The findings of the re-licensure survey, conducted 10/14/21 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 Home and Community Based Services Regulations OARs 411 Division 004.

Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.

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 10/14/21, conducted 02/04/22 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, OARs 411 Division 004 Home and Community Based Services Regulations, and OARs 411 Division 57 for Memory Care Communities.

Based on observation, interview and record review, it was determined the facility failed to ensure required postings were displayed in a routinely accessible and conspicuous location to residents and visitors and available for inspection. Findings include, but are not limited to:

A tour of the facility conducted on 10/14/21 identified the following:

* The Ombudsman Notification Poster was not posted in the facility .

The need to ensure all required postings were in an accessible and conspicuous location for the public was discussed with Staff 1(Administrator). She acknowledged the findings.

The ombudsman poster has been ordered and arrived.  Additional posters are on hand if needed.  

The poster is placed in a large frame, mounted to the wall for all residents and family to see.  

The poster will be viewed weekly to ensure it is securely in place.  

The frame protects the poster from being torn off the wall by memory care residents.

Administrator will be responsible for weekly check.

Based on observation, interview and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities was assessed thoroughly by an RN, PT or OT prior to use for 1 of 1 sampled resident (#2) who had a full-length side rails on their bed. Findings include, but are not limited to:

Observation of Resident 2's room on 10/14/21 at 1:42 pm, revealed there were two full length side rails in the raised position on the bed.  

Review of the resident's clinical record revealed the following:

* No documented evidence of an assessment completed by an RN, Physical Therapist or Occupational Therapist for the use of the side rails; and

* No documented evidence other less restrictive alternatives had been attempted prior to use.

The need to complete an assessment and the required components for the use of devices with restraining qualities was discussed on 10/14/21 with Staff 1 (Administrator). She acknowledged the findings.

Community RN has completed a bed rail asssessment which included a less restrictive alternative being attempted and caregivers being instructed on correct use and precautions.  Documentation on the need for this is a device for residents quality of life.

Care plan and evaluation list for all residents will include any quarterly evaluations including but not limited to smoking, restrictive device etc.

Quarterly review will be conducted to ensure compliance.

Administrator and Regional Director will review all assessments.

Based on observation and interview, it was determined the facility failed to ensure exit doors did not include locks that delayed evacuation. Findings include, but are not limited to:

On 10/14/21 the following was observed:

* One of the exit gates, located in the secured courtyard area to the rear of the building had a locked padlock that required a key to open.

On 10/14/21 the need to ensure exit doors did not have locks that would delay evacuation was discussed with Staff 1 (Administrator). She acknowledged the finding.   

The lock has been removed and the fence is now a solid structure. This gate was never an approved or designated exit by the community or the fire dept.

N/A

N/A

N/A

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to C 152 and C 513.  

Weights have been attached to the outdoor furniture adding 20 lbs to each piece making it adequate weight  

Any new furniture placed outside for the residents use will have the weights transferred over.

The weights and furniture will be inspected multiple time each week to ensure the weights are present and properly secured to the furniture.

The Administrator and designated staff will be responsible to inspect the furniture.  Regional Director will conduct quarterly audits.

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to C 340.

refer to C340

Based on observation and interview, it was determined the facility failed to ensure outdoor furniture was of sufficient weight to prevent resident injury or aid in elopement. Findings include, but are not limited to:

The facility was toured on 10/14/21. The following was identified:

* Several outdoor patio chairs and furniture were not of sufficient weight and could be easily moved, which created a potential safety and/or elopement risk.

The need to ensure outdoor furniture was of sufficient weight to prevent resident injury or aid in elopement was discussed with Staff 1 (Administrator) on 10/14/21. She acknowledged the findings.

Refer to 142