Print Inspection: 59DM

The findings of the re-licensure survey, conducted 8/23/21 through 8/24/21, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

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 8/24/21, conducted 11/03/21 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

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 second revisit to the re-licensure survey of 08/24/21, conducted on 03/17/22, are documented in this report. It was determined the facility was in compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was kept clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:

Observations of the kitchen on 8/23/21 showed the following:

* Multiple walls, doors and door frames had chips, dings, dirt/dust accumulation, gouges and/or spills;

* Edges of the floor had black dust/dirt accumulation underneath the lower cupboards;

* Shelving units in the small dry storage closet had exposed, untreated wood;

* Multiple cabinets and drawers had dirt, spills, splatters on the outside surfaces, debris on knobs and/or spills and debris inside the cupboards or drawers;

* Refrigerator and freezer units had spills, debris on the bottoms and doors, cracked plastic at the inner bottoms of the units and a side by side unit in the kitchen had torn door seals partially held in place by duct tape.

* Ice machine had light brown stains on the inner panel;

* The counter top island, nearest the stove had a large section where the top layer of laminate had worn away with rough sections noted;

* Multiple scrapes, gouges and missing chunks of linoleum floor were noted throughout the kitchen;

* Baseboards under the open sink area were pulling away from the wall and had black accumulation at the edges;

* Window sills behind the sink had stains, debris and dead insects;

* Light covers in the kitchen/dry storage had debris. The dry storage area had an open outlet box in the ceiling with exposed wires and multiple small to medium sized holes in the ceiling.

The need to ensure the kitchen was kept clean and in good repair was discussed with Staff 1 (Administrator) on 8/24/21. She acknowledged the findings.

1.  *all doors in dinning room and kitchen will be cleaned and painted. Walls washed and repainted. Kitchen floor corners steam cleaned and new flooring applied.

* shelving in dry storage to be painted with high performance epoxy paint.

*All kitchen cabinets and drawers will be cleaned inside and out and new paint applied.

*Refrigerator and freezer units have been cleaned and will continue to be cleaned on a weekly basis. New seal for refrigerator unit has arrived and is installed. Cracked plastic on bottom of units was repaired with JB-Weld plastic repair or freezer removed.

*Stains in ice machine come from city's hard water and has been cleaned and will continue our schedule of monthly deep cleaning and daily/weekly clean.

*Island in kitchen will be replaced along with all kitchen counter tops.

*New kitchen floor will be put in and floor to be steam cleaned prior to new flooring applied.

*Baseboards will be replaced with new floor and deep steam cleaning behind baseboards prior to new application.

*Dry storage(pantry)light to be properly fitted to wiring and holes from previous light fixtured will be filled and painted over.

2. System will be corrected by having weekly checks by administrator through Kitchen and dinning area. Daily, Weekly, Monthly schedule has been implemented.

3. Weekly and random daily checks by administrator to determine cleanliness of kitchen.

4. Trish Denney, administrator will be responsible for completion and monitoring of kitchen staff.

Facility kitchen and related areas were not reviewed during the survey based on the facility requesting an exception until 12/31/21 to complete necessary repairs.

1.  *all doors in dinning room and kitchen will be cleaned and painted. Walls washed and repainted. Kitchen floor corners steam cleaned and new flooring applied.

* shelving in dry storage to be painted with high performance epoxy paint.

*All kitchen cabinets and drawers will be cleaned inside and out and new paint applied.

*Refrigerator and freezer units have been cleaned and will continue to be cleaned on a weekly basis. New seal for refrigerator unit has arrived and is installed. Cracked plastic on bottom of units was repaired with JB-Weld plastic repair or freezer removed.

*Stains in ice machine come from city's hard water and has been cleaned and will continue our schedule of monthly deep cleaning and daily/weekly clean.

*Island in kitchen will be replaced along with all kitchen counter tops.

*New kitchen floor will be put in and floor to be steam cleaned prior to new flooring applied.

*Baseboards will be replaced with new floor and deep steam cleaning behind baseboards prior to new application.

*Dry storage(pantry)light replaced fitted to wiring and holes from previous light fixtured will be filled and painted over.

2. System will be corrected by having weekly checks by administrator through Kitchen and dinning area. Daily, Weekly, Monthly schedule has been implemented.

3. Weekly and random daily checks by administrator to determine cleanliness of kitchen.

4. Trish Denney, administrator will be responsible for completion and monitoring of kitchen staff.

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 (#2) whose evaluations were reviewed. Findings include, but are not limited to:

Resident 2 was admitted to the facility on 6/1/21.

