The findings of the re-licensure survey conducted 02/06/23 through 02/08/23 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCCMemory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first revisit to the re-licensure survey of 02/08/23, conducted 05/24/23 through 05/25/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

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 second revisit to the re-licensure survey of 02/08/23, conducted 07/19/23, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

Based on interview and record review, it was determined the facility failed to implement effective methods of responding to and resolving resident complaints. Findings include, but are not limited to:

During a group interview, conducted on 02/07/23, with two unsampled residents, multiple complaints or concerns were identified. The complaints included:

* There were no beauty/barber services available at the facility;

* The menu lacked variety and residents often received the same foods several times a week; and

* Residents did not have a way to affordably access the community (stores, events, etc.).

Residents stated they had brought these concerns to the attention of the administration may times over the past year and were not aware of any other process to address and resolve concerns.

A review of the "Participant Advisory Committee" notes provided by the facility, dated 05/22/22, documented resident concerns regarding access to the community and concerns regarding the lack of variety on the menu.

A review of Resident 2's charting notes, dated 01/04/23, documented the resident expressed s/he was "not happy with the food menus and how its always the same" during the service plan review meeting.

In an interview on 02/08/23, Staff 1 (Interim Administrator) and Staff 3 (Lead Assistant Administrator) acknowledged the facility did not have a system in place to document how the facility attempted to resolve complaints that residents shared with them.

The need to ensure the facility implemented effective methods of responding to and resolving resident complaints was discussed with Staff 1 and Staff 3 on 02/08/23. They acknowledged the findings.

1.  Written grievance document will be consistenly made available to the residents and staff who may offer assistance to residents.  Residents and staff will be instructed on process to submit grievances, as well as process explaining response and resolution.  Grievances will also be offered as applicable during monthly Resident council meetings.

2.  Grievance logs / data will be documented and tracked monthly including topics, dates of submission and resolution.

3.  Cully RCF grievance data will be monitored and submitted to ElderPlace Quality Assurance Specialist quarterly.

4.  RCF Administrator

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

Resident 3 was admitted to the facility in 07/2022.

The move-in evaluation failed to address the following elements:

* Vital signs;

* Cognition, including memory and orientation;

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

* History of dehydration or unexplained weight loss or gain; and

* Environmental factors that impact behavior, including lighting and room temperature.

The need to ensure move-in evaluations included all required elements was discussed with Staff 1 (Interim Administrator) and Staff 3 (Lead Assistant Administrator) on 02/08/23. They acknowledged the findings. No further information was provided.

1.  Resident #3  record will be reviewed and all required elements will be added to her move-in evaluation.

2.  Move-in evaluation components will be crosswalked with facility EHR to assure all required elements are included.  Any elements that may not be included in the facility EHR will be added through additional documentation.  Define which team members will be completing all components of the move-in evaluation.

3.  100% of  facility records will be audited and any missing elements will be added to move-in evaluation.

4.  10% of records will be audited by facility Administrator monthly for compliance.   

2. Resident 3 was admitted to the facility in 07/2022 with diagnoses which included schizoaffective disorder and history of falls.

Service plan dated 11/22/22 was reviewed and interviews on 02/07/23 were conducted with Resident 3 at 12:30 pm and Staff 9 (Resident Services Assistant) at 1:40 pm.

Resident 3's service plan was not reflective of the resident's needs, did not provide clear direction regarding the delivery of services and did not include a written description of who shall provide the services and what, when, how, and how often the services shall be provided in the following areas:

* Skin monitoring;

* Bathing assistance;

* Oxygen use and maintenance;

* Toileting assistance;

* Behaviors; and

* Current fall interventions.

The need to ensure the service plan reflected the resident's needs, provided clear direction regarding the delivery of services and included a written description of who shall provide the services and what, when, how, and how often the services shall be provided was discussed with Staff 1 (Interim Administrator) and Staff 3 (Lead Assistant Administrator) on 02/08/23. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure resident service plans were reflective of resident needs and provided clear direction to staff regarding the delivery of services for 2 of 3 sampled residents (#s 1 and 3) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 05/2020.

During an interview with Resident 1 on 02/07/23, s/he stated they used their PRN oxygen at nighttime. There was no specific information on the service plan as to who should clean the tubing or how frequently. Side rails were observed on the resident's bed.

The resident's 01/26/23 service plan was not reflective of the resident's current needs and did not provide clear direction to staff in the following areas:

* Side rails;

* Bed alarm; and

* Oxygen.

