The findings of the re-licensure survey, conducted 12/14/21 through 12/15/21, 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

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 12/15/2021, conducted on 1/24/2022, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OAR's 411 Division 004 for Home and Community Based Services Regulations.

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 provide security and to alert staff when residents exited the building. Findings include, but are not limited to:

The building was toured on 12/14/21 with Staff 1 (ED).  Staff 1 confirmed the doors residents exited the facility did not have a working alarm or other acceptable system to alert staff when residents left the building.

The need to ensure exit doors were equipped with an alarming device or other acceptable system was discussed with Staff 1 on 12/14/21. No other information was provided.

1. On 12/15/21, a magnetic door alarm was installed at each exit door to alert staff when residents exit the building.

2. Door alarms were installed and will remain in place to ensure staff is alerted when residents exit the building. All staff will be inserviced on proper response to door alarm.  

3. Door alarms will be monitored by the Maintenance Director monthly to ensure they are in proper working condition.

4. Maintenance Director will check door alarms monthly and report to the Executive Director with any concerns. Monitoring of door alarms will be documented in the TELS preventative maintanacne electronic program monthly.