Resident 2's new move-in evaluation labeled "Initial Evaluation," dated 5/28/21 failed to address the following areas:

* Customary routines, sleeping, eating and bathing;

* Memory, orientation, confusion and decision making abilities;

* Pain, drug and non-drug interventions and how a person expresses pain/discomfort

* Ability to manage medications and use the call system;

* Emergency evacuation ability;

* Complex medication review;

* Smoking ability/safety;

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

* ADLs including toileting, bowel/bladder management, hygiene, dressing, grooming, bathing, ambulation, transfers;

* Eating, dental status and assistive devices; and

* Environmental factors that impact the resident's behavior, including noise, lighting and room temperature.

The need to ensure move-in evaluations included all required elements was discussed on 8/24/21 with Staff 1 (Administrator). She acknowledged the findings.

1. New evaluation form created to include routines, sleeping, eating, bathing. The new form will also include: memory, orientation, confusion and decision making abilities. Pain both drug and non-drug interventions and how they express their pain. Ability to manage medications and use our call bell systems. The residents ability to evacuate the building in the case of an emergency. This new form will include residents complex medication (if applied to resident). Form will include residents smoking status and their ability to safely smoke(if applied to resident). Residents ability to cope with difficult situations. ADL's including toileting, bowel/bladder management, hygiene, dressing grooming, bathing and ambulation transfers. Will include eating, dental status and assistive devices. Environmental factors that impact the resident such as lighting, noise and room temperature.

2. System to be corrected by implementing tracking of all residents when they have had and when due for evaluation. Both RN and administrator to do initial evaluation of all new residents together prior to move in. All 90/30 day evaluations, significant change and return to community evaluations will be done by administrator.  

3. This will be kept up in new tracking system identifying when due and when last evaluation was completed.

4. Both RN Darlene Starr and Administrator Trish Denney will be responsible for making corrections on current deficiency as well as keeping up on future evaluations in the proper timely manner.

Based on 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 1 of 2 sampled residents (#1) whose service plans were reviewed. Findings include, but are not limited to:

Resident 1 was admitted to the facility in July 2015 with diagnoses including congestive heart failure.

Review of the resident's service plan dated June 2021 showed the service plan was not reflective of the resident's current care needs and/or did not provide clear direction to staff in the following areas:

* Oxygen use;

* Choking episodes/swallowing issues;

* Arm pain, hand and foot numbness;

* Edema, diuretic use and daily weight changes;

* Toileting, incontinence and recliner use;

* Transfers and ambulation;

* Behaviors related to refusing care; and

* Fluid assistance between meals.

The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (Administrator) on 8/24/21. She acknowledged the findings.

1. Service plan revised to reflect correct needs of resident in 1 (from example). Meeting held with all care staff about "closing the loop" when findings such as arm pain, choking, edema, transfers and ambulation, refusing care and fluid assistance between meals. All staff on board with correct steps to follow for any of above situations who to notify and what to chart to reflect steps taken.

2. All service plans are currently being evaluated and ensure correct information contained. This is being done by facility RN.

3. Service plans will be evaluated every 90 days unless significant change of condition occurs and evaluation and service plan need completed sooner.

4. Facility RN Darlene Starr will be responsible and monitoring all residents service plans.

Based on interview and record review, it was determined the facility failed to ensure residents who had short term changes of condition were evaluated, resident-specific instructions or interventions were developed and the condition was monitored to resolution at least weekly for 2 of 2 sampled residents (#s 1 and 3) who experienced changes of condition.  Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in July 2015 with diagnoses including congestive heart failure.

The resident's June 2021 service plan, 5/1/21 through 8/23/21 progress notes, temporary service plans and physician communications were reviewed. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness and/or lacked resident specific directions to staff in the following areas:

* Arm pain and knee pain;

* Difficulty swallowing, gagging and vomiting;

* Left ankle swollen and red;

* Significant daily weight fluctuations, edema and diuretic use;

* Skin tear to hand, pressure ulcer to tailbone and a slit/skin tear between buttocks;

* Diarrhea;

* Antibiotic use, medication changes, medication refusals; and

* Una boot and diabetic shoe refusals and foot wound.

The need to ensure short term changes of condition had documentation to reflect monitoring to resolution at least weekly and provided clear resident specific directions to staff was discussed  with Staff 1 (Administrator) on 8/24/21. She acknowledged the findings.

2. Resident 3 was admitted to the facility in June 2015 with diagnoses including congestive heart failure.

The resident's June 2021 service plan, 5/1/21 through 8/23/21 progress notes, temporary service plans and physician communications were reviewed. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness and/or lacked resident specific directions to staff in the following areas:

* Weight;

* Fall with bruising and fractures to left and right foot/ankle;

* Dizziness and statements of feeling like passing out; and

* Diarrhea and blood in stool.

