The findings of the re-licensure survey conducted 01/03/23 through 01/05/23 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

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 01/05/23, conducted on 05/10/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs Division 54 for Residential Care and Assisted Living Facilities.

Based on interview and record review, it was determined the facility failed to ensure pre-service dementia care training had been completed, with certification, prior to staff providing direct care to residents, for 4 of 4 newly hired staff (#s 6, 10, 11 and 12). Findings include, but are not limited to:

The facility's training records reviewed on 01/04/23 revealed:

Staff 6 (CG), hired 07/14/22, Staff 10 (Cook), hired 10/11/21 Staff 11 (CG), hired 10/04/22 and Staff 12 (CG), hired 12/08/22, lacked documented evidence they had completed the required pre-service infection training prior to providing direct care to residents.

Requirements for pre-service training were reviewed with Staff 1 (ED) on 01/05/23. She acknowledged the findings.

1.  All employee files will be reviewed for incomplete pre-service training. All missing pre-service training will be assigned and completed, and certificate of completion is placed in employee file.

2.  "training" prior to providing direct care to residents.

3.  Ensure that training is complete prior to a new hire performing direct care to residents.

4.  Executive Director will be responsible to see that the corrections are completed/monitored.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired direct care staff (#s 6, 11 and 12) demonstrated competency of skills in all assigned job duties within 30 days of hire. Findings include, but are not limited to:

Training records were reviewed on 01/04/23 and identified the following:

Staff 6 (CG) hired 07/14/22, Staff 11 (CG) hired 10/04/22 and Staff 12 (CG) hired 12/08/22 lacked documentation of demonstrated competency in changes associated with normal aging and first aid/abdominal thrust.

The need to ensure staff demonstrated competency in all assigned job duties within 30 days of hire was discussed with Staff 1 (ED) on 01/05/23. She acknowledged the findings.

1.  All employee files will be reviewed for demonstrated competency of skills in all assigned job duties. Employee files missing training will be assigned and completed. Skills Check list will be filed in employee's file.

2.  Demonstrated competency of skills in all assigned job duties will be assigned to and completed with all new hires within 30 days of hire, including normal aging and first aid/abdominal thrust.

3.  Employee Files will be audited prior to new hires completing their 30 days and quarterly to ensure completion of demonstrated competencies.

4.  Executive Director will be responsible to see that the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure documented evidence of the required 12 hours of annual in-service training, including six hours of dementia care training, was completed for 3 of 3 long term staff (#s 5, 7 and 8) whose training records were reviewed. Findings include, but are not limited to:

Staff training records were reviewed on 01/04/23.

Annual training records, provided through online training courses and monthly staff meetings, based on anniversary date of hire, for Staff 5 (CG) hired 01/27/21, Staff 7 (MT) hired 10/02/17 and Staff 8 (CG) hired 10/10/18 were reviewed.

The records indicated Staff 5, 7 and 8 did not complete all twelve hours of in-service training on topics related to dementia care or community based care.

The need to ensure direct care staff completed the required annual training was reviewed with Staff 1 (ED) on 01/05/23. She acknowledged the findings.

1.  All employee files will be reviewed for required annual training. Missing annual trainings will be assigned and completed, with documentation of completion placed in employee's file. Training will be completed prior to the associate's anniversary hire date.

2.  Staff will receive monthly staff training in the form of a staff meetings or online training courses.  Staff will receive no less than 6 hours of dementia training and an additional 6 hours of community-based care. Documentation of completion will be filed in employee's file.

3.  System will be reviewed quartley and 1 month prior to anniversay date to ensure staff is receiving the training they need and that it is documented in the appropriate 12-month period.

4.  Executive Director will be responsible for ensuring that the corrections are completed/monitored.

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

Review of fire drill and fire and life safety records from 06/18/22 through 12/22/22 identified the following:

a. The facility failed to provide fire and life safety instruction to staff on alternate months.

b. The facility failed to document the following required elements on firs drills;

* Escape route used;

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

* Number of occupants evacuated; and

* Alternate routes used during fire drills were not documented.

The need to ensure the facility documented all required elements for fire drills and fire life safety training was completed on alternate months was reviewed with Staff 1 (ED). She acknowledged the findings.

1. (a) The facility will provide fire and life safety instruction to staff on alternate months.  (b) the facility will document all elements on fire drills.

2.  Monthly fire and safety  instructions will be completed.  (b) All elements will be addressed  and documented.

3.  (a)(b) Area of correction to be evaluated.

4.  Executive Director will be responsible to see that the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to instruct new residents on fire and life safety within 24 hours of admission and provide Fire and Life Safety instruction to residents annually. Findings include, but are not limited to:

Fire drill records, from 06/2022 through 12/2022, were reviewed on 01/04/23 with Staff 1 (ED) and revealed the following:  

* There was no documented evidence new residents were instructed on fire and life safety within 24 hours of admission; and

* Staff 2 stated the facility was not providing or documenting annual instruction for residents 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.

The requirements for Fire and Life Safety instruction for residents were reviewed with Staff 1 on 01/04/23. She acknowledged the findings.

1.All resident files will be reviewed for incomplete training.

2."training" Residents will receive training within 24 hours of move in and annually

3."training" will be review quarterly.

4.Executive Director will be responsible to see that the corrections are completed and monitored.