to administer medications with time ranges.

The need to ensure a safe medication system and adequate professional oversight was discussed with Staff 1 (ED), Staff 2 (LPN) and Staff 5 (Chief Operating Officer) on 08/02/23. They acknowledged the findings.

1- Action taken- Audit of medpass conducted to re-view orders without specific times.  New order requested from MD to clarify, with resident preferences in mind.

2-System correction- Medication policy updated to give specific parameters when generic times are given unless indicated by specific MD order.  Training with medtechs around those parameters and to alert HSD of any new or current orders with unclear times or parameters.

3- Ongoing Evaluation-Quarterly

4-HSD, RN, ED

Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 1 of 1 sampled resident (# 4) whose MAR and Controlled Substance Drug Disposition logs were reviewed. Findings include, but are not limited to:

Resident 4 was admitted to the facility in 12/2022.

Resident 4 had signed physician orders for hydrocodone/acetaminophen 5-325 mg, a half tablet two times daily as needed for pain.  

Resident 4's 07/01/23 through 07/31/23 MAR and the Controlled Substance Disposition Log were reviewed and revealed the following:

* Staff documented the hydrocodone/acetaminophen 5-325 mg was administered on the Controlled Substance Disposition log on 07/22/23, 07/25/23, 07/26/23 and 07/27/23.

* There was no documented evidence on the MAR that the medication was administered to Resident 4 on those days.

Inconsistencies between the MAR and Controlled Substance Disposition logs were reviewed on 08/02/23 with Staff 1 (ED), Staff 2 (LPN) and Staff 5 (Chief Operating Officer). They acknowledged the findings.

1- Action taken- Medaide training conducted - ensuring they sign narcotics out of NARC book AND out of PCC.

2 System correction- If Narcotic and its order were received to community but are not yet in PCC medtech instructed to speak with LN

3- Ongoing Evaluation-Triple check system in place to track all narcotics and medications

4- Responsible Party- CSS, RCC, HSD,  

Based on observation, interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed by the resident's physician for 1 of 3 sampled residents (# 4) whose MAR/TAR was reviewed. Findings include, but are not limited to:

Resident 4 was admitted to the facility in 12/2022 with diagnoses including diabetes and heart disease.

The resident's 06/29/23 signed physician's orders and 07/01/23 through 07/31/23 MAR/TAR were reviewed and showed the following:

a. A physician order indicated to check CBG two times daily and call if  CBG was greater than 350. The MAR showed eight occasions the resident's CBG was greater than 350. There was no documented evidence the facility staff notified the CBG results to the prescriber as ordered.   

b. A physician's order indicated to administer oxygen at the rate of 2 L/min when visibly short of breath. The order was not transcribed to the MAR to carry out as ordered. Oxygen supplies were not observed in the resident's room.

c. A physician's order indicated to administer hydrocodone/acetaminophen 5/325 mg two times a day. The MAR showed the medication was administered three times a day on 07/10/23 and four times on 07/19/23, not two times a day as prescribed.

The need to ensure the facility administered all medications and treatments as prescribed was discussed with Staff 1 (ED), Staff 2 (LPN) and Staff 5 (Chief Operating Officer) on 08/02/23. They acknowledged the findings.

1-Immediate Action Taken- All orders received to community put through triple check system

2-System Correction- Med tech training to include the triple check system on receiving and processing orders.

3-Ongoing Evaluation- Weekly audit of parameters, ensuring notification to MD of findings outside of said parameters.

4- Responsible Party- HSD, CSS

2. Resident 4 was admitted to the facility in 12/2022 with diagnoses including diabetes.

Resident 4's 07/01/23 through 07/31/23 MAR/TAR and current physician's orders were reviewed and a signed physician order stated, "Notify hospice [of] 3 consecutive doses of any refused medications." The resident's MAR/TAR revealed the following medication refusals:

* Baza protect cream to the coccyx area on 19 occasions;

* Docusate sodium for constipation on three occasions; and

* Barrier cream treatment on 15 occasions.

On 08/02/23 Staff 2 (LPN) reported there was no documented evidence the facility staff notified the physician of the resident's medication and treatment refusals. There was no evidence the facility had a system for notifying the prescriber when a resident refused to consent to orders.