The need to ensure short term changes of condition had documentation to reflect monitoring to resolution at least weekly and provided clear resident specific directions to staff was discussed with Staff 1 (Administrator) on 8/24/21. She acknowledged the findings.

1.Meeting held with all care staff concerning the "change of conditions" that were not followed through. All staff aware to follow through with closing the loop when change of condition is found. This includes notifying PCP and facility RN and correctly documenting steps take with the change of condition. Also sent for clarifying orders from PCP for parameters to follow with weight change concerning resident 1. All staff instructed to notify RN when others like resident 3 has change that is not monitored daily but noticed by them as well as "close the loop" by setting follow up reminder to check back with resident and have other care staff check as well.

2. Implementing new electronic system QuickMAR. System has capability to set reminders for situations in which the resident should be followed up on.

3. This will need to be followed up by all care staff and facility RN constantly to ensure all residents have the loop closed.

4. Facility RN Darlene Starr and administrator Trish Denney will follow up on making sure system is working and that all staff are setting reminders and closing loop.

Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused to consent to orders for 1 of 2 sampled residents (#1) who had documented medication refusals. Findings include, but are not limited to:

Resident 1's 5/1/21 through 8/23/21 progress notes and physician communications and 8/1/21 through 8/23/21 MAR were reviewed. The resident's record showed multiple refusals of Furosemide (a diuretic medication to remove fluid).  

There was no documented evidence the facility notified the physician each time the resident refused to consent to the orders.  

The need to ensure the facility notified physicians of medication refusals was discussed with Staff 1 (Administrator) on 8/24/21. She acknowledged the findings.

1. Staff meeting held notifying all care staff of findings and that at anytime a treatment or medication is refused PCP is to be tonified.

2. System corrected by staff meeting making all aware that PCP is to be notified at anytime there is a refusal of medication or treatment.  

3. Facility RN to do weekly checks of care notes to ensure that any medication or treatment refused was given proper notification to PCP.

4. Administrator Trish Denney and facility RN responsible.

Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was maintained for all facility administered medications including resident specific parameters for PRN medications for 1 of  2 sampled residents (#1) whose medication records were reviewed. Findings include, but are not limited to:

Resident 1 was admitted to the facility in July 2015 with diagnoses including congestive heart failure.

Review of the resident's 5/1/21 through 8/23/21 progress notes, physician communications and the 8/1/21 through 8/23/21 MARs showed the following:

* Daily weights recorded, with fluctuations ranging up and down between four and 11 pounds.

There were no parameters for reporting the weight changes or actions to be taken.

* "Laxative" 17 grams mixed into cranberry juice PRN for constipation.

The MAR gave no direction to staff on when to start the medication.

* Tylenol 325 mg take two tablets every six hours PRN for moderate pain or headache, Hydrocodone 5/325 mg give 1 to 2 tablets every six hours PRN pain and Tylenol two tablets (650 mg) every four hours PRN for mild-moderate headache, joint pain, muscle aches or pain.

The MAR gave no direction to staff on which medication to use first for the resident's pain or when to use one tablet vs two tablets of the Hydrocodone.

The need to ensure MARs were complete and included clear direction to staff for PRN medication administration was discussed with Staff 1 (Administrator) on 8/24/21. She acknowledged the findings.

1. Clarification for resident 1 was corrected with PCP.

2. All new/changing orders will be put into new electronic MAR only by facility RN and administrator. Orders put in by one will be double checked by other.

3. Will be evaluated initially by imputing all orders in new EMAR and every time new order is send or changed will be evaluated by RN and administrator.

4. Compliance will be monitored by both RN and administrator.

Based on interview and record review, it was determined the facility failed to ensure residents who chose to self administer medications had a physician's order in place for the self administration for 1 of 1 sampled resident (#3) reviewed for self administration. Findings include, but are not limited to:

During the acuity interview on 8/23/21 Resident 3 was identified as administering her/his own medications.

The resident was admitted to the facility in June 2015 with diagnoses including hypertension.

The resident's 5/1/21 through 8/23/21 progress notes, evaluations, physicians orders and the 8/1/21 through 8/23/21 MAR were reviewed and showed the following:

* No current physician's order in the resident's record regarding self administration of her/his medications.

The need to ensure all medications that were self administered had a current physician's order in place was discussed with Staff 1 (Administrator) on 8/23/21 and 8/24/21. Staff 1 acknowledged the findings and a current order was obtained on 8/24/21.

