Print Inspection: 00YU

The findings of the re-licensure survey, conducted 04/03/23 through 04/06/23, 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

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 re-visit to the re-licensure survey of 04/06/23, conducted from 08/07/23 through 08/09/23, 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.

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

Fire and life safety records were reviewed on 04/04/23 and identified the following:

There was no documented evidence the facility conducted fire drills every other month as required and provided fire and life safety instruction to staff on alternating months from fire drills.

On 04/06/23, the need to ensure fire drills were conducted, and staff instruction was provided according to the OFC was discussed with Staff 1 (Administrator) and Staff 6 (Maintenance Director). They acknowledged the findings.

C 420 OAR 411-054-0090 Fire and Life Safety: Safety

1. The leadership team reviewed the OARs and OFC to create a sustainable system for compliance tracking and training. BlueStep electronic modifications were made by the IT department for improved efficiency, tracking, notifications, and compliance documentation. The maintenance team received focused education on their role and responsibilities, BlueStep electronic integration, staff education, and scheduling.

2. Fire Drills and staff education have been added to the tracking in Bluestep (the staff and resident EHR). The Maintenance Director and the Administrator will receive email alerts with the schedule alternating every other month. The Maintenance Director will document and upload a copy of the fire logs into BlueStep to increase transparency for auditing by the Administrator.

3.The Maintenance team will provide continous compliance and the Administrator will audit compliance on a monthly basis.

4. The Maintenance Director and Administrator will be responsible for upholding ongoing compliance.

Based on interview and record review, it was determined the facility failed to provide fire safety instruction to residents, at least annually, in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to:

Review of facility records on 04/05/23 identified the following:  

There was no documented evidence annual training on fire safety was provided to residents.

On 04/05/23 the need to provide and document fire safety instruction to residents, at least annually, in accordance with the OFC was discussed with Staff 1 (Administrator) and Staff 6 (Maintenance Director). They acknowledged the findings.

C 422 OAR 411-054-0090 (5) Fire and Life safety: Training for Residents

1.The leadership team reviewed the OARs and OFC to create a sustainable system for compliance tracking and training. The maintenance team received focused education on their role and responsibilities for resident training, on fire and life safety within 24 hours of admission, and re-instruction, at least annually, and the electronic integration of BlueStep for their compliance documentation.

2. The Maintenance team will document resident training on admission and re-instruction, per the OARs and OFC directly into BlueStep.

3.The Maintenance team will provide continous compliance and the Administrator will audit compliance on a monthly basis.

4. The Maintenance Director and Administrator will be responsible for upholding ongoing compliance.