The need to ensure service plans were reflective and provided clear direction to staff was discussed with Staff 1 (Interim Administrator) and Staff 3 (Lead Assistant Administrator) on 02/08/23. They acknowledged the findings.

1.  Records of resident #1 and #3 will be reviewed and updated to reflect current status.  

2.  Audit all current service plans to assure they are reflective of resident status. To assure that service plans are reflective of current status, they must be updated when changes occur, and changes will be dated and initialed or captured with a significant change of condition as needed.

3.  Ongoing audit of 10% of service plans monthly to assure they are reflective of current status.

4. RCF Administrator

Based on interview and record review, it was determined the facility failed to determine and document what action or intervention was needed for the resident, communicate the determined action or intervention to staff on each shift as well as monitor and document at least weekly progress noted until the condition resolved for 1 of 3 sampled residents (#3) who were reviewed for short term changes of condition. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 07/2022 with diagnoses including a history of falls.

The resident's 11/22/22 service plan and progress notes dated 11/28/22 through 02/03/23 were reviewed and revealed the following changes of condition:

* 12/16/22 - Fall while out of the facility;

* 01/11/23 - Unable to fully respond when staff answered his/her call light;

* 01/14/23 - Fall out of bed;

* 01/21/23 - Fall in dining room and medication changes; and

* 01/23/23 and 01/25/23 - Feeling light headed.

Per interview with Staff 3 (Lead Assistant Administrator) on 02/06/23 at 3:14 pm, it was confirmed there was no direction to staff pertaining to monitoring Resident 3's fall on 12/16/22. The two subsequent falls on 01/14/23 and 01/21/23 lacked documented evidence that staff determined and documented what action or intervention was needed for the resident and that the determined action or intervention was communicated to staff on each shift.

Resident 3's service plan directed staff to "report unresponsiveness or not answering full questions to housing RN/and or clinic right away." On 01/11/23, staff documented that when the caregiver answered the resident's call light, Resident 3 was not able to state why s/he called for assistance. There was no documented evidence the facility determined and documented what action or intervention was needed for the resident, communicated the determined action or intervention to staff on each shift or monitored the resident through resolution.  

Resident 3's feeling of being light headed noted on 1/23 and 1/25/23 lacked documented evidence the facility determined and documented what action or intervention was needed for the resident, communicated the determined action or intervention to staff on each shift or monitored the resident through resolution.  

The need to ensure the monitoring of short term changes of condition included determining and documenting what action or intervention was needed for the resident, communicate the determined action or intervention to staff on each shift, and monitor and document at least weekly progress noted until the condition resolved was reviewed with Staff 1 (Interim Administrator) and Staff 3 (Lead Assistant Administrator) on 02/08/23. They acknowledged the findings.

1.  Complete temporary significant change of condition assessment related to falls if they occur going forward for resident #3.

2.  Housing RN education on temporary significant change of condition related to falls will occur on 2.21.  Going forward caregivers will communicate changes to RN in shift change meetings, and proper documentation will occur.

3.  RN review with housing staff any residents with potential temporary significant change with alert charting process to assure documentation is occuring.

4. RN Housing Manager

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

Resident 2 was admitted to the facility in 10/2021 with diagnoses including diabetes and chronic kidney disease.

Charting notes documented the following:

12/12/22: wound on right thigh (open wound);

12/12/22: "active wound" on right buttock; and

01/03/23: wound on right lateral lower shin, "red drainage noted".

The new open wounds constituted a significant change in condition and an assessment by the facility RN was required.

In interviews on 02/07/23 and 02/08/23, Staff 1 (Interim Administrator) and Staff 12 (Regional RN) indicated the resident was receiving wound care from the Providence Clinic (home health). While the facility RN would accompany the home health "clinic" RN frequently during visits for wound monitoring, no RN assessment was available for the new open wounds.

The facility failed to ensure an RN assessment was completed for the open wounds which documented findings, resident status and interventions made as a result of the assessment.

The need to ensure an RN assessment was completed which documented findings, resident status and interventions made as a result of the assessment was discussed with Staff 1, Staff 2 (Lead Assistant Administrator) and Staff 12 on 02/08/23. They acknowledged the findings.

1.  Complete change of condition assessement for resident #2.

2.  Housing RN education on significant change of condition related to pressure wounds will occur on 2.21.  Going forward caregivers will communicate changes to RN in shift change meetings.

3.  RN review with housing staff any residents with potential significant change once weekly, assuring it is reflected on the service plan and documentation is occurring.

