The findings of the re-licensure survey, conducted 02/21/23 through 02/22/23, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 Home and Community Based Services Regulations.

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 02/22/23, conducted on 06/13/23, are documented in this report. It was determined the facility was in compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004.

Based on interview and record review, it was determined the facility failed to ensure it had a trained and designated Infection Control Specialist. Findings include, but are not limited to:

In an interview on 02/21/23, Staff 1 (ED) stated the facility did not have a designated Infection Control Specialist.

On 02/21/23 the need to designate an Infection Control Specialist, who had completed all required training, was reviewed with Staff 1. He acknowledged the findings.

C 295

1.The Executive Director will complete the Infection Control Specialist Training by 3/3/2023

2.The community has identified an additional associate who has complete required training to ensure coverage.

3.The Executive Director or designee will maintain compliance with Infection Control Specialist training as changes in training and guidelines occur.  

4.The Executive Director and/or designee is responsible for this plan of correction.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted and documented every other month. Findings include, but are not limited to:

On 02/21/23, fire drill records for the previous six months were requested.

Review of the documentation provided identified there was no documented evidence unannounced fire drills were recorded every other month at different times of the day, evening and night shifts for the memory care unit.

In an interview with Staff 4 (Maintenance Manager) on 02/22/23, he acknowledged there was no documented evidence of fire drills conducted on the facilities memory care unit.

On 02/22/23 the requirements regarding fire drills were reviewed with Staff 1 (Executive Director). He acknowledged the findings.

C 420

1) Fire drill will be conducted in Clare Bridge by 3/31/23

2) Maintenance Director has been educated on regulation pertaining to fire drill requirements and frequency.

3) Fire drill documentation will be maintained through TELS task management software and recorded in physical fire safey binder. Executive Director and/or designee will routinely review fire drill documentation monthly.

4) The Executive Director and Maintenance Director are responsible for this plan of correction.

Based on observation and interview, it was determined the facility failed to ensure all exit doors were equipped with an alarming device or other acceptable system to alert staff when residents exited the building. Findings include, but are not limited to:

Observations on 02/21/23 found exit doors to the memory care unit courtyards did not have an operational alarm or other acceptable system to alert staff when residents exited the building.

The need to ensure exit doors were equipped with an alarming device or other acceptable system was discussed with Staff 1 (ED) on 02/21/23. He  acknowledged the findings.

C 555

1) Door alarms were added to the courtyard doors prior to surveyors exiting the community.

2) Associates will be educated on the door alarm requirements and procedures during all staff meeting by 3/20/23. Maintenance of these alarms was added to out TELS task management software.

3) Door alarm function will be validated on routine community walk throughs at minimum of weekly.

4) The Executive Director and Maintenance Director are responsible for this plan of correction.

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 295, C 420, and C 555.

Z 142

See above for: C 295, C 420, and C 555.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 sampled newly hired staff (#s 7 and 8) completed the pre-service Infectious Disease Prevention training curriculum. Findings include, but are not limited to:

Training records for Staff 7 (CG), hired 11/23/22, and Staff 8 (CG), hired 1/17/23, were reviewed with Staff 5 (Business Office Manager) on 02/22/23.

There was no documented evidence Staff 7 and 8 had completed all of the required pre-service Infectious Disease Prevention training curriculum.

The need to ensure staff completed all required pre-service training was discussed with Staff 1 (ED) on 02/22/23. He acknowledged the findings.

Z 155

1) Staff 7 & 8 will complete required infection control training by 3/31/23. Infection control classes to meet regulation and have been assigned to new associates upon hire and completed before performing any job duties.

2) All required classes have been added to our curriculum to be assigned to new associates upon hire

3) Business Office Manager will monitor training records and staff will not be released for on the floor training until pre-service topics are complete as verified by their transcript.  The Executive Director and/or designee will review new hire training files for completion for the next 60 days and then conduct random audits monthly thereafter as part of the ongoing quality assurance process.  

4) The Executive Director is responsible for this plan of correction.