Print Inspection: 02BU

The findings of the re-licensure survey, conducted 12/06/22 through 12/07/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 for Home and Community Based Services Regulations.

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 first re-visit to the re-licensure survey of 12/07/22, conducted 05/12/23 through 05/17/23 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, OARs 411 Division 57 for Memory Care Communities 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

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 re-visit to the re-licensure survey of 12/07/22, conducted 08/01/23 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 provide a daily activity program of social and recreational activities based on individual and group interests, physical, mental and psychosocial needs, and create opportunities for active participation in the community at large. Findings include, but are not limited to:

During the survey, the MCC was home to 12 residents.   

Random resident observations made on 12/06/22 and 12/07/22, review of the activity calendar, and interviews with staff revealed the following:

a. The December 2022 Memory Care Activity Program calendar provided during the entrance conference indicated the following activities would occur on 12/06/22:

* 9:00 am: News;

* 9:30 am: Mini Mani's:

* 10:00 am: Painting with Margi;

* 11:30 am: Balloon Toss;

* 1:00 pm: Fitness with Sam;

* 2:00 pm: Baking with Staff; and

* 3:30 pm: Mind Game.

On 12/06/22, the only facility led activities observed in the MCC between 9:30 am - 3:30 pm was a painting activity. Although television movies and holiday music played sporadically, no other activities were observed.

b. On 12/07/22, the activity calendar and a posted daily activity plan (written on a dry erase board in the activity area) noted the following activities would occur:

* 9:00 am: News;

* 9:30 am: Coloring;

* 9:30 am: Craft time;

* 10:00 am: Tea time with staff;

* 10:00 am: Hydration and snacks;

* 11:00 am: Daily Chronicle;

* 11:00 am: Fitness with Sam;

* 1:15 pm: Puzzle time;

* 2:00 pm: Hot cocoa;

* 3:00 pm: Holiday Movie;

* 3:30 pm: Music Therapy; and

* 4:15 pm: Balloon Toss.

The only facility led activities observed between 8:30 am - 3:30 pm was a holiday craft where one resident participated, and an afternoon snack of cookies and drinks. The television and holiday music played sporadically; however, no other facility led activities were observed.

Failure to provide a daily activity program of social and recreational activities based on individual and group interests, physical, mental, and psychosocial needs, and that created opportunities for active participation in the community at large was discussed with Staff 1 (Administrator) on 12/07/22 at 3:30 pm. She acknowledged the findings.

OAR 411-054-0030 (1)(c-d) Resident Services: Activities

Staff was inserviced immediately on the importance of following scheduled activties or finding alternate options based on resident interests outlined in service plans. Operations Leader reviewed company standards related to activities in Memory Care with Memory Care Manager and General Manager. Staff training was conducted with all memory care staff related to company memory care programs to provide a daily activity program of social and recreational

activities based on individual and group

interests, physical. Memory Care manager to conduct a daily audit to ensure scheduled activities are being conducted. General Manager is responsible to see that the corrections are completed and monitored.            

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

Resident 3 was admitted to the facility in 11/2022.

A review of the resident's move-in evaluation failed to address the following:

* Customary routines;

* Spiritual, cultural preference and traditions;

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

* Complex medication regimen;

* Recent losses; and

* Environmental factors that impact the residents behavior, including but not limited to: noise, lighting and room temperature.

The facility's failure to complete all required elements for Resident 3's move-in evaluation was discussed with Staff 1 (Administrator) and Staff 3 (ALF Administrator) on 12/07/22. They acknowledged the findings.

OAR 411-054-0034 (1-6) Resident Move -in and Eval: Resident Evaluation

Resident 3 has been reassessed and service plan was updated to reflect complete and accuragte resident care needs.

Prior to the residents moving in to Memory Care, the Memory Care Manager, and Health and Wellness Director will review the evaluation- and service plan to ensure it reflects all evaluation elements. Evaluations will be reviewed 30 days after the initial move in and quaterly.

Evaluation training was held with the Memory Care Manager and RCC. Evaluations will be audited by the memory care manager monthly and the H&W director, RN. Weekly meeting will be held with GM and Health and Wellness team to audit processes. General Manager will be responsible for overall compliance.

2. Resident 1 was admitted to the MCC in 2020 with diagnoses which included dementia.

Interviews with care staff and observations of Resident 1 during the survey revealed s/he was incontinent, received assistance for several ADL care needs, and did not use a call light to summon assistance.

Resident 1's service plan, dated 10/19/22, revealed it was not reflective of the resident's needs and lacked clear direction regarding the delivery of services in the following areas:

* Skin rash and treatments;

* UTI medication;

* Forehead wound;

* Activities; and

* Use of eye glasses.