1. New self administering order obtained 8/24/21 for resident 3. This was followed by immediately confirming that all self administering residents had current signed order from PCP.

2. New tracking system created to update administrator of time due for new orders when resident is self administering. There will also be reminders set in new electronic MAR for reminder. If a resident becomes unable to administer self medications during time when order is not due, new evaluation and order from PCP will be obtained.

3. Will be evaluated quarterly and new orders signed annually with no change from PCP.

4. Administrator will be responsible for ensuring correct action taken with self administering orders.

Based on interview and record review, it was determined the facility failed to ensure pre-service orientation, pre-service dementia training, and Food Handler's certification was completed prior to beginning work in the facility for 2 of 2 newly hired staff (#s 3 and 8) whose training records were reviewed. Findings include, but are not limited to:

Staff training records were reviewed on 8/24/21.

* Staff 3 (CG), hired 6/11/21, lacked documented evidence of having completed pre-service orientation and pre-service dementia training; and

* Staff 8 (Cook), hired 6/11/21, lacked documented evidence of having completed pre-service orientation and Food Handler's certification.

The need for staff to complete all required pre-service orientation, dementia training and Food Handler's certification before working with residents was reviewed with Staff 1 (Administrator) on 8/24/21. She acknowledged the findings.

1. All staff records will be updated to reflect current training. Any staff who has not completed a training will be required to complete immediately.

2. Administrator will assure no staff start work without proper training requirements met.

3. Upon hire of staff, 30 days following hire date and annually.

4. Administrator will be responsible for ensuring all training met.

Based on interview and record review, it was determined the facility failed to ensure fire and life safety instruction to staff was provided on alternate months and that documentation reflected all required fire drill components. Findings include, but are not limited to:

Fire drill and fire and life safety records were reviewed from March 2021 to July 2021. The following deficiencies were identified:

* There was no documented evidence the facility was conducting fire drills every other month on alternating shifts;

* There was no documented evidence the facility was providing fire and life safety training on alternating months for staff; and

* The one evacuation/drill conducted in July 2021 did not contain information on the number of occupants evacuated.

The requirements regarding fire drills and fire and life safety instruction for staff were reviewed with Staff 1 (Administrator) on 8/23/21 and 8/24/21. Staff 1 acknowledged there was no documentation related to fire drills previous to July 2021. Staff 1 further indicated they were working with the local fire marshal regarding their fire safety plan.

1. As per plan from recent fire Marshall visit, calendar reflecting dates and times for monthly drill and trainings on rotating months and shifts will be implemented immediately. This plan of action was started in July.

2. Plan in place for rotating drills and trainings started in July. Will add number of residents evacuated to current training record.

3. Evaluated monthly.

4. Administrator responsible for conducting and monitoring all trainings and drills.

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 Division. Findings include, but are not limited to:

Refer to C240 and C513.

1.  *all doors in dinning room and kitchen will be cleaned and painted. Walls washed and repainted. Kitchen floor corners steam cleaned and new flooring applied.

* shelving in dry storage to be painted with high performance epoxy paint.

*All kitchen cabinets and drawers will be cleaned inside and out and new paint applied.

*Refrigerator and freezer units have been cleaned and will continue to be cleaned on a weekly basis. New seal for refrigerator unit has arrived and is installed. Cracked plastic on bottom of units was repaired with JB-Weld plastic repair or freezer removed.

*Stains in ice machine come from city's hard water and has been cleaned and will continue our schedule of monthly deep cleaning and daily/weekly clean.

*Island in kitchen will be replaced along with all kitchen counter tops.

*New kitchen floor will be put in and floor to be steam cleaned prior to new flooring applied.

*Baseboards will be replaced with new floor and deep steam cleaning behind baseboards prior to new application.

*Dry storage(pantry)light to be properly fitted to wiring and holes from previous light fixtured will be filled and painted over.

2. System will be corrected by having weekly checks by administrator through Kitchen and dinning area. Daily, Weekly, Monthly schedule has been implemented.

3. Weekly and random daily checks by administrator to determine cleanliness of kitchen.

4. Trish Denney, administrator will be responsible for completion and monitoring of kitchen staff.

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

Observations of the facility on 8/23/21 and 8/24/21 showed the following areas in need of cleaning or repair:

* Multiple walls and door frames in the dining room had, scrapes, splatters/drips, peeling wall paper or gouges;

* Multiple door frames/doors at facility exits had chips, gouges and/or scrapes;

* Two tables in the dining room had large pieces of missing laminate/veneer surface with exposed wood and rough edges;

* A vinyl beauty chair in the resident tub room, had multiple large tears to the seat and back with exposed foam;

* Window sills in the dining room had debris, dead insects and dark stains;

* Overhead light fixtures in the dining room and charting room had debris and dead insects;

* Carpet in the dining room and in the hallway near room 123 had multiple black stains of varying sizes; and

* Wood wall trim in the back of the dining room was cracked and separating and two vents had caked on dust, webs and/or debris.

The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (Administrator) on 8/23/21 and 8/24/21. She acknowledged the findings.

1. Plan of dinning room remodel taking place currently. All wall paper will be removed and replaced with wainscoting and pain. New chair railing will be put up. Door frames are in process of being repainted currently. Tables in dinning room will be replaced at a rate of 2 every quarter until all replaced(first 2 ordered now expected in October). Vinyl beauty chair will be re-upholstered as soon as we can get it into shop expected by end of September. Charting room lights have been cleaned, light fixtures in dinning room are ordered and will be replaced with remodel. Carpet in dinning room and all halls will be cleaned by professional scheduled for 9/23/21 and scheduled 2 times annually. All vents in building to be pulled down and cleaned.

2. Plan of dinning room remodel taking place currently. All wall paper will be removed and replaced with wainscoting and pain. New chair railing will be put up. Door frames are in process of being repainted currently. Tables in dinning room will be replaced at a rate of 2 every quarter until all replaced(first 2 ordered now expected in October). Vinyl beauty chair will be re-upholstered as soon as we can get it into shop expected by end of September. Charting room lights have been cleaned, light fixtures in dinning room are ordered and will be replaced with remodel. Carpet in dinning room and all halls will be cleaned by professional scheduled for 9/23/21 and scheduled 2 times annually. All vents in building to be pulled down and cleaned. All staff have been addressed and understand the cleanliness as kept is unacceptable and will need to be improved immediately.

3. All areas evaluated daily on administrators shift. Corrections need to be complied immediately.

4. Administrator responsible.

Facility environment was not reviewed during the survey based on the facility requesting an exception until 12/31/21 to complete necessary repairs.

1.  *all doors in dinning room and kitchen will be cleaned and painted. Walls washed and repainted. Kitchen floor corners steam cleaned and new flooring applied.

* shelving in dry storage to be painted with high performance epoxy paint.

*All kitchen cabinets and drawers will be cleaned inside and out and new paint applied.

*Refrigerator and freezer units have been cleaned and will continue to be cleaned on a weekly basis. New seal for refrigerator unit has arrived and is installed. Cracked plastic on bottom of units was repaired with JB-Weld plastic repair or freezer removed.

*Stains in ice machine come from city's hard water and has been cleaned and will continue our schedule of monthly deep cleaning and daily/weekly clean.

*Island in kitchen will be replaced along with all kitchen counter tops.

*New kitchen floor will be put in and floor to be steam cleaned prior to new flooring applied.

*Baseboards will be replaced with new floor and deep steam cleaning behind baseboards prior to new application.

*Dry storage(pantry)light to be properly fitted to wiring and holes from previous light fixtured will be filled and painted over.

2. System will be corrected by having weekly checks by administrator through Kitchen and dinning area. Daily, Weekly, Monthly schedule has been implemented.

3. Weekly and random daily checks by administrator to determine cleanliness of kitchen.

4. Trish Denney, administrator will be responsible for completion and monitoring of kitchen staff.

Based on observation and interview, it was determined the facility failed to ensure a manually operated emergency call system was located in each toilet facility used by residents and visitors. Findings include, but are not limited to:

Observations on 8/23/21 and 8/24/21 showed multiple residents independently used the common area restroom, located near the front of the facility. Observations of the interior of the restroom on 8/24/21 showed there was no manually operated call system for residents or visitors to obtain help. Staff 1 (Administrator) was unable to locate any call system in her inspection of the restroom.

A temporary call system was set up in the restroom for resident safety prior to survey exit. Staff 1 additionally had a plan for installation of a permanent call system in the restroom once the call system company could be reached.

The need to ensure all toilet facilities used by residents and visitors was equipped with a manually operated call system was discussed with Staff 1 (Administrator) on 8/24/21. She staff acknowledged the findings.

1. Temporary system used until new pull system arrived from Systems Technology. New system arrived 9/1/21 and was installed in bathroom used by public and residents.

2. Temporary system used until new pull system arrived from Systems Technology. New system arrived 9/1/21 and was installed in bathroom used by public and residents.

3. Completed but will include in monthly check for ensuring system working properly.

4. Administrator responsible.