4. RN Housing Manager

Based on interview and record review, it was determined the facility failed to ensure the RN performed an assessment, interventions were developed based on the condition of the resident, and the service plan updated for 1 of 1 sampled resident (# 4) who experienced a significant change of condition related to weight loss. This is a repeat citation. Findings include, but are not limited to:

Resident 4 was admitted to the facility in 08/2010 with diagnoses including essential hypertension.

Resident 4's weight record and the 03/27/23 - 05/19/23 progress notes were reviewed during the survey and identified the resident had a significant change of condition related to weight.

Weight records were reviewed from 04/02/23 - 05/10/23. The weight records noted:

* 02/02/23 - 427. 4 pounds;

* 05/02/23 - 389.6 pounds; and

* 05/10/23 - 387.7 pounds.

From 04/02/23 to 05/02/23 Resident 4 lost 37.8 pounds or 8.84 % total body weight within one month.

The weight loss represented a significant change of condition.

The RN made a note on 05/15/23 that "... the resident appears to have lost 39.7 pounds since 4/02... Furosemide was started in mid April while resident was in the hospital."

The facility failed to ensure the RN assessment documented findings, resident status, and interventions made as a result of the assessment.  

On 05/25/23, during an interview with Staff 2 (RN), the resident's weight loss was reviewed.  Staff 2 acknowledged the RN note did not address the resident status, findings as a result of the assessment including interventions as appropriate.    

The need to ensure an RN assessment was completed and documented the resident status, findings and interventions was shared with Staff 1 (Administrator) and Staff 2 on 05/25/23. They acknowledged the findings.

1. Complete significant change of condition assessment for resident # 4.

2. Housing RN education on temporary significant change will occur on 6.17.23. Going forward caregivers will communicate changes to RN in shift change meetings and nurse evalution and proper documentaion will occur.

3. RN review with housing staff any residents with potential temporary significant change with alert charting process to assure documenation is occuring.

4. RN Housing Manager

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

1. Resident 3 was admitted to the facility in 07/2022 with diagnoses including schizoaffective disorder.

The resident's 01/01/23 through 02/05/23 MARs and physician's orders were reviewed. The following PRN bowel medications lacked resident specific parameters or instructions to direct non-licensed staff on which medication should be administered and in what order:  

* Colace;

* Miralax; and

* Senna.

During an interview on 02/07/23, Staff 5 (MT/Lead Residential Services Assistant) confirmed the electronic MAR system did not have parameters on which medication should be administered and in what order listed for staff.

The need to ensure resident's MAR was accurate and included resident specific parameters and instructions for PRN medications was reviewed with Staff 1 (Interim Administrator) and Staff 3 (Lead Assistant Administrator) on 02/08/23. They acknowledged the findings.

2. Resident 2 was admitted to the facility in 10/2021 with diagnoses including diabetes and chronic kidney disease and experienced occasional constipation.

The resident's 01/01/23 through 02/05/23 MARs and physician's orders were reviewed. The following PRN bowel medications lacked resident specific parameters or instructions to direct non-licensed staff on which PRN medication should be administered and in what order:  

* Docusate sodium; and

* Polyethylene glycol.

The need to ensure the MAR included resident specific parameters and instructions for staff as required for PRN medications was reviewed with Staff 1 (Interim Administrator) and Staff 3 (Lead Assistant Administrator) on 02/08/23. They acknowledged the findings.

1.  Review resident #2 & #3 and add bowel medication parameters.

2.  Audit 100% bowel medication orders for parameters.

3.  Inform PCP's and PharmD's that parameters will be needed for bowel medications going forward.  Housing RN will monitor through medication reconciliation process quarterly.

4.  Housing RN

Based on interview and record review, it was determined the facility failed to ensure non-pharmacological interventions were attempted and documented to be ineffective prior to the administration of PRN psychotropic medications for 1 of 1 sampled resident (#2) who received psychotropic medications to treat behaviors. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 10/2021 with diagnoses including depression and anxiety.

The resident's 01/01/23 through 02/05/23 MARs and physician orders were reviewed and the following was noted:

Resident 2 was prescribed PRN alprazolam for anxiety. Resident 2 was administered the medication twice in 01/2023 to treat anxiety.

The records lacked documented evidence that non-pharmacological interventions were tried and had ineffective results prior to administration of the medication.

During an interview on 02/08/23, Staff 3 (Lead Assistant Administrator) confirmed the electronic MAR system did not have non-pharmacological interventions listed for staff to try prior to administering the PRN medication.

