Print Inspection: BJKF

The findings of the re-licensure survey, conducted 01/08/24 through 01/11/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

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 revisit to the re-licensure survey of 01/11/24, conducted 07/29/24 through 07/31/24, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

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 re-visit to the re-licensure survey of 01/11/24, conducted on 10/10/24, are documented in this report. It was determined the facility was in compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004.

2. On 01/09/24, between 9:28 am and 11:21 am, observations were made outside of Resident 3's apartment. On six occasions, staff knocked on the resident's door as they were walking in. Staff were observed not waiting for Resident 3's permission to enter his/her apartment.

3. On 01/09/24, at 11:30 am, three unsampled residents attended a Group Interview with the survey team. They reported staff knock on their apartment doors but do not wait for the residents' permission to enter their apartments.

The need to ensure residents receive services in a manner that protects privacy and dignity was discussed with Staff 1 (Campus Administrator) on 01/09/24. She acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure residents were treated with dignity and respect and received services in a manner that protected privacy and dignity for 1 of 1 sampled resident (#3) and multiple unsampled residents. Findings include, but are not limited to:

1. While observing meal service during the survey, on 01/09/24 and 01/10/24, Staff 7 (Dining Services Director) was overheard making comments to residents. The comments included, but were not limited to:

* "Don't give me that, you'll be fine," in response to a resident asking for a different meal option;

* "Let's wait for slow poke buddy over here";

* "You don't even have the manners to wait, can't you see I'm in a conversation";

* "Put your finger down, what are you praying to the gods"; and

* "I don't want to get any more lip from you today."

The recipients of the above comments did not banter or laugh during these interactions with Staff 7. One resident was overheard saying , "Oh, he's being mean to me again today."

The need to ensure all residents were treated with dignity and respect was discussed with Staff 1 (Campus Administrator) and Staff 5 (Wellness Services Director) on 01/11/2024. They acknowledged the findings.

1. Written documentation of conversation to DSD completed and placed in employee file addressing violation of Resident Rights performed by DSD. DSD to complete Oregon Care Partner Class Community-Based Care Values for Protecting Resident Rights assigned and to be completed by 3/11/24. Care partner instructions performed on 1/11/24, 1/12/24, 1/15/24 and 1/16/24 on knocking and waiting for response before entering their apartments. 2. This has been added to the training curriculum upon hire and yearly training. 3. Quarterly competency will be performed all on direct care staff. See Exhibit A. 4. RCC to complete quarterly assessments and discuss with Administrator as needed.  

2. Resident 6 was admitted to the facility in 06/2022 with diagnoses including chronic pain.

The resident's Observation Notes, dated 10/02/23 through 01/08/24, and investigations for the same time period were reviewed during the survey.

On 12/18/23, staff documented, "Resident did not [go] back to [his/her] room due to [his/her spouse raising his/her] fist earlier today. Resident appeared very scared and refused to go back to [his/her] room until care staff offered to walk [him/her] back and [s/he] even had the med tech check if [his/her spouse] was asleep. Resident is currently back in [his/her] room and if [s/he] feels unsafe [s/he] will push [his/her] pendant."

On 01/10/24 at 9:48 am, Staff 1 (Campus Administrator) confirmed she investigated the incident on 12/19/23, and the resident moved to a different apartment on that same day. There was no documented evidence the facility had reported the incident to the local SPD office.

The need to immediately report to the local SPD office when a resident experienced abuse was discussed with Staff 1 and Staff 5 (Wellness Services Director) on 01/10/24. They acknowledged the findings. The facility provided proof the incident was reported prior to survey exiting the building.

Based on interview and record review, it was determined the facility failed to investigate incidents or injuries of unknown cause to rule-out abuse, document all required areas of an investigation, and report to the local SPD office, if abuse could not reasonably be ruled out, for 2 of 3 sampled residents (#s 4 and 6) with incidents or injuries of unknown cause. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 04/2020 with diagnoses including heart failure and history of cerebral infarction.

Staff were interviewed, and the resident's service plan, 10/08/23 through 01/08/24 Temporary Service Plans, Observation notes and Incident Investigations were reviewed. The following was identified:

* 10/22/23 - Injury of unknown cause to right arm and lack of incontinence care resulting in resident laying in "soaked" brief and clothing for extended period of time;

* 10/27/23 - Injury of unknown cause to right elbow; and

* 12/01/23 through 01/08/24 - Administration of twice the prescribed dose of blood thinner medication.

There was no documented evidence the incidents had been investigated at the time of occurrence, the investigations included all required components, or the incidents were reported to the local SPD office if abuse could not be reasonably ruled out.

The need to ensure all incidents and injuries of unknown cause were promptly investigated, contained all required areas of documentation including if abuse could be ruled out, and if not, incidents and injuries of unknown cause were reported to the local SPD office, was discussed with Staff 1 (Campus Administrator) and Staff 5 (Wellness Services Director) on 01/11/24. They acknowledged the findings. The facility provided proof the incidents were reported prior to survey exiting the building.

1.Wellness Team received training on Abuse, neglect, and reporting. All examples provided in the survey were reported on 1/11/24. 2. Abuse decision tree will be utilized with each incident at the facility. See Exhibit B. Incidents will be reviewed within 24 business hours. 3. Daily wellness meeting to review all incidents. 4. The Wellness Director will perform the monthly audits to ensure compliance with reporting.

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

Observation of the main kitchen and dining room service area were conducted on 01/08/24, 01/10/24, and 01/11/24.

a. An accumulation of food spills, splatters, loose food, dirt, dust, and/or black matter was visible on or underneath the following:

* Multiple service carts;

* Left side of the stove/oven (next to the fryer);

* Interior/exterior of ovens;

* Interior/exterior of the fryer and underneath the fryer had a build-up of grease;

* Juice machine and tray had a build-up of dried juice in and around the nozzles;

* Floor drains underneath the warewasher machine, three-compartment sink, and juice machine; and

* Ceiling vents and ceiling tiles (above the ovens and steam table).

b. Multiple garbage cans lacked covers when not in use.

c. The Beverage Air salad cooler was inoperable and in need of repair.

d. Food Storage:

* Multiple food items in the reach-in refrigerator, walk-in freezer, reach-in freezer (next to the fryer), and in the dry food storage area were open and uncovered, which exposed the food items to potential frost burn and/or environmental cross contamination.

