The findings of the re-licensure survey, conducted 01/08/24 through 01/09/24, 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, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for 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 first revisit to the relicensure survey of 01/09/24, conducted 03/27/24, 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 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Based on observation, interview, and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities was documented in the resident's service plan, restrictive alternatives prior to use were documented, and instruction was provided to caregivers on the correct use of and precautions for the device, for 1 of 1 sampled resident (#2) who had a side rail on his/her bed. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 10/2023 with diagnoses including dementia.

Observation of the resident's room 01/08/23 revealed a half-length side rail on the left side of the resident's bed. During an interview on 01/09/23, Staff 9 (Resident Aide) stated the resident used the side rail for bed mobility.

There was no documented evidence the following required elements were completed:

* Documentation of less restrictive alternatives evaluated prior to use of the device;

* Instruction provided to staff on the correct use and precautions related to the device; and

* Documentation of the side rail in the resident's service plan.

The need to ensure the use of a supportive device with potentially restraining qualities included documentation of all required elements and was included in the resident's service plan was discussed with Staff 2 (Administrator) on 01/09/23. He acknowledged the findings.

1.

a.Restrictive Device Documentation for Resident 2 will be updated to include less restrictive alternatives evaluated prior to the use of the device.

b.Instruction will be provided to staff on the correct use and precautions related to the device.

c.Service Plan for Resident 2 will be updated to include the use of the restrictive device.

2.

a.Restrictive Device Assessments will be updated to include documentation of less restrictive devices evaluated prior to use of the device.

b.Resident Evaluations and Service Plans, including Restrictive Device Assessments, will be combined into a Comprehensive Evaluation and Service Plan to be completed and tracked in Blue Step.

c.Staff will receive instruction on the correct use of and precautions related to restrictive devices at time of hire, or upon device implementation, and annually thereafter.

3.

a.Comprehensive Evaluation and Service Plans, including Restrictive Devices, will be evaluated every 90 days or less, as resident needs change.

b.Staff Instruction regarding restrictive devices will be tracked in Blue Step with annual alerts when instruction is due.

4.

a.Comprehensive Evaluation and Service Plans will be reviewed jointly by Administrator and Facility Nurse every 90 days or less, as resident requirements change. Service Plans will be tracked in Blue Step with alerts when routine reviews are due.

b.Staff Instruction regarding Restrictive Devices will be tracked in Blue Step and reviewed annually by Administrator and Facility Nurse

Based on interview and record review, it was determined the facility failed to provide fire and life safety instruction to staff on alternating months, conduct fire drills consistently every other month, and to document all required elements for fire drills in accordance with Oregon Fire Code (OFC) requirements. Findings include, but are not limited to:

Fire and life safety records were reviewed with Staff 2 (Administrator) and Staff 6 (Maintenance Manager) on 01/09/24 at 11:00 am.

The facility provided documentation of two fire drills in the last six months, which occurred on 10/24/23 and 12/28/23. Fire drills were not consistently conducted every other month at different times of day, and written fire drill documentation did not include the evacuation time period needed.

There was one documented example of fire and life safety instruction to staff on alternating months, which occurred on 12/15/23.

During an interview on 01/09/23, Staff 6 confirmed the fire drills and fire and life safety instruction to staff had not occurred consistently over the last six months.

The need to provide fire and life safety instruction to staff on alternate months, to consistently conduct fire drills every other month, and to document all required elements for fire drills as required by the OFC was discussed with Staff 2 and Staff 6. They acknowledged the findings.

1. Staff 2 and Staff 6 will review in detail the Oregon Fire Code specific to fire safety. Staff 2 and Staff 6 will create a calendar moving forward for 2024 scheduling fire drills every other month for all shifts. Staff 2 and Staff 6 will schedule specific education/training for all staff on alternate months. Staff 6 will schedule two trainings to be done by the Fire Marshall's staff for two of the six months that are designated for training/education. Staff 6 will keep consistent and complete documentation regarding all fire drills, including all elements for fire drills as required by the OFC. Documentation will include the evacuation time period needed for each fire drill, for all shifts, conducted every other month. Staff 2 will ensure that all staff are aware of the requirements for assistance during evacuation for each resident by posting evacuation information in the medication room for ease of reference. Staff 2 will oversee and review all documentation on a regular basis, will assist in facilitating all education/training, and will accept responsibility to see that Staff 6 adhers to the schedule of fire drills and/or education/training in accordance with the OAR and OFC.

2. A system of accurate documentation of fire drills and education/training on alternate months will be created in accordance with the OAR and OFC. Staff 6 will be responsible for documentation with Staff 2 oversight monthly. Fire drills will be conducted on alternate months, at varying times of each shift, for all three shifts and documented accordingly. Documentation will include evacuation time period needed for each drill. Staff 2 and Staff 6 will review outcome with managers at the monthly managers' meeting. Education/training will be designed and conducted for 2024 in accordance with the OAR and OFC. All staff will be responsible for knowing the evacuation assistance required for each resident. Evacuation assistance needed for each resident will be included in the individual Resident Care Plans.

3. Staff 2 and Staff 6 will review documentation of fire drills and/or ecucation/training at the beginning of each month.

4.  Staff 2 will be responsible for confirming that all actions/corrections described herein are completed

by 3/1/2024. Staff 2 and Staff 6 will be responsible for ongoing compliance moving forward from 3/1/2024.

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 420.

1. Education on fire drills and training to be set up with Fire Marshall. Fire drills to be schedule every other month and education on life safety on alternate months.

2. Fire drills and education to be scheduled at the beginning of the month and reviewed after they are done  to ensure correct documentation and proper procedures have been followed.

3. On a monthly basis during the first week of each month.

4. Administrator and Maintenance Manager are responsible to for monitoring that fire drills and life safety have been completed.

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.

a.Restrictive Device Documentation for Resident 2 will be updated to include less restrictive alternatives evaluated prior to the use of the device.

b.Instruction will be provided to staff on the correct use and precautions related to the device.

c.Service Plan for Resident 2 will be updated to include the use of the restrictive device.

2.

a.Restrictive Device Assessments will be updated to include documentation of less restrictive devices evaluated prior to use of the device.

b.Resident Evaluations and Service Plans, including Restrictive Device Assessments, will be combined into a Comprehensive Evaluation and Service Plan to be completed and tracked in Blue Step.

c.Staff will receive instruction on the correct use of and precautions related to restrictive devices at time of hire or device implementation and annually thereafter.

3.

a.Comprehensive Evaluation and Service Plans, including Restrictive Devices, will be evaluated every 90 days or less, as resident needs change.

b.Staff Instruction regarding restrictive devices will be tracked in Blue Step with automated annual alerts when instruction is due.

4.

a.Comprehensive Evaluation and Service Plans will be reviewed jointly by Administrator and Facility Nurse every 90 days or less, as resident needs change. Service Plans will be tracked in Blue Step with automated alerts when routine reviews are due.

b.Staff Instruction regarding Restrictive Devices will be tracked in Blue Step and reviewed annually by Administrator and Facility Nurse

Based on interview and record review, it was determined the facility failed to ensure an individualized activity plan was developed for each resident based on their activity evaluation, for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose records were reviewed. Findings include, but are not limited to:

Resident 1, 2, 3, and 4's service plans, assessments, and evaluations were reviewed. There was some information included, but the records lacked documented evidence the facility evaluated the sampled residents activities to include:

* Past and current interests;

* Current abilities and skills;

* Emotional and social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for the resident to participate; and

* Activities that could be used as behavioral interventions, if necessary.

On 01/09/24, the need to ensure all residents had individualized activity plans based on the evaluation to engage residents in meaningful activities was discussed with Staff 2 (Administrator) and Staff 3 (RN). They acknowledged the findings.

1.Individualized Activity Plans will be updated for Residents 1, 2, 3, and 4 to include:

a.Past and current interests;

b.Current abilities and skills;

c.Emotional and social needs and patterns;

d.Physical abilities and limitations;

e.Adaptations necessary for the resident to participate; and

f.Activities that could be used as behavioral interventions, if necessary.

2.Resident Evaluations and Service Plans, including Individualized Activity Plans, will be combined into a Comprehensive Evaluation and Service Plan to be completed and tracked in Blue Step. The Individualized Activity Plan portion will be completed by the Life Enrichment Coordinator.

3.Comprehensive Evaluation and Service Plans, including Individualized Activity Plans, will be evaluated every 90 days or less, as resident needs change.

4.Comprehensive Evaluation and Service Plans, Including Individualized Activity Plans, will be reviewed jointly by Administrator and Facility Nurse every 90 days or less, as resident needs change. Comprehensive Evaluation and Service Plans will be tracked by Blue Step with automated alerts when routine reviews are due.