The need to ensure the facility notified the physician/practitioner of medication refusals as ordered was discussed with Staff 1 (ED), Staff 2 and Staff 5 (Chief Operating Officer) on 08/02/23. They acknowledged the findings.

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 2 of 2 sampled residents (#s 1 and 4) who had medication refusals. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 06/2023 with diagnoses including neurological disorder and Parkinson's disease.

Resident 1's 07/01/23 through 07/31/23 MAR and current physician's orders were reviewed. The resident's record showed refusals of the following medications:

* Finesteride daily for urinary symptoms;

* Galantamine daily for dementia;

* Vitamin D3 daily for supplement;

* Sertraline daily for depression;

* Carbidopa-Levidopa (two doses) for Parkinson's;

* Divalproex daily for seizures;

* Omeprazole daily for GERD; and

* Acetaminophen three times daily for pain.

The MAR indicated the resident refused all of the medications on 07/22/23 and some of the medications on 07/23/23.

On 08/02/23, Staff 2 (LPN) confirmed there was no documented evidence the facility notified the physician each time the resident refused medications. There was no evidence the facility had an effective system for notifying prescribers when a resident refused to consent to orders.

The need to ensure the facility had a system to notify the physician/prescriber of medication refusals was discussed with Staff 1 (ED), Staff 2 and Staff 5 (Chief Operating Officer) on 08/02/23. They acknowledged the findings.

1- Immediate Action Taken- Faxed  Dr's- getting clarification on how often they want to be notified of missed meds.

2-System correction- spreadsheet to be created- each resident and how often the MD wants to be notified.  CSS to ensure it is up to date Monthly.  Audit of all resident charts for MD request of missed med notification clarification.

3-Ongoing- CSS will run monthly refusal reports.  MD will be asked Quarterly to update their preferences and the spreadsheet will be updated.  Spreadsheet audited monthly for accuracy by CSS

4-Responsible Party- AA- creating and updating spreadsheet, CSS spreadsheet audit, RCC to quarterly fax MD for preferences, CSS to run refusal reports

3. Resident 4 was admitted to the facility in 12/2022 with diagnoses including diabetes.

a. Resident 4's physician orders and 07/01/23 through 07/31/23 MARs were reviewed during the survey and showed the following:

* Baqsimi nasal spray (to treat low blood sugar) for "severe hypoglycemia".

There were no resident-specific parameters or instruction to unlicensed staff that indicated when to administer the nasal spray.

b. The MAR had multiple blanks.

The need to ensure the resident's MARs were accurate and included resident-specific parameters was discussed with Staff 1 (ED), Staff 2 (LPN) and Staff 5 (Chief Operating Officer) on 08/02/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included resident-specific parameters for PRN medications for 3 of 3 sampled residents (#s 1, 2, and 4) whose medications were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 08/2022 with diagnoses including history of intracranial hemorrhage and repeated falls.

Resident 2's 07/01/23 through 07/30/23 MAR was reviewed and the following was identified:

A. The following PRN medications lacked clear parameters for administration:

* PRN lorazepam 0.5 mg and PRN haloperidol 2 mg/ml were both prescribed to treat anxiety and lacked clear parameters for the sequence of administration.

B. The following PRN medications had administration parameters which were not followed:

* PRN acetaminophen 160 mg/5 ml and ibuprofen 200 mg were both prescribed for pain, with acetaminophen to be administered first, and ibuprofen to be administered second. On 07/01/23 and 07/27/23, ibuprofen was administered, and acetaminophen was not administered.

C. The MAR lacked the initials of the Medication Aide who administered the following:  

* Sodium Fluoride 1.1% on 07/04/23 and 07/08/23;

* Tramadol HCL 50 mg on 07/06/23 and 07/08/23;

* Acetaminophen 160 mg/5 ml on 07/08/23; and

* Lidocaine 4% on 07/08/23.

The need to ensure MARs included clear parameters for multiple PRN medications that were prescribed to treat the same condition, parameters were followed as indicated, and MARs included all required components was discussed with Staff 1 (ED), Staff 2 (LPN), and Staff 5 (Chief Operating Officer) on 08/02/23. They acknowledged the findings.