The kitchen was toured and discussed with Staff 1 (Campus Administrator), Staff 2 (Assistant Administrator), and Staff 7 (Dining Services Director) on 01/11/24. They acknowledged the findings.

1. Kitchen received deep clean day of inspection to address service carts, ovens including all vertical and horizontal surfaces. The fryer was cleaned to address all surfaces surrounding and including fryer with degreaser. Juice Machine was cleaned. Floor Drains were cleaned. The tile and vents were cleaned. Trash cans with lids to be purchased and placed. The Beverage air salad cooler is not in use currently by any staff member. All Food in the Freezer next to the fryer will be covered and properly labeled at the end of meal service and placed in the reach in fridge and freezer to prevent cross contamination and frost burn. Food in the walk-in fridge and freezer were immediately covered and labeled on 1/11/24. Dry Foods were addressed immediately and covered properly on 1/11/24. 2. All cleaning schedules will be overseen by DSD. Audits for cleanliness will be performed as indicated below. Walk in Fridge and Freezer as well as Dry Food area will have bimonthly audits to ensure proper food storage. 3.Carts are now on daily wipe down cleaning list in addition to monthly detailing schedule by DSD or Soux chef oversight. The stove and oven will be wiped down daily by line cook. Soux chef to deep clean stove, oven, and line every Wednesday including all vertical and horizontal surfaces. The fryer will be clean and filtered daily by line cook. Oil to be changed every Tuesday and Saturday. Fryer will be "boiled" out monthly by DSD. Inside and outside of Fryer with all removeable attachments to be cleaned monthly with degreaser. Juice machine will be taken apart and cleaned daily by server staff. DSD to perform bi-weekly checks to ensure cleanliness. Floor Drains will be checked weekly by DSD for buildup and cleaned monthly and as needed by DSD or Soux chef to prevent build up. Ceiling tiles and vents to be checked daily by line cook. DSD to clean monthly and as needed. Garbage cans to be randomly checked to ensure lids are placed appropriately. Beverage air cooler will be serviced or disposed of by 3/11/24. If disposed of it will be discarded properly under all applicable state and county laws and codes. Food in the freezer next to the fryer will be properly labeled and stored in a walk-in freezer at the end of meal service. Freezer and walk-in fridge training was provided on 1/11/24 and 1/12/24 covering all "cooks" in the kitchen on proper label and covering guidelines. DSD to perform audit of Fridge and Freezer bi-monthly to ensure compliance. Dry storage training was provided on 1/11/24 and 1/12/24 on proper covers in the Dry Food area. DSD to provide bi-monthly audits to assure compliance.  4. Administrator and DSD will do monthly walk through of kitchen area to ensure compliance with all deficiencies are being met.  

2. Resident 3 was admitted to the facility in 10/2019 with diagnoses including post traumatic stress disorder, traumatic brain injury, and diabetes.

The resident's most recent service plan, the Behavior Support Services Behavior Plan dated 02/17/20, and the 11/2023 and 12/2023 Task Administration Records were reviewed. Staff were interviewed and Resident 3's apartment was observed.

The following areas of the service plan were not reflective and lacked clear direction to staff regarding the delivery of services, and the service plan did not include a written description of who should provide the services and what, when, how, and how often the services should be provided:

* The use of a bed side commode;

* Walker use;

* Transfer ability;

* The use of compression stockings;

* How staff are able to identify the resident's anxiety;

* Bucket used for catheter placement under the resident's bed;

* Specific instructions of how the resident wants his/her catheter bag cleaned;

* Behaviors associated with his/her catheter;

* The use of portable oxygen when going out to appointments;

* Liter flow for oxygen use;

* If the resident used a Continuous Positive Airway Pressure (CPAP) or a Bilevel Positive Airway Pressure (BiPAP) machine;

* The tubing and filter maintenance for the CPAP or BiPAP machine;

* Two hour checks;

* Having a DexCom (a device that was attached to the resident's arm that monitored blood glucose readings every five minutes) and the maintenance needed from staff;

* Referenced a "mood disorder care plan" for staff if the resident was having behaviors, but staff did not have access to the document; and

* Directed staff to give six ounces of apple juice for blood sugar readings of under 80, but per a physician's note dated 02/26/20 stated apple juice gave the resident "severe [yeast] infections."

The need to ensure the resident's service plan was reflective of the resident's current care needs and provided clear direction to staff was discussed with Staff 1 (Campus Administrator) and Staff 5 (Wellness Services Director) on 01/11/24. They acknowledged the findings.

3. Resident 6 was admitted to the facility in 06/2022 with diagnoses including dehydration, chronic pain, and a history of falls.

The resident's most recent service plan and the 01/2024 Task Administration Record were reviewed. Resident 6 and staff were interviewed and the resident's apartment was observed.

The following areas of the service plan were not reflective and lacked clear direction to staff regarding the delivery of services, and the service plan did not include a written description of who should provide the services and what, when, how, and how often the services should be provided:

* Daily bed-making;

* Requests for ice;

* Had outside services for blood draws;

* Stand-by assist for all showers;

* Mechanical soft diet;

* Food preferences;

* Preference of only wanting breakfast and dinner;

* Two hour checks;

* Fall interventions;

* The use of a cane for transfers from bed;

* Variable wake and sleep times;

* Who the resident lived with;

* Staff were directed to put clothes away in the resident's dresser, there was no dresser observed in the resident's apartment; and

* Being the "Welcome Person" for new admissions to the facility.

