The findings of the re-licensure survey, conducted 07/10/23 through 07/12/23, 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, Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.

Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.

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 07/12/23, conducted 11/20/23 through 11/21/23 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 57 for Memory Care Communities.

Based on observation, interview, and record review, it was determined the facility failed to ensure a prompt investigation of injuries of unknown cause, resident-to-resident altercations and elopement was documented to rule out abuse and/or neglect and reported to the local SPD office as required for 2 of 3 sampled residents (#s 1 and 2) whose incidents were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 04/2023 with diagnoses including dementia and anxiety.

Observations of the resident, interviews with staff, and review of the resident's 05/29/23 service plan, 04/27/23 through 07/10/23 temporary service plans, progress notes, physician communications, and incident investigations were completed.

The resident was noted to be confused, anxious and had frequent agitation. The resident was independent with most ADL care with minimal staff intervention. The resident required frequent redirection by staff throughout the day and was a high risk for exit seeking and elopement. The resident did have a history of slamming and pounding on doors and breaking items when upset.

Review of the resident's records showed the following:

* A progress note dated 05/17/23, indicated during 15-minute checks the resident could not be located. Staff began a search, and the resident was found approximately three minutes away from the facility campus. Staff 1 (Administrator) was able to pick the resident up and drive him/her back to the facility. No injuries were noted.

No investigation was completed related to the elopement and the incident was not reported to the local SPD office.

* A progress note dated 05/19/23 at 12:50 pm, indicated the resident went down the hall towards his/her room while staff were setting up drinks. The resident had been pacing significantly during the early part of the day. The note further indicated while activity staff were bringing other residents back to the unit through the front door, Resident 1 started walking towards the parking lot. The resident told staff s/he "just jumped over."

In an interview on 07/11/23, Staff 1 (Administrator) and Staff 3 (RCC) indicated they were not sure if the resident made it out of the unit. In a follow up interview on 07/12/23, Staff 3 stated from what she could determine the resident tried to make it out, but had not actually exited the unit.

No investigation was completed related to the potential elopement and no other information was documented about the incident to indicate if the resident did or did not exit the secured area of the unit.

The need to ensure all incidents had a complete and prompt investigation completed to rule out abuse and/or neglect and reported to the local SPD as needed, was discussed with Staff 1, Staff 2 (Assistant Administrator), Staff 3 (RCC), Staff 5 (LPN) and Staff 6 (LPN) on 07/12/23. The staff acknowledged the findings.

Staff 1 was asked to report the elopement and a confirmation was provided prior to survey exit.

2. Resident 2 was admitted to the facility in 06/2017 with diagnoses including dementia.

Observations of the resident, interviews with staff, and review of the resident's 04/27/23 service plan, 04/10/23 through 07/10/23 temporary service plans, progress notes, physician communications, and incident investigations were completed.

The resident was noted to be confused, but could make some needs known. The resident required one staff assist for multiple ADLs. The resident required a hoyer lift for transfers with the assistance of one staff. The resident could self-propel once s/he was transferred into the wheelchair. The resident had fragile skin with a history of bruising. The resident had a screen door on the entrance to his/her room that was kept closed when the inner door was open to discourage others from wandering into the room.  

Review of the resident's records showed the following:

* A progress note dated 06/17/23, indicated the resident had a small scabbed area to the left cheek of 0.5 cm. The resident stated it was from scratching.  

A complete investigation was not documented related to the skin injury to confirm the cause and rule out abuse and neglect.

In interview on 07/11/23, Staff 1 (Administrator) indicated they believed the scabbed area was likely caused by the resident scratching himself/herself so had not documented a full investigation.  

* A progress note dated 06/24/23, indicated the resident had redness to the right side of his/her forehead. The area was reported to have occurred on the previous day during the resident's shower. Staff reported the strap of the hoyer sling grazed the resident's forehead and "they would be more careful."

A complete investigation which addressed required components, was not documented related to the red area and the staff report, to confirm the cause and to rule out abuse and neglect.

