The findings of the re-licensure survey, conducted 01/31/23 through 02/01/23, 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 OARs 411 Division 004 for Home and Community Based Services Regulations.

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

MCCMemory 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 re-visit to the re-licensure survey of 01/31/23 through 02/01/23, conducted 03/01/23, are documented in this report. It was determined the facility was in substantial compliance with OARS 411 Division 54 for Residential Care and Assisted Living Facilities and OARS 411 Division 004 for Home and Community Based Regulations.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted according to the Oregon Fire Code (OFC) and fire drill records included documentation of all required components. Findings include, but are not limited to:

The facility's fire and life safety records, including fire drill records, dated 02/15/22 through 12/24/22, were reviewed during survey. The following were identified:

1. The following required components were not consistently documented in fire drill records:

*Location of simulated fire origin;

*Escape route used;

*Problems encountered related to residents who resisted or failed to participate in drills:

*Evacuation time-period needed; and

*Number of occupants evacuated.

2. There was no documented evidence the facility used alternate exit routes during fire drills.

The need to ensure fire drills were conducted according to the Oregon Fire Code (OFC) and fire drill records included documentation of all required components was discussed with Staff 1 (ALF ED) and Staff 3 (Director of Environmental Services) on 01/31/23 and with Staff 1 and Staff 2 (ED) on 02/01/23. They acknowledged the findings.

1. Simulation of fire drill will be documented with all required elements inculding the below missing from prior documentation:

* Location of simulated fire origin;

* Escape route used;

* Problems encountered related to residents who resisted or failed to participate in drills;

* Evacuation time-period needed;

* Number of occupants evacuated;

2. Documentation of alternate exit routes taken during fire drills to be completed.