The need to ensure the resident's service plan was reflective of the resident's current care needs and provided clear direction to staff was discussed with Staff 1 (Campus Administrator) and Staff 5 (Wellness Services Director) on 01/11/24. 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' needs, provided clear direction to staff regarding care and services, and were implemented for 3 of 4 sampled residents (#s 3, 4, and 6) whose service plans were reviewed. Findings include, but are not limited to:

Resident 4 was admitted to the facility in 04/2020 with diagnoses including heart failure and history of cerebral infarction.

Observations of the resident, interviews with staff, review of the resident's most recent service plan, and review of the 12/2023 Task Administration Record showed the service plan was not reflective of the resident's current care needs, did not provide clear direction to staff, or was not being implemented in the following areas:

* Use of "air boots" three days per week;

* Bathing;

* Leg elevation and placement of "inflatable compression device" twice per day;

* Preferred clothing;

* Evacuation process;

* Activities;

* Bedding;

* Pressure-relieving mattress; and

* Number of care providers required for care including toileting and dressing.

The need to ensure service plans were reflective of current care needs, provided clear direction to staff, and were implemented by staff was discussed with Staff 1 (Campus Administrator) and Staff 5 (Wellness Services Director) on 01/11/24. They acknowledged the findings.

1. Wellness Director, Administrator, Resident Care Coordinator, will read each care plan of all residents to ensure accuracy of task performed and Care giver instructions. Moon boots, bathing, leg elevation, preferred clothing, evacuation process, activities, bedding and instruction for pressure-relieving mattress, and number of care partners all addressed in care plan for resident 4. Bedside Commode, walker use, transfer ability, compression stockings, anxiety indicators, catheter instructions (including placement of bucket), behaviors associated with catheter, portable o2 instructions, liter flow, CPAP instruction, DexCom instruction, mood disorder, and updated precautions for blood sugar readings were added to resident 3. Bed making instruction, ice preference, outside services, stand by assistance for showering, mechanical soft diet, food preference, frequent checks, fall interventions, cane usage, sleep patterns, where to place clothing, and welcoming committee added to care plan added for resident 6. Residents does not have a roommate currently. 2. Moving forward Wellness Team to perform 2 random Care plan audits utilizing care plan audit forms. 3. Care plan audits will be performed monthly using exhibit AB. 4. The Wellness Director will ensure audits are being done as listed above.

Based on observation, interview, and record review, it was determined the facility failed to evaluate residents for their changes of condition, determine and document what action or intervention was needed for the resident, communicate the action or intervention to staff on each shift, make the staff instructions or interventions part of the resident's record, document weekly progress until the condition resolved, and ensure the reporting protocol was utilized by staff to report on resident's conditions 24-hours a day, seven days a week, to a staff member who could determine if a change in the resident's condition required further action for 2 of 4 residents (#s 4 and 6) who experienced changes of conditions. Findings include, but are not limited to:

1. Resident 6 was admitted to the facility in 06/2022 with diagnoses including dehydration, chronic pain, and had a history of falls.

a. The resident's medical chart was reviewed, and the following falls were identified:

* 09/07/23 - Fall with an abrasion to the left eye;

* 09/09/23 - Fall without injury;

* 09/14/23 - Fall without injury;

* 10/28/23 - Fall without injury; and

* 11/22/23 - Fall without injury.

b. On 11/05/23, staff faxed the resident's medical provider that they sent Resident 6 to the hospital as the resident was, "shaking, pale, jaundice, fever, [and had shortness of breath]."

c. During an interview with Resident 6 on 01/11/24 at 10:20 am, the resident reported s/he had a fall while shopping with his/her daughter on 12/01/23. The resident showed a healing bruise on his/her right thigh, approximately three and a half inches long and two inches wide. When asked if s/he reported the fall to staff, the resident confirmed s/he had when s/he returned to the facility that same day. When asked if anyone checked the bruise, the resident confirmed no one had.

On 01/11/24, when asked about the fall Resident 6 had on 12/01/23, Staff 1 (Campus Administrator) and Staff 5 (Wellness Services Director) confirmed they had no knowledge of the fall or the bruising.

d. On 12/18/23, staff documented that "Resident did not [go] back to [his/her] room due to [his/her spouse raising his/her] fist earlier today. Resident appeared very scared and refused to go back to [his/her] room until care staff offered to walk [him/her] back and [s/he] even had the med tech check if [his/her spouse] was asleep. Resident is currently back in [his/her] room and if [s/he] feels unsafe [s/he] will push [his/her] pendant."

On 01/10/24 at 9:48 am, Staff 1 confirmed she investigated the incident on 12/19/23 and the resident moved to a different apartment that day.

There was no documented evidence the resident was evaluated for the above-mentioned changes of condition, if the resident's evaluated needs determined any action or intervention needed for the resident, and if so, those actions and interventions were communicated to staff on each shift, staff instructions or interventions were made part of the resident's record, nor was there documentation of weekly progress noted through resolution. In addition, there was no documented evidence of a reporting protocol, which could be utilized by staff to report on the resident's condition 24-hours a day, seven days a week, to a staff member who would be able to determine if a change in the resident's condition required further action.

The need to ensure residents who experienced short-term changes of condition were evaluated, had actions or interventions determined, the actions or interventions were communicated to staff on each shift, weekly progress was noted through resolution, and staff used a reporting protocol to communicate changes of condition was discussed with Staff 1 and Staff 5 on 01/11/24. They acknowledged the findings.

2. Resident 4 was admitted to the facility in 04/2020 with diagnoses including heart failure and history of cerebral infarction.

Observations of the resident, interviews with staff, and review of the resident's most recent service plan, Observation Notes, Alert Charting Notes, Temporary Service Plans, and Incident Investigations from 10/08/23 through 01/08/24 were completed.

The facility record lacked documentation that the resident was evaluated, had actions or interventions determined and communicated to staff on all shifts, and/or progress noted at least weekly through resolution for the following short-term changes of condition:

* 10/09/23 - Choking;

* 10/16/23 - Sliding and falling out of bed;

* 10/27/23 - Skin tear to right elbow; and

* 11/04/23 - Pain and bleeding from anus.

