Print Inspection: J400

The findings of the re-licensure survey, conducted 04/29/24 through 05/03/24, 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, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 for Home and Community Based Services Regulations.

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

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first re-visit to the re-licensure survey of 05/03/24, conducted 10/28/24 through 10/31/24, 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, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 for Home and Community Based Services Regulations.

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

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the second re-visit to the re-licensure survey of 05/03/24, conducted 03/11/25, are documented in this report. It was determined the facility was in compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.

Based on observation, interview, and record review, it was determined the facility failed to exercise reasonable precautions against any condition which could threaten the health, safety or welfare of residents for 2 of 4 sampled residents (#s 1 and 4) who received an inaccurate diet texture and an unclarified order for fluid consistency. Findings include, but are not limited to:

During the survey on 04/29/24, two sampled residents were identified as requiring modified texture meals and/or modified liquid consistencies.

1. Resident 4's clinical records were reviewed. Resident 4's current service plan dated 03/20/24 noted the resident had a swallow evaluation on 04/17/23 and received orders for a mechanical soft, soft food and puree as needed, and thin liquids. Resident 4 had signed physician orders dated 08/09/23, indicating s/he required mechanical soft textures with "thickened" liquids and a physician clarification order dated 04/29/24, indicated s/he required puree textures with "thickened" liquids.

During meal observations of Resident 4, and interviews with staff on 04/29/24 through 05/02/24, the following was noted:

* Resident 4 was observed with "thickened" liquids at the lunch meal, and the powder thickener had separated in the glasses of liquids. Staff 7 (Lead MT) told Staff 8 (CG) to add more thickener to Resident 4's liquids.

* Staff 8 stated Resident 4 required "thick" liquids and she followed the directions on the container of powder thickener for mildly thick nectar consistency.

* Staff 13 (Cook) showed the surveyor the physician order taped to the refrigerator that indicated Resident 4 required "thickened" liquids. Staff 13 stated she told the staff to follow the directions on the container of powder thickener for mildly thick nectar consistency.

* Multiple staff indicated they were aware Resident 4 was on "thickened" liquids but the order did not specify if the liquid consistency was nectar or honey thick.

* On 04/30/24 at 12:45 pm, the surveyor shared the observations and interviews with Staff 1 (Administrator) and she acknowledged the physician order for "thickened" liquids for Resident 4 needed to be clarified for nectar or honey thick consistency. Staff 1 put a plan in place that indicated a clarification order on diet texture and liquid consistency would be obtained, and hospice would provide pre-thickened liquids. Staff 1 stated Resident 4 would receive an updated swallow evaluation to determine the appropriate diet texture and liquid consistency.

The need to ensure the facility exercised reasonable precautions against any condition which could threaten the health, safety, or welfare of residents was discussed with Staff 1 and Staff 2 (RCC) on 05/03/24. They acknowledged the findings.

2. Resident 1's clinical records were reviewed and revealed a 04/15/24 physician order for mechanical soft texture diet. The service plan, dated 02/27/24 noted the resident was on a mechanically soft diet and thin liquids.

During meal observations and interviews with staff on 04/30/24 through 05/03/24, the following was noted:

* On 4/30/24, observations during lunch indicated Resident 1 was served whole pieces of cut up chicken with gravy, full size steamed baby carrots, rotini pasta, and a roll.

* Observation of a white board used in the kitchen for residents with modified dietary needs revealed that Resident 1 needed "Special utensils" but did not indicate a mechanical soft diet.

* Staff 13 (Cook) on 04/30/24 at 12:37 pm, indicated Resident 1 had a "normal diet but it needs to be cut up".

During an interview with Staff 1 (Administrator) on 04/30/24 at 12:45 pm, she confirmed Resident 1 should be served a mechanical soft diet and implemented a plan for Resident 1 that included "staff to follow special diet order using food processor or blender to ensure correct texture of diet order met and maintained."

* On 5/01/24, observations during lunch revealed Resident 1 was served whole pieces of cut up ham, whole pieces of steamed mixed vegetables, a roll and mashed potatoes.

On 05/01/24, the surveyor reviewed observations of the diet texture consistency with Staff 1 and she acknowledged Resident 1 did not receive a mechanical soft diet when the ham and mixed vegetables were served and would follow up with kitchen staff. Observations during subsequent meals on 05/02/24 and 05/03/24 confirmed Resident 1 received a mechanical soft diet.

The need to ensure the facility exercised reasonable precautions against any condition which could threaten the health, safety, or welfare of residents was discussed with Staff 1 and Staff 2 (RCC) on 05/03/24. They acknowledged the findings.

1.Resident diet orders have been clarified by PCP and updated in the service plan and dietary communication form.  

2.The Dietary department and caregivers to be retrained on following diet orders.  If discrepancies are noted, staff to be trained on notification procedures.

3.At move in and with each service plan update.

4.       Dietary Manager, RCC, Administrator

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean, in good repair, food properly stored, and infection control measures were practiced in accordance with the Food Sanitation Rules OAR 333-150-0000. Findings include, but are not limited to:

Observation of the kitchen on 04/29/24 at 9:30 am through 12:35 pm revealed the following deficiencies:

a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black and rust colored matter and grease was visible on or underneath the following:

* Flooring under hampers;

* Flooring and piping near ware washer;

* Shelving above, and trim and caulking behind handwashing sink;

* Commercial can opener blade;

* Vent on ceiling in dry storage area;

* Vent and ceiling fire sprinkler above food prep area;

* Stove and grill top, area around grill, and grease trap;

* Inside and outside of oven including doors and knobs;

* Mixer;

* Knife holder;

* Tray next to toaster storing condiments and thermometer;

* Handles and shelves of multiple serving carts;

* Open shelving storing cooking oil;

* Inside of microwave;

* Brown tray storing salt, pepper and baskets of plastic utensils;

* Open stainless steel shelving storing dishes;

* Track for stainless steel cabinet holding paper products;

* Juice dispenser; and

* Cupboards and knobs in dining room beverage area.

b. The following areas were in need of repair:

* Shelf above stove with chipped and peeling paint;

* Ware washing machine not operational; and

* Walls by handwashing sink, three compartment sink, next to door exiting into dining room and near toaster, and a shelf storing cleaning supplies had dings, chips or rough surfaces causing an uncleanable surface.

c. The following items were not stored appropriately:

* Oats, pasta, coffee and brown sugar had scoops in their respective bins;

* Staff food was stored in kitchenette refrigerator that was used to store snacks for residents;

* Mixer, food processor and blender lacked protective coverings when not in use to prevent possible contamination;

* Multiple food items stored in reach-in fridge and freezer not properly labeled, dated and/or sealed;

* Measuring cups, pots, pans, plates and bowls stored face up on open shelving with potential contamination; and

* A pan of banana sheet cake covered with parchment paper was stored on counter next to handwashing sink with no barrier, increasing risk of potential contamination.

d. During the tour identified via test strips that the sanitizer system was not working and kitchen staff were not aware. Staff 3 (Maintenance Supervisor) was alerted and the sanitizing system was repaired prior to exiting.

e. Staff was not observed to consistently check temperatures of food items prior to beginning of tray service.

f. A kitchen staff was observed to contaminate hands and food items while preparing and serving food when s/he did not consistently wash or sanitize hands when switching from dirty to clean tasks and lacked a protective covering for his/her clothing. A kitchen staff was also observed to touch food items while wearing contaminated gloves.

g. Trash can missing a lid when not in use.

h. Two of two paper towel dispensers lacked paper towels and no alternatives available to dry hands after performing hand hygiene.

During an interview and tour with Staff 1 (ED) and Staff 4 (Dietary Manager) on 04/29/24 at 1:45 pm, they acknowledged the identified areas needing to be cleaned, repaired, improper storage of food in the freezers, cooler and dry storage, temping foods prior to serving, use of test strips for proper sanitizing and infection control practices.

1.Areas noted to be dirty have been cleaned.  The shelf above stove and walls by handwashing sink to be repaired.  The ware washing machine to be repaired.

2.The Dietary manager has been counseled and retrained along with the dietary team on the necessity to keep a clean and in good repair kitchen.  The team has been retrained on using the Maintenance log for issues that needs to be repaired. Dietary manager to attend upcoming offsite training to be educated on updated OARs and food sanitation rules. Kitchen task sheet updated to reflect deficient areas.

3.Daily by cooks and dietary aides, weekly by Dietary Manager, Administrator.

4.Dietary Manager, Administrator.

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

Resident 3 was admitted to the facility in 12/2023 with diagnoses including dementia.

The resident's new move-in evaluation was completed on 12/15/23. The following elements were not addressed or had conflicting information in the move-in evaluation:

* Customary routines: eating;

* Interests, hobbies, social, leisure activities;

* Spiritual, cultural preferences & traditions;

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

* History of treatment;

* Pain: pharmaceutical and non-pharmaceutical interventions;

* Emergency evacuation ability;

* History of dehydration or unexplained weight loss or gain;

* Recent losses;

* Unsuccessful prior placements; and

* Environmental factors that impact the resident's behavior including, but not limited to: noise, lighting, room temperature.

The need to ensure all required elements were addressed in move-in evaluations prior to a resident being admitted, was discussed with Staff 1 (Administrator) on 05/03/24. She acknowledged the findings.

1. The Pre Admission Evaluations noted to be updated to reflect the deficiencies.

2. Re-trained on Pre-Admission Evaluation requirements.  Administrator/RCC/Nurse to collaborate to ensure the move in admission evaluation is complete and reflects the required elements.

3. Evaluated prior to each admission.

4. RCC, Administrator

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of the resident's needs, readily available, provided clear direction to staff regarding the delivery of services, and were implemented for 3 of 3 sampled residents (#s 1, 2 and 4), whose service plans were reviewed. Findings include, but are not limited to:   

1. Resident 2 was admitted to the facility in 05/2023 with diagnoses including vascular dementia and was receiving hospice services.

Observations of the resident and interviews with staff were conducted throughout the survey. The resident's current service plan, dated 04/09/24, resident alerts and facility progress notes from 03/02/24 through 04/27/24 were reviewed.

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

* Hospice services including the tasks they were responsible to provide and how to contact the hospice provider;

* Nutrition including food and fluid preferences.

The need to ensure service plans were reflective of the resident's needs and preferences, provided clear direction regarding the delivery of services, services were implemented and was readily available to staff was discussed with Staff 1 and Staff 2 (RCC) on 05/03/24. They acknowledged the findings.

2. Resident 4 was admitted to the facility in 12/2019 with diagnoses including Alzheimer's disease.

Observations of the resident and interviews with staff were conducted throughout the survey. The resident's current service plan, dated 03/20/24, outside provider notes dated 04/17/23 and MD orders dated 04/29/24 were reviewed.

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

* Diet status including diet texture and fluid consistency.

The need to ensure service plans were reflective of the resident's needs and preferences, provided clear direction regarding the delivery of services, services were implemented and was readily available to staff was discussed with Staff 1 and Staff 2 (RCC) on 05/03/24. They acknowledged the findings.

3. Resident 1 was admitted to the facility 09/2020 with diagnoses including Alzheimer's disease and was receiving hospice services.

a. Observations of the resident and interviews with staff were conducted throughout the survey. The resident's current service plan, dated 02/27/24, resident alerts and facility progress notes from 03/02/24 through 04/27/24 were reviewed.

The service plan was not reflective of the resident's current status, did not provide clear direction to staff and/or was not being implemented in the following areas:

* Assistance needed for bed mobility, and toileting;

* Assistance with ambulation, including inside and outside the facility;

* Eating, including diet texture and assistance needed;

* Hospice services including the tasks they were responsible to provide and how to contact the hospice provider;

* Placement of pillow when in bed and what to monitor;

* Instructions for oxygen use including when to use, liter flow, cleaning and replacing supplies;

* Fall intervention regarding leaving door open during waking hours;

* Non-pharmacological interventions for pain;

* Use of fabric bed protectors instead of disposable; and

* Evacuation ability.

b. The behavior section of the service plan revealed that Resident 1 had been in an "intimate encounter" with another resident and to "See attached safety plan ..." The safety plan was not found in the service plan binder on 04/30/24 and was provided to surveyor upon request. There was no documented evidence the safety plan was available to staff in the service plan binder during the remainder of the survey through 05/03/24.

The safety plan indicated the following:

* Resident 1 should be seated at a table with [gender] residents only; and

* Staff should "redirect [Resident 1] to another seat and watch for signs of distress or agitation" if s/he was found seated next to the resident involved in the incident.

Observations during mealtime identified the following:

* During lunch on 05/01/24 Resident 1 was seated at a table with another [gender] resident.

* During breakfast on 05/03/24, Resident 1 was seated next to the resident identified in the safety plan.

During an interview on 05/03/24 with Staff 15 (MA), she was not aware of the safety plan regarding who Resident 1 should not sit with during meals.

During an interview with Staff 1 (Administrator) on 05/03/24, observations regarding the safety plan not being followed and available were shared and she acknowledged the findings.

c.  During the acuity interview, staff indicated that the service plan binder was located in the med room. Observations during the survey, 04/29/24 through 05/03/24, confirmed the service plan binder for all of the residents was located in the med room. In an interview on 04/30/24, Staff 14 (CG) confirmed the caregivers do not have keys to the med room and they looked at service plans when the med room was open.

The need to ensure service plans were reflective of the resident's needs and preferences, provided clear direction regarding the delivery of services, services were implemented and was readily available to staff was discussed with Staff 1 and Staff 2 (RCC) on 05/03/24. They acknowledged the findings.

1. Service Plans noted to be deficient to be updated to reflect the diet, current care needs, who will be providing the care and other deficiences noted.

2.  Re-train staff on following service plans as written, Stop and Watch procedure to capture and document care changes and preferences to be implemented in resident service plans.  Safety plans and care plans relocated for all staff to access.

3.  Service plans reviewed by care team and updated quarterly and at change of condition.  

4. RCC, Dietary Manager, Administrator

2. Resident 5 was admitted to the facility in 05/2023 with diagnoses including Alzheimer's disease, falls, and muscle weakness.

The resident's clinical record was reviewed, which included the service plan, dated 10/04/24, and progress notes, dated 08/01/24 through 10/28/24. Resident 5 was observed, and staff were interviewed.

The service plan lacked clear direction to staff which included a written description of who should provide the services and what, when, how, and how often the services shall be provided in the following areas:

* Fall interventions, including keeping the bed in the lowest position;

* Frequency of incontinence and repositioning assistance;

* Number of staff needed for specific ADL tasks;

* Frequency of safety checks;

* Direction to staff relating to the resident's heel protectors, including if they were observed to be soiled;

* Dressing preferences;

* Days when a bath aide assisted the resident and instruction to staff if the bath aide was unable to come;

* Frequency of one-on-one visits from staff;

* Where the resident's barrier cream was stored and who applied it;

* Behavior interventions;

* Person-specific ways the resident non-verbally communicated pain;

* Which mobility aids the resident was able to utilize;

* Emergency evacuation assistance needed;

* Frequency of bed linen changes; and

* Frequency of trash removal from the resident's apartment.

The need to ensure resident service plans provided clear direction to staff was discussed with Staff 1 (Administrator) and Staff 2 (RCC) on 10/31/24 at 12:15 pm. They acknowledged the findings.

3. Resident 7 was admitted to the facility in 11/2022 with diagnoses including severe cognitive impairment.

The resident's clinical record was reviewed, which included the service plan, dated 08/27/24, and progress notes, dated 08/02/24 through 10/25/24. Resident 7 was observed, and staff were interviewed. The resident's service plan lacked clear direction for delivery of services in the following areas:

* Behavior interventions including refusals and agitation;

* What signs and symptoms staff should monitor for relating to urinary tract infections;

* Assistance needed with finger and toe nails; and

* Emergency evacuation assistance.

The need to ensure resident service plans provided clear direction to staff was discussed with Staff 1 (Administrator) and Staff 2 (RCC) on 10/31/24 at 12:50 pm. 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' care needs and provided clear direction to staff for 3 of 4 sampled residents (#s 4, 5, and 7) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 12/2019 with diagnoses including dementia.

The resident's clinical record was reviewed, including the service plan, dated 10/25/24, and progress notes, dated 08/01/24 through 10/27/24, the resident was observed, and interviews were conducted.

The resident's service plan lacked clear direction for delivery of services in the following areas:

* Emergency evacuation; and

* Diet texture, with conflicting information regarding whether the resident should be served mechanical soft or puree diet texture.

The need to ensure resident service plans provided clear direction to staff was discussed with Staff 1 (Administrator) and Staff 2 (RCC) on 10/29/24 at 2:30 pm. The findings were acknowledged.

1. Service Plans noted to be deficient updated to reflect specific emergency evacuation ability, diet, current care needs including number of staff required, frequency, interventions, mobility aides, preferences and other deficiences noted.

2.  Re-train RCN, RCC on service agreements to be reflective of resident care needs and will give clear direction including who, what, where, when and how often.   

3.  Service plans reviewed by care team and updated as needed, quarterly and at change of condition.  

4. RCN, RCC, Administrator

Based on observation and interview, it was determined the facility failed to establish and maintain infection prevention and control protocols to provide a safe, sanitary, and comfortable environment for multiple sampled and unsampled residents during ADL care and meal service. Findings include, but are not limited to:

Observations made from 04/29/24 to 05/02/24 revealed the following:

1. Observations of lunch and snack services from 04/29/24 through 05/02/24 revealed the following:

* Multiple universal caregivers served food and provided direct feeding to residents without donning a protective barrier over potentially contaminated clothing.

* Multiple universal caregivers were observed serving meals and beverages, opening the kitchen door, feeding one resident and then moving to feed another resident and touching residents without changing their gloves or performing hand hygiene.

* On 4/29/24 and 4/30/24 at 10:15 am and 3:15 pm respectively, staff were observed carrying snack trays with fruit cups and pieces of cake through the facility uncovered.

2. Staff 12 (MA/CG) was observed providing incontinent care to an unsampled resident at 11:10 am on 05/02/24. She donned single use gloves in the room without performing hand hygiene and assisted the resident to the toilet. Staff 12 assisted the unsampled resident with wiping after toileting. Staff 12 doffed the single use gloves, exited the room and did not perform hand hygiene.

The need to ensure universal precautions for infection control were exercised, including appropriate hand hygiene for ADL care and while serving meals to the residents, was discussed with Staff 1 (ED) and Staff 2 (RCC) on 05/03/24. They acknowledged the findings.

3. During an ADL observation of Resident 1 on 05/01/24 at 11:45 am, the following was observed:

* Two caregiving staff donned gloves without performing hand hygiene first and assisted the resident with incontinence care. Both caregivers provided handhold assist with the resident's hands to guide him/her into the bathroom. Once in front of the toilet, both staff assisted with lowering briefs and pants and assisted the resident onto the toilet;

* One staff provided perineal care that included using wipes. Both staff then pulled up the resident's briefs and pants, adjusted his/her shirt, doffed their gloves and provided handhold assist for the resident to exit the bathroom; and

* Both caregivers then performed hand hygiene after leaving the resident's room.

The need to maintain effective infection prevention and control while providing ADL care was reviewed with Staff 1 (ED) and Staff 2 (RCC) on 05/03/24. They acknowledged the findings.

1.All staff retrained on infection control policies and procedures, including hand hygiene when donning/doffing gloves before and after ADL's and when handling food.  Staff retrained on requirement to wear an apron when serving food and feeding residents and requirement to cover food/beverages when walking through facility.

2.Hand washing audits to be completed, audit posted signage is up to date, review of infection control practice reviewed quarterly at staff development and as needed.

3. Daily by Cook, Caregiver, Life enrichment coordinator/assistant. Weekly by Dietary Manager and RCC.

4. Dietary Manager, RCC, Life Enrichment, Administrator

2. Resident 5 admitted to the facility in 05/2023 with diagnoses including Alzheimer's disease.

Incontinence care was observed on 10/29/24 at 1:15 pm, and the following was observed:

* Staff removed the resident's soiled brief and provided personal hygiene with gloves donned;

* Staff removed the soiled bed protector located under the resident's bottom;

* Staff replaced the bed protector and brief with clean ones without doffing the gloves;

* Staff provided additional personal hygiene, taped the brief shut, and replaced the pillows and the blanket without doffing gloves;

* Staff tied the plastic garbage bag with the soiled items shut, doffed gloves, and placed them on top of the closed garbage bag;

* Staff took the garbage bag and soiled gloves outside of the resident's room, touching the door handle without performing hand hygiene; and

* Staff discarded the garbage bag and soiled gloves in a garbage receptacle, put hand sanitizer on, then donned clean gloves.

The need to maintain effective infection prevention and control while providing incontinence care was reviewed with Staff 1 (Administrator) on 10/29/24 at 1:35 pm. She acknowledged the findings.

Based on observation and interview, it was determined the facility failed to establish and maintain infection prevention and control protocols to provide a safe, sanitary, and comfortable environment for 2 of 2 residents (#s 4 and 5) for whom incontinence care was observed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 12/2019 with diagnoses including dementia.

On 10/29/24 at 1:30 pm, incontinence care was observed, and the following was identified:

* Hand hygiene was not completed prior to the staff member donning gloves;

* Staff removed the resident's dirty brief and dirty shirt;

* While wearing the soiled gloves, laid out a clean brief, including opening it and touching multiple areas, opened the resident's closet and touched multiple clean shirts, and assisted the resident in donning a clean shirt;

* Staff assisted the resident with perineal care, then removed the soiled gloves;

* The staff member did not complete hand hygiene or don clean gloves, and assisted the resident in donning his/her pants, transferring to standing, and walking hand-in-hand to the resident's recliner; and

* No hand hygiene was observed prior to the care staff leaving the resident's room and entering the hall to assist other residents.

The need to maintain effective infection prevention and control while providing incontinence care was reviewed with Staff 1 (Administrator) and Staff 2 (RCC) on 10/31/24 at 12:15 pm. They acknowledged the findings.

1.All staff retrained on infection control policies and procedures related to resident care, donning and doffing gloves at appropriate times with hand hygiene, removal of soiled garment/bedding and discarding trash.

2.    Infection control practices to be reviewed monthly at staff development and audited weekly .

3.    Weekly by RCN, RCC and Administrator or designee assigned by Administrator.

4.    RCN,  RCC, Administrator

Based on observation, interview and record review, it was determined the facility failed to have an effective system for tracking controlled substances for 1 of 1 sampled resident (# 1) who was administered PRN narcotic medication. Findings include, but are not limited to:

Resident 1 was admitted to the facility 09/2020 with diagnoses including Alzheimer's disease and was receiving hospice services.

The resident had a 02/27/24 physician's order for morphine sulfate 0.25 ml (5mg) every one hour as needed for pain and/or shortness of breath.

A review of Resident 1's 03/01/24 through 04/29/24 MARs and the Controlled Substance Disposition Record revealed the following discrepancies:

a. Two pages were found in the Controlled Substance Disposition log which included:

* One page had directions to take morphine sulfate 0.25 ml (5 mg) every two hours as needed and was dated 11/24/23. Records indicated morphine was administered on two occasions on 04/12/24, at 4:30 pm and 5:30 pm.

* A second page had directions to take morphine sulfate 0.25 ml (5 mg) every one hour as needed for "pain/SOB (shortness of breath) with no date noted. Records indicated no morphine had been administered.

Review of the MAR lacked documentation the resident received the PRN medication.

b. On 05/02/24 at 2:30 pm, a comparison of the morphine bottle to the disposition log showed the following:

* Two bottles of morphine were observed in the locked medication cart. One bottle was dated 11/24/23 with instructions to take every two hours as needed. The second bottle was dated 02/28/24 with instructions to take every one hour as needed.

Observation of both bottles indicated the morphine was administered from the bottle dated 11/24/23.

In an interview with Staff 7 (Lead MA) on 05/02/24, she indicated Resident 1's morphine orders may have changed when s/he switched to a different hospice agency.

On 05/02/24 shared findings with Staff 1 (Administrator) and Staff 2 (RCC). Staff 2 acknowledged the disposition log and the bottle should have a sticker when the medication changed and confirmed the bottle dated 11/24/23 would be destroyed.

Inconsistencies between the MAR and Controlled Substance Disposition logs and the need to ensure the facility had an effective system for tracking controlled substances was discussed with Staff 1 and Staff 2 on 05/03/24. They acknowledged the findings.

1.Morphine bottle was destroyed. A note to be made in the mar to relfect administration.

2. Medication Aides to be retrained on comparing medication labels to the MAR and steps to take if they do not match (fax PCP for clarification, change of direction sticker, etc.).  Medication Aides retrained on proper documentation in the MAR when giving a PRN medication, controlled and non-controlled.  

3. Daily by Medication Aides and weekly by RCC.

4.RCC, Administrator

Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 1 of 1 sampled resident (# 7) whose MARs and Controlled Substance Drug Disposition logs were reviewed for accuracy. This is a repeat citation. Findings include, but are not limited to:

Resident 7 was admitted to the facility in 11/2022 with diagnoses including severe cognitive impairment.

The resident had an order for oxycodone (narcotic analgesic) 2.5 mgs three times daily as needed for severe back pain.

Resident 7's Controlled Substance Disposition Logs and MARs, dated 08/01/24 through 10/28/24, were reviewed and revealed two occasions when staff signed on the drug disposition log that the oxycodone was administered, but the MAR lacked documentation that the resident received the medication.

Inconsistencies between the MARs and Controlled Substance Disposition Logs were reviewed with Staff 1 (Administrator) and Staff 2 (RCC) on 10/31/24 at 12:50 pm. They acknowledged the findings.

1.  Retraining of MAs on proper documentation on medication administration to MAR and Narcotic administration log.

2. MAR has been updated to reflect dosing as documented on narcotic adminsitration log.  

3. Daily by Medication Aides and weekly by RCC.

4.RCN, RCC, Administrator

Based on observation, interview, and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 1 of 3 sampled residents (# 1) whose orders were reviewed. Findings include, but are not limited to:

Resident 1 was admitted to the facility 09/2020 with diagnoses including Alzheimer's disease and was receiving hospice services.

Resident 1's 02/01/24 through 04/29/24 MARs, corresponding progress notes, and physician's orders, dated 02/27/24 and 04/15/24 were reviewed. They showed the following:

a. Resident 1 had physician's orders as follows:

* Quetiapine fumarate 25 mg one tablet as needed for agitation, with instruction to use first;

* Haloperidol 0.25 ml (0.5 mg) every six hours as needed, with instructions to use second.

On two occasions, 03/18/24 and 04/27/24, Resident 1 was administered haloperidol without administering quetiapine first.  

b. Resident 1's physician orders indicated a mechanical soft diet.

* On 4/30/24, observations during lunch indicated Resident 1 was served whole pieces of cut up chicken with gravy, full size steamed baby carrots, rotini pasta, and a roll.

During an interview with Staff 13 (Cook) on 04/30/24 at 12:37 pm, she stated Resident 1 had a "normal diet but it needs to be cut up". Observation of a white board used in the kitchen for residents with modified dietary needs indicated Resident 1 needed "Special utensils" but did not indicate a mechanical soft diet.

During an interview with Staff 1 (Administrator) on 04/30/24 at 12:42 pm, she confirmed Resident 1 should be served a mechanical soft diet and provided a plan that included "staff to follow special diet order using food processor or blender to ensure correct texture of diet order met and maintained."

* On 5/01/24, observations during lunch indicated Resident 1 was served whole pieces of cut up ham, whole pieces of steamed mixed veggies, a roll and mashed potatoes.

On 05/01/24, the surveyor reviewed observations of the diet consistency with Staff 1 and she acknowledged Resident 1 did not receive a mechanical soft diet when the ham and mixed veggies were served and would follow up with staff.

The need to have signed physician orders in the resident's chart and follow all physician orders as prescribed was discussed with Staff 1 and Staff 2 (RCC) on 05/03/24. They acknowledged the findings.

1.  Medication Administration record for residents reivewed to ensure they are being followed.

2. Medication Aides to be retrained on requirement to carry out the Physician Orders as prescribed to ensure accurate medication, treatment and dietary administration and importance of following speciifc sequencing parameters on PRN medications.  

3. To be reviewed daily by medaide and weekly by RCC.

4. RCC, Dietary Manager, Administrator

Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 3 of 4 sampled residents (#s 5, 6, and 7) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 5 admitted to the facility in 05/2023 with diagnoses including Alzheimer's disease.

The resident's MARs, dated 09/01/24 through 10/28/24, and physician's orders were reviewed. The following medications were not administered per physician's orders:

* Scheduled acetaminophen (for pain) on 10/05/24 at 5:00 pm;

* Ketoconazole (for rash) on 10/20/24 and 10/21/24; and

* Scheduled senna/docusate (for bowel management) on 10/08/24, 10/10/24, and 10/11/24.

The need to carry out physician's orders as prescribed was discussed with Staff 1 (Administrator) and Staff 2 (RCC) on 10/31/24 at 12:15 pm. They acknowledged the findings.

2. Resident 7 was admitted to the facility in 11/2022 with diagnoses including severe cognitive impairment.

The resident's MARs, dated 08/01/24 through 10/28/24, and physician's orders were reviewed. The following medications were not administered per physician's orders:

* 08/02/24: Letrozole (for breast cancer);

* 08/17/24: Memantine (for dementia), quetiapine (for behaviors), atorvastatin (for high cholesterol), acetaminophen (for pain), and the removal of a lidocaine patch (for back pain);

* 10/05/24: Aspercreme (for back pain), memantine, quetiapine, and vitamin B-12 (for supplement);

* 10/19/24: Calcium (for supplement), vitamin D3 (for supplement);

* 10/23/24: Atorvastatin; and

* 10/24/24: Lidocaine patch and atorvastatin.

The need to carry out physician's orders as prescribed was discussed with Staff 1 (Administrator) and Staff 2 (RCC) on 10/31/24 at 12:50 pm. They acknowledged the findings.

3. Resident 6 was admitted to the facility 09/2024 with diagnoses including dementia.

The resident's MARs, dated 09/06/24 through 10/27/24, and signed physician's orders, dated 09/05/24, were reviewed.

Resident 6 had signed physician's orders which stated:

*Blood pressure: "Take 1.5 hours after blood pressure medication", and

*Blood pressure: "Take blood pressure along with heart rate twice a day morning [sic] and evening."

There was no documented evidence that the resident's blood pressure was being monitored as ordered by the physician.

In an interview on 10/29/24 at 9:32 am, Staff 17 (MT) stated that there were no orders in the system to trigger MTs to monitor blood pressure for Resident 6.

The need to carry out treatment orders as prescribed was discussed with Staff 1 (Administrator) and Staff 2 (RCC) on 10/29/24 at 2:30 pm. They acknowledged the findings.

1.  MAR has been updated to reflect action taken as to why medications were not administered.  PCP's have been notified.

2. Medication Aides to be retrained on following physician orders.  If medication not available, retrained on proper documentation on steps to be taken to get medication on site.  

3. To be reviewed daily by medaide and weekly by RCC, RCN.

4. RCC, RCN, Administrator

Based on interview and record review, it was determined the facility failed to review the Acuity Based Staffing Tool (ABST) for each resident no less than quarterly and to use the results to develop and routinely update the facility's staffing plan. Findings include, but are not limited to:

The facility's ABST was reviewed with Staff 2 (RCC) on 04/30/24 at 11:35 am.

During an interview on 04/30/24 at 11:35 am, Staff 2 stated she was using the ABST to develop and update the facility's staffing plan. Staff 2 acknowledged the night shift hours were incorrect as the resident care minutes were not reflective for that shift. Instead, Staff 2 stated she staffs to what she knows the facility needs are for the night shift. The data in the ABST was not up to date to accurately reflect the amount of staff time needed to meet the 24-hour scheduled and unscheduled needs of the residents.

The need to ensure residents' ABST was reviewed no less than quarterly and the tool was used to develop and update the facility's staffing plan was discussed with Staff 1 (Administrator) and Staff 2 on 05/03/24. They acknowledged the findings.

1.ABST tool and staff plan updated to meet resident needs.

2.ABST updated per regulation, quarterly and upon change of condition.

3.      ABST and staffing plan to reflect resident care needs.

4.RCC, Administrator.

Based on interview and record review, it was determined the facility failed to conduct unannounced fire drills according to the Oregon Fire Code (OFC) and failed to provide fire and life safety instruction to staff on alternate months. Findings include, but are not limited to:

On 05/01/24, fire drill and fire and life safety records for the previous six months were requested. Review of the documentation provided revealed:

1. Staff did not evacuate or relocate residents during all fire drills. Therefore, fire drill records did not include information on:

* Problems encountered and comments relating to residents who resisted or failed to participate in the drills;

* Evacuation time period needed; and

* Number of occupants evacuated.

2. There was no documented evidence the facility provided fire and life safety training consistently to staff on alternate months.

The need to ensure the facility conducted unannounced fire drills according to the OFC and provided fire and life safety instruction to staff on alternate months was discussed with Staff 1 (Administrator) and Staff 3 (Maintenance Supervisor) on 05/01/24. They acknowledged the findings. No further information was provided.

1.Retrain on fire drill requirements.  

2.Community will conduct fire drills on alternating months listing "encountered problems", essential internal evacuations including identifying resident participation, time of drills and number of occupants evacuated.

3.Reviewed after each fire drill for accuracy and completion.

4.Maintenance, Administrator.

Based on interview and record review, it was determined the facility failed to conduct and document fire drills according to the Oregon Fire Code (OFC), including making immediate changes to ensure the evacuation standards were met. This is a repeat citation. Findings include, but are not limited to:

On 10/28/24, the facility's fire drill records were reviewed, including fire drills completed on 09/25/24, 08/23/24, and 07/16/24. The following was identified:

During the fire drills on 09/25/24 and 07/16/24, the following problems were identified by the facility:

* 09/26/24: "[Two] residents act out from alarm noise," and

* 07/16/24: "[One] resident did not want to leave room."

There was no documented evidence that the facility made an immediate effort to make changes to ensure the evacuation standard was met.

During interviews on 10/28/24 and 10/29/24, six staff, consisting of CGs and MTs, were interviewed. Staff were unable to describe how they would evacuate residents, especially residents who required one- or two-person transfer assistance, to a point of safety.

The need to ensure the facility conducted and documented fire drills according to the OFC, including immediate changes to ensure the evacuation standard was met, was reviewed with Staff 1 (Administrator) on 10/29/24 and 10/30/24. She acknowledged the findings.

1.Fire drill designee will be trained on problems encountered procedure with designee informing appropriate department and//or staff of problem identified.

2.Problems encountered during fire drills will be discussed with appropriate department and Administration to determine resolution

3.Reviewed after each fire drill for accuracy and completion.

4.Maintenance, Administrator and other department management.

Based on 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 260, C 295, C 302, C 303, C 420, Z 142, and Z 162.

See C260, C295, C302, C303, C420, Z142 and Z162

Based on observation and interview, it was determined the facility failed to ensure the grounds were free of litter and refuse, and the exterior pathways were made of hard, smooth material and maintained in good repair. Findings include, but are not limited to:

On 04/30/24, the outdoor areas of the facility were toured and the following was identified:

a. Potential fall hazard areas were identified for residents who use the courtyard and included:

* Multiple drop-offs measuring up to two inches were noted along pathway edges along sidewalks in the courtyard;

*  A concrete step and an approximately three inch raised concrete border of a garden bed, both could not be distinguished from the sidewalk;

* A one inch gap in the sidewalk by the front door; and

* One section of the sidewalk on the south side of the building was uneven and in need of repair.

b. Green and black debris was observed on the ground around and under two patio chairs.

The need to ensure grounds were free of litter and refuse and outside surfaces were maintained in good repair was discussed with Staff 1 (Administrator) and Staff 3 (Maintenance Supervisor) on 05/01/24. They acknowledged the findings.

1. Edge drop-off's to be filled with dirt and/or decorative rock. Raised concrete step to be painted a different color than sidewalk. Sidewalk areas noted to be deficient to be fixed.

2. Staff trained on monitoring perimeter and pathways for hazards.

3. Maintence supervisor to walk the perimeter weekly.

4. Maintenace Supervisor, Administrator

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

The facility was toured on 04/29/24 and the following was observed:

a. Exterior of building:

* Dirt, debris and black matter were found on patio furniture including a table, multiple chairs and patio cushions.

* The front porch area had cobwebs, dirt and debris noted on a light fixture and under the covered overhang, and gouges, dirt and debris on the front door;

* Window screen was bent in hallway window near Room 13;

* Multiple sections of the perimeter fencing had black debris along the bottom of the fence; and

* A small portable swimming pool and a box of decorative rocks was stored on the patio table leaving no useable portion of the table.

b. Interior of the building:

* Multiple dining room tables had dings on multiple corners and edges;

* Two lightbulbs were burned out in the community bathroom used by residents;

* An approximate four-inch section of edging was missing on the kitchenette countertop exposing a sticky substance and sharp edges;  

* Multiple walls throughout the building have gouges, peeling paint and different swatches of paint color; and

* A recliner chair next to fireplace was stained.

The need to ensure the interior and exterior of the building was clean and maintained in good repair was discussed with Staff 1 (Administrator) and Staff 3 (Maintenance Supervisor) on 05/01/24. They acknowledged the findings.

1. Exterior: The patio furniture, fencing and front porch to be cleaned.  The swimming pool and rocks on the patio table to be removed to allow usable space for residents.  Interior: Lightbulbs in community bathroom to be replaced.  Furniture to be cleaned and wall gouges fixed and painted. Kitchenette edging to be repaired.

2. Community walk throughs to be scheduled to monitor apartments and common areas for needed repairs/cleaning.  

3.  Monthly and as needed.

4. Maintenance supervisor, Administrator.

Based on observation and interview, it was determined the facility failed to provide a lockable storage space (e.g., drawer, cabinet or closet) for the safekeeping of a resident's small valuable items and funds. Findings include, but are not limited to:

During the environmental inspection of multiple occupied resident apartments on 04/30/24 and 05/01/24, there was no lockable storage spaced identified in any of the apartments.

On 5/01/24 an interview with Staff 1 (Administrator) revealed that they used to have cabinets with lockable storage but acknowledged that the majority of residents did not have them anymore. Staff 1 also acknowledged the facility was looking for lockable storage space that was secured and could not be moved by another resident.

The need to ensure the facility provided a lockable storage space that was secure was discussed with Staff 1 and Staff 3 (Maintenance Supervisor) on 05/01/24. They acknowledged the findings.

1.  Lockable storage space for apartments to be purchased.

2.  Lockable storage space to be added to apartments.

3. With each move in and move out.

4. Maintenance supervisor, Administrator.  

Based on observation and interview, it was determined the facility failed to ensure washing machines had a minimum rinse temperature of 140 degrees Fahrenheit or used a chemical disinfectant when washing soiled linens and soiled clothing. Findings include, but are not limited to:

The facility laundry rooms were observed on 04/29/24. The washing machines were of residential type, with no indicator for the water temperature. The laundry detergent observed in the staff laundry room did not appear to contain a disinfectant.

An interview on 04/29/24 at 3:00 pm, Staff 1 (Administrator) confirmed the laundry detergent did not have a chemical disinfectant.

An interview on 05/01/24 with Staff 3 (Maintenance Supervisor) revealed it was difficult to check the rinse temperature in the washing machine because the water shuts off when the lid opens so he was not able to reliably test the water temperatures.

The need to ensure soiled laundry was properly disinfected was discussed with Staff 1 on 05/03/24. She acknowledged the findings.

1. Laundry disinfectant to be ordered.

2. Staff trained on the requirement for laundry detergent to contain a disinfectant.

3. Monthly

4. Maintenance supervisor, Administrator

Based on observation and interview, it was determined the facility failed to ensure hot water temperatures in residents' units and common areas were maintained within a range of 110 to 120 degrees Fahrenheit. Findings include, but are not limited to:

A tour of the facility on 04/30/24 revealed the following:

*The spa room next to the med room, also used as a community bathroom by residents, had water that when turned on, was hot to the touch. The hot water temperature, taken by the surveyor with a digital thermometer, was 134.3 degrees Fahrenheit.

* Various residents' bathroom sinks' hot water was between 96.9 and 124.4 degrees Fahrenheit.

During an interview with Staff 1 (Administrator) on 04/30/24 at 1:35 pm, the surveyor reviewed water temperature findings and the need to ensure residents were supervised when using the water in the spa room. Staff 1 implemented a plan that included locking the spa room door, communicating to staff on all shifts that residents must be supervised when using the water in the spa room and posting a sign on the door as a reminder.

During an interview with Staff 3 (Maintenance Supervisor) on 05/01/24, he revealed the temperatures were adjusted and confirmed they tested between 112 and 114 degrees Fahrenheit for all of the rooms identified.

The need to ensure hot water temperatures were monitored and maintained within a range of 110 - 120 degrees Fahrenheit was discussed with Staff 1 on 05/03/24. She acknowledged the findings.

1.Hot water tanks were adjusted and fixed while survey team in community.  

2.Temps will be audited weekly to ensure adequate temperatures meet requirements

3.Maintenance supervisor, Administrator.

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

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

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

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

Refer to: C 295, C 361, C 420, C 510, C 513, C 515, C 530, C 545.

Refer to C295, C361, C420, C510, C513, C515, C530, C545

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

Refer to: C 295 and C 420.

See C295 and C420

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

Refer to: C 160, C 252, C 260, C 302, C 303.

Refer to C160, C252, C260, C302, C303

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

Refer to: C 260, C 302, and C 303.

See C260, C302 and C303

Based on interview and record review, it was determined the facility failed to ensure individualized nutrition and hydration plans were developed and included in the service plan for 2 of 2 sampled residents (#s 1 and 2) whose records were reviewed. Findings include, but are not limited to:

Resident 1 and 2's current service plans, dated 02/27/24 and 04/09/24, respectively, were reviewed. Both service plans were found to be lacking information and staff instructions related to an individualized nutritional plan.

The need to develop an individualized nutritional plan for each resident and include it in the service plan was discussed with Staff 1 (Administrator), and Staff 2 (RCC) on 05/03/24. They acknowledged the findings.

1. Each resident to be interviewed to discuss nutrition and hydration preferences and needs. Service Plans to be updated to reflect findings.

2. Retrain staff on existing Service Planning Policy and Procedure and need to identify nutrition and hydration needs and preferences.

3.  At move in and with each service plan update and change of condition.

4. RCC, Dietary Manager, Adminstrator

2. Resident 1's service plan and Life Enrichment Plan offered some information about the resident's interests, however, the facility had not completed an evaluation that addressed the following:

* Past and current interests;

* Emotional and social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for the resident to participate; and

* Identification of activities for behavioral interaction.

There was no specific activity plan that detailed what, when, how and how often staff should offer and assist the resident with individualized activities s/he would benefit from.

The need to ensure the facility evaluated all residents for activities was discussed with Staff 1 (Administrator) and Staff 2 (RCC) on 05/03/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure activity evaluations addressed all required components and individualized activity plans were developed for 2 of 2 sampled residents (#s 1 and 2) whose activity plans were reviewed. Findings include, but are not limited to:

Resident 1, and 2's records were reviewed, and observations were made during the survey. There was no documented evidence activity evaluations addressed all the required components, and that service plans had been individualized to reflect the following:

1. Resident 2's service plan offered some information about the resident's interests. Resident 2's Life Enrichment Plan was currently blank and required an evaluation that addressed the following:

* Current abilities and skills;

* Emotional/social needs and patterns;

* Physical abilities and limitation;

* Adaptations needed to participate;

* Identification of activities for behavioral interventions; and

* There was no specific activity plan which detailed what, when, how and how often staff should offer and assist each resident with individualized activities.

The need to ensure activity evaluations addressed all required components and individualized activity plans were developed was discussed with Staff 5 (Life Enrichment Coordinator), Staff 1 (Administrator) and Staff 2 (RCC) on 05/03/24. They acknowledged the findings.

1. Residents life enrichment and service plans to be updated to reflect the residents current and physical abilities, emotional and social needs, including activites that may be used for behavioral intervetions, and any adaptations that may be needed. They will also be updated with details for staff to know what, when and how often to assist the residents.  

2. Retrain to existing policy, Life Enrichment Plans and activity section of service plan to be reviewed prior to move in, quarterly and with each change of condition.  

3. Life Enrichments Plans and activity section of service plan to be evaluated with each update.

4. Life Enrichment Coordinator, Administrator  .

Based on observation and interview, it was determined the facility failed to provide access to a secured outdoor space which allowed residents to enter and return without staff assistance, except when indicated by OAR 411-057-0170(5)(e). Findings include, but are not limited to:

Observations of the facility interior on 05/01/24 and 05/02/24 revealed interior courtyard doors were locked, preventing residents from entering and exiting without staff assistance. There were no observations of inclement weather during that time.

In an interview on 05/01/24, Staff 8 (CG) was not aware when the doors were to be unlocked and who was responsible for unlocking them.

On 5/03/24 the need to provide access to secured outdoor space and walkways which allowed residents to enter and return without staff assistance was discussed with Staff 1 (Administrator). She acknowledged the findings and provided an updated facility policy that included specifications on when doors will be locked and unlocked based on time of year and defined "inclement weather".

Z168

1.Community policy updated to reflect regulation.  Sign posted on egress doors noting hours doors unlocked and conditions when they may be locked.   

2.Staff retrained on policy, signs posted on doors to indicate times/inclimate weather, etc.

3.Weekly evaluation of signs and staff knowledge.

4.Administrator

Based on observation and interview, it was determined the facility failed to ensure the fencing that surrounded the perimeter of the outdoor recreation area was no less than six feet in height to reduce the risk of resident elopement. Findings include, but are not limited to:

A tour of the facility courtyard on 10/28/24 revealed the following areas where the fencing around the perimeter of the secured outdoor area measured less than six feet (or 72 inches) in height:

* Multiple areas along the fence that was adjacent to 21st Avenue measured from approximately 68 inches to 70 1/2 inches tall; and

* Multiple areas along the fence that was adjacent to Hawthorne Street measured at approximately 70 inches.

The need to ensure outdoor courtyard fencing was constructed to reduce the risk of resident elopement was discussed with Staff 1 (Administrator) on 10/28/24 and Staff 14 (Senior Project Manager) on 10/29/24. They acknowledged the findings.

1.  Areas where dirt was able to be moved has been completed.

2.  Other bids are being obtained for project completion.

3. Quarterly walk around to fence perimeter to be completed.

4. Maintenance, Administrator.