The need to ensure the service plan was reflective of Resident 1's current care needs and provided clear direction to staff was discussed with Staff 1 (Administrator) on 12/07/22 at 3:25 pm. She acknowledged the findings. No further information was provided.

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

1. Resident 2 was admitted to the facility in 12/2021 with diagnoses including dementia.

Observations of the resident and interviews with staff during the survey, and review of the clinical record including the 12/06/22 service plan and Temporary Plan of Care (TSPs) from 09/01/22 through 12/06/22, revealed the service plan was not reflective of the resident's needs and lacked clear direction regarding the delivery of services in the following areas:

* Skin condition;

* Bathing and shower services;

* Use of boots on legs;

* Toileting status;

* Use of air mattress;

* Use of floor mat on each side of bed; and

* Ted hose status.

The need to ensure the service plan was reflective of Resident 2's current care needs and provided clear direction to staff was discussed with Staff 1 (Administrator) on 12/07/22. She acknowledged the findings.

OAR 411-054-0036 (1-5) Service Plan: General

Resident 1 & 2 have been evaluated, current health needs, clear direction regarding the delivery of services have been updated and are now reflective of the residents care needs.

Resident 1 & 2 now address the needs listed as deficient and those service needs are reflective on the service plan.

Resident # 2 has clear direction on hospice care orders in the service plan including the use of the air mattress and the floor mats on each side of the bed. Bathing services updated to reflect hospice care conducting them.

Resident #1 has clear direction to reflect the needs and provide direction to the staff on how to deliver the care the resident needs.  

Service plan development & training was conducted by the memory care manager with the team.

Weekly meeting will be held with GM and Health and Wellness team to audit processes. General Manager will be responsible for overall compliance.          

Based on observation, interview and record review, it was determined the facility failed to ensure an RN assessment was completed for residents who had significant changes of condition which included documented findings, resident status, and interventions made as a result of the assessment for 1 of 2 sampled residents (#2) who experienced a significant change of condition in weight status. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 12/2021 with diagnoses including dementia and edema.

During the acuity interview on 12/06/22, the resident was identified to have a weight change.

The resident was observed on 12/06/22 in the dining room for lunch. The resident ate the meal independently and consumed 100 %.

Resident 2's weight records were reviewed during the survey and revealed the following:

* 01/05/22 - 228.0 pounds;

* 06/02/22 - 252.0 pounds;

* 08/04/22 - 242.0 pounds;

* 11/03/22 - 252.0 pounds; and

* 12/01/22 - 232.4 pounds.

From 01/2022 to 06/2022, Resident 2 gained 24.0 pounds or 10.52 % of his/her body weight in five months, and from 11/03/22 to 12/01/22, the resident lost 20.6 pounds or 8.51 % of his/her body weight in a month, which represented a significant change of condition.

The facility RN completed an assessment on 07/24/22 and stated the "current weight 238 [pounds]" and noted "weight entered on 6/22 is likely data error entry as all other weights are consistent and range for 6 months". However, there was no documented evidence the RN evaluated the resident's weight to support the 06/2022 weight data was an error such as a re-weigh of the resident or obtained the resident's weight in 07/2022.

There was no RN assessment for the significant weight loss between 11/2022 and 12/2022 at the time of survey.

The need to ensure significant changes of condition were assessed by an RN and the assessment included documentation of findings, the resident's status and interventions made as a result of the assessment was discussed with Staff 1 (Administrator) and Staff 3 (ALF Administrator) on 12/07/22. They acknowledged the findings.

OAE 411-054-0045 (1) (a-f) (A) (C-F) Resident health services

Resident 2 has been reassessed for Significant Change of Condition for weight change by the RN. The service plan has been updated to reflect those changes. Memory care manager and RN will review notes, incident reports and alerts daily and will have the assessments and service plan updates completed for all the significant change of conditions within 48 hours.

Memory Care Manager will review notes, incident reports, and alerts daily and communicate significant change of conditions to RN. All care staff were re-trained on reporting changes for residents per company policy. RN will have assessment and service plan updates completed for all significant changes of conditions within 48 hours.

Service Planning and Significant Change of Condition training was conducted by H&W Director and Corporate RN with the nursing team. All care staff were re-trained on reporting changes for residents per company policy using.

Weekly meeting will be held with GM and Health and Wellness team to audit processes. Memory Care Manager will be responsible for overall compliance.