The need to ensure residents who experienced short-term changes of condition were evaluated, had actions or interventions determined and communicated to staff on each shift, and had weekly progress noted through resolution was discussed with Staff 1 (Campus Administrator) and Staff 5 (Wellness Services Director) on 01/11/24. They acknowledged the findings.

1. Instruction to care staff to complete incident reports immediately and instruction on what needs an incident report was provided on 1/11/24, 1/12/24, 1/15/24, 1/16/24. SCOC completed on resident 6. Residents chart notes to be read daily by Wellness Team and assessed as needed. Falls, choking incident, falling out of bed incident, skin tear, and bleeding from anus evaluated by wellness director and chart notes entered.  2. Ongoing training will be provided for care staff to recognize and document all changes in condition. Wellness team to review observations daily. 3. The Wellness Team will review observations and incident reports daily.  Wellness Director to keep tracker for falls and complete weekly weight analysis. 4. Wellness Director responsible for ensuring that these tasks are performed as outlined.

Based on interview and record review, it was determined the facility failed to ensure an RN assessment had been completed for 1 of 2 sampled residents (#6) who experienced a significant change of condition. Findings include, but are not limited to:

Resident 6 was admitted to the facility in 06/2022 with diagnoses including dehydration, chronic pain, and chronic obstructive pulmonary disease.

The resident's 07/01/23 through 01/06/24 weight records and the medical chart were reviewed.

On 09/01/23, Resident 6 weighed 162.1 pounds. On 10/01/23, the resident weighed 151.6 pounds, which was a 10.5 pound weight loss. This constituted a severe weight loss of 6.47 % in one month.

During the acuity interview, staff identified Resident 6 had a weight loss and that the loss was "planned."

There was no documented evidence of a planned weight loss nor was there an RN assessment which included findings, resident status, and interventions made as a result of this assessment.

The need to have an RN assessment for a significant change of condition was reviewed with Staff 1 (Campus Administrator) and Staff 5 (Wellness Services Director) on 01/11/24. They acknowledged the findings.

1. SCOC assessed, and RN completed SCOC listed in examples and care plans updated. 2. Weight reports to be done weekly on Wednesdays. Wellness team to notify RN of any returns to facility. RN to assess any SCOC within 24 hours. Staff education on how to properly weigh and when to notify Wellness Team performed on 1/31/24 durring Monthly inservice meeting. Daily wellness meeting to identify SCOC.  3. Wellness Director to perform daily wellness meeting to identify any SCOC and to notify RN as needed. These meetings will include weights, chartnotes, alerts, falls, incident reports and any changes in ADL'S.  4. Wellness Director will be responsible to ensure compliance.  

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

During the re-licensure survey, conducted 01/08/24 through 01/11/24, professional oversight of the medication and treatment administration system was found to be ineffective, based on deficiencies in the following areas:

* C 303 - Medication and Treatment Orders;

* C 305 - Refusals;

* C 310 - Accuracy of MARs;

* C 325 - Self-administration of Medications; and

* C 330 - PRN Psychotropic Mediations.

Please refer to the report.

1. Deep Dive into resident MAR performed. Refusals evaluated. Medication orders addressed, refusal faxed to PCP, Mar accuracy performed, self-medication evaluations completed and sent to PCP for signatures. PRN psychotropic addressed. Physician Orders addressed. 2. Moving forward weekly Mar audits to be performed. See Exhibit CD. Staff Competency eval to be completed quarterly. See Exhibit A.  Self-Medication quarterly evaluation due dates added to tasks. 3. Monthly Audits to ensure all evaluations are being done per policy. 4. Wellness Director to oversee.   

2. Resident 3 was admitted to the facility in 10/2019 with diagnoses including migraines, diabetes, and traumatic brain injury.

The resident's 12/01/23 through 01/08/24 MARs, medical prescriber's orders, and medical chart were reviewed. Staff were interviewed. The following was identified:

a. A physician's order dated 10/24/23 directed staff to administer pantoprazole (for heartburn, acid reflux) with Prilosec. Prilosec was not on the resident's MAR for administration nor was there documented evidence the order was discontinued by a physician.

b. On 10/24/23, there was a physician's order for the facility to administer an Emgality (for migraines) injection on the 16th of every month. The order was not transcribed to the resident's MAR and there was no documented evidence of a physician's order to discontinue the injections.

c. The resident had an order for Refresh Relieva eye drops (for dry eyes), also dated 10/24/23. The order specified that the facility could use "house stock." Per staff documentation, Resident 3 did not receive the eye drops, four times a day, from 12/01/23 through 12/07/23 as staff noted they were waiting on Resident 3's family to bring it in.

d. The facility did not administer Metformin (for diabetes) on 12/25/23 as they were "waiting on pharmacy."

e. Staff documented on the pass notes that the resident was out of Levothyroxine (for thyroid) from 12/24/23 through 12/26/23.

The need to ensure all written, signed orders from a legally recognized practitioner were carried out as prescribed was discussed with Staff 1 (Campus Administrator) and Staff 5 (Wellness Services Director) on 01/11/24. They acknowledged the findings.

3. Resident 6 was admitted to the facility in 06/2022 with diagnoses including dehydration and chronic pain.

The resident's 12/01/23 through 01/08/24 MARs, medical prescriber's orders, and medical chart were reviewed. Staff were interviewed. The following was identified:

a. There were no current orders for the following medications:

* Lokelma (for high levels of potassium);

* Ondansetron (for nausea);

* Nitroglycerin (for chest pain);

* Milk of Magnesia (for constipation); and

* Baclofen (for muscle spasms).

b. The resident had an order for hydrocodone (for pain) to be administered twice a day at "0800 and 2000," which would be 8:00 am and 8:00 pm. The facility was administering the medication at 5:00 pm each evening.

c. On 11/07/23, staff sent a fax to the resident's medical provider asking if the facility could start taking Resident 6's weights weekly, and the provider agreed to the request. There was no documented evidence the facility obtained the resident's weights weekly on:

* 11/21/23;

* 11/28/23;

* 12/12/23;

* 12/19/23;

* 12/26/23; or

* 01/02/24.

