Print Inspection: XVGZ

The findings of the re-licensure survey, conducted 06/25/24 through 06/27/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first revisit to the re-licensure survey of 06/27/24, conducted 01/15/25 to 01/16/25, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

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

Based on interview and record review, it was determined the facility failed to ensure injuries of unknown cause were reported to the local SPD office or the local AAA as suspected abuse, unless an immediate facility investigation reasonably concluded and documented that the injury was not the result of abuse for 1 of 2 sampled residents (# 3) whose incidents were reviewed. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 06/2024 with diagnoses including stroke.

The resident's Temporary Service Plan (TSP), dated 06/14/24, an incident report, progress notes dated 06/14/24 through 06/23/24, Oregon Shift Reports, and interviews with staff revealed the following:

Resident 3's TSP, dated 06/14/24, directed staff to reposition him/her every two hours and PRN.

A progress note relating to the 06/22/24 unwitnessed fall, stated that Resident 3 was "found on the floor yesterday morning" and that the resident was "unable to say what happened." The note goes on to report Resident 3 had "a small skin tear to [the] right foot, and a small abrasion to [his/her] left forehead."

The Oregon Shift Report, dated 06/22/24, reported staff repositioned Resident 3 every three hours on the "Night Shift." And on the "Day Shift", the resident "had a fall out of bed" with "bruising on forehead, shoulder, cheek [left] side."

The incident report dated 06/22/24 had no documented evidence the physical injury was not the result of abuse.

On 06/27/24, Staff 3 (Health and Wellness Coordinator) stated she had not reported the above incident to the local SPD or AAA office. Survey requested the facility report the incident to the local office.  

On 06/27/24 at 10:48 am, verification was received of the report to the local office.

The need to ensure all injuries of unknown cause were reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concluded and documented that the physical injury was not the result of abuse was discussed with Staff 1 (Business Office Coordinator), Staff 3, and Staff 7 (Designee) on 06/27/24. They acknowledged the findings.   

On June 27th, 2024 the incident of injury of unknown injury was reported according to OAR 411-054-0028.

Training will be provided to facility staff specifically related to abuse/neglect reporting for injuries of unknown origin including mandatory reporting. Understanding and knowledge check with completion of test related to training. If applicable a second training will be offered for any facility employees that missed the first training. Training will be conducted by July 31st, 2024.

New hires will be have training on mandatory reporting and reporting on injuries of unknown origin. Facility will review in daily stand-up along with reviewing shift to shift report and any incidents that occurred that would warrant reporting.

Executive Director, Health & Wellness Director or designee.       

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

Resident 3 was admitted to the facility in 06/2024 with diagnoses including stroke, hypertension, and heart disease.

The Resident Evaluation and Personal Service Assessment were reviewed and revealed missing information in the following required elements:

* List of medications and PRN use;

* Visits to health practitioner(s), emergency room, hospital, or nursing facilities in the past year;

* Vital signs if indicated by diagnoses, health problems, or medications;

* Mental health issues including effective non-drug interventions;

* Independent activity of daily living including transportation; and

* Recent losses.  

The need to ensure the move-in evaluation included all required elements was reviewed with Staff 1 (Business Office Coordinator), Staff 3 (Health and Wellness Coordinator), and Staff 7 (Designee) on 06/27/24. They acknowledged the findings.

Sampled resident # 3 evaluation was corrected in accordance with evaluation requirement required.  

Executive Director, Health Wellness Director (RN), or Health Wellness Coordinator will review standards pursuant to OAR 411-054-0034 (Resident Move-in and Evaluation) to provide a thorough understanding of  the elements required to meet resident service needs and preferences. Furthermore to identify if facility can meet the resident's needs while considering the other residents.

Audit of evaluations will be reviewed upon move-in and random sample monthly.  

Executive Director or designee.

Resident 3 was admitted to the facility in 06/2024 with diagnoses including stroke, hypertension, and heart disease.

