The findings of the re-licensure survey, conducted 05/24/22 through 05/26/22, 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 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

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 2nd revisit to the re-licensure survey of 05/26/22, conducted 07/20/22 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 observation, interview and record review, it was determined the facility failed to ensure food was prepared in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:

Observations of the kitchen on 05/25/22 revealed:

* There were no garbage can lids for garbage cans near food prep areas; and

* Multiple dented cans.

The need to ensure food was prepared in accordance with the Food Sanitation Rules OAR 333-150-000 was discussed with Staff 1 (Executive Director) and Staff 4 (Executive Chef) on 05/25/22. They acknowledged the findings.

We have purchased 3 new 55 gallon trash cans with lids and have cut a 6" x 6" hole in the top as recommended by surveyer and 2 space specific trash cans with foot control lids for use on the line in order to meet the requirement of OAR 411-054-0030.  Lids will remain on the cans during all food preparation times.  Executive Director / Administrator will periodically (at least once a week) inspect that the regulation is being followed.  

Dented cans are to be reported within 48 hours of delivery to the appropriate provider and discard immediately to the trash.  

Additional training has been provided to all kitchen staff that are responsible for checking in deliveries to report, document and discard all dented cans.  Executive Director / Administrator will periodically (at least once a week) inspect the dry storage to affirm that the regulation is being followed.  

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

Fire drill and fire safety instruction records were reviewed from 11/2021 through 05/2022.

Review of the records revealed the lack of the following components:

* Escape route used;

* Staff members on duty and participating; and

* Evacuation time period needed.

Fire drill documentation requirements was discussed with Staff 1 (Executive Director) on 05/25/22. She acknowledged the findings.

The Fire Drill reporting form has been reviewed to assure all applicable regulations of OAR 411-054-0090 have been addressed appropriately.  

Executive Director / Administrator will review the Fire Drill reporting form with Plant Manager to assure completeness prior to signing off and will continue to do so to assure all components are addressed in a complete and clear manner.

We have executed a plan to assure that appropriate evacuations are completed timely and documented as per regulation to assure compliance.