3. Resident 6 was admitted to the facility with diagnoses including dementia, HTN and was on hospice.

Resident 6's weight record was reviewed during the survey and revealed the following:

* 02/2023 - 148 pounds;

* 03/2023 - 140 pounds;

* 04/2023 - 133 pounds; and

* 05/03/23 - 136 pounds.

From 02/2023 to 03/2023, Resident 6 lost 8 pounds or 5.4% of his/her body weight. Between 03/2023 to 04/2023, Resident 6 lost another 7 pounds or 5% of his/her body weight, both of which represented a significant change of condition.

There was no documented evidence the RN conducted an assessment of the resident's weight loss from 02/2023 through 04/2023, which included findings, a description of resident status and a plan of care to address the weight loss.

Resident 6 was observed eating lunch and snacks independently on 05/15/23 and 05/16/23. S/he ate well when placed with other residents who were eating.

On 05/11/23, one month after the second significant weight loss, the new facility RN, Staff 12, completed a significant change of condition assessment for the weight loss and included interventions of encourage resident to eat and drink at meal times, encourage resident to snack during the day and remind of all meals.

The requirement to document a timely RN assessment of a resident's significant change of condition was discussed with Staff 1 (Administrator) and Staff 3 (ALF Administrator) on 05/17/23. They acknowledged the findings. No further information was provided.

Based on observation, interview and record review, it was determined the facility failed to ensure an RN assessment was completed for residents who had significant changes of condition, which included documented findings, resident status, and interventions made as a result of the assessment for 2 of 2 sampled residents (#s 1 and 6) who experienced a significant change of condition. This is a repeat citation. Findings include, but are not limited to:

Resident 1 was admitted to the facility with diagnoses including dementia and Kidney disease (stage III).

Resident 1's record was reviewed during the survey and revealed the following:

1. The MCC "Weight Report" for Resident 1 documented a monthly gain 26 pounds in 04/2023, and then a loss of 17 pounds in 05/2023.

*03/2023 179 pounds;

*04/2023 205 (26 pound weight gain); and

*05/2023 188 (17 pound weight loss).

The significant weight fluctuations between 03/2023 and 04/2023 and also 4/2023 to 5/2023 constituted a significant change of condition.

In interview on 05/09/23 Staff 1 (Administrator) stated the weight fluctuation were data errors due to staff using different scales for weights, however, there was no re-weigh, evaluation of the weight data, or referral to the RN for assessment of the weight fluctuation.

2. A progress note dated 04/23/23 noted Resident 1 was found on the floor "holding left shoulder stating it hurts terrible", and "called 911 to have resident evaluated."

Resident 1's service plan was updated at return from the emergency room to include the information "returned with a broken left collarbone and large skin tear on left elbow".

A 04/24/23 progress note documented "resident struggles with transfers since return from the hospital. Often becomes flustered making ADL unsafe for resident and staff".

Also on 04/24/23, a note stated "continue to use PRN acetaminophen (pain medicine) and Risperidone (psychotropic medication) every 6 hours for pain and agitation", and on 04/25/23 "Mobility Change: needing two person assist when getting up from dining room chairs".

A "RN post-fall note" dated 04/24/23 failed to document or assess the "large skin tear", fractured bone, unsafe ADL, increased pain and PRN pain medication use, mobility changes requiring two person assist, or to update the service plan with fall interventions.

The requirement to document an RN assessment of a resident's significant change of condition that included assessment, findings, resident status, and service plan interventions made as a result of the assessment was discussed with Staff 1 (Administrator) and Staff 3 (ALF Administrator) on 05/17/23. They acknowledged the findings.

C280 - OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services

Resident 1 has been assessed by the RN for a significan change of condition for the weight change and a weight monitoring plan of only using the weight chair for weighing not only this resicent but                  all residents is in place. The service plan has been updated to reflect those changes. Memory care manager and RN will review notes, incident reports and alerts daily and will have the assessments and service plan updates completed for all the significant change of conditions within the 48 hours.

Memory Care manager and Resident Care coordinators will review notes, incident reports, and alerts daily and communicte those change of conditions to the RN. All the staff have been re-trained on the process of reporting changes for residents per our company policy. The RN will have all significant change of conditions completed withing 48 hours. Service plan and change of condittion training completed by the H&W director as well as the RN with the nursing team. The staff of the Memory care community were trained on reporting changes for the residents per company policy. Weekly meeting is held for the H&W team, GM to discuss residents of concern and ensure compliance is being met. Memory Care Manager will be responsible for the overall compliance.  

