Print Inspection: BTYT

The findings of the re-licensure survey, conducted 08/08/23 through 08/09/2023, 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 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 re-visit to the re-licensure survey of 08/09/23, conducted on 05/20/24, 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.

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 08/09/23, conducted 07/25/24, 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 004 Home and Community Based Services Regulations.

Based on observation, interview, and record review, it was determined the facility failed to notify the department related to a change to the administrator of record. Findings include, but are not limited to:

On 08/08/23, during the initial walk-through, it was revealed the manager of the facility that was identified on the posted schedule was not known to the Division as the Administrator of the facility.

In an interview with Staff 1 (Administrator in training) on 08/08/23, she explained she was the Administrator in training and had started the position on 07/06/23.

On 08/08/23, in communication with the Division, it was revealed a notification of the change had not been done.

OAR 411-054-0025 (6) Facility Administration: Notification

Ashley Manor is actively recruiting for a qualifting licensed Administrator and will promptly notify the Department when onboarded.    

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

Observations of the facility kitchen, food storage areas, food preparation and food service on 08/08/23 revealed:

* Packaged foods not dated when opened;

* Open package of taco shells in the dry storage;

* Scoops left with the handles in food in bulk containers in dry storage;

* Butter, a potentially hazardous food, was stored on the counter;

* Documented food temperatures noted to be below minimum requirements and no evidence of consistently documenting food temperatures;

* The food thermometer was visibly dirty;

* No documented evidence of monitoring refrigerator temperatures;

* Staff were observed to not wash or sanitize hands upon entry to the kitchen, gloves were not changed between tasks; and

* Universal Workers, who assisted residents with bathing and toileting, did not use aprons while cooking and serving food.

The food storage and handling concerns, and areas in need of cleaning were reviewed with Staff 1 (Administrator in training). She acknowledged the findings.

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule

1) All packaged foods wil be properly stored, sealed and dated. Scoops will be removed from any bulk containers.  Food and refrigerator temps wills be documented accordingly.  Food thermometer will cleaned and sanitized. Retraining with staff on proper food storage,hand washing techniques, apron use and glove use will be completed.

2)  Training and review with staff will be completed on proper kitchen and food sanitation rules including proper storing of foods and thermometer sanitation, apron use, glove use, proper  food/fridge temps per regulation, how to document and who to notify if out of range as well as proper hand hygiene.

3) Packaged foods, food temps and fridge temps and general cleanliness will be audited  daily as well as monthly using the Administrator Quality Assurance audit .

4) The administrator/designee will be responsible to ensure the system has been corrected/monitored, with oversight from the Regional Director of Operations.

Based on observation, interview, and record review, it was determined the facility failed to provide an activity program based on individual and group interests, physical, mental, and psychosocial needs, and opportunities for active participation in the community at large. Findings include, but are not limited to:

During the re-licensure survey 08/08/23 through 08/09/23, there was a lack of scheduled and unscheduled activities provided for residents living in the facility.

The facility was home to 10 residents and had one Universal Worker scheduled to provide for all needs including:

* Caregiving;

* Medication pass;

* Housekeeping;

* Laundry;

* Cooking, serving, and clean up for meals; and

* Activity program.

An activity calendar was provided for the community and included scheduled activities for each day of the week.    

Scheduled activities during the week had no identified scheduled times. Activities listed on the calendar for 08/08/23 and 08/09/23 included Morning Motivation, Pledge of Allegiance, Storyline, This Day in History, Chair Exercises, Sing-a-Long, Sit and Sip, and Poetry.

No activities were offered on 08/08/23 from 8:00 am through 5:00 pm.

No activities were offered on 08/09/23 from 8:00 am through 1:00 pm. A volunteer group arrived to sing hymns with the residents at approximately 1:15 pm. Staff 1 (Administrator in training) explained the group came once a month.

During the survey, residents were observed sleeping in their rooms, wandering the halls, or sitting in front of the TV in the common living room area.

The lack of an activity program was discussed with Staff 1. She acknowledged the findings.

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

1) Administrator/Designee will update individual and group interests in each resident's service plan and ensure a daily program of social and recreational activities that are based upon individual and group interests and physical, mental and psychosocial needs are provided for residents. They will incorporate the use of the activity program provided by the home office each month.

2) Review of processes and documentation of the activities program will be completed with Administrator /Designee

3) Activity program will reviewed daily and monthly with Administrator Quality Assurance audit.

4) Administrator/Designee will be responsible for monitoring, corrections and resident updates with RDO oversight.  

Based on interview and record review, it was determined the facility failed to ensure evaluations were completed at least quarterly for 2 of 2 sampled residents (#s 1 and 2). Findings include, but are not limited to:

Resident 1 was admitted in 10/2022 and Resident 3 was admitted in 01/2023.

The most recent quarterly evaluations of all required elements for Residents 1 and 2 had been reviewed and updated in 03/2023.

The need to ensure evaluations were reviewed quarterly was discussed with Staff 1 (Administrator in training). She acknowledged the findings.

OAR 411-054-0034  resident move in and eval

1) Evaluations of resident #1 and #3 will be reviewed and updated to reflect most current needs.

2) The Administrator/Designee will be provided training on the resident evaluation, all required components including training on the time frame of reviews.  All resident evaluations will be reviewed and updated  to ensure all required componets are reflective of his / her needs.

3) All new admissons will have a completed move in evaluation and current residents will have evaluations completed at least quarterly or with change of condition. This will be monitored monthly with the Administrator Quality Assurance audit.

4) The administrator/designee will be responsible to ensure the system has been corrected/monitored, with oversight from the Regional Director of Operations.

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

1. Resident 1 was admitted to the facility in 10/2022 with diagnoses including dementia.

Observations of the resident and interviews with staff were conducted throughout the survey. The resident's current service plan, dated 03/07/23, and facility Observation Notes from 05/08/23 through 08/08/23 were reviewed.

The resident's service plan was not reflective and did not include clear instruction for staff in the following areas:

* The use compression hose; and

* The use of an oxygen concentrator and the need to monitor water levels and the filter.

There was no evidence the service plan had been reviewed and updated quarterly.

The need to ensure service plans were reflective of the resident's current health status and provided clear instruction to staff was discussed with Staff 1 (Administrator in training) during the survey. She acknowledged the findings.

2. Resident 2 was admitted to the facility in 01/2023 with diagnoses including dementia.

Observations of the resident and interviews with staff were conducted throughout the survey. The resident's current service plan, dated 03/21/23, and facility Observation Notes from 05/08/23 through 07/31/23 were reviewed.

The resident's service plan was not reflective and did not include clear instruction for staff in the following areas:

* The use of compression leg pumps; and

* Assistance needed with hearing aids.

There was no evidence the service plan had been reviewed and updated quarterly.

The need to ensure service plans were reflective of the resident's current health status and provided clear instruction to staff was discussed with Staff 1 (Administrator in training) during the survey. She acknowledged the findings.

OAR 411-054-0036 (1-4) Service Plan: General

1) Resident  #1's service plan will be updated to reflect the use of compression hose, oxygen concentrator  and the need to monitor water levels and filter. Resident #2's service plan was updated 7/5/23  to reflect discontinuing the use of compression leg pumps and assistance with compression stockings, service plan will be updated to reflect use hearing aids.

2)The Administrator/Designee will be provided training on the resident evaluation and all required components, including training on the timeframe of all reviews. All resident service plans will be reviewed and updated  to ensure all required componets are reflective of their needs.

3) All resident service plans will be completed at least quarterly or with change of condition to reflect the health status and provide clear instruction to staff. This will be monitored monthly with the Administrator Quality Assurance audit.

4) The administrator/designee will be responsible to ensure the system has been corrected/monitored, with oversight from the Regional Director of Operations.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a service planning team that included the resident, the resident's legal representative if applicable, any person of the resident's choice, the Administrator or designee, and at least one other staff person who was familiar with or who was going to provide services to the resident for 2 of 2 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to:

The most recent service plans for Residents 1 and 2 were reviewed during the survey. The records lacked documented evidence the service plans were developed by a service planning team and involved family members and case managers were notified in advance of the service-planning meeting.

On 08/09/23, the need to ensure service plans were developed by a service planning team was discussed with Staff 1 (Administrator in training). She acknowledged the findings.

OAR 411-054-0036 (5) Service Plan: Service Planning Team

1) Service planning team will be established for residents #1 & #2.  Documentation of team and meeting will be completed regarding review of updated service plans.

2)  The Administrator/Designee will be provided training on the requirements and importantance of a service planning team and the role of the team. The team will consist of the resident, resident's legal representative/person of the resident's choice, Administrator/Designee, case manager (if applicable), nursing, and at least one other staff person who is familiar with or providing services to the resident.