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        The need to ensure non-pharmacological interventions were tried and documented to be ineffective prior to the administration of PRN psychotropic medications was discussed with Staff 1 (Interim Administrator) and Staff 3 on 02/08/23. They acknowledged the findings.

1.  Review resident #2 record and add non-pharmacological interventions to the medication administration record.

2.  Audit 100% prn psychotropic medication on facility MARs, and add non-pharmacological intervention options to the MAR.

3.  Housing RN will monitor to assure options are on MAR through quarterly medication reconciliation process.

4.  Housing RN

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 02/06/23, Staff 1 (Interim Administrator) was asked to provide documentation of her Residential Care Facility Administrator license. Staff 1 revealed her license had expired.

The requirement to have a current Residential Care Facility Administrator was discussed with Staff 1 on 02/08/23. She acknowledged the findings.

1. Interim Adminstrator will complete all requirements and acquire Residential Care Facility Administrator License.  

2.  Facility will assure fully licensed Administrator in place going forward.

3.  Director of Operations will monitor / oversee RCF Administrator at Cully 100% of the time.

4.  PEP Director of Operations

Based on interview and record review, it was determined the facility failed to provide fire and life safety instruction to staff on alternating months. Findings include, but are not limited to:

On 02/07/23, fire and life safety training records for the previous six months were reviewed with Staff 3 (Lead Assistant Administrator). Fire and life safety instruction was not consistently provided to staff on alternate months.

The requirements regarding fire and life safety instruction for staff were reviewed with Staff 1 (Interim Administrator) and Staff 3 on 02/08/23. The findings were acknowledged.

1.  Fire drills will be completed on alternate shifts every other month.  Fire & life safety instruction will be completed on alternate months.

2.  Proper instruction / education will be provided and documented related to fire and life safety.

3.  Drill and education records will be audited monthly.

4.  RCF Administrator

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements for residents were met. Findings include, but are not limited to:

The facility lacked documentation that the residents were being instructed on fire and life safety procedures (including in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places inside or outside the building) within 24 hours of admission.

In an interview on 02/07/23, Staff 3 (Lead Assistant Administrator) acknowledged residents were not being provided fire and life safety training within 24 hours of admission.

The need to have documented evidence of all fire and life safety training components was discussed with Staff 1 (Interim Administrator) and Staff 3 on 02/08/23. They acknowledged the findings.

1.  Education materials have been developed to provide instruction on fire and life safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places inside & outside of the building.

2.  Going forward all new residents will be provided these materials within 24 hours of admission.  100% of current residents will also be provided this instruction.

3.  10% of resident files will be audited monthly.

4.  RCF Administrator

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

Refer to C 280.

1.Significant changes will be evaluated by RN and documented in resident charts.

2. Housing RN will be educated on significant change assessments and when to do so on 6/17/23. RN and caregivers will communicate when significant change occurs so that follow up will happen.

3. Weekly audits by RN Housing manager to make sure significant changes are assessed by housing RN and documented.

4. RN Housing Manager

Based on observation and interview, the facility failed to keep grounds orderly and free of litter and refuse. Findings include, but are not limited to:

The facility grounds were toured on 02/07/23 and the following was identified:

* The grounds surrounding the facility were observed to have disposable cups, face masks and food wrappers present; and

* The courtyard was observed to have cigarette butts, disposable cups, food wrappers, a rolled up rug and hardware present during the tour.

The need to ensure facility grounds were kept orderly and free of litter and refuse was discussed with Staff 1 (Interim Administrator) and Staff 4 (Contracted Environmental Services) on 02/07/23 at 2:35 pm. They acknowledged the findings.

1.  Facility grounds have been cleaned of all trash and debris.

2.  Daily cleaning of 100% of facility grounds has been added to facility housekeeping duties.

3.  Weekly environmental rounds of facility grounds will occur by facility leadership to assure grounds are free of trash and debris.

4. RCF Administrator   

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

The environment was toured on 02/06/23 and 02/07/23 and the following was identified:

1. First Floor

a. The combined dining and activity area:

* Tables had built up matter on legs;

* The exit doors leading to the courtyard were scuffed, had black matter present and paint was chipping off;

* The exit door to the left of the beverage station was scuffed, had black matter present and paint was chipping off; and

* The wall opposite of the smoking area was scuffed and had paint chipping off.

b. General:

* The public bathroom door, located across from the front entrance, had gouges in the wood on both sides; and

* A light was flickering above the door to room 117.

c. Grounds:

* A large planting pot located to the left of the front entrance was breaking apart;

* The awning over the front entrance of the building had built up cobwebs and debris;

* There was a build up of ashes around the smoking area in the courtyard; and  

* There was built up debris observed along the upper portion of the walls located in the smoking area.

2. Elevator

* The casing of the elevator, both on the first and second floor had chipped paint;

* There was debris visible in the interior part of the light covers; and

* The bottom right corner wall, located on the second floor was in disrepair, had chipped paint, and the wood located on the trim above was observed to have gouged wood.

3. Second floor

* The ceiling between rooms 213 and 214 had a hole present with paint missing around the area;

* The area around a sprinkler head, located in the ceiling between rooms 213 and 214 was in disrepair approximately 1/2 of an inch around the fixture;

* A chair across from room 210 was in need of cleaning;

* There were six disposable cups, containing orange liquid, clear liquid and white liquid, sitting on a table to the left of the chair across from room 210, covered by a napkin (observed 02/06, 02/07 and 02/08); and

* An area resembling a nurse's station, located across the hall from the staff breakroom, right wall was in disrepair on the corner where plaster and metal was exposed.

4. Throughout the building

* Multiple areas in need of paint that were located under the handrails (under the mailboxes, between rooms 113 and 119, and between rooms 209 and 210);

* Handrails were observed to have rough areas or were in disrepair;

* Multiple doors and door jambs were observed with gauges in the wood, gouges in Plexiglas kickboards, splintering wood and scuff marks; and

* Various items, including mechanical lifts, wheelchairs and footrests, blood pressure machines, over bed tables, shower benches and boxes of disposable tableware and goods were stored in the hallways throughout the facility as well as in the combined dining and activity area.

The environment was toured with Staff 1 (Interim Administrator) and Staff 4 (Contracted Environmental Services) on 02/07/2023 at 2:30 pm and the above mentioned areas were discussed.

1.  Multiple walk-throughs have been completed with our property management team.  All mentioned cleaning / repairs / replacements will be completed by alleged date of compliance.  Damaged wood doors will be fitted with kick plates.  Damaged hand rails will be repaired / replaced.  Door frames and areas with chipped paint will be repainted.  Hallways will be cleared of unnecessary furnishings and other personal belongings.

2.  Weekly monitoring of needed repairs and environment will be implemented and completed by Housing leadership until everything is completed.

3.  Weekly environmental rounds will be implemented by RCF Administrator.  Quarterly check-ins have been implemented with property management company.  

4.  RCF Administrator

Based on observation and interview, it was determined the facility failed to ensure the capacity to seat 100% of the residents in the combined dining and activity area. Findings include, but are not limited to:

The facility's census at the time of survey was 27. Residents were observed throughout the day doing activities and eating meals in the combined area on 02/06/23, 02/07/23 and 02/08/23.  

The facility's combined dining and activity area was toured on 02/07/23 at 10:24 am. There were multiple large boxes of disposable tableware observed, a stand up piano, and an approximately six by four foot area that was dedicated to activity supplies.

Although there was a sufficient amount of tables and chairs set up, the space did not provide a minimum of 30 square feet per resident for the combined dining and activity area.  

The need to ensure a minimum of 30 square feet per resident for combined dining and activity area seating was discussed with Staff 1 (Interim Administrator) and Staff 4 (Contracted Environmental Services) on 02/07/2023 at 2:50 pm. They acknowledged the findings.  

1.  All cardboard boxes / kitchen supplies will be relocated.  Activity supplies will be consolidated.  

2.  Square footage for a full census x 30 square feet / resident will be calculated.  Dining room will be reconfigured to guarantee adequate resident space.  Additional dining tables / chairs will be acquired as needed.  

3.  Weekly environmental rounds will be implemented to include assessment and review of dining room furnishings and configuration.  Adjustments will be immediately made as needed.

4.  RCF Administrator

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 provide security and to alert staff when residents exited the building. Findings include, but are not limited to:

Observations during the survey revealed the facility's main entrance door and all exit doors leading to the courtyard did not have an operational alarm or other acceptable system to alert staff when residents exited.

The need to ensure exit doors were equipped with an alarming device or other acceptable system was discussed with Staff 1 (Interim Administrator) and Staff 4 (Contracted Environmental Services) on 02/07/23. They acknowledged the findings.

1.  Facility has been fit with a new call system.

2.  All RCF exit doors will be fitted with transmitters that will alert new call system staff pagers upon any door opening.

3.  Weekly environmental rounds will be completed to assure call system is in proper repair in terms of exit door notification.

4.  RCF Administrator