The resident's Temporary Service Plan (TSP) dated 06/14/24, and progress notes dated 06/14/24 through 06/23/24, were reviewed. Observations of the resident, and interviews with staff were conducted.

The TSP was found to lack clear caregiving instruction, which included a written description of who shall provide the services and what, when, how, and how often the services shall be provided in the following areas:

* Ability to communicate needs and wants;

* Right sided (dominant prior to stroke) weakness and any instructions to promote independence relating to eating, drinking, television remote, and pendent use;

* Wound care;

* Bed bound status;

* Which services hospice provided and frequency of the services;  

* Monitoring an air pressure relieving mattress and who staff would contact if it was in disrepair;

* Incontinent care and frequency;

* Personal preference relating to straw use, small cup use, and finger foods; and

* Emergency evacuation assistance.

The need to ensure service plans had clear caregiving instruction, which included a written description of who shall provide the services and what, when, how, and how often the services shall be provided was discussed with Staff 1 (Business Office Coordinator), Staff 3 (Health and Wellness Coordinator), and Staff 7 (Designee) on 06/27/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs and provided clear direction to staff regarding the delivery of services for 1 of 6 sampled residents (# 3) whose service plans were reviewed. Findings include, but are not limited to:

Sampled resident # 3 service plan was corrected in accordance with evaluation requirement required.

Executive Director, Health Wellness Director (RN), or Health Wellness Coordinator will review standards pursuant to OAR 411-054 (Service Plan General) and then provide staff training to set a foundation for ongoing participation in service planning and identify the elements required to meet resident needs and provide person-centered service.

Audit of service plans upon move-in and audit a random sample monthly.

Executive Director or designee.

2. Resident 3 was admitted to the facility in 06/2024 with diagnoses including stroke, hypertension, and heart disease.

The resident's progress notes, dated 06/14/24 through 06/23/24, and MAR, dated 06/14/24 through 06/25/24, was reviewed and revealed Resident 3 missed four doses of his/her scheduled Baclofen (for muscle spasms) between 06/14/24 and 06/15/24.  

On 06/26/24 at 11:30 am, Staff 2 (RN) confirmed there was no documented evidence the facility determined and documented what action or intervention was needed for the resident, communicated the determined actions or interventions to staff on each shift, or documented with weekly progress noted until the condition resolved.

The need to ensure the facility determined and documented what action or intervention was needed for the resident, communicated the determined actions or interventions to staff on each shift, or documented with weekly progress noted until resolution was discussed with Staff 1 (Business Office Coordinator), Staff 3 (Health and Wellness Coordinator), and Staff 7 (Designee) on 06/27/24. They acknowledged the findings.

3. Resident 5 was admitted to the facility in 01/2024 with diagnoses including Parkinson's disease.

The resident's progress notes, dated 04/05/24 through 06/20/24, were reviewed and identified the following changes of condition:

* 04/29/24 - vomiting;

* 05/21/24 - low blood pressure; and

* 06/20/24 - loose stools.

On 06/27/24 at 9:20 am, Staff 3 (Health and Wellness Coordinator) confirmed there was no documented evidence the facility determined and documented what action or intervention was needed for the resident, communicated the determined actions or interventions to staff on each shift, or documented with weekly progress noted until the condition resolved.

The need to ensure the facility determined and documented what action or intervention was needed for the resident, communicated the determined actions or interventions to staff on each shift, or documented with weekly progress noted until resolution was discussed with Staff 1 (Business Office Coordinator), Staff 3, and Staff 7 (Designee) on 06/27/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to determine and document what actions or interventions were needed for changes of condition, including resident-specific instructions communicated to staff on each shift, and weekly progress noted until the condition resolved for 3 of 4 sampled residents (#s 2, 3 and 5) who had changes of condition. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 07/2023, with diagnoses including Multiple Sclerosis, congestive heart failure, and hypertension.