2. Resident 1 moved into the facility in 06/2023 with diagnoses including neurological disorder.

Resident 1's physician orders and 07/01/23 through 07/31/23 MARs were reviewed and showed the following:

* Senna 8.6 mg tab, Take 1 - 2 tabs by mouth twice daily as needed for constipation.

There were no resident-specific parameters or instructions to staff regarding when to give one tablet or when to give two tablets for constipation.

The need to ensure the resident's MARs were accurate and included resident-specific parameters was discussed with Staff 1 (ED), Staff 2 (LPN) and Staff 5 (Chief Operating Officer) on 08/02/23. They acknowledged the findings.

1- Action Taken- PRN medication orders were audited, adding clear parameters where missing.

2-System Correction- Medaide training- triple check process of new orders needs to include looking for clear parameters.  LN will add specific parameters where missing.

3- Ongoing Evaluation- monthly Audit of PRN's- RCC or CSS will pull PRN report monthly- audit for clear parameters

4-HSD, RCC, CSS

Based on interview and record review, it was determined the facility failed to evaluate a resident's ability to safely self-administer medications for 1 of 2 sampled residents (#4) who chose to self-administer their medications. Findings include, but are not limited to:

Resident 4 moved to the facility in 12/2022 with diagnoses including history of urinary tract infection and diabetes.

Resident 4's clinical record and charting notes, reviewed from 04/03/23 through 07/27/23, showed the following:

* 05/01/23 - The resident was on alert charting for antibiotic use for urinary tract infection; and

* 05/04/23 - Staff documented "... self administered abx [antibiotic]".

On 08/02/23 at 11:40 am, Staff 2 (LPN) confirmed the antibiotic was not administered by facility staff.

There was no documented evidence the facility evaluated Resident 4's ability to safely self-administer the antibiotic.

The failure to evaluate the resident's ability to self-administer medications was discussed with Staff 1 (ED), Staff 2, and Staff 5 (Chief Operating Officer) on 08/02/23. They acknowledged the findings.

1- Action Taken- RN to conduct self med assessment for resident  4

2- System Correction- Medtech training to include notifying LN if family brings in a short term med and plans to administer it themselves.  

3-Ongoing Evaluation- quarterly, during service plan updates, RCC to see if additional OTC or short term meds are being taken by resident, not in the system and will alert LN if found.

4- Responsible Party-RCC, HSD, RN

3. Resident 2 was admitted to the facility in 08/2022 and had a significant change of condition on 05/10/23. The resident's ABST was last updated on 03/30/23 which indicated it had not been updated quarterly or following the significant change of condition.

The need to ensure the facility's ABST was updated following a significant change of condition and no less than quarterly was reviewed with Staff 1 (ED), Staff 2 (LPN), and Staff 5 (Chief Operating Officer) on 08/02/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to review the Acuity-Based Staffing Tool (ABST) following a significant change of condition and no less than quarterly. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 11/2019 and had a significant change of condition on 07/12/23. The resident's ABST was last updated on 03/30/23 which indicated it had not been updated quarterly or following the significant change of condition.

2. The ABST for multiple sampled and unsampled residents had not been reviewed or updated quarterly.

The need to ensure the facility's ABST was updated following a significant change of condition and no less than quarterly was reviewed with Staff 1 (ED), Staff 2 (LPN) and Staff 5 (Chief Operating Officer) on 08/02/23. They acknowledged the findings.

1- Immediate Action Taken- service plans reviewed and ABST updated

2-System Correction- ED and CSS will meet monthly to review ABST to accuracies.  Health Service Department will notify ED of significant changes that effect ABST.

3-Ongoing Evaluation- Monthly audits and updates

4-Responsible party-ED, CSS

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 8, 9 and 12) demonstrated satisfactory performance in any assigned duty within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed on 08/01/23 and revealed the following:

There was no documented evidence Staff 8 (MA), Staff 9 (CG) or Staff 12 (MA), hired 06/12/23, 02/20/23 and 04/11/23, respectively, demonstrated satisfactory performance in one of more of the following required 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; and

* General food safety, serving and sanitation.

The need for direct care staff to demonstrate satisfactory performance in assigned job duties within 30 days of hire was discussed with Staff 1 (ED), Staff 2 (LPN) and Staff 5 (Chief Operating Officer) on 08/02/23. They acknowledged the findings.

