The findings of the re-licensure survey, conducted 3/14/22 through 3/15/22 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 Home and Community Based Services Regulations OARs 411 Division 004.

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 first revisit to the re-licensure survey of 03/15/22, conducted 05/26/22, 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 pre-service orientation in all required topics was completed prior to beginning job duties for 1 of 3 newly hired staff (#11). Findings include, but are not limited to:

Facility training records reviewed with Staff 14 (Business Office Manager) on 03/14/22 at 1:00 pm, and revealed the following:

Staff 11 (MT) did not have documented evidence of training for the following required pre-service topics:

* Fire safety and emergency procedures; and

* Pre-service dementia training.

The need to ensure staff completed all pre-service orientation topics prior to beginning job duties was discussed with Staff 1 (Executive Director) and Staff 2 (Executive Director in Training) on 03/15/22 at 10:15 am. They acknowledged the findings.

A complete audit will be done of all training records.  All trainings will be complete and up to date for current employees no later than 5/14/22.

To prevent recurrence, training grid will be utilized to ensure that all staff have required trainings completed within the timeframe required. Staff will not be allowed to work on the floor unsupervised until all of their required trainings are completed. Monthly, as part of facility continuous quality improvement (CQI) meetings, training grid will be reviewed to ensure staff members have completed pre-service training as required prior to working on the floor. Incomplete trainings will be reviewed five days a week as part of daily standup meeting to identify missing training components and to review the status of new hires and where they are at with their trainings.

This system will be evaluated monthly as part of the facility continuous quality improvement process and will include a review of the training grid.

The Executive Director and Business Office Manager will be responsible for maintaining this system.

Based on interview and record review, it was determined the facility failed to ensure 1 of 1 newly hired caregiver staff (#11) demonstrated competency in all required areas of job duties within 30 days of hire. Findings include, but are not limited to:

Staff training records reviewed with Staff 14 (Business Office Manager) on 03/14/22 at 1:00 pm, and revealed the following:

There was no documented evidence Staff 11 (MT), hired on 11/27/21,  had demonstrated competency of job duties in all required areas within 30 days of hire for topics including:

* Role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Changes associated with normal aging;

* Identification, documentation and reporting of changes of condition;

* Conditions that require assessment, treatment, observation and reporting;

* General food safety, serving and sanitation; and

* Other duties as applicable (Medication pass, treatments).

The need to ensure newly hired staff had documentation of demonstrated competency in all required areas within 30 days of hire was reviewed with Staff 1 (Executive Director) and Staff 2 (Executive Director in Training) on 03/15/22 at 10:15 am. They acknowledged the findings.

A complete audit will be done of all training and competency records.  All trainings and competencies will be complete and up to date for current employees no later than 5/14/22.

To prevent recurrance, all staff will be required to complete the required training and job specific competencies within 30 days of hire.

Incomplete trainings and competencies will be reviewed five days a week as part of daily standup meeting to identify missing components and to review the status of new hires and where they are at with their trainings to ensure all training is completed withing 30 days of hire.

This system will be evaluated monthly as part of the facility CQI program and will include a review of all current staff members and the status of their required trainings.

The Executive Director and Business Office Manager will be responsible for maintaining this sytem.

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 2 of 3 long-term staff (#s 7 and 10) whose training records were reviewed. Findings include, but are not limited to:

Staff training records reviewed with Staff 14 (Business Office Manager) on 03/14/22 at 1:00 pm, and revealed the following:

Staff 7 (MT), hired 06/25/19, and Staff 10 (CG), hired 11/27/22,  lacked  documentation that a minimum of 12 hours of annual in-service training, including six hours of dementia care training, was completed.

The need to ensure staff completed 12 hours of annual training, including six hours on topics related to dementia care was reviewed with Staff 1 (Executive Director) and Staff 2 (Executive Director in Training) on 03/15/22 at 10:15 am. They acknowledged the findings.

A complete audit will be done of all annual training records.  All trainings will be complete and up to date for current employees no later than 5/14/22.

To prevent recurrance all staff will be required to complete the monthly required Relias trainings which meet the requirement for 12 hours of annual training, including 6 hours of dementia training and 6 hours of CBC training.

This system will be evaluated monthly as part of the facility CQI program and will include a review of all current staff members and the status of their monthly required trainings.

The Executive Director and Business Office Manager will be responsible for maintaining this sytem

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

Review of fire drill records on 03/14/22, for October 2021 through March 2022, showed the facility failed to document the following required components:

* Escape route used; and

* Problems encountered, comments relating to residents who resisted or failed to participate in the drills.

On 03/14/22, the need to ensure all required components of fire drills were documented was discussed with Staff 1 (Executive Director) and Staff 2 (Executive Director in Training). They acknowledged the findings.

A training was done with Maintenance Director that included a review of all required components related to the correct procedure for fire drills. All staff will be re-educated at staff meeting in April on the fire drill procedure.

To prevent recurrance, company fire drill form has been updated to include all required components and computer program used to document fire drills has been updated to include all required components as well as rotating schedule for locations and shifts.

Fire drills and fire and life safety trainings will be reviewed monthly as part of our CQI process to ensure compliance.

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

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 for October 2021 through March 2022 were provided. Review of the records revealed a lack of documented evidence related to the following required elements:

* Alternate evacuation routes used during fire drills; and

* Documentation of interventions and/or resolution for resident evacuation concerns identified during fire drills.

The need to have all components of fire and life safety training documented was discussed with Staff 1 (Executive Director) and Staff 2 (Executive Director in Training) on 03/14/22. They acknowledged the findings.

A training was done with Maintenance Director that included a review of all required components related to the correct procedure for fire drills. All staff will be re-educated at staff meeting in April on the fire drill procedure.

To prevent recurrance company fire drill form has been updated to include all required components and computer program used to document fire drills has been updated to include all required components as well as rotating schedule for locations and shifts.

Fire drills and fire and life safety trainings will be reviewed monthly as part of our CQI process to ensure compliance.

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