Review of Resident 2's progress notes, dated 03/25/24 through 06/25/24, revealed the resident experienced the following changes of condition:

* On 04/05/24, Resident 2 experienced an episode where s/he was nauseated, "dry heaved", and was pale. The resident also stated s/he had not had a bowel movement in five days; and

* On 06/10/24, staff reported the urine in Resident 2's suprapubic catheter bag appeared "cloudy and concentrated".

The facility failed to document monitoring of Resident 2's medical changes of condition, at least weekly, to resolution, and failed to determine actions or interventions needed, and communicate them to staff on each shift.

On 06/27/24, the need to ensure the facility had a system for monitoring changes of condition, with weekly progress noted, to resolution, and to determine actions or interventions needed, and communicate those to staff on each shift was discussed with Staff 1 (Business Office Coordinator), Staff 3 (Health and Wellness Coordinator) and Staff 7 (Designee). They acknowledged the findings.

Review of shift to shift report form was immediately implemented as part of the clinical meeting to review any noted changes in residents during each shift.

District Director of Clinical Services will also conduct an inservice with Executive Director, Health Wellness Director, & Health Wellness Coordinator on or before August 1st, 2024. Training provided will provide a foundation to understand the change of condition (short term and significant change) process and what forms are to be used to clearly document change of conditions and frequency of said documentations. Furthermore training will then be provided to all care staff on the what should be communicated and documented on shift report form to alert the RN of a change of condition. This training will be provided by August 9th. 2024.

During the clinical meeting that occurs routinely and at a minimum of 3 times a week.

Executive Director or designee will review any change in resident's needs along with documentation and follow-up with RN during the clinical meeting to monitor correct documentation has occurred.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate, included medication specific instructions, and was initialed by staff for 2 of 3 sampled residents (#s 3 and 5) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 3 was admitted in 06//2024 with diagnoses including stroke.

Resident 3's physician and prescriber orders and MAR, dated 06/01/24 through 06/25/24 was reviewed and revealed the following inaccuracies:

* An entry on the MAR instructed staff to monitor him/her for being new to community from 06/14/24 through 06/18/24, three times per day. Two of the 12 entries were blank.

* Another entry on the MAR directed staff to ensure bilateral pressure relieving boots were on three times a day. There was no documentation on 06/15/24 for the evening check.

* An order for 0.1% atropin sulfate ophthalmic solution (for excessive secretions), directed staff to administer four drops by mouth every eight hours, PRN. The facility transcribed the amount as 1% instead of 0.1% on the MAR.

* On 06/14/24, a physician wrote an order for one hydrocodone-acetaminophen tablet to be administered by mouth every four hours. On 06/15/24, a prescriber wrote a new order to reflect the administration of two tablets of the same medication given PRN every six hours. The order written on 06/14/24 was the one reflected on Resident 3's MAR.  

The need to ensure MARs were accurate, included medication specific instructions, and were initialed by staff was discussed with Staff 1 (Business Office Coordinator), Staff 3 (Health and Wellness Coordinator), and Staff 7 (Designee) on 06/27/24. They acknowledged the findings.

2. Resident 5 was admitted to the facility in 01/2024 with diagnoses including Parkinson's disease.  

The resident's 05/01/24 through 06/25/24 MARs, and progress notes, dated 04/05/24 through 06/20/24, were reviewed and revealed the following inaccuracies:

* On 05/17/24, directions were added to the MAR instructing staff to "Please chart any nausea, vomiting, diarrhea. Please chart and call if any rash occurs. Please give with food." There was no direction to staff relating to who to call and what to give with food.

* On 06/11/24, a multivitamin (for supplement) was added to the MAR. Staff documented the multivitamin was not available on 06/11/24, 06/12/24, 06/14/24, 06/15/24, and 06/17/24. Staff documented on 06/13/24 and 06/17/24 that the multivitamin was administered. Additionally, there was no documented evidence if the multivitamin was administered on 06/18/24.

