Print Inspection: RL003139

OAