The findings of the re-licensure survey, conducted 01/17/23 through 01/19/23, 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
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 re-visit to the re-licensure survey of 01/19/23, conducted 04/07/23, 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 and OARs 411 Division 004 for Home and Community Based Services Regulations.
Based on observation and interview, it was determined the facility failed to ensure all interior materials and surfaces were kept clean and in good repair. Findings include, but are not limited to:
The interior of the facility was toured on 01/17/23 at 11:05 am.
a. The following areas needed repair:
* The linoleum floor behind the washer and dryer equipment in Laundry Room A and Laundry Room B was torn making it an uncleanable surface; and
* The wall under the wastewater outlets of both washing machines in Laundry Room A had flaking and peeling paint caused by water damage.
b. The following areas needed cleaning:
* The ceiling vent in the dining area directly above the window for passing food trays from the kitchen was covered with layers of dust; and
* Kitchen cabinet surfaces in the Activity Room had dried debris and were sticky.
The building was toured and areas needing cleaning or repair were discussed with Staff 1 (Executive Director) and Staff 3 (Maintenance Director) at 09:40 am on 01/18/23. They acknowledged the areas needing cleaning and repair.
The Laundry Room walls were scheduled to be painted and floors replaced in February. Flooring has been ordered.
The ceiling vent and Activity Room kitchen cabinets have been cleaned.
These items have been added to the custodian's cleaning checklist.
Monthly
Executive Director
There are no detail notes for this visit.
Based on observation and interview, it was determined the facility failed to provide exit door alarms or other acceptable systems for security purposes and to alert staff when residents exit the ALF. Findings include, but are not limited to:
The interior of the facility was toured on 01/17/23 at 11:05 am.
* The doors leading to the central courtyard lacked a system that alerted staff when a resident exited the building.
The building was toured and areas needing alarms were discussed with Staff 1 (Executive Director) and Staff 3 (Maintenance Director) at 09:40 am on 01/18/23. They acknowledged the need to install exit door alarms.
This is a new interpretation for door alarms to the courtyard. Alarms are being ordered and will be installed.
Alarms will be installed on doors leading out to the courtyard.
Once alarms are installed they will be monitored by maintenance during monthly routine checks.
Executive Director
There are no detail notes for this visit.