The need to ensure all written, signed orders from a legally recognized practitioner were documented in the resident's record and were carried out as prescribed was discussed with Staff 1 (Campus Administrator) and Staff 5 (Wellness Services Director) on 01/11/24. They acknowledged the findings.

4. Resident 4 was admitted to the facility in 04/2020 with diagnoses including heart failure and history of cerebral infarction.

The resident's current physician orders and 11/01/23 through 01/08/24 MARs were reviewed.

Resident 4 was prescribed Eliquis (a blood thinner) on 11/21/23. The physician order stated Eliquis was to be taken by mouth, one tablet of 2.5 mg, twice per day. The resident's MAR showed the facility administered 5 mg, twice per day, from 12/01/23 through 01/08/24. This constituted the resident receiving twice the daily prescribed dose of blood thinner each day.

When this finding was brought to their attention during an interview on 01/10/24, Staff 1 (Campus Administrator) and Staff 5 (Wellness Services Director) stated they were not aware the dose being provided did not match the signed physician orders. No additional information was provided.

See C 231.

The need to ensure all written, signed orders from a legally recognized practitioner were documented in the resident's record and were carried out as prescribed was discussed with Staff 1 and Staff 5 on 01/11/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure all written, signed orders for medications and treatments from a legally recognized practitioner were documented in resident records and carried out as prescribed for 4 of 4 sampled residents (#s 1, 3, 4, and 6) whose records were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 09/2021 with a diagnosis of dementia.

The resident's 12/01/23 through 01/08/24 MARs and Skilled Nursing Facility discharge orders, dated 11/07/23, were reviewed during the survey. The following was identified:

* The MARs indicated Resident 1 was administered "red yeast rice w/ coenzyme Q10" twice daily from 12/01/23 through 01/07/24 and a single dose in the morning on 01/08/24; and

* There were no signed orders for facility staff to administer "red yeast rice w/ coenzyme Q10."

On 01/10/24, the need to ensure all written, signed orders from a legally recognized practitioner were documented in resident records was discussed with Staff 1 (Campus Administrator), Staff 3 (RCC), and Staff 5 (Wellness Services Director). They acknowledged the findings.

1. Deep Dive into all resident MAR for accuracy checks performed and clarifications sent to PCP. All orders are in MAR according to the most recent orders on file and Mars updated to PCP instruction. Full Audits of Medication Cart to Mar performed for accuracy. 2. Weekly MAR audits to be performed. See exhibit BC. Weekly overview of all missed medications. Staff competency evals to be performed quarterly moving forward. See Exhibit A. 3. Weekly and Monthly audits to be performed. 4. Wellness Director to oversee this task.

Based on interview and record review, it was determined the facility failed to ensure all physician's orders were carried out as prescribed for 1 of 4 sampled residents (#8) whose records were reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 8 was admitted to the facility in 11/2019 with a diagnosis of dementia and chronic kidney disease.

The resident's 06/01/24 through 07/29/24 MARs and most recent physician's orders, dated 07/02/24, were reviewed during the survey. The following was identified:

Resident 8 was prescribed Dapsone (an antibiotic) on 06/24/24 to be taken twice a day for two weeks, for a total of 28 tablets.

The MARs and interviews with Staff 1 (Campus Administrator) confirmed that Resident 8 had only received 14 doses of the medication.

On 07/31/24, the need to ensure all orders were followed was discussed with Staff 1 (Campus Administrator) and Staff 3 (RCC). They acknowledged the findings.

1.This was corrrected by faxing the prescribing physician and informing him of the missed medication. 2. Fax sent to all residents physicians with requests on when to be notified of missed medications. Care staff to notify physicians of all missed medications until clarification is received and placed into ECP (Mar). 3. Daily clinical with Wellness Director and RCC to review all missed medication from prior day. RCC to follow up with faxes to ensure compliance. Administrator to perform monthly Audit of 3 random MAR and document findings. 4. Wellness Director is to ensure corrections are completed. Administration is to perform monthly audits to monitor and ensure compliance with POC.

2. Resident 3 was admitted to the facility in 10/2019 with diagnoses including traumatic brain injury.

The resident's 12/01/23 through 01/08/24 MARs, medical prescriber's orders, and medical chart were reviewed. Staff were interviewed. There were multiple documented refusals for the following:

* Flonase (for allergies); and

* Refresh Relieva (for dry eyes).

When Staff 13 (MT/CG) was asked on 01/10/24 at 12:26 pm what the system was for notifying the medical prescriber when a resident refused to consent to orders, she stated they reported refusals once a month, "depending on the medication."

There was no documented evidence the facility reported the refusals to the practitioner.

The need to notify the physician or other practitioner each time a resident refused to consent to orders was discussed with Staff 1 (Campus Administrator) and Staff 5 (Wellness Services Director) on 01/11/24. They acknowledged the findings.

3. Resident 6 was admitted to the facility in 06/2022 with diagnoses including chronic pain.

The resident's 12/01/23 through 01/08/24 MARs, medical prescriber's orders, and medical chart were reviewed. Staff were interviewed. There were multiple documented refusals for the following:

* Lidocaine patch (for pain); and

* Ibuprofen (for pain).

When Staff 13 (MT/CG) was asked on 01/10/24 at 12:26 pm what the system was for notifying the medical prescriber when a resident refused to consent to orders, she stated they reported refusals once a month, "depending on the medication."

There was no documented evidence the facility reported the refusals to the practitioner.

The need to notify the physician or other practitioner each time a resident refused to consent to orders was discussed with Staff 1 (Campus Administrator) and Staff 5 (Wellness Services Director) on 01/11/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused to consent to orders for 3 of 3 sampled residents (#s 3, 4, and 6) who had documented medication and/or treatment refusals. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 04/2020 with diagnoses including heart failure and history of cerebral infarction.