3)  Initially, quarterly, with signifigant change of condition, and with monthly Administrator Quality Assurance Audit.

4) The Administrator/Designee will be responsible for scheduling the service plan team meetings with Regional Director of Operations oversight  

Based on observation, interview, and record review, it was determined the facility failed to have sufficient number of caregiving staff to meet the 24-hour scheduled and unscheduled needs of residents to compensate for staff duties beyond direct resident care. Findings include, but are not limited to:

Observations, interviews, and record review during the survey revealed the following:

* The facility utilized Universal Workers whose job duties included passing medications, providing care and services to residents, housekeeping, laundry, cooking, serving, and cleaning up after meals, and activities.

* Review of the staffing schedule and interviews with Staff 1 (Administrator in training) during the survey revealed the facility had one Universal Worker scheduled on all shifts.

* Interviews with Universal Workers revealed, if a resident fell, staff were not able to assist them up and called emergency services for assistance.

* A resident family member noted it was "really chaotic" over the weekend and only one staff was available.

* Universal Workers did not have time to engage residents in Life Enrichment activities.  (Refer to C 242).

The need to increase staffing levels to compensate for increased staff duties and unscheduled resident needs was discussed with Staff 1. She acknowledged the need for increased staff.

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing

1) Facility is actively recruiting and hiring additional staff for  additional support to current staff and census.  New hires are currently in training and agency staffing is being used to supplement.

2) Facility will continue to recruit, hire and train new staff to ensure adequate staffing is present and available.

3) The scheule will be reviewed frequently and staff hours will adjusted as needed to ensure all resident and staffing needs are met.

4) The Administrator/designee and Regional Director of Operations will be responsible to ensure completion.  

Based on observation, interview, and record review, it was determined the facility failed to have sufficient number of caregiving staff to meet the 24-hour scheduled and unscheduled needs of residents to compensate for staff duties beyond direct resident care. This is a repeat citation. Findings include, but are not limited to:

Observations, interviews, and record review during the survey revealed the following:

* The facility utilized Universal Workers whose job duties included passing medications, providing care and services to residents, housekeeping, laundry, cooking, serving, cleaning up after meals, and activities.

* Review of the staffing schedule and interviews with Staff 6 (Administrator) during the survey revealed the facility had 1.5 - 2 Universal Workers scheduled on day and swing shifts, and one Universal Worker scheduled during the night shift.

* An Interview with Staff 10 (Universal Worker) on 05/20/24 revealed she was the main person responsible for passing medications, cooking lunch, cleaning, providing care to the residents, and doing activities.

* The Acuity Based Staffing Tool and residents' service plans were reviewed. The minimum staff needed for Universal Workers to meet the residents scheduled and unscheduled needs were two staff members on duty for each shift.  

The need to increase staffing levels to compensate for increased staff duties and unscheduled resident needs was discussed with Staff 6, Staff 7 (Designee), Staff 8 (RN), and Staff 9 (Regional Director of Compliance) on 05/20/24. They acknowledged the need for increased staff.

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing

1-The ABST will be updated to reflect universal worker duties according to the ODHS Training Webninar.

2-Training will be completed with Administrator and Designee on how to correctly reflect hours on the ABST for all workers.

3-Upon admission of each new resident, with each change of condion and quarterly evaluation update, and  bi-weekly as staff schedules are created.

4- The Administrator/Designee  will be responsible to ensure the corrections are completed and monitored, with Regional Director of Operations oversight   

Based on observation, interview, and record review, it was determined the facility failed to ensure all residents were entered into the staffing tool and ABST entries were not reflective of the resident's current care needs for 2 of 2 residents reviewed (# 1 and 2). Findings include, but are not limited to:

1. Observations of Resident 1, interviews with staff, and review of the resident's records noted ABST entries were not reflective of the resident's current care needs.  

A review of Resident 1's ABST, revealed an inaccuracy of minutes assigned in the following areas:

* Medication administration;

* Providing treatment; and

* Monitoring behavioral condition or symptoms.

2. Observations of Resident 2, interviews with staff, and review of the resident's records noted ABST entries were not reflective of the resident's current care needs.  

A review of Resident 2's ABST, revealed an inaccuracy of minutes assigned in the following areas:

* Bathing;

* Transferring;

* Medication administration;

* Providing treatment;

* Cueing or redirecting due to cognitive impairment or dementia; and

* Monitoring behavioral condition or symptoms.

3. Not all facility residents were entered in to the ABST to account for all resident care needs and facility staffing needs.

Inaccuracies on resident entries for the ABST tool, not including all residents in the tool, and potential inaccurate staffing calculations were discussed with Staff 1 on 08/09/23. She acknowledged the findings.

OAR 411-054-0037 (1-8) Acuity-Based Staffing Tool

1) ABST for resident #1 will be updated to include accurate minutes for medication administration, providing treatments and monitoring behavioral conditions/symptoms.  ABST for resident #2 will be updated to include accurate minutes for bathing, transfering, medication administration, providing treatments, cueing/redirecting due to cognitive impairment or dementia; and monitoring of behavioral conditions/symptoms. All facility residents will be added to ABST to account for all resident care needs and staffing needs.

2) Administrator/Designee will be provided training on how and when to accurately update the ABST to ensure  accurate staffing needs are met.

3)ABST will be updated promptly and accurately initially, quarterly, with signifigant change of condition, as well as monthly using the Administrator Quality Assurance Audit.

4) The Administrator/Designee will be responsible to ensure the corrections are completed/monitored with Regional Director of Operations oversight  

Based on interview and record review, it was determined the Administrator failed to show documented evidence of a current Residential Care Facility Administrator license. Findings include, but are not limited to:

On 08/08/23, Staff 1 (Administrator in training) was asked to provide documentation of her Residential Care Facility Administrator license. Staff 1 explained she had not yet taken the course to become a licensed Administrator. Staff 1 further stated she was not approved to become an Administrator until she had further experience.

Staff 1 was not aware of any other corporation staff being designated as the Administrator of record for the facility.

In communication with the Division, there was no designated Administrator for the facility or current exception.

The requirement to have a current Residential Care Facility Administrator was discussed with Staff 1 on 08/09/23. She acknowledged the findings.

OAR 411-054-0070 (2) Staffing Rqmt and Training: Training Rqmts

Ashley Manor is actively recruiting for a qualifying licensed Administrator and will promptly notify the Department when onboarded.    

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 newly hired caregiving staff (#s 2 and 4) demonstrated satisfactory performance in all job duties, and 1 of 2 (# 2) were trained in First Aid and abdominal thrust within 30 days of hire. Findings include, but are not limited to:

Training records were reviewed on 08/08/23.

1. There was no documented evidence Staff 2 (Universal Worker), hired 06/16/23, and Staff 4 (Universal Worker), hired 01/31/23, had demonstrated competence in providing assistance with ADLs within 30 days of hire.

Staff 2 lacked evidence of demonstrating competence with the Role of service plans in providing individualized care.

2. There was no documented evidence Staff 2 and Staff 4 had demonstrated competence in medication administration. Staff 5 (Administrator of another facility in the corporation) immediately completed and documented medication pass training, including demonstration of competence.  

3. There was no documented evidence Staff 2 had completed First Aid and abdominal thrust training within 30 days of hire.

The need to ensure staff had documentation of demonstrated competence in all job duties within 30 days and were trained in First Aid  and abdominal thrust was reviewed with Staff 1 (Administrator in training) on 08/09/23. She acknowledged the findings.

OAR 411-054-0070 (6)(9) Training within 30 days: Direct Care Staff

1) Documented evidence of demonstrated competencies of ADLs and medication administration for staff #2 & #4 are completed. Role of service plans in providing individualized care, CPR and first aid training will be completed for staff # 2.

2) An audit of staff training records will be completed and any staff without the required demonstrated competencies within 30 days of hire will be provided the training. A Review of training requirements will be completed with Administrator/ Designee and will include the process and documentation of staff training intially, with in 30 days and ongoing.

3) To ensure the system is corrected and staff remain in compliance with all training requirements, at time of hire a review of training documents with be completed to ensure compliance, as well as monthly using the monthly Administrator Quality Assurance audit.

4) The Administrator/Designee will be responsible to ensure the corrections are completed/monitored with Regional Director of Operations oversight    

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

On 08/09/23, fire drill and fire and life safety training records for the previous six months were requested.

Staff 1 (Administrator in training) reported fire drills and fire life safety training had not been done. She acknowledged the fire drills and fire and life safety instruction requirement was not met.

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety

1) Fire Drills will be conducted and recorded at a minimum of every other month at different times of the day, evening, and night shift. Fire and Life Safety Training will be provided on alternating months.

2) Review of fire drills, Life safety requirements and processes according to OARs will be completed with staff, and the Administrator/Designee.

