The findings of the re-licensure survey, conducted 07/29/24 through 07/31/24, 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 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.

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 revisit to the re-licensure survey of 07/31/24, conducted on 09/20/24, are documented in this report. It was determined the facility was in compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004.

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

Fire drill records from 12/2023 through 06/2024 were reviewed with Staff 1 (Health Services Director) on 07/30/24, and the following was identified:

a. The facility lacked documentation fire drills were being conducted on alternating months.

b. For fire drills which were completed between 12/2023 and 06/2024, the following required elements were not documented:

* Escape route used; and

* Evidence alternate routes were used during the fire drills.

c. There was no documented evidence fire and life safety instruction for staff had been on alternate months.

The need to provide fire and life safety instruction to staff and conduct unannounced fire drills on alternate months and document all required elements was discussed with Staff 1 on 07/30/24 and 07/31/24. He acknowledged the findings.

What actions will be taken to correct the rule violation? Alternating months of Fire and Life Safety training are Relias videos.  This has been reviewed and confirmed to be corrected for the remainder of the year and moving forward into 2025. The unannounced fired drills will continue to be scheduled and conducted every other month following calendar in the Fire and Life Safety Binder and calendar appointments to those who conduct and oversee these drills. .

How will the system be corrected so this violation will not happen again? The Health Services Director/Administrator will confirm that the correct Fire and Life Safety videos are correctly populated when new hires are brought on for alternating months of active drills.   The correct form for fire drills will be used for all active fire drills on appropriate months and will have a detailed description of the route of evacuation and will ensure compliance of alternating those evacuation routes correctly documented.  

How often will the area needing correction be evaluated? This will be done at time of hire, ensuring correct Relias training templates, and on alternating months of the active fire drills ensuring correct documentation.

Who on your staff will be responsible to see that the corrections are completed/monitored? The Health Services Director/Administrator  

Based on 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 C420.

** See previous POC for tag C420

Based on interview and record review, it was determined the facility failed to ensure 3 of 4 caregiving staff (#s 6, 8, and 13) demonstrated satisfactory performance in all job duties within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed with Staff 1 (Health Services Director) on 07/30/24 and 07/31/24.

There was no documented evidence Staff 6 (CG), hired 06/04/24, Staff 8 (MA), hired 06/12/24, and Staff 13 (CG), hired 03/11/24, had demonstrated competency all job duties including:

* Providing assistance with ADLs;

* 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 had demonstrated competence in all job duties within 30 days of hire was reviewed with Staff 1 on 07/30/24 and 07/31/24. He acknowledged the findings.

What actions will be taken to correct the rule violation? Checklist has been updated to cover all the required training competencies, including role of service plan, Relias videos covering providing assistance, changes associated with normal aging, Identifying, documentation and reporting changes of condition and Conditions that require assessment, treatment, observation and reporting have been confirmed to be correctly templated with state approved trainings.  Additionally, all team members have completed any missing training to come into compliance with the required training in the first 30 days.  

How will the system be corrected so this violation will not happen again? Moving forward, no team members will be allowed to work without the Health Services Director/Administrator reviewing that all training and documentation of training is complete before working the floor solo.

How often will the area needing correction be evaluated? Upon new hire and again within the 30 days of start date.

Who on your staff will be responsible to see that the

corrections are completed/monitored? The Health Services Director/Administrator.