The findings of the re-licensure survey, conducted 02/09/22 through 02/10/22, 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 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 re-visit to the re-licensure survey of 02/10/22, conducted 04/27/22, 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 interview and record review, it was determined the facility failed to ensure 2 of 2 sampled newly-hired direct care staff (#s 5 and 6) completed a total of 16 hours of in-service training annually, including six hours of annual dementia care training. Findings include, but are not limited to:

Staff training records were reviewed with Staff 7 (Business Office Manager) on 02/10/22. The following deficiencies were identified:

Staff 5 (Med Tech) was hired on 10/17/16 and Staff 6 (Med Tech) was hired on 06/26/18. The facility lacked documented evidence each employee completed a minimum of 16 hours of in-service training for the most recent year based on their hire dates.

Staff 7 acknowledged the facility had not accurately tracked employee in-service training hours.

The need to ensure long term direct care staff completed 16 hours of in-service training annually, including six hours of annual dementia care training, was reviewed with Staff 1(ED) and Staff 2 (RN) on 02/10/22. They acknowledged the findings.

1.Employees will complete required 12 hours of annual in-service training also including 6 hours of dementia care training.

2.Administrative Assistant will monitor for compliance weekly with reports to ED for noncompliance.

3.Weekly review of plan will be conducted in standup on Wednesdays.

4.Administrative Assistant and ED will be responsible for monitoring to see that the corrections will be completed.

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

Fire drill and fire and life safety records were reviewed from 08/01/21 to 02/01/22. The following deficiencies were identified:

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

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

The requirements regarding fire drills and fire and life safety instruction for staff were reviewed with Staff 1 (Executive Director) and Staff 4 (Maintenance Lead) on 02/10/22. Staff acknowledged the facility was not providing fire and life safety instruction to staff every other month and was not relocating or evacuating residents during fire drills. Staff 1 stated the process of fire drills and documentation would be updated.

1.Maintenance Director educated on the regulation and policy regarding unannounced fire drills and required components and providing instruction to staff on alternant months.

2.To prevent recurrence fire drill records will include documentation of the following components: - Problems encountered, including comments relating to residents who resisted or failed to participate in drills; - Staff members on duty and participating; - Number of occupants evacuated; and Fire and life safety instruction will be consistently provided to staff on alternate months.

3.Maintenance Director will review documentation weekly as a part of our standup process and monthly during our CQI process to ensure compliance.

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

Based on interview, it was determined the facility failed to re-instruct residents at least annually in general safety procedures, evacuation methods, responsibilities during fire drills and designated meeting places outside the building or within the fire safe area in the event of an actual fire and failed to use alternate exits during fire drills. Findings include, but are not limited to:

* The facility failed to relocate or evacuate residents during the monthly fire drills. Therefore, documentation was lacking regarding the alternating escape route used; and

* The facility failed to document resident instruction within 24 hours of admission and re-instruction at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building.

The requirements regarding evacuation and alternating escape routes during drills and annual safety instruction for residents were reviewed with Staff 1 (Executive Director) and Staff 4 (Maintenance Lead) on 02/10/22. Staff 1 (Executive Director) acknowledged the facility was not providing fire and life safety instruction to residents annually, and that the facility was not relocating or evacuating residents during fire drills. Staff 1 stated the process of fire drills and documentation would be updated.

1.Education provided to Maintenance Director and DSO regarding regulation and policy that fire and life safety training must be provided to residents within 24 hours of move-in; and that annual fire and life safety training must be provided to residents to include all required training topics. Additionally, all staff must receive training and be aware of the designated point of safety.

2.To prevent recurrence: The DSO will play an active role in providing fire and life safety training to residents within 24 hours of move-in. The Maintenance Director will ensure the annual training is provided to residents to include all required training topics. The Maintenance Director will also ensure all staff have received training and are aware of the designated point of safety.

3.Maintenance Director and the DSO will review documentation weekly as a part of our standup process and monthly during our CQI process to ensure compliance.

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