The need to ensure MARs were accurate and included medication specific instructions was discussed with Staff 1 (Business Office Coordinator), Staff 3 (Health and Wellness Coordinator), and Staff 7 (Designee) on 06/27/24. They acknowledged the findings.

The MAR (medication administration record) was corrected for sampled resident 3 and MAR was reviewed against orders in chart to cross reference for accuracy. Sampled resident 5's MAR was reviewed against orders in chart to cross reference accuracy of orders to MAR.

Health Wellness Director or Health & Wellness Coordinator will be responsible for doing a second & third check that will include a stamp with signed initials and or signature to verify that transcription of orders were checked by a nurses and medication technician.

During the quarterly orders reviews the accuracy of MAR's to orders will be reviewed. The second check process will be also provide ongoing evaluation.

Executive Director or Health Wellness Director.  

Based on interview and record review, it was determined the facility failed to implement an Acuity-Based Staffing Tool (ABST) that converted residents' evaluated care needs into staff hours to generate a facility staffing plan. Findings include, but are not limited to:

On 06/26/24 at 2:57 pm, the ABST was reviewed with Staff 1 (Business Office Coordinator).

Staff 1 confirmed that she was provided with a certain number of hours for staff scheduling purposes each week from their corporate office. She could not recall assigning care minutes to each resident for the corporate office to use to determine the weekly allotment.  

The need to implement an ABST that converted residents' evaluated needs into staff hours to generate a facility staffing plan was discussed with Staff 1 on 06/26/24. She acknowledged the findings.

As we continue to partner with DHS on reviewing our ABST tool, we will continue to staff according to our Brookdale acuity based staffing tool.

Our home office team will continue to establish proper communication with DHS regarding

The ABST tool and the 22 elements that make up the ABST tool, we will continue to staff at or

Above staffing levels currently identified in our tool.

This will be evaluated by the Health and Wellness Director/Resident Care Coordinator to ensure that proper staffing levels are scheduled according to the 22 elements to ensure the scheduled and unscheduled needs of the residents are being met.

The Executive Director is responsible for monitoring that staffing levels are appropriate as defined by our staffing tool.      

Based on interview and record review, it was determined the facility failed to fully implement an Acuity Based Staffing Tool (ABST) that met the regulation. Findings include, but are not limited to:

In an interview on 01/16/25, Staff 17 (ED) stated the facility's ABST (Service Alignment) had been approved by the department; however, would not be fully implemented until 01/31/25.

The facility was unable to provide documented evidence that all 22 of the required ADLs were individually addressed for each resident, nor was the amount of staff time needed for each of the 22 ADL elements.

On 01/16/25, the need to ensure the facility fully implemented an ABST that met the regulation was discussed with Staff 17 (ED). He acknowledged the findings.

-Communtiy has implemented new ABST system per State guidenace

-Executive Director and Business Office Coorindator has completed training on new system

-Leadership team will continue to monitor and review ABST to maintain compliance

Based on interview and record review, it was determined the facility failed to ensure 5 of 5 staff members (#s 4, 5, 9, 10, and 14) had completed the Home and Community Based Services (HCBS) training by 03/31/24, and 3 of 3 new staff (#s 9, 10, and 14) had completed pre-service infectious disease training as required. Findings include, but are not limited to:

Three new staff training records were reviewed on 06/26/24.

Staff 14 (CG) hired 6/22/23, Staff 9 (MT) hired 2/19/24, and Staff 10 (MT) hired 2/14/2, lacked evidence of completion of both HCBS training and of pre-service infection control and prevention in Community Based Care.

Two long term staff training records were reviewed on 06/26/24.

Staff 4 (Maintenance Manager) hired 10/01/21, and Staff 5 (Dining Services Coordinator) hired 10/12/21, lacked evidence of completion of HCBS training.

The need to ensure staff completed the HCBS training and infectious disease prevention training was discussed with Staff 1 (Business Office Coordinator), Staff 3 (Health and Wellness Coordinator), and Staff 7 (Designee) on 06/27/24. They acknowledged the findings.