In interview on 07/12/23, Staff 1, Staff 3 (RCC) and Staff 6 (LPN) indicated there was no abrasion but just a reddened area that lasted a day or two. The resident reported no concerns that they were aware of and it seemed to be an accident. Staff 1 was unsure if service planned interventions were followed at the time and had no further documentation of an investigation of the incident.  

* A progress note dated 07/06/23, indicated the resident had sustained two skin tears, side by side to the forearm near the wrist. The note does not indicate which side the skin tears were located. The resident reported s/he scraped his/her arm on the lift when in the shower. Staff documented the resident was not an accurate historian and it was possible the resident's watch may have caused the skin tears due to the textured metal band and loose fit.

A complete investigation was not documented to confirm or rule out a cause and to rule out abuse and neglect.

In interview on 07/11/23, Staff 1, Staff 3 and Staff 5 (LPN) indicated the resident often refused to have his/her watch removed. Staff 1 stated the two skin tears seemed to line up with the watch band which might have been a more likely explanation than the resident's statement about the hoyer lift. The staff indicated an investigation was not completed regarding the skin tears.

The need to ensure all incidents had a complete investigation, which was promptly documented to rule out abuse and/or neglect and reported to the local SPD as needed, was discussed with Staff 1, Staff 2, Staff 3, Staff 5  and Staff 6 (LPN) on 07/12/23. The staff acknowledged the findings.

1- In response to C231, we have two residents and multiple examples based on not completing a complete and prompt investigation to rule out abuse or neglect. The action described below will be taken to correct the rule violation for each example and resident.

Gateway Gardens Administration Team will do a full review of our Nursing Department's Policies and Procedures regarding Special Incident Reports (SIR's) and OAR 411-054-0028 to fully understand the law and better understand the requirement for prompt investigation of injuries of unknown cause, resident-to-resident altercations, and elopement are investigated to rule out abuse or neglect and the appropriate authorities are notified.

2- Our Administration Team will review the Nursing Department's Policies and Procedures regarding SIR's and OAR 411-054-0028, specifically OAR 411-54-0028 (2)(a-d) & (3) with the Nursing Department's Nurses and Resident Care Managers (RCM) to ensure they fully understand when to investigate and the importance of investigating potential abuse or neglect.

During our next Direct Staff Monthly Mandatory Meeting for continuing education, we will review our Medpassing Manual's Procedures regarding Incident Reporting and OAR 411-54-0028 (2)(a-d) to refresh and remind all staff, specifically our Medpassers, the importance of reporting all injuries of unknown cause during their assessments.

3- While preparing for our quarterly Resident Care Conferences, the Nursing Department and the Administration Team will review all chart notes in preparation for the conference to ensure no incidents were overlooked and not investigated appropriately.  

4- Gateway Gardens Administration team will be responsible for seeing that all corrections are completed. The Administration Team and the Nursing Department will be responsible for monitoring SIR's and chart notes to ensure all injuries of unknown cause, suspicion of abuse, or neglect are reported appropriately.  

Based on observation and interview, it was determined the facility failed to ensure a daily program of social and recreational activities that was based upon individual and group interests and physical, mental, and psychosocial needs was provided for residents. Findings include, but are not limited to:

During the survey, 07/10/23 through 07/12/23, observations of the three units showed one to two group activities were conducted inside each of the houses. The television was on throughout the day. Residents from each house could attend activities in other houses, but minimal travel between houses was observed.  

In an interview on 07/12/23, Staff 23 (Activity Director) indicated she worked Monday to Friday and her activity assistant worked Wednesday to Sunday. They typically had a scheduled activity in each house, listed on the calendar, and outings with residents were conducted on the days there were two activity staff. Staff 23 indicated each of the houses had a cupboard with multiple activity options for staff to do with residents, these were not reflected on any calendar or schedule. She could not say why the staff were not consistently providing activities for the residents.

The need to ensure a daily activity program was provided for residents to address their mental, physical and psychosocial needs was reviewed with Staff 1 (Administrator), Staff 2 (Assistant Administrator), Staff 3 (RCC) and Staff 23 on 07/12/23. The staff acknowledged the findings.