1- Immediate Action Taken- Audit of staff trainings completed, 30 day competencies updated

2- System Correction- CSS and HSD to ensure competencies are completed for direct care staff within 30 days of hire date.

Normal signs of aging and food safety added to 30 day Competency checklist.

3- Ongoing Evaluation- AA to assist ED in auditing and tracking new hires and their documentation nd training.  Audit done withing a week of onboarding a new staff and monthly.

4-Responsible Party-AA, CSS, ED

Based on interview and record review, it was determined the facility failed to ensure long-term employees completed 12 hours of annual in-service training related to the provision of care in a CBC setting for 4 of 4 long-term staff (#s 6, 10, 13 and 15). Findings include, but are not limited to:

Staff training records were reviewed on 08/01/23 and revealed the following:

Staff 6 (MA), Staff 10 (MA), Staff 13 (CG) and Staff 15 (Activities), hired 08/05/2021, 12/27/2019, 03/26/2014 and 04/16/2021, respectively, failed to have documented evidence of completing 12 hours of annual in-service training related to the provision of care in a CBC setting.

The need to ensure long-term staff completed the required number of annual training hours was discussed with Staff 1 (ED), Staff 2 (LPN) and Staff 5 (Chief Operating Officer) on 08/02/23. They acknowledged the findings.

1- Immediate Action Taken- Staff audit done, those with missing hours willl be assigned additional hours of training to be in compliance

2- System Correction- all staff will be scheduled time, outside of shift, to complete hourly training.  

3-Ongoing Evaluation-monthly audits of trainings to be completed by AA.  ED will contact staff and remove them from schedule if they are more than one month behind on trainings.

4- Responsible Party- AA, ED

Based on interview and record review, it was determined the facility failed to conduct fire drills every other month and document all required components on fire drill records. Findings include, but are not limited to:

Fire and life safety records from 02/2023 through 07/2023 were reviewed. The fire drill records did not consistently include documentation of the following required components:

* Escape route used;

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

* Evacuation time-period needed;

* Number of occupants evacuated; and

* Evidence alternate routes were used during fire drills.

On 08/01/23 an interview with Staff 1 (ED) revealed the facility was not relocating or evacuating residents as part of the fire drill process.   

On 08/02/23 the need to ensure the facility conducted and documented fire drills according to the Oregon Fire Code (OFC) was discussed with Staff 1, Staff 2 (LPN), and Staff 5 (Chief Operating Officer). They acknowledged the findings.

1-Immediate Action Taken- Maintenance Director to receive additional training on conducting a fire drill.

2-System Correction- Prior to drill, ED will go over fire drill plan with Maintenance Director.  After Drill, ED will participate in a debriefing of drill, making sure all parts of form are filled in.

3-Ongoing Evaluation- Drills to be conducted every other month.

4-Responsible party- ED, Maintenance Director

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

Observations of facility pathways, the inside and outside courtyards and seating areas on 07/31/23 identified the following:

* Multiple drop-offs of 2-4 inches were noted along pathway edges around the perimeter of the inside and outside courtyards.

The need to ensure pathways around the facility were in good repair with no potential tripping hazards was discussed with Staff 1 (ED), Staff 2 (LPN), Staff 4 (Maintenance Director) and Staff 5 (Chief Operating Officer) on 08/02/23. They acknowledged the findings.

1- Immediate Action taken- Landscaper called to add additional dirt or barkdust where the drop is greater than 2 inches

2-System Correction- Quarterly inspection of pathways to ensure no dangerous drop off pavement done by Maintenance Director and Landscapers

3-Ongoing Evaluation- Quarterly walk throughs.

4-Responsible Party- Maintenance Director

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

Observations on 07/31/23 and 08/02/23 showed two exit doors to the parking lot and four exit doors to the inner courtyard did not have an operational alarm or other acceptable system to alert staff when residents exited the building.

The need to ensure exit doors were equipped with a functional alarming device or other acceptable system was discussed with Staff 1 (ED), Staff 2 (LPN), Staff 4 (Maintenance Director) and Staff 5 (Chief Operating Officer) on 08/02/23. They acknowledged the findings.

1- Immediate Action Taken- exit doors fitted with alarm system,

2- System Correction- Quarterly checks that all door alarms work

3- Ongoing Evaluation- Quarterly

4- Responsible party- Maintenance Director