All staff identified in survey will complete both HCBS training and infection control and prevention training on or before August 26th, 2024.

Business Office Manager will audit all employee training files and any staff memebers identified will have training completed prior to August 26th, 2024. Moving forward Executive Director in partnership with the Business Office Manager will have all staff complete their HCBS prior to resident contact and or be put on the schedule to the department they are assigned.

All employee training will be reviewed during the orientation process and prior to being added to the schedule to the department they are assigned.        

Executive Director/Business Office Manager or designee.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 long-term direct care staff, and 2 of 2 long-term non direct care staff (#s 4, 5, 8, 11, and 16) completed annual infectious disease training. Findings include, but are not limited to:

Staff training records for 3 direct care and 2 non-direct care staff were reviewed on 06/26/24.

Staff 4 (Maintenance Manager) hired 10/01/21, Staff 5 (Dining Services Coordinator) hired 10/12/21, Staff 8 (MT) hired 0/06/21, Staff 11 (MT) hired 01/07/21, and Staff 16 (CG) hired 08/03/21, lacked evidence they had completed annual infectious disease training as required.

The need to ensure that long term direct care and non-direct care staff completed annual infectious disease training as required was discussed with Staff 1 (Business Office Coordinator), Staff 3 (Health and Wellness Coordinator), and Staff 7 (Designee) on 06/27/24. They acknowledged the findings.

Health & Wellness Director has completed the required infectious disease training control training per the Oregon Requirements on June 25th, 2024. For all other identified staff the Health & Wellness Director or Health & Wellness Coordinator will conduct this required training with all staff prior to August 26th, 2024.

Annual in-service requirements will follow a standard calendar year and offer annual training a minimum of every 6 months to capture all requirements needed.

The Executive Director or Health Wellness Director will meet with Business Office Manager quarterly to review any upcoming annual orientation required.           

Executive Director, Health Wellness Director, & Business Office Manager.

Based on interview and record review, it was determined the facility failed to include and document all required elements in fire drills, and to provide fire and life safety instruction to staff on alternating months, in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to:

Review of facility records on 06/26/24 identified the following:

* The facility failed to relocate or evacuate residents during the monthly fire drills. Therefore, documentation was lacking regarding escape routes used, residents who resisted or failed to participate in the drills, evacuation time periods needed, and number of occupants evacuated.

* There was no documented evidence the facility was providing fire and life safety instruction to staff on alternating months.

On 06/27/24, the need to include and document all required elements of fire drills, and to provide fire and life safety instruction to staff, in accordance with the OFC was discussed with Staff 1 (Business Office Coordinator), Staff 3 (Health and Wellness Coordinator), Staff 4 (Maintenance Manager), and Staff 7 (Designee). They acknowledged the findings.

Executive Director and Maintenance Director implemented the Fire & Life Safety Requirements according to OAR 411-054-0090. A July fire drill will be conducted on alternate on shifts to meet the monthly requirements. Fire drill will be provided & dcoumented as required on or before July 31st, 2024. This will continue to be offered monthly as a ongoing training.

Maintenance Director will add this regulatory requirement to the TELS system that alerts when specific regulatory tasks are due.

Executive Director and Maintenance Director will review TELS tasks and documentation of such drill on a monthly basis.    

Executive Director and Maintenance Director.

Based on interview and record review, it was determined the facility failed to provide fire safety instruction to residents, at least annually, in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to:

Review of facility records on 06/26/24 identified the following:  

There was no documented evidence that annual training on fire safety was provided to residents.

On 06/27/24, the need to provide and document fire safety instruction to residents, at least annually, in accordance with the OFC was discussed with Staff 1 (Business Office Coordinator), Staff 3 (Health and Wellness Coordinator), Staff 4 (Maintenance Manager), and Staff 7 (Designee). They acknowledged the findings.