Based on interview and record review, it was determined the facility failed to coordinate care with outside providers in order to ensure the continuity of care, for 1 of 2 sampled residents (#2) who received outside services. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 12/2021 with diagnoses including dementia and right foot pain.

During the acuity interview on 12/06/22, the resident was identified to receive hospice services.

Resident 2's clinical record, dated 10/04/22 through 12/13/22, was reviewed during the survey and revealed the following outside provider recommendations:

* A 12/02/22 note instructed staff to try to keep "[resident] in bed. Will talk w/[with] provider about course of ABX [antibiotic]"; and

* On 12/03/22, a note indicated "if pt [resident] is bedbound, please make sure to reposition Q4H [every four hours] to maintain skin integrity".

There was no documented evidence the recommendations were communicated to staff or implemented.

On 12/07/22, the need to ensure on-going coordination of care was discussed with Staff 1 (Administrator) and Staff 3 (ALF Administrator). Staff acknowledged the findings.

OAR 411-054-0045 (2) Res Hlth Srvc: on-and Off- site health srvc.

Resident 2 has been evaluated, service plan has been updated to reflect current needs and home health recommendations. Coordinator, Memory Care manager, and RN have been trained to request all notes from Home Health during their visits, if unable to obtain they will call the Home health agency to obtain notes.

Home Health/outside provider notes will be reviewed daily by the memory care team as well as the licensed nurse during the clinical meetings and recommendations will be updated in service plan as needed. Coordination of care training has been provided by the health and wellness director.

Service Plans will be audited quarterly to ensure HH recommendations are incorporated and updated in service plans. Weeky meeting with GM and Health and Wellness team take place to monitor compliance.

Memory Care Manager will be reponsible for monitoring compliance.  

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted every other month, and fire/life safety instruction was provided to staff on alternating months. Findings include, but are not limited to:

On 12/06/22, fire drill and fire/life safety training records for the previous six months were requested.

Review of the documentation provided identified the following:

* No fire drills had been completed in the MCC during the six-month time frame reviewed; and

* No fire and life safety instruction was provided to staff.

The requirements regarding fire drills and fire/life safety instruction for staff were reviewed with Staff 1 (Administrator) on 12/06/22 at 2:00 pm. The findings were acknowledged.

OAR 411-054-0090 (1) (a-d) Fire and LIfe Safety: Drills and instruction

SOD placed in fire drill binder as the vilation cannot be corrected for past dates. Operations Director has provided fire drill process and documentation education to the plant operations supervisor. Plant operations supervisor will ensure a separate memory care drill and staff training is conducted in compliance with company policy. General manager will audit all fire drills for the memory care monthly and hold weekly meetings with Plant Operations Director to monitor ongoing compliance.  

Based on interview and record review, it was determined the facility failed to ensure residents received fire and life safety training within 24 hours of admission and annually. Findings include, but are not limited to:

Fire and life safety records were requested during the survey. The following deficiencies were identified:

* Documentation of fire and life safety training provided to residents within 24 hours of move in; and

* Documentation of annual fire and life safety training provided to residents.

The need to ensure residents received fire and life safety training within 24 hours of admission and re-instructed, at least annually, was discussed with Staff 1 (Administrator) on 12/07/22 at 1:15 pm. She acknowledged the findings. No further information was provided.

OAR 411-054-0090 (5) Fire and LIfe Safety:Training for residents

SOD placed in fire drill binder as the vilation cannot be corrected for past dates. Operations Director has provided fire drill process and documentation education to the plant operations supervisor. Plant operations supervisor and or MC manager will ensure resident has been instructed on the procedures per OFC within 24 hours of admission into Memory Care and will be re-insturcted annually. Documentation will be keep to reflect those trainings. Weekly meeting will be held between GM and Plant Operations Supervisor to monitor compliance.

General Manager will be reponsible for monitoring compliance.   

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

Refer to C 280.

C 455 OAR 411-054-0105 (2-4)

refer to C280

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 C 242, C 420 and C 422.

OAR 411-057-0140 (2) Administration compliance

All staff that will be conducting, monitoring, and reviewing the preceeding tags: C242, C420, and C422 have been instructed and trained on proper protocols to ensure that resident evaluations, service plans, coordination of care, significant change of condition processes meet the licensing requirements for the facility.

General Manager and Memory Care Manager will be reponsible for monitoring compliance.   