A review of the resident's 12/01/23 through 01/08/24 MARs revealed the resident refused the following medications:

* Docusate-Senna (for constipation);

* Eliquis (blood thinner);

* Mirtazapine (for anxiety);

* Oxycodone (for pain);

* Acetaminophen (for pain);

* Refresh (for dry eyes);

* Sertraline (for depression); and

* Furosemide (for edema).

There was no documented evidence the physician was notified of any of the above refusals.

The need to notify the physician of resident medication and/or treatment refusals was discussed with Staff 1 (Campus Administrator) and Staff 5 (Wellness Services Director) on 01/11/24. They acknowledged the findings.

1. Staff education on procedure with Refusals performed on 1/31/24 during Med Tech meeting. Refusals sent to PCP for all residents residing within our community.  2. Moving forward weekly audits on missed medications to be performed See Exhibit A. 3. Weekly audits on all missed medications 4. RCC to complete using audit tool.  

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

1. Resident 3 was admitted to the facility in 10/2019 with diagnoses including traumatic brain injury.

The resident's 12/01/23 through 01/08/24 MARs and medical prescriber's orders were reviewed. Staff were interviewed and the following inaccuracies were identified:

The Refresh Relieva eye drops (for dry eyes) were ordered for the facility to administer them four times a day. Documentation by staff showed the medication was not available on:

* 12/01/23 - twice;

* 12/02/23 - once;

* 12/03/23 - three times; and

* 12/07/23 - once.

However, staff documented it was administered at different times than the above on:

* 12/01/23 - twice;

* 12/02/23 - three times;

* 12/03/23 - once;

* 12/05/23 - four times; and

* 12/07/23 - once.

Staff documented on the pass notes that the resident was out of Levothyroxine (for thyroid) from 12/24/23 through 12/26/23. Staff signed that the medication was administered on 12/24/23 and 12/25/23.

The need to ensure staff documented accurately on the resident's MAR was discussed with Staff 1 (Campus Administrator) and Staff 5 (Wellness Services Director) on 01/11/24. They acknowledged the findings.

2. Resident 4 was admitted to the facility in 04/2020 with diagnoses including heart failure and history of cerebral infarction.

Resident 4's 12/01/23 through 01/08/24 MARs were reviewed. The following PRN medications lacked resident-specific parameters for administration:

* Polyethylene Glycol powder (for constipation)

* Senna/Docusate (for constipation); and

* Bisacodyl (for constipation).

The need to ensure the MAR included resident-specific parameters and instructions for PRN medications was discussed with Staff 1 (Campus Administrator) and Staff 5 (Wellness Services Director) on 01/11/24. They acknowledged the findings.

1. Mar audits completed for all residents. Physician orders reviewed, PRN medications reviewed, and directions entered for 2. Weekly audits on MAR for accuracy to ensure all meds are being given and third checks to ensure clear directions for all PRN'S are correct and clear. Monthly med audits to be completed. 3. Weekly and Monthly audits performed by RCC. 4. Wellness Director will oversee this task.   

Based on observation, interview, and record review, it was determined the facility failed to ensure a resident who self-administered a medication had a physician's order and was evaluated at least quarterly to ensure the ability to safely self-administer medications for 1 of 2 sampled residents (#3). Findings include, but are not limited to:

Resident 3 was admitted to the facility in 10/2019 with diagnoses including post traumatic stress disorder, diabetes, and traumatic brain injury.

The resident's MARs dated 12/01/23 through 01/08/24, medical practioner's orders, and chart were reviewed. Staff were interviewed. The following was identified:

a. Resident 3 returned to the facility after a Skilled Nursing Facility stay on 10/25/23. There were signed orders for, "Insulin Glargine Subcutaneous Solution Pen-injector 100 UNIT/ML. Directions: Inject 34 units subcutaneously one time a day related to TYPE 2 DIABETES MELLITUS WITH HYPERGLYCEMIA." The signed order did not specify approval for the resident to self-administer the insulin.

On 01/10/24 at 8:25 am, Staff 10 (MT/CG) confirmed Resident 3 administered his/her own insulin.

Resident 3's MARs directed staff to check the resident's CBGs three times a day at 8:00 am, 12:00 pm, and 5:00 pm.

On 01/10/24 at 12:26 pm, Staff 13 (MT/CG) confirmed the resident had a device called a DexCom which monitored his/her CBGs every five minutes. The resident would take a picture of the reading via his/her cell phone prior to eating and show the picture to staff when they came in to check the CBGs. Staff 13 also stated that the device needed to be changed every 10 days, but staff did it as the resident was unable to.

As Staff 13 was being interviewed, another staff member came into the medication room and handed her two empty insulin pens. Survey asked who ordered the insulin for Resident 3 and Staff 13 confirmed the resident gives them the pens when they were empty and staff re-order the insulin for the resident.

There was no documented evidence of a medical practioner's order to self-administer the insulin, nor was there documented evidence the resident was evaluated to be able to safely administer the insulin. Staff's assistance to the resident for his/her diabetic regimen does not constitute the resident's ability to manage the medication and all the necessary steps independently.

b. There was a medical practioner's order dated 10/24/23 for the resident to self-administer the following medications: albuterol nebulizer treatment (for shortness of breath), nasal spray (for congestion), voltaren gel (for pain), biotene (for dry mouth), calazime (to protect skin), and an Epi pen (for anaphylactic shock relating to an allergic reaction).

During an interview with Staff 13 on 01/10/24 at 12:24 pm, she reported being aware of the resident self-administering some of the medications, stated the resident needed staff assistance with some of the topical treatments, and was not aware of the Epi pen.

There was no documented evidence the resident was evaluated to safely administer the above medications and treatments.

The need to have a medical practitioner's order and the facility to complete at least quarterly evaluations of a resident's ability to self-administer medications was discussed with Staff 1 (Campus Administrator) and Staff 5 (Wellness Services Director) on 01/11/24. They acknowledged the findings.

1. Self-Medications Evaluation was completed 1/10/24 and sent to PCP. Care Plan and Mar Updated to reflect what resident can do for herself and what care staff need to do for her. Signed orders to be obtained for residents by 03/11/24. 2. Self-Medication evaluations added to evaluation process for move in and care planning. 3. Self-Medication Evaluations to be performed upon move in and Quarterly and as needed for SCOC. 4. Wellness Director will oversee this task.    