1- Gateway Gardens Activity Director created an In-House Activity Calendar and provided supplies for the listed activities.

2- The Activity Department added a weekly task to include reviewing the In-House Activity Calendar, ensuring supplies are provided, and updating the calendar as needed.

3- Our Activity Director will use feedback from residents to make any requested changes to the In-House Activity program and audit the calendar and supplies weekly.

4- Gateway Gardens Activity Director will be responsible for ensuring the corrections are completed and monitored weekly.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements and were completed prior to the resident being admitted to the facility for 2 of 2 sampled residents (#s 1 and 6). Findings include, but are not limited to:

1. Resident 1 was admitted to the facility on 04/27/23 with diagnoses including dementia and anxiety.

The resident's new move in evaluation was completed on 04/25/23.  The following elements were not addressed or had conflicting information in the move-in evaluation:

* Visits to health practitioner(s), ER, Hospital or NF in the past year;

* Presence of depression, thought disorders, behavioral or mood problems;

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

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

* Skin Condition;

* History of dehydration or unexplained weight loss;

The need to complete move-in evaluations prior to a resident being admitted to the facility and to address all required elements was discussed with Staff 1 (Administrator) and Staff 2 (Assistant Administrator) on 07/12/23. The staff acknowledged the findings.

2. Resident 6 was admitted to the facility in 06/2023 with diagnoses including dementia, Type 1 diabetes, and history of hip fracture.

Resident 6's initial evaluation, dated 05/28/22, contained inaccurate or incomplete information in the following area:

* Visits to health practitioners, emergency room, hospital, or nursing facility in the past year.

The evaluation documented "N/A" for MD visits in the past year and "N/A" for hospital visits in the past year.

In a telephone interview with Witness 1 (Family) on 07/12/23, Witness 1 reported the resident had seen his/her endocrinologist in the past few months and had been in the hospital in February 2023.

The need to ensure initial evaluations addressed all required elements was discussed with Staff 1 (Administrator), Staff 2 (Assistant Administrator), Staff 3 (RCC), Staff 5 (LPN)) and Staff 6 (LPN) on 07/12/23. They acknowledged the findings.

1- In response to C252, we have two examples of not ensuring move-in evaluations address all required elements and are completed before the resident is admitted. The action described below will be taken to correct the rule violation for each example.

Gateway Gardens Evaluators will review OAR 411-054-034 (1-6) to ensure all move-in evaluations address all required elements and complete the assessment before the resident is admitted to Gateway Gardens. Making a specific note not to use N/A anywhere on the evaluation, and if the resident, family, or others cannot answer the questions, it will be documented with the response given.

2- The Evaluators, Administration Team, and the Nursing Department, which includes RCM's, will review OAR 411-054-034 (1-6) as stated in number 1 above. This will provide redundancy as well as a check and balances within our admission procedures.

3- The RCM will review all evaluations while they enter the data from the evaluation into our Electronic Medical Administration Record (EMAR) to ensure the evaluation is completed in its entirety prior to the resident's admission.

4- Our check and balance will be the responsibility of both the Evaluator and the RCM. The Evaluator will verify that the evaluation is completed in its entirety before sending it to the Nursing Department for admission. The RCM will verify that the evaluation is complete while entering the resident's information into our EMAR. If there are any errors, the RCM will return the evaluation to the Evaluator for completion.

4. Resident 1 was admitted to the facility in 04/2023 with diagnoses including dementia and anxiety.  

Observations of the resident, interviews with staff, and review of the resident's service plan dated 05/29/23 and progress notes dated 04/27/23 to 07/10/23 were completed. The resident was noted to be independent with most ADLs but did require frequent staff redirection related to leaving the facility. The resident had a history of aggression with staff and other residents and exit seeking.

The resident's service plan was not reflective and/or did not provide clear direction to staff in the following areas:

* Verbal aggression towards individual residents;

* Excessive pacing, statements of leaving and attempts to climb the exterior fence;

* Jumping or climbing over the kitchen gate, increased hunger and food seeking;

* Actual elopement from the secured courtyard and attempts to leave through front door;

* Chronic pain, non-drug interventions and effect on behaviors;

* Climbing out his/her bedroom window to the courtyard and safety interventions; and

* Interventions and activities to engage the resident and when to utilize for agitation.

The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (Administrator), Staff 2 (Assistant Administrator), Staff 3 (RCC), Staff 5 (LPN) and Staff 6 (LPN) on 07/11/23 and 07/12/23. The staff acknowledged the findings.

3. Resident 4 was admitted to the facility in 12/2020 with diagnoses including dementia and multiple sclerosis.

The resident's service plan, dated 06/13/23, interim and change of service plans dated 04/10/23 through 07/10/23 were reviewed, and the resident and staff were interviewed.

Resident 4 was observed on 07/10/23 to have quarter length side rails on the bed.  The side rail closest to the wall was in the up position and the side rail on the open side of the bed was in the down position.

The service plan identified that side rails were used to aide in positioning, although did not include instruction for caregivers on the correct use and precautions related to use of the device.

The resident reported that the side rail on the open side of the bed stayed in the down position and the wall side rail was used to help him/her reposition in bed.

Care staff interviewed during survey were unaware of any precautions to monitor for related to safety with side rail use.  

The need for the service plan to provide clear instruction to staff regarding correct use and precautions for safety with side rail use was discussed with Staff 1 (Administrator), Staff 2 (Assistant Administrator), Staff 3 (RCC), Staff 5 (LPN)) and Staff 6 (LPN) on 07/12/23. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs and provided clear direction regarding the delivery of services for 4 of 6 sampled residents (#s 1, 4, 5, and 6) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 5 was admitted to the facility in 01/2021 with diagnoses including dementia and seizures.

The resident was identified during the acuity interview on 07/10/23, as smoking independently, including keeping a pack of cigarettes and a lighter in his/her room.

Review of the resident's current service plan dated 06/28/23, resident observations and staff interviews, indicated the resident's service plan was not reflective and did not provide clear instruction to staff in the following area:

* Independence with smoking and storage of smoking items.

The resident was observed on 07/11/23 coming from his/her room, walking to the designated smoking area, lighting, and smoking a cigarette.

The resident's service plan stated, "Cigarettes and lighter to be stored in the med room at all times."

The need to ensure service plans were reflective and provided clear direction regarding delivery of services was discussed with Staff 1 (Administrator), Staff 2 (Assistant Administrator), Staff 3 (RCC) , Staff 5 (LPN) and Staff 6 (LPN) on 07/12/23. They acknowledged the findings.

2. Resident 6 was admitted to the facility in 06/2023 with diagnoses including dementia, type 1 diabetes, and history of hip fracture.

Review of the resident's current service plan dated 06/09/23 and Physical Therapy note dated 06/23/23, and interviews with staff, indicated the resident's service plan was not reflective and did not provide clear instruction to staff in the following areas:

* Frequent call light use;

* Weight-bearing status; and

* Instructions and precautions related to use of side rails.

The need to ensure service plans were reflective and provided clear direction regarding delivery of services was discussed with Staff 1 (Administrator), Staff 2 (Assistant Administrator), Staff 3 (RCC) , Staff 5 (LPN)) and Staff 6 (LPN) on 07/12/23. They acknowledged the findings.

Example #1

1- Resident's Service Plan was updated to reflect that this resident is independent with smoking, and they can keep their cigarettes and lighter on their person and lock both in a drawer in their room. Gateway Garden's RN will do a smoking/safety assessment quarterly during Quarterly Care Conferences or as needed due to any decline in resident's mentation.

Example #2

1- Resident's Service Plan was updated to reflect increased call light usage, transfer status, and side rail usage. Precautions related to the use of side rails were added to their Service Plan.

Example #3

1- Resident's Service Plan was updated with usage and precautions related to side rail usage.

Example #4

1- Resident's Service Plan was completely redone to reflect Verbal aggression towards individual residents; Excessive pacing, statements of leaving and attempts to climb the exterior fence; Jumping or climbing over the kitchen gate, increased hunger and food-seeking; Actual elopement from the secured courtyard and attempts to leave through the front door; Chronic pain, non-drug interventions and effect on behaviors; Climbing out their bedroom window to the courtyard and safety interventions; and Interventions and activities to engage the resident and when to utilize for agitation.

Examples #1-4

2- Staff was notified of all Service Plan changes, and education was provided to report all Service Plan changes or requests on a new section of their Caregiver worksheet designed for communication with the Nursing Department and educated about our universal guidelines and precautions related to residents with side rails.

Examples #1-4

3- The Nursing Department and Administration Team will audit Service Plans during our Quarterly Care Conferences or as needed.

Examples #1-4

4- The Nursing Department, which includes our RCM, will complete any updates to Service Plans as needed, and our Administration Team will monitor the workflow to verify that all Service Plans are current and reflect each resident appropriately.      

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 or as requested by the prescriber for 1 of 1 sampled resident (#3), who had documented medication refusals. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 04/2019 with diagnoses including dementia and anxiety.

Resident 3's 04/10/23 through 07/10/23 progress notes and  07/01/23 through 07/10/23 MARs were reviewed. The resident's record showed multiple medication refusals.

An order dated 05/18/23 directed the facility to notify the physician of medication refusals on a monthly basis.

There was no documented evidence the facility notified the physician of Resident 3's medication refusals for the month of June, 2023.

During an interview on 07/12/23, Staff 3 (RCC) reported that the medication refusals had not been reported to the physician for the month of June because the resident was now on hospice.

On 07/12/23, the need to ensure the physician/practitioner was notified when a resident refused to consent to orders or as requested by the prescriber related to medication refusals was discussed with Staff 1 (Administrator), Staff 2 (Assistant Administrator), Staff 3 , Staff 5 (LPN ) and Staff 6 (LPN) on 07/12/23. The staff acknowledged the findings.

1- A fax was sent on 07/27/2023 to document Resident 3's July medication refusals with a request for how often they would like to be notified. Hospice's replied with specific instructions that are recorded on our EMAR and procedures.

2- Gateway Gardens revised its Physician Orders (PO) template to include the medication refusal requests section, which is currently being used.

3- The Nursing Department will conduct a monthly audit of resident medication refusals and communication with their Primary Care Physicians (PCP) to ensure we meet OAR 411-054-055(1)(k).

4- The Nursing Department, specifically the RCM, has completed the correction and will monitor medication refusals and communications going forward.  

Based on interview and record review, it was determined the facility failed to ensure PRN medications used to treat a resident's behavior  had documented evidence that non-pharmacological interventions had been tried with ineffective results, prior to administering the PRN medications for 1 of 2 sampled residents (#3). Findings include, but are not limited to:

Resident 3 was admitted to the facility in 04/2019 with diagnoses including dementia and anxiety.

Review of the resident's 07/01/23 through 07/10/23 MARs, progress notes and current physician orders showed the following:

* Haloperidol oral solution 2 mg/ml, give 1.0 mg every four hours PRN for agitation, restlessness, hallucinations or nausea.

The haloperidol was administered on five occasions between 07/01/23 and 07/10/23.

* Lorazepam 0.5 mg, give every hour PRN for anxiety, shortness of breath or nausea.

The lorazepam was administered on five occasions between 07/01/23 and 07/10/23.

There was no documented evidence that non-pharmacological interventions had been tried with ineffective results prior to administering the PRN psychotropic medications.

The need to ensure there was documented evidence that non-pharmacological interventions were tried with ineffective results prior to administering PRN medications to treat a resident's behaviors was discussed with Staff 1 (Administrator), Staff 2 (Assistant Administrator), Staff 3 (RCC), Staff 5 (LPN) and Staff 6 (LPN) on 07/12/23. The staff acknowledged the findings.

1- Non-pharmacological interventions were added to our medication delivery system within our EMAR for Resident 3's psychotropic PRN's. As well as an audit of all resident psychotropic PRN's to ensure there are non-pharmacological interventions meeting OAR 411-054-0055 (6).

2- The Nursing Department added a check and balance to their workflow when adding psychotropic medications to our EMAR System.

3- The Nursing Department and Administration Team will audit psychotropic PRN's to ensure there are non-pharmacological interventions listed during our Quarterly Care Conferences. The RCM will review any medication changes or as needed.

4- The Nursing Department, specifically the RCM, has completed the correction and will monitor all residents' psychotropic PRN use with non-pharmacological use going forward.

Based on interview and record review, it was determined the facility failed to ensure the Acuity-Based Staffing Tool (ABST) was updated to accurately reflected resident care needs for 4 of 5 sampled residents (#s 1, 2, 3 and 6), whose ABST data was reviewed. Findings include, but are not limited to:

Review of four sampled residents' records, interviews with staff, and interviews and observations of the residents noted ABST entries were not reflective of the current care needs.  The ABST data showed multiple areas which reflected zero minutes when the resident required limited to extensive staff assistance with those activities.

In an interview on 07/11/23, Staff 3 (RCC) indicated she updated everyone in the last 2-3 weeks when staff were all changed to 12 hour shifts. Staff 3 stated she used the service plan to help determine the amount of care residents needed but did have some confusion on how to enter items.

Inaccuracies for resident entries on the ABST tool and potentially inaccurate staffing calculations were discussed with Staff 1 (Administrator), Staff 2 (Assistant Administrator), Staff 3, Staff 5 (LPN) and Staff 6 (LPN) on 07/12/23. The staff acknowledged the service plans for the sampled residents were not reflective; therefore, the ABST data was not accurate and potentially created inaccurate staffing.

Refer to C260.

1- In response to C361, we have four resident examples of not ensuring the ABST is updated to reflect resident care needs accurately. The action described below will be taken to correct the rule violation for each example and resident.

The RCM contacted the ABST Team, who provided education and direction for better accuracy to reflect resident care needs. RCM then applied what was learned to Gateway Gardens ABST for better accuracy with staffing calculations.

2- With the education our RCM received from the ABST Team, we now have the appropriate knowledge to enter resident care timeframes into the ABST tool correctly. This education will be applied to all new residents and if any current residents' needs change.

3- The ABST will be updated with any Service Plan change, 30-day service plan updates, and during our Quarterly Care Conferences.

4- The Nursing Department, specifically the RCM, has completed the corrections and will monitor resident needs and update the ABST as needed.  

Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to C231, C242 and C361.

Refer to C231, C242 and C361

Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to C252, C260, C305 and C330.

Refer to C252, C260, C305 and C330

Based on observation and interview, it was determined the facility failed to ensure fences surrounding the perimeter of the outdoor recreation area were no less than six feet (or 72 inches) in height. Findings include, but are not limited to:

The facility was toured on 07/10/2023. The following was identified:

Sections of fencing surrounding the perimeter of the outdoor courtyard and rear outdoor walkway failed to meet the six foot height requirement. The surveyor measured several sections of the fence, which measured between 66.5 to 71.5 inches in height.

On 7/10/23, the need to ensure fences surrounding the perimeter of the outdoor recreation area were no less than six feet (or 72 inches) in height was discussed with Staff 1 (Administrator). She acknowledged the findings and the facility immediately began taking measures to increase fence height to six feet.

1- Gateway Gardens Maintenance personnel immediately began taking measures to increase the fence height to six feet (or 72 inches) in height. Our fencing is now current with OAR 411-057-0170 (5) (b).

2- Our Maintenance Division added checking the height of our fencing to their quarterly walk-through and checks.

3- Our Maintenance Division has a standing quarterly walk-through and checks. As stated above, fence height has been added to their task list.  

4- The Administration Team and Maintenance personnel will monitor and correct any fencing in accordance with OAR 411-57-0170 (5) (b).