Executive Director and Maintenance Director wil review our Fire Safety Instructions upon resident move in and have the resident initial that they understand. To correct right away a annual training including documented training will be provided to all residents prior to August 26th, 2024.  

All new resident move-ins will have documented instructions on facility's fire and life safety procedures per OFC. For annual fire training this will be added as a regulatory item in the TELS system.                                 

Executive Director and Maintenance Director to review this as residents move-in as part of the move-in process and the annual requirments will alert the Maintenance Director when due and Executive Director can review all overdue tasks in the TELS system.                                                              

Executive Director and Maintenance Director.  

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

Refer to C 361.

-Communtiy has implemented new ABST system per State guidenace

-Executive Director and Business Office Coorindator has completed training on new system

-Leadership team will continue to monitor and review ABST to maintain compliance

Based on observation and interview, it was determined the facility failed to ensure all exterior pathways were made of hard, smooth material. Findings include, but are not limited to:

The exterior of the facility was toured on 06/25/24 and 06/26/24. The following was identified:

Exterior concrete pathways, including the outside of the facility and in two of the three courtyards, contained multiple drop-offs.  

These drop-offs created potential hazards for residents that frequently walked the pathways.

The building's exterior was toured with Staff 4 (Maintenance Manager) 06/26/24. He acknowledged the findings.

As of 7.22. 24. Maintenance Director and Executive Director have fixed the areas of concern the exterior concrete pathways along with exterior courtyards adressed in the relation to C510.

Maintenance Director will continue to monitor exterior pathways and courtyards on an ongoing basis, including but not limited to weekly, monthly, & quarterly.

Ongoing monitoring monthly and and as needed with any extreme weather changes.                              

Executive Director & Maintenance Director.    

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

Observations of the facility's inner courtyard on 06/25/24 revealed two raised gardening beds that were in disrepair.

The gardening bed closest to the exit doors had nails along the perimeter which were rusted with the sharp ends exposed.

The gardening bed near the center of the courtyard had a supporting board from underneath the bed that was half way detached.  

The areas in need of repair were shown to and discussed with Staff 4 (Maintenance Manager) on 06/26/24. He acknowledged the findings.

Maintenance Director fixed the immediate issues that were of concern, such as fixing sharp ends and remove the rusty screws. The remaining issues posed in OAR 411- 054-0200 citation C513 extension was approved to be completed by October 18th, 2024.

Maintenance Director will continue walk exterior of facility on an ongoing basis including but not limited to  weekly, monthly & quarterly.

Ongoing monitoring monthly and as needed with any extreme weather changes.                              

Executive Director & Maintenance Director.    

Based on observation and interview, it was determined the facility failed to ensure exit doors were equipped with an alarming device or other acceptable system to alert staff when residents exited the building. Findings include, but are not limited to:

The facility was toured on 06/25/24 through 06/26/24.

Interviews with staff during the survey confirmed the doors by which residents could exit the facility to the inner courtyard did not have a working alarm or other acceptable system to alert staff when residents exited the building.

Staff also stated the doors in which residents could exit the facility were connected to staff's pagers and would alert staff when the doors would open.

During the tour of the facility with Staff 4 (Maintenance Manager) on 06/26/24 at 11:25 am, it was confirmed that not all exit doors alerted staff's pagers when opened.

The need to ensure exit doors were equipped with an alarming device or other acceptable system to alert staff when residents exited the facility was discussed with Staff 4 on 06/26/24. He acknowledged the findings.

Maintenance Director to Audit all Exterior doors for sensor doors compliance and any new sensors or additional sensors needing will be installed on or before July 26th, 2024. Furthermore, new pagers were ordered and will be distributed on or before July 26th, 2024.  

This will be in the TELS sytem as a regulatory task according to the rules noted in OAR 411-054-0200.   

The TELS system will alert Maintenance Director for completion of task including but not limited to monthly or quarterly.

Executive Director and Maintenance Director.