Based on interview and record review, it was determined the facility failed to ensure 1 of 3 sampled newly hired staff (#6) completed all required pre-service training prior to performing any job duties, and 2 of 3 direct care staff (#s 9 and 10) failed to complete a minimum of 16 hours of annual in-service training annually on topics related to the provision of care for persons in a community-based care setting, including six hours of annual in-service training on dementia care. Findings include, but are not limited to:

Staff training records were reviewed with Staff 1 (Administrator) on 12/07/22. The following deficiencies were identified:

1. Staff 6 (CG) was hired 09/07/22.

a. There was no documented evidence she had completed the following elements of the required pre-service orientation and dementia training prior to performing any job duties:

* Dementia disease process including progression of the disease, memory loss and psychiatric & behavioral symptoms;

* Techniques for understanding, communicating and responding to distressful behavioral symptoms;

* Strategies for addressing social needs and engaging persons with dementia in meaningful activities;

* Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food/fluids, preventing wandering, use of person-centered approach;

* Environmental factors that are important to a resident's well-being (e.g. staff interactions, lighting, room temperature, noise, etc.)

* Family support and the role the family may have in the care of the resident;

* How to recognize behaviors that indicate a change in the resident's condition and report behaviors that require on-going assessment;

* How to provide personal care to a resident with dementia, including an orientation to the resident's service plan; and

* Use of supportive devices with restraining qualities in memory care communities.

2. Staff 9 (CG) was hired 10/17/19 and Staff 10 (CG) was hired 11/08/19. Review of annual training, based on their anniversary date of hire, revealed the following:

a. Staff 9 lacked documented evidence of having completed at least 16 hours of annual in-service training on topics related to the provision of care for persons in a community-based care setting, including six hours related to dementia care.

b. Staff 10 lacked documented evidence of having completed at least 10 hours of annual in-service training related to the provision of care for persons in a community-based care setting.

Staff training requirements were reviewed with Staff 1 (Administrator) on 12/07/22. She acknowledged the findings.

OAR 411-057-0155 (1-6) Staff Training Requrements:

Copy of Sod will be placed in employee file for Staff 6, 9, and 10 and Staff 6, 9, 10 will complete required trainings on Relias and Memory Care Manager has completed their observations for competency. Operations Leader provided training for Memory Care Manager on new hire training process and requirement. All staff that are hired will be required to complete all required relias trainings to meet the licensing rules. Staff will continue to conduct continuing education training throughout the year to meet the required 16 hours of training annually. Memory care manager as well as RCC will check on staff relias training weekly to ensure that trainings are being completed and done on time.

Annual training will also be completed using Relias and Relias records will be audited quarterly by Memory Care Manager. Weekly department meeting will be conducted to monitor compliance.

The General Manager is responsible to see that the corrections are completed and monitored.        

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to C252, C 260, C 280 and C290.

OAR 411-057-0160 (2b) Compliance with Rules Health Care

Memory care manager as well as RCC & facility RN will ensure that resident routines are identified and in the service plan for the direct care staff to be able to provide the care for the resident. Proper coordination of care is added to the service plan for residents for staff to care for the residents based on their individual care needs and routines. related to C252, C260, C280, C290.

Weekly meeting with General Manager and Health & wellness team will be held to monitor compliance. Memory Care Manager will be responsible for compliance.

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to C 280.

Z-162 - OAR 411-057-0160(2b)

Based on observation and interview, it was determined the facility failed to have a written facility policy which detailed when doors to the outdoor recreation area may be locked during nighttime hours or during severe weather. Findings include, but are not limited to:

During the survey, the following was revealed:

* The doors to access interior courtyard were observed to be unlocked during daylight hours on 12/06/22 and 12/07/22;

* When the doors were opened, there was no sound to alert staff; and

* Staff 11 (Maintenance Director) was unsure about the alert system and the policy detailed when doors to the outdoor recreation area may be locked during nighttime hours or during severe weather.

On 12/07/22, Staff 1 confirmed the facility did not have a written policy for when the courtyard doors would be locked.

On 12/07/22 at 4:30 pm, during the exit interview, Staff 1 and Staff 3 (ALF Administrator) acknowledged the above findings.

OAR 411-0057-0170 Secure Outdoor Recreation Area.

Operations Director reviewed company Opal Key Control policy with General Manager and Memory Care Manager. Doors to courtyard are not locked, they are alarmed 24 hours a day to allow resident access to secured courtyard. When door opens alert of the alarm will be sent to all memory care staff requiring staff to check the courtyard and ensure resident safety. During bad weather staff will be instructed by Memory Care manager to lock courtyard doors to ensure resident safety. Locking mechnaism will be added to courtyard doors. Staff will be inserviced on company Key Control policy which outlines monitoring and securing of enclosed courtyard. Compliance will be reviewed in weekly meetings. Memory Care Manager will be responsible for overall compliance.