3) The system will be evaluated to ensure all requirements have been met and documented using the Monthly Administrator Quality Assurance audit.  

4) The Administrator/Designee and Maintenance Director will be responsible to ensure the corrections are completed/monitored  with Regional Director of Operations oversight  

Based on interview and record review, it was determined the facility failed to provide fire and life safety instruction to staff on alternating months, conduct fire drills consistently every other month, and to document all required elements for fire drills in accordance with Oregon Fire Code (OFC) requirements. This is a repeat citation. Findings include, but are not limited to:

Fire and life safety records were reviewed with Staff 6 (Administrator) on 05/20/24 at 2:30 pm.

The facility provided documentation of two fire drills in the last six months, which occurred on 01/31/24 and 03/08/24. Written fire drill documentation on 03/08/24 did not include problems encountered and comments relating to residents who resisted or failed to participate in the drills.

There was one documented example of fire and life safety instruction to staff on alternating months, which occurred on 04/20/24.

During an interview on 05/20/24, Staff 6 confirmed the fire drills and fire and life safety instruction to staff had not occurred consistently over the last six months.

The need to provide fire and life safety instruction to staff on alternate months, to consistently conduct fire drills every other month, and to document all required elements for fire drills as required by the OFC was discussed with Staff 6, Staff 7 (Designee), Staff 8 (RN), and Staff 9 (Regional Director of Compliance). They acknowledged the findings.

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety

1) Fire Drills will be conducted and recorded at a minimum of every other month at different times of the day, evening, and night shift. Fire and Life Safety Training will be provided on alternating months.

2) Review and training for fire drills, Life safety requirements and processes according to OARs including documentation of all required elements for fire drills will be completed with staff, and the Administrator/Designee.

3) The system will be evaluated to ensure all requirements have been met and documented using weekly one on one meeting with RDO and Administrator/Designee as well as the Monthly Administrator Quality Assurance audit.  

4) The Administrator/Designee and Maintenance Director will be responsible to ensure the corrections are completed and monitored with Regional Director of Operations oversight  

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

Refer to C 360, C 420, and C 510.

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval

Refer to C 360, C 420, and C 510.

Based on observation and interview, it was determined the facility failed to prevent the entry of pests, ensure exterior pathways were maintained in good repair, and storage was provided for all maintenance equipment. Findings include, but are not limited to:

1. The facility grounds were toured during the survey and the following was observed:

* Drop-offs from the sidewalk to the adjacent planting beds of approximately four inches; and

* Yard maintenance equipment lying about the yard including: shovel, hose, rake, and lawn mower.

2. The back door lacked a screen and was left open. Multiple flies were noted in the dining room and kitchen.

On 08/09/23, a resident seated at the dining room table stated s/he was "...chasing flies away all morning, there's two now..."  

The building exterior and the need to take measures to prevent the entry of pests including flies was reviewed with Staff 1 (Administrator in training) on 08/08/23.  She acknowledged the findings.

OAR 411-054-0200 (3) General Building Exterior

1) Maintenance will remove and store yard equipment including; shovel, hose, rake and lawn mower. Bids are in process torepair drop-offs from the sidewalk to the adjacent planting beds. The back door will be monitored when residents enter/exit to ensure it is closed to reduce risk of allowing flies into the communty.

2) Administrator/Designee will be provided training on The Administrator daily walk through of community to ensure above items are in compliance.

3) The Administrator/Designee will complete a daily walk through of community as well as monthly using the Administrator Quality Assurance Audit. Regional Director of Operations will complete Quarterly Environmental Audit. All concerns will be addressed promptly with the Maintenance Director.

4)The Administrator/Designee and Maintenance Director are responsible to ensure corrections are completed/monitored with Regional Director of Operations oversight.

Based on observation and interview, it was determined the facility failed to ensure exterior pathways were maintained in good repair and the grounds were kept orderly and free of litter and refuse. This is a repeat citation. Findings include, but are not limited to:

The facility grounds were toured during the survey and the following was observed:

* Drop-offs from the sidewalk to the adjacent planting beds of approximately four inches;

* Cement used to ensure an even surface on the walkway was chipped thus created a tripping hazard; and

* Litter and refuse including: an empty soil bag, dead plants in small pots, a faucet cover, and a stained mattress.

The building exterior was toured with Staff 6 (Administrator) on 05/20/24. She acknowledged the findings.

OAR 411-054-0200 (3) General Building Exterior

1) Maintenance will fix all stated issues including the drop offs from side walk and chipped cement on walkways. Litter and refuse has been removed including empty soil bag, dead plants in pots, faucet cover and stained mattress.

