The findings of the re-licensure survey conducted 10/20/21 through 10/21/21 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 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

MCCMemory 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 10/21/21, conducted 12/16/21, are documented in this report. It was determined the facility was in substantial 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.

Based on interview and record review, it was determined the facility failed to include required components on fire drill records. Findings include, but are not limited to:

Fire and life safety records, reviewed between 04/2021 - 09/2021, revealed the following:

Fire drill records lacked the following components:

* Escape route used; and

* Number of occupants evacuated.

In an interview on 10/20/21 at 1:30 pm, Staff 4 (Maintenance) acknowledged facility fire drill records lacked the required components.

Fire and life safety training and documentation was discussed with Staff 1 (Health Care Services Administrator), Staff 2 (Director of Nursing) and Staff 3 (RCM) on 10/21/21. They acknowledged the findings.  

1. A review of all fire drill requirements & fire drill documentation requirements will be completed.

2. The Fire Drill form and procedure will be adjusted to include escape route used, number of occupants evacuated, and problems encountered and comments relating to residents who resisted or failed to participate in the drills.        

3. Staff will be educated regarding the fire drill requirements and fire drill documentation requirements.

4.  Fire drills will conducted using the revised form.

5. Fire drill documentation will be audited monthly by the Administrator or their designee.

6. Audit results including recommendations for improvement will be presented to the Quality Assurance Committee.

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements were being met. Findings include, but are not limited to:

Fire and life safety records, reviewed between 04/2021 - 09/2021, revealed the facility lacked documented evidence of the following:

* Alternate exit routes were used during fire drills; and

* Documented evidence of evacuation levels.

The need to ensure alternate exit routes are used during fire drills and evacuation levels were documented was discussed with Staff 1 (Health Care Services Administrator), Staff 2 (Director of Nursing) and Staff 3 (RCM) on 10/21/21. They acknowledged the findings.  

1. A review of all fire drill requirements & fire drill documentation requirements will be completed

2. The Fire Drill form will be adjusted to include evidence that alternative exit routes were used and evidence that staff were aware of the designated point of safety   

3. Staff will be educated regarding the fire drill requirements and fire drill documentation requirements

4.  Fire drills will conducted using the revised documentation form.

5. Fire drill documentation will be audited monthly by the Administrator or their designee.

6. Audit results including recommendations for improvement will be presented to the Quality Assurance Committee.

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:

Observations during the survey revealed exit doors to courtyard lacked alarms or other acceptable systems to alert staff when residents exited.

In a 10/21/21 interview, Staff 1 (Administrator) confirmed the facility lacked an alarming device or other acceptable system to alert staff when all residents exited the building.

The need to ensure exit doors were equipped with an alarming device or other acceptable system to alert staff when residents exited the building was discussed with Staff 1 and Staff 2 (Director of Nursing) on 10/21/21. They acknowledged the findings.

1.The exit doors to courtyard will be installed with alarms to alert staff when residents exit.

2.A review of all exit doors needing alarms to alert staff when a resident exits will be completed.

3.Staff will be educated regarding exit door alarms that alert when resident's exit.

4.Monthly audits will be conducted on the functionality of the alarms and reviewed by The Administrator or their designee.

5.Audit results including recommendations for improvement will be presented to the Quality Assurance Committee.