Based on interview and record review, it was determined the facility failed to ensure non-pharmacological interventions were attempted and documented as unsuccessful prior to PRN psychotropic medication being administered for 1 of 2 sampled residents (#3) who were prescribed as needed psychotropic medications. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 10/2019 with diagnoses including post traumatic stress disorder and traumatic brain injury.

The resident's 12/01/23 through 01/08/24 MARs, medical prescriber's orders, and medical record were reviewed and staff were interviewed.

Resident 3 had a medical practitioner's order for "mirtazapine, 7.5 mg tab, 1 tablet by mouth every day as needed for anxiety or panic attacks." The resident received the PRN medication six times between 12/01/23 and 01/08/24.

On 01/10/24 at 12:26 pm, Staff 12 (MT/CG) was requested to check the computer medication system for direction relating to non-drug interventions to try with Resident 3 prior to administering the PRN psychotropic. Staff 12 confirmed there were no interventions listed for staff to try prior to administration.

The need to ensure non-pharmacological interventions were documented as attempted and failed prior to the administration of PRN psychotropics was discussed with Staff 1 (Campus Administrator) and Staff 5 (Wellness Services Director) on 01/11/24. They acknowledged the findings.

1. MAR audit to identify all PRN psychotropic medications and ensure non pharmaceutical interventions are attempted with follow up results recorded in MAR. Staff training on PRN psychotropic and new system in place performed on 1/31/24. Required Questions added to MAR that must be attempted with each PRN psychotropics medication which include what interventions were tried, why it was being administered, and follow up if medication was successful. 2. Weekly Mar Audits and Quarterly review of psychotropics to be performed by wellness team and pharmacy. 3. Weekly and Quarterly. 4. Wellness Director.  

Based on interview and record review, it was determined the facility failed to update an acuity-based staffing tool (ABST), based on the evaluated care needs for 4 of 4 sampled residents (#s 1, 3, 4, and 6) and multiple unsampled residents, and the ABST failed to convert the evaluated care needs of the residents into staff hours that were used to generate an accurate facility staffing plan. Findings include, but are not limited to:

On 01/10/24, the ABST and the facility staffing plan was reviewed with Staff 1 (Campus Administrator) and Staff 3 (RCC). The following was identified:

* The facility had not updated the ABST to reflect all evaluated care needs for Resident 3, 4, and 6;

* The facility failed to update the ABST following Resident 1's significant change of condition;

* Multiple unsampled residents were not updated at least quarterly; and

* The ABST failed to convert the evaluated care needs of the residents into staff hours that were used to generate an accurate facility staffing plan.

The need to ensure the facility updated the ABST to convert evaluated care needs of residents into staff hours needed to generate a facility staffing plan was discussed with Staff 1 and Staff 3 on 01/10/24. They acknowledged the findings.

1. ABST is being updated as we do our deep dive into each residents care plans. This is to assure accuracy of ABST moving forward. Resident ADL'S are being assesed and updated in ABST. Care Partner interviews performed and ABST updated with average times for each resident utalitizing new time information sheet.    2. ABST to be updated with each care plan meeting including initial, quarterly and SCOC. 3. Quarterly and as needed. 4. RCC to update ABST tool. Administrator to perform random Audits quarterly to ensure accuracy and compliance.

Based on interview and record review, it was determined the facility failed to ensure all pre-service orientation topics and pre-service dementia training had been completed prior to staff providing direct care to residents for 3 of 3 newly-hired staff (#s 10, 11, and 13) and infectious disease prevention training was completed for 1 of 1 long-term non-direct care staff (#6) by 07/01/22 and annually thereafter. Findings include, but are not limited to:

The facility's training records were reviewed on 01/08/24 and identified the following:

a. There was no documented evidence Staff 10, 11, and 13 (all MT's/CG's), hired 12/04/23, 09/03/23, and 11/08/23, respectively, completed one or more of the following pre-service orientation topics:

* Abuse reporting requirements;

* Infectious Disease Prevention (two hour course); and

* Fire safety and emergency procedures.

b. There was no documented evidence Staff 13 completed the following pre-service dementia training courses:

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

* Techniques for understanding, communicating and responding to behaviors: reducing use of antipsychotics;

* Strategies for addressing social needs & engaging them in meaningful activities; and

* Specific aspects of dementia including pain, proving food/fluids, preventing wandering, use of person-centered approach.

c. There was no documented evidence Staff 6 (Maintenance Director), hired on 04/06/2020, completed Infectious Disease Prevention (two hour course) by 07/01/22 and annually thereafter, as required.

The requirements for pre-service training and annual infectious disease prevention training for all employees was reviewed with Staff 1 (Campus Administrator), Staff 2 (Assistant Administrator), and Staff 3 (RCC) on 01/10/24. They acknowledged the findings.

1. All staff have been assigned to the Oregon Care Partner Classes to be completed by 2/20/24. Pre- Service Dementia Training, Pre- Service Infection and Control and Elder Abuse Prevention, Investigation, and Reporting. 2. These three classes will be done upon hire as onboarding for all future employees. 3. Audits performed Quarterly to assure compliance. 4. Assistant Administrator will oversee training.

Based on interview and record review, it was determined the facility failed to ensure all pre-service orientation topics and pre-service dementia training had been completed prior to staff providing direct care to residents for 2 of 4 newly-hired staff (#s 20 and 22) and infectious disease prevention and Home and Community Based Services (HCBS) was not completed for 1 of 4 new staff (#20). This is a repeat citation. Findings include, but are not limited to:

The facility's training records were reviewed on 07/30/24 and identified the following:

a. There was no documented evidence Staff 20 (Caregiver) hired on 06/08/24, completed the following pre-service orientation topics:

* Infectious Disease Prevention (two hour course); and

* Home and Community Based Services (HCBS) training.

b. There was no documented evidence Staff 20 (Caregiver) hired on 06/08/24, or Staff 22 (Caregiver) hired on 04/23/24, completed the following pre-service dementia training courses:

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

* Techniques for understanding, communicating and responding to behaviors: reducing use of antipsychotics;

* Strategies for addressing social needs & engaging them in meaningful activities; and

* Specific aspects of dementia including pain, proving food/fluids, preventing wandering, use of person-centered approach.