2) Administrator/Designee, Manitenance Director and RDO will complete an audit of yard maintenance and create a check off list for regular maintenance and upkeep with daily walk throughs to ensure safety.

3) Administrator/Designee will evaluate needs weekly during one on one meetings and monthly via monthly Administrator Quality Assurance Audit.  RDO will evaluate monthly through in person audit as well as once a quarter via Quarterly Environmental Audit.

4) The Administrator/Designee and Maintenance Director will ensure corrections are completed and monitored with Regional Director of Operations oversight.  

Based on observation and interview it was determined the facility failed to clearly post the electronic code needed to exit the facility for residents, visitors, and staff use.

An electronic key pad was located near the front entrance of the facility. The code required to open the door was hidden in a photo and poem above the key pad.

On multiple occasions during the survey from 08/08/23 through 08/09/23, visitors had to request assistance from staff to exit the facility because they could not read or locate the code needed to open the door.

The requirement to clearly post the code for the front door key pad was discussed with Staff 1 (Administrator). She acknowledged the findings.

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors

1) The door code will be reposted near the key pad and door and positioned to be clear for residents, visitors and staff to use.

2) Correction will be made with reposting of the code in a clear fond and placement. Training with Admininstrator/Designee on appropriate code postings.

3) This correction will be reviewed monthly via the monthly Quality Assurance Audit

4) Administrator/Designee with Regional Director of Operations oversight.

Based on observation and interview, it was determined the facility failed to ensure all exit doors were equipped with an alarming device or other acceptable system to provide security and to alert staff when residents exited the building, and that a manually operated emergency call system was provided in each toilet and bathing facility used by residents and visitors. Findings include, but are not limited to:

1. Observations on 08/08/23 and a tour of the facility with Staff 1 (Administrator in training) on 08/08/23 revealed exit doors did not have  operational alarms or other acceptable system to alert staff when residents exited the building.

2. The common bathrooms (toilet and bathing facilities) of the facility did not have a manually operated emergency call system for use by residents and visitors.

The need to ensure exit doors were equipped with a system to alert staff when residents exited and the need for a call system in bathrooms was discussed with Staff 1 on 08/08/23. She acknowledged the findings.

OAR 411-054-0200 (11-13) Call Sys, Exit Dr Alarm, Phones, TV, or Cable

1) Maintenance to install working alarms on exit doors and install additional call buttons in all toilets, bathing facilities and common use bathrooms, adding to the current call system.

2) Exit door alarm checks will be added to staff daily task sheets to ensure proper functioning of alarms. Staff will receive training on reporting non-functioning alarms.

3) The system will be evaluated daily to ensure alarms are operational and alerting staff of when residents and visitors enter/exit the building.

4) The Administrator/designee and Maintenance Director to ensure the corrections are completed/monitored with Regional Director of Operations oversight.

Based on observation, record review, and interview, the facility failed to ensure residents who lived in the facility were provided a key to their units per evaluated need. Findings include, but are not limited to:

Review of records for Residents 1 and 2 revealed no documented evidence the residents had been evaluated for the ability to manage keys to their rooms.

In an interview with Resident 1 on 08/09/23, s/he reported s/he was not provided a key to his/her room.

In an interview with Staff 1 (Administrator in training) on 08/09/23, she was not aware of any evaluations of residents' ability to manage keys and was not aware if current residents in the facility were provided keys to their apartments.

The need to ensure all residents were evaluated for the ability to manage keys to their units and providing keys based on those evaluations was discussed with Staff 1. She acknowledged the findings.

OAR411-004-0020(2)(e) Individual Door Locks: Key Access

1) Resident #1 and #2 will be evaluated for the ability to manage keys to their rooms.

2) Review of the requirements and process of key evaluations  for all residents to be completed with Administrator/Designee.  

All current and new residents will be evaluated for the ability to manage keys to their room with proper documentation of the outcome.  

3)Monitoring will be completed monthly using the Administrator Monthly Quality Assurance audit.

4) The Administrator/Designee will be responsible to ensure the corrections are completed/monitored with Regional Director of Operations oversight  

Concerns were identified and the facility was provided with technical assistance in the following areas:

H 1518: Individual Door Locks: Key Access OAR 411-004-0020(2)(e)

(2) Provider owned, controlled, or operated residential settings must have all of the following qualities:

(e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit.