Print Inspection: T2NO

The findings of the re-licensure survey, conducted 08/22/22 through 08/24/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities 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

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 08/24/22, conducted 12/20/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

cc:cubic centimeter

CG:caregiver

cm:centimeter

F:Fahrenheit

HH:Home Health

HS or hs:hour of sleep

LPN:Licensed Practical Nurse

MA:Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

O2 sats:oxygen saturation in the

blood

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

RN:Registered Nurse

SP:service plan

TAR:Treatment Administration

Record

tid:three times a day

The findings of the 2nd revisit to the re-licensure survey of 08/24/22, conducted on 03/21/23 are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and maintained in accordance with the Food Sanitation Rules OAR 333-150-0000. Findings include, but are not limited to:

Based on observations on 08/22/22 at 10:20 am, the facility kitchen needed cleaning and repair in the following areas:

a. Food spills, splatters, dirt, dust and black matter was observed on or beneath the following:

* Walls and light switch in dish washer area;

* Handwashing sink to the right of the ice machine:

* Inside of microwave;

* Air conditioning unit vents above ice machine;

* The underside of the motor housing on the stand mixer;

* Telephone located on a shelf above rear prep counter;

* Floor around the deep fryer;

* Lower storage shelves of the steam table;

* Inside of the plate warmer;

* Handles and shelves of multiple serving carts;

* Large round floor fan; and

* Grates on the exhaust fans in the walk-in refrigerator.

b. The following areas needed repair:

* Caulking around the warewashing area;

* Weather strip on trim of the "In" door;

* Scoop holder next to the ice machine;

* Laminate was missing on the steam table cabinet;

* Paint was peeling from the "Out" door;

c. The following areas in the beverage/serving stations in the Dining Room needed repairs:

* Hole in the wall of the beverage station;

* Laminate was worn exposing bare wood in the beverage station cabinet where the garbage can was stored; and

* Laminate was missing on the serving station cabinets.

The areas needing cleaning and repair were reviewed with Staff 12 (Dietary Services Manager) on 08/22/22 and Staff 1 (ED) and Staff 8 (Plant Operations Assistant) on 8/24/22. They acknowledged the findings.

1. All identified areas in the kitchen have been deep cleaned, and all repairs have been completed or scheduled.

2. Routine cleaning schedules for kitchen and diet`ary carts have been updated to include areas that were missing. Dietary Manager will be reviewing cleaning schedules weekly, at a minimum, and will follow up as needed. Dietary Mananger will complete a monthly kitchen sanitation audit, to include repair work needed, and ensure any deficencies will be corrected timely.

3. System will be evaluated monthly as part of the Continuous Quality Improvement process to include a review of the monthly kitchen sanitation audits.

4. Executive Director and Dietary Manager will be responsible for maintaining this system

Based on interview and record review, it was determined the facility failed to evaluate service-planned interventions for effectiveness, initiate new interventions following a series of repeated falls, and monitor conditions through resolution for 2 of 4 sampled residents (#s 3 and 4) who experienced changes of condition. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 07/2022 with diagnoses including Multiple Sclerosis, chronic urinary tract infections and muscle weakness. The service plan noted a history of falls and identified the resident as a fall risk.

The resident's service plan, dated 08/03/22, progress notes, dated 07/12/22 through 08/22/22, interim service plans, and incident reports were reviewed.

The records indicated Resident 4 experienced three falls from 07/14/22 through 07/18/22. Interim service plans were created, which initiated the following interventions:

* Staff will perform safety checks on the resident every 2-3 hours (07/18/22);

* Staff will encourage the resident to use pendant to call for assistance (07/18/22); and

* The resident should wear non-skid shoes/slippers and socks to promote secure footing (initiated 07/19/22).

Resident 4 had six additional falls from 07/19/22 through 08/12/22 which occurred after these interventions were in place. There was no documented evidence these service-planned interventions were evaluated for effectiveness, and interim service plans written after these subsequent falls did not include new interventions to help prevent further falls.

On 08/24/22 the need to implement resident-specific interventions following changes of condition, and to evaluate those interventions for effectiveness was discussed with Staff 1 (ED), Staff 2 (RN/ Director of Health Services) and Staff 3 (LPN). They acknowledged the findings.

2.  Resident 3 was admitted to the facility in 05/2022. Review of the resident's progress notes, dated 05/23/22 through 08/17/22 revealed the resident experienced the following injuries:

* 05/27/22- Skin tear to right hand; and

* 05/29/22-Skin tear to left hand.

The facility lacked documented evidence interventions were determined and communicated to staff on all shifts, and the injuries monitored at least weekly, through resolution.

In an 08/23/22 Interview with Staff 2 (RN), she confirmed the resident's injuries were not properly recorded, and therefore were not monitored by the facility.                                                           

The need to ensure short term changes of condition were evaluated, interventions determined, communicated to staff on each shift and monitored with progress noted at least weekly through resolution was discussed with Staff 1 (Executive Director), Staff 2 and Staff 3 (LPN) on 08/24/22. They acknowledged the findings.

1. A complete root cause analysis for resident #4 has been completed including a review of all falls and efficacy of interventions. RN initiated change of condition assesment for significant falls. RN to follow weekly to review plan and evaluate interventions. RN has updated and reviewed service plan. Care conference is scheduled with resident and son to review current interventions and service plan. Resident #3 has been assessed by LN and service plan has been updated with current interventions to reduce the risk of injury.

2. To prevent recurrence, 24 hour summary and alert charting audit will be reviewed five days a week as part of daily standup meeting. On Mondays, the 72-hour summary will be reviewed to include review of all documentation from the weekend. When a change of condition is identified, such as a skin tear, the resident will be placed on alert charting. A LN assessment will be done and initiate any changes in the plan of care. The change of condition will be monitored until resident is stable or condition resolves in a weekly skin integrity note. Incident report investigations will include a review of any previous interventions and their efficacy and interventions will be updated as needed. Any changes to service plans as a result of a change of condition will be communicated to staff via either an ISP or updated full service plan to review and sign.

3. This system will be evaluated five days a week as part of daily stand up meeting.

4. The Executive Director and LNs are responsible for maintaining this system.

2. Resident 9 was admitted to the facility in 08/2022.

Review of the resident's progress notes, dated 10/23/22 through 12/20/22, revealed the resident experienced the following:

* 11/25/22 -  Moved into the assisted living from memory care facility; and

* 12/08/22 - Returned from a hospital stay (12/01/22 - 12/08/22).

The facility lacked documented evidence the short term changes of condition were evaluated and monitored with progress noted at least weekly through resolution.

The need to ensure short term changes of condition were evaluated and monitored with progress noted at least weekly through resolution was discussed with Staff 1 (Executive Director) and Staff 2 (RN/Director of Health Services) on 12/20/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure residents who experienced short-term changes of condition were evaluated, actions or interventions were determined and communicated with staff on all shifts, and/or were monitored through resolution with at least weekly documentation for 2 of 4 sampled residents (#s 6 and 9) who experienced changes of condition. This is a repeat citation. Findings include, but are not limited to:

1. Resident 6 was admitted to the facility in 07/2022 with diagnoses including asthma, atrial fibrillation, and arthritis.

A review of the resident's clinical record, including progress notes dated 10/23/22 through 12/20/22 and staff interviews revealed the following;

* The resident had a physician's order to self-administer his/her medications without supervision.

* Between 11/08/22 and 11/28/22 staff documented five occasions where caregivers were assisting the resident with taking his/her medications by "putting them in [the resident's] mouth" and reminding him/her to take them. According to a progress note dated 11/28/22 the resident "was struggling to take them [medications] and dropping them on the floor."

* On 11/30/22, Staff 2 (RN/Director of Health Services), documented she had spoken with the resident's sister about facility staff having to remind him/her to take their medications often. The RN asked the sister if she thought the facility needed to start administering the resident's medications. The sister stated she would speak with the family about the issue.

* Between 12/03/22 and 12/19/22, staff documented an additional three occasions on which staff assisted the resident with his/her medications.

* On 12/19/22, Staff 4 (Resident Care Coordinator) documented she spoke with the resident about his/her medications and asked if s/he " ... would like for us to manage them  ..." The resident responded, "not right now I just need to be woke up earlier so I can take them on time". The RCC documented she "set up a wake time of 7am" in the resident's service plan.

In an interview with Staff 2 on 12/20/22, she stated she was aware of staff assisting the resident with taking medication on several occasions. She reported she had observed the resident taking his/her medications without assistance on more than one occasion, and s/he was able to self-administer without any difficulties. Staff 2 reported she had not evaluated the resident's ability to safely self-administer their medications during the time period reviewed.

The need to ensure changes of condition were evaluated and monitored through resolution, with at least weekly documentation of progress, was discussed with Staff 1 (Executive Director), Staff 2, and Staff 24 (Regional Nurse Consultant) on 12/20/22. They acknowledged the findings.

1. Resident #6 now realizes she is having difficulty taking her medications and agreed for community to manage. After a thorough medication review is conducted to reconcile her doctor's medication list to her list of medications she is self administering, and we have acccurate orders, Resident #6's medications will be managed by community. Evaluation and service plan will be updated to reflect community is managing her medications. Resident #9 has been placed on alert and staff have been adding updates on her in progress notes.

2. To prevent recurrence, the 24 hour summary, communciations, and alert charting audit will be reviewed five days a week as part of daily standup meeting with the clinical management team. A list of residents on alert will be printed and reviewed during standup. On Mondays, the 72-hour summary will be reviewed to include review of all documentation from the weekend. When a resident change of condition is identified, the resident will be placed on alert charting which will include a LN assessement and any changes to the plan of care. Any changes to service plans as a result of a change of condition will be communicated to staff via either an ISP or updated full service plan to review and sign.  

3. This system will be evaluated five days a week as part of daily stand up meeting. This system will further be evaluated monthly as part of the facility CQI process which includes a review of all residents who require change of condition monitoring.

4. The Executive Director and LNs are responsible for maintaining this system.

2.  Resident 3 was admitted to the facility in 05/2022.

The resident's physician's orders, dated 05/02/22 and MAR, dated 08/01/22 through 08/22/22 were reviewed, and it was determined there were no signed physician's orders for the following PRN bowel medications and treatments:

* Bisacodyl Laxative suppository;

* Mi-Lanta suspension;

* Loperamide suspension;

* Milk of Magnesia suspension; and

* Polyethylene Glycol powder.

In an interview on 08/24/22, Staff 2 (RN/Director of Health Services) acknowledged the facility lacked written, signed orders in the resident's record for the medications.

The need to ensure written, signed orders were in the resident's record for all medications and treatments administered by the facility was discussed with Staff 1 (Executive Director), Staff 2 and Staff 3 (LPN) on 08/24/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed, and signed physician orders were documented in the resident's facility record for all medications and treatments the facility was responsible to administer, for 2 of 4 sampled residents (#s 1 and 3) whose orders were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 08/2018.

A review of the 08/01/22 through 08/22/22 MAR and current physician's orders revealed the following medications were not documented to be administered as prescribed:

* Humalog (insulin);

* Gabapentin (anticonvulsant);

* Acetaminophen (pain reliever); and

* Velphoro (end stage renal disease).

The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (ED) and Staff 2 (RN/Director of Health Services) on 08/24/22. They acknowledged the findings.

1. Physician orders for residents #1 and #3 have been reconciled to original orders to ensure accuracy and have been sent to provider for review and signature. A review was completed of all resident Physician Orders to ensure quarterly POs are up to date.

2. To prevent recurrence, all clinical staff will be re-educated on the regulation that all medications entered in the MAR must have signed physician order. When taking over medication administration, staff will enter medications using signed orders only. Orders will then go through the triple check process, which includes LN review for accuracy of order transcription.

3. All medication and treatment orders will be reconciled quarterly and sent to provider for review and signature.

4. Executive Director and LNs will be responsible for maintaining this system.

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

Resident 1 was admitted to the facility in 08/2018 with diagnoses including diabetes and end stage renal disease.

Resident 1's MAR was reviewed for the time period of 08/01/22 through 08/22/22.

Staff documented Resident 1 refused the following medications multiple times:

* Humalog (insulin); and

* Velphoro (end stage renal disease).  

There was no documented evidence the facility notified Resident 1's physician/practitioner of the refusals.

The need to notify the physician of resident medication refusals was discussed with Staff 1 (ED) and Staff 2 (RN/Director of Health Services) on 08/24/22. They acknowledged the findings.

1. Resident #1's provider has been notified regarding all recent medication refusals. A fax form has been created for Med Aides to use to notify providers of refusals. Med Aides have been re-educated regarding the need to communicate refusals to the provider, unless the provider has requested not to be notified.

2. To prevent recurrence, 24- hour summary will be reviewed at daily standup which includes all documented medication refusals. On Mondays 72-hour summary will be reviewed to include documentation from the weekend. Resident Care Coordinator will verify that all necessary provider notifications have been made.

3. This system will be evaluated 5 days a week as part of daily standup meeting. Medication refusals will also be reviewed as part of evaluation process at 30 days, quarterly or with significant change of condition to ensure providers have been notified if needed.

4. Executive Director and LNs are responsible for maintaining this system.  

Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused to consent to orders for 1 of 1 sampled resident (# 8) who had documented medication refusals. This is a repeat citation. Findings include, but are not limited to:

Resident 8 was admitted to the facility in 08/2022 with diagnoses including anxiety.

Resident 8's MAR was reviewed for the time period of 12/01/22 through 12/20/22, and signed physician orders and progress notes were reviewed from 10/23/22 through 12/20/22.

Staff documented Resident 8 refused the following medications multiple times in several days consecutively:

 * Citalopram (antidepression);

 * Retaine MGD eye drops; and

 * Systane complete solution eye drops.

The resident's signed physician order, dated 08/23/22, indicated to notify if the resident refused any medications or treatment "for more than 2 days in a row".

There was no documented evidence the facility notified Resident 8's physician/practitioner of the refusals as ordered.

The need to notify the physician of resident medication refusals was discussed with Staff 1 (ED) and Staff 2 (RN/Director of Health Services) on 12/20/22. They acknowledged the findings.

1. Resident #8's provider has been notified regarding all recent medication refusals. A fax form has been created for Med Aides to use to notify providers of refusals. Med Aides have been re-educated regarding the need to communicate refusals to the provider, unless the provider has requested not to be notified.

2. To further prevent recurrance, 24- hour summary will be reviewed at daily standup which includes all documented medication refusals. A clipboard has been placed on the top of each medcation cart and treatment cart for blank medication refusal PCP orders forms to be completed by medication technicians, to be placed in faxed refused meds box in medication room, to be reviewed by LNs before standup every morning.  On Mondays 72-hour summary will be reviewd to include documentation from the weekend. Resident Care Coordinator will verify that all necessary provider notifications have been made.

3. This system will be evaluated 5 days a week as part of daily standup meeting. Medication refusals will also be reviewed as part of evaluation process at 30 days, quarterly or with significant change of condition to ensure providers have been notified if needed.

4. Executive Director and LNs are responsible for maintaining this system.  

Based on interview and record review, it was determined the facility failed to ensure 1 of 3 sampled newly-hired direct care staff (#22) demonstrated competency in all assigned job duties within 30 days of hire. Findings include, but are not limited to:

Training records were reviewed on 08/23/22 and revealed the following:

Staff 22 (CG), hired on 07/05/22, lacked documentation of demonstrated competency in:

* Changes associated with normal aging;

* Identification, documentation and reporting of changes of condition; and

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

The need to ensure staff have documented evidence of competency demonstrated in assigned duties within 30 days of hire was discussed with Staff 1 (ED), Staff 5 (RCC) and Staff 10 (Business Office Manager) on 08/23/22.  They acknowledged the findings.

1. A complete audit will be done of all training and competency records.  All trainings and competencies will be complete and up to date for current employees no later than 10/23/22.

2. To prevent recurrence, all staff will be required to complete the required training and job specific competencies within 30 days of hire.

Incomplete trainings and competencies will be reviewed five days a week as part of daily standup meeting to identify missing components, to review the status of new hires' trainings to ensure all training is completed within 30 days of hire.

3. This system will be evaluated monthly as part of the facility CQI program and will include a review of all current staff members and the status of their required trainings.

4.  The Executive Director and Business Office Manager will be responsible for maintaining this sytem.

Based on interview and record review, it was determined the facility failed to ensure 12 hours of annual in-service training, including 6 hours of dementia care training, had been completed for 2 of 3 long-term staff (#s 16 and 23) whose records were reviewed. Findings include, but are not limited to:

On 08/23/22, training records were reviewed and revealed the following:

* Staff 16 (MT), hired 05/11/18, and Staff 23 (CG), hired 12/07/20, lacked documentation of having completed a minimum of 12 hours annual in-service training, including 6 hours of the dementia care training.

The need to ensure that all staff had documented evidence of completing a minimum of 12 hours annual in-service training, including 6 hours of dementia care training, was discussed with Staff 1 (ED), Staff 5 (RCC), and Staff 10 (Business Office Manager). They acknowledged the findings.

1.  A complete audit will be done of all annual training records.  All trainings will be complete and up to date for current employees no later than 10/23/22.

2.  To prevent recurrence, training grid will be utilized to ensure that all staff have required monthly and annual trainings completed within the specified timeframe including Relias trainings which meet the requirement for 12 hours of annual training, including 6 hours of dementia training and 6 hours of CBC training.

3.  This system will be evaluated monthly as part of the facility CQI program and will include a review of all current staff members and the status of their monthly required trainings.

4.  The Executive Director and Business Office Manager will be responsible for maintaining this sytem

Based on interview and record review, it was determined that the facility failed to conduct fire drills according to the Oregon Fire Code (OFC). Findings include, but are not limited to:

Fire and life safety records from 03/2022 through 07/2022 were reviewed. The fire drill records did not consistently include documentation of the following required components:

* Location of simulated fire origin;

* Escape route used;

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

* Evacuation time-period needed; and

* Number of occupants evacuated.

In an interview on 08/24/22, Staff 7 (Plant Operations Manager) reported that the facility was not relocating or evacuating residents as part of the fire drill process. While the facility had completed one full evacuation drill in April 2022, resident participation was not documented, and fire drill records revealed that residents were not consistently involved in the fire drill process.  

The need to ensure the facility conducted and documented fire drills according to the OFC was discussed with Staff 1 (ED) and Staff 7 on 08/24/22.  They acknowledged the findings.

1. A training was done with Maintenance Director that included a review of all required components related to the correct procedure for fire drills and all required components that must be documented. All staff were re-educated at staff meeting in September on the fire drill procedure.

2. To prevent recurrence, company fire drill form has been updated to include all required components and computer program used to document fire drills has been updated to include all required components as well as rotating schedule for locations and shifts.

3. Fire drills and fire and life safety trainings will be reviewed monthly as part of our CQI process to ensure compliance.

4. The Executive Director and Maintenance Director will be responsible for maintaining this system.

Based on record review and interview, it was determined the facility failed to ensure residents were instructed on general safety procedures, evacuation methods, responsibilities during fire drills and designated meeting places within 24 hours of admission and re-instructed at least annually. Findings include, but are not limited to:

On 08/22/22, Staff 1 (ED) was asked to explain the process of providing resident instruction upon admission and reinstruction annually. Staff 1 (ED) stated that fire drill and safety procedures were reviewed with the resident within the first week of admission, and not within the first 24 hours of admission. Staff 1 (ED) stated that re-instruction was not provided annually.

The need to ensure residents were instructed on general safety procedures within 24 hours of admission and re-instructed at least annually was discussed with Staff 1, Staff 7 (Plant Operations Manager) and Staff 8 (Plant Operations Assistant) on 08/24/22. They acknowledged the findings.

1. Fire and life safety training has been completed and documented for all current residents.

2. To prevent recurrence, admission packet has been updated to include a form to document fire and life safety training within 24 hours of admission. Environmental evaluation, which is completed semi-annually for all residents was also updated to include documentation of re-instruction on fire and life safety training.

3. Fire drills and fire and life safety trainings will be reviewed monthly as part of our CQI process to ensure compliance.

4. Executive Director and Maintenance Director will be responsible for maintaining this system.

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 270 and C 305.

1. All C tag violations will be resolved no later than 1/19/23.

2. To prevent recurrence, refer to systems put in place for tags C270 and C305.

3.All systems pertaining to C tags will be evaluated as part of the monthly facitlity CQI program to ensure compliance.

4. Executive Director will be responsible for maintaining all systems.

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

The exterior of the facility was toured on 08/22/22.  The following was noted as needing repair:

* A section of the exterior pathway at the rear of the facility had standing water and was not easily passable.

The exterior was toured with Staff 1 (ED), Staff 7 (Plant Operations Manager) and Staff 8 (Plant Operations Assistant) on 08/24/22 at 10:15 am. They acknowledged the findings.

1.  Cause of standing water has been identified and repaired.

2. To prevent recurrence, grounds will be walked 5 days a week to identify issues. A comprehensive walkthrough will be done once a week to be reviewed at standup meeting and a monthly groundskeeping audit has been implemented.

3. This system will be evaluated monthly as part of our CQI process, which will now include a monthly groundskeeping audit.

4. Executive Director and Maintenance Director will be responsible for maintaining this system.

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

Observations of the facility on 08/22/22 revealed the following:

* The following doorframes, doors or walls were gouged or scraped:

- Dining room entrance and exit doors;

- First, second and third floor elevator doors;

- Facility main entrance doorways;

- Corners of the wall in the hallway next to the Activity Room; and

- Resident apartments 308 and 310.

* Light fixtures throughout the dining room had visible debris in the fixture;

* Second and third floor laundry rooms had a large amount of debris behind the machines;

* A washing machine in the second floor laundry room was full of standing water;

* There were holes in the wall on the right side of the third floor game room above the puzzle table; and

* There were long screws protruding from the bases of several of the legs of the pergola on the back patio.

The facility was toured with Staff 1 (ED), Staff 7 (Plant Operations Manager) and Staff 8 (Plant Operations Assistant) on 08/24/22 at 10:15 am.  They acknowledged the findings.

1. All identified areas including doors, walls, light fixtures, machinery, and courtyard have been deep cleaned, and all repairs have been completed or scheduled.

2.  To prevent future occurrence, routine cleaning schedules for common areas have been updated to include areas that were missing.  A comprehensive walkthrough will be done once a week to be reviewed at standup meeting and a monthly groundskeeping audit has been implemented. Maintenance Director will also conduct monthly groundskeeping audit, monthly exterior inspections and monthly interior safety inspections to include repair work needed, and ensure any deficencies will be corrected timely.

3. System will be evaluated monthly as part of the Continuous Quality Improvement process to include a review of the monthly sanitation and repair audits.

4. Executive Director and Maintenance Director will be responsible for maintaining this system  

Based on observation and interview it was determined that the facility failed to ensure operable windows were designed to prevent accidental falls when sill heights are lower than 36 inches and above the first floor.  Findings include, but are not limited to:

The facility was toured on 08/22/22. Resident windows and common area windows on the second and third floors opened vertically and windowsills were lower than 36 inches. The windows lacked a mechanism to prevent the window from opening fully to prevent accidental falls.

The lack of a mechanism to prevent accidental falls was discussed with Staff 1 (ED), Staff 7 (Plant Operations Manager) and Staff 8 (Plant Operations Assistant).  They acknowledged the findings.

1.  All windows located on 2nd and 3rd floors have been repaired with a latching mechanism preventing risk of falls.

2. To prevent future occurrence, locking mechanisms will be inspected for efficacy during yearly window latch gap inspection. Windows located in resident apartments will be inspected twice a year during the environmental evluation.

3. All windows will be inspected during routine, semi-annual environmental evaluations to ensure compliance.

4. Executive Director and Maintenance Director will be responsible for maintaining this system.

Based on observation and interview it was determined that the facility failed to ensure that covers, grates or screens of wall heaters do not exceed 120 degrees Fahrenheit.  Findings include, but are not limited to:

During a tour of the facility on 08/22/22, the following observations were made:

* At 2:40 pm, a wall heater was observed in apartment 102.  When turned on, the surface temperature was 220 degrees Fahrenheit.

* At 2:55 pm, a wall heater was observed in apartment 220.  When turned on, the surface temperature was 200 degrees Fahrenheit.

* At 3:00 pm, a wall heater was observed in apartment 313.  When turned on, the surface temperature was 240 degrees Fahrenheit.

The need to ensure that all covers, grates or screens of wall heaters and associated heating elements do not exceed 120 degrees Fahrenheit was discussed with Staff 1 (ED), Staff 7 (Plant Operations Manager) and Staff 8 (Plant Operations Assistant) on 08/24/22.  They acknowledged the findings. Staff 7 stated he would disconnect any wall heaters that were in resident apartments.

1. All wall heaters in resident apartments have been disconnected.

2.  Electricity to all resident wall heaters has been permanently disconnected.

3. All units will be inspected during routine semi annual enviromental evluations.

4. Executive Director and Maintenance Director will be responsible for maintaining this system.