The requirements for pre-service training training for all employees were reviewed with Staff 23 (Business Office Manager) and Staff 19 (Campus Administrator) on 07/31/24. They acknowledged the findings.

1. Staff 20 and 22 have been removed from schedule until they complete their trainings. 2. Upon hire care staff will complete trainings with Buisness Office Manager (BOM) before any on the floor trainings are performed. Once these required trainings are completed they will begin the on the floor training. 3. This will be monitored by BOM every new hire. 4. Administrator will review tracker Monthly to assure compliance.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly-hired staff (#s 10, 11, and 13) had documented demonstration of competency in all required areas within 30 days of hire. Findings include, but are not limited to:

Review of the facility's training records on 01/08/24 indicated the following:

There was no documented evidence Staff 10 (MT/CG), hired 12/04/23, Staff 11 (MT/CG), hired 09/03/23, and Staff 13 (MT/CG), hired 11/08/23, demonstrated competency within 30 days of hire in one or more of the following areas:

* The role of service plans in providing individualized resident care;

* Providing assistance with the activities of daily living;

* Changes associated with normal aging;

* Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition;

* Conditions that require assessment, treatment, observation and reporting;

* General food safety, serving and sanitation; and

* First Aid/abdominal thrust training.

The need to document demonstrated competency in all job duties assigned was discussed with Staff 1 (Campus Administrator), Staff 2 (Assistant Administrator), and Staff 3 (RCC) on 01/10/24. They acknowledged the findings.

1. Competency evaluations to be performed on all current Direct care staff. 2. Moving forward competency evals to be completed as part of the training. These will be completed and reviewed before scheduled shifts. 3. Upon hire and Quarterly competency evaluation. See exhibit A.  4. RCC to perform Evaluations with Wellness Director oversight

Based on interview and record review, it was determined the facility failed to ensure 1 of 1 long-term direct care staff (#9) completed a total of 12 hours of in-service training annually, which included six hours of approved dementia care training and two hours of approved infectious disease prevention training. Findings include, but are not limited to:

Training records were reviewed on 01/08/24. The following deficiencies were identified:

There was no documented evidence Staff 9 (MT/CG), hired 12/24/97, completed a minimum of 12 hours of annual in-service training which included at least six hours of approved dementia care training and two hours of approved infectious disease prevention training.

The need to ensure long-term direct care staff completed 12 hours of in-service training annually, which included six hours of approved dementia care training and two hours of approved infectious disease prevention training, was discussed with Staff 1 (Campus Administrator), Staff 2 (Assistant Administrator), and Staff 3 (RCC) on 01/10/24. They acknowledged the findings.

1. Current care staff are completing their Oregon Care Partner training. 2. Facility to utilize Oregon Care Partner Administrator trainings to assign trainings to employees. 3. Trainings will be assigned monthly. Quarterly Audits to ensure compliance of staff of completing training requirements. 4. Assistant Administrator.  

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted in accordance with Oregon Fire Code (OFC) and included all required components. Findings include, but are not limited to:

Fire drill and fire and life safety records were reviewed from 06/2023 through 12/2023. The following deficiencies were identified:

a. The facility failed to document the following required components:

* Escape route used;

* Problems encountered, comments relating to residents who were unwilling to participate in the drills;

* Staff members on duty and participating;

* Number of occupants evacuated; and

* Evidence alternate routes were used during each fire drill.

b. During the 12/28/23 fire drill the facility documented multiple residents didn't participate in the fire drill. The following deficiency was identified:

* There was no documented evidence of what changes were made to ensure the evacuation standard was met.

Fire and life safety instruction and the required fire drill components were reviewed with Staff 6 (Maintenance Director) on 01/09/24. He acknowledged the findings.

1. Updated fire drill form used when completing fire drills. 2. The Maintenance Director updated the fire drill forms to include the following information: escape route, problems encountered, staff members on duty, participants, number of residents evacuated, alternate routes. See Exhibit D. 3. Forms to be reviewed quarterly to ensure compliance. 4. Maintenance Director and Administrator to audit quarterly for accuracy and 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 303 and C 370.

1. Immediate action of the above rules were implemented upon exit interview. 2. New process in place for POC. 3. Both actionable items to be audited monthly by Administrator for accuacy and compliance. 4. Administrator will be responsible for seeing that these corrections are completed.

Based on observation and interview, it was determined the facility failed to ensure covers, grates, or screens of wall heaters and associated heating elements did not exceed 120 degrees Fahrenheit (F) when installed in locations that were subject to incidental contact by individuals. Findings include, but are not limited to:

On 01/09/24, a double-sided fireplace was observed in the common area near the facility entrance. Residents were observed throughout the day standing next to the fireplace and reaching towards it. The upper portion of the metal fireplace frame measured 175 degrees F when measured with the surveyor's thermometer.

In an interview on 01/09/24, Staff 1 (Campus Administrator) and Staff 6 (Maintenance Director) acknowledged the surface was too hot to touch and stated the fireplace would be turned off until they were able to find another solution.

On 01/10/24, the fireplace was observed to be on, and the upper portion of the metal frame measured 194 degrees F.

The need to ensure residents could not come into incidental contact with fireplace elements that exceeded 120 degrees F was discussed with Staff 1 and Staff 5 (Wellness Services Director) on 01/11/24. They acknowledged the findings.

1. Fireplace has been turned off until a time when solution can be met. Maintenance looking into different types of Fireplace gates. 2. Gates to be placed around the fireplace for awareness and to ensure residents are not injured from heat. 3. Daily walkthrough to ensure gate is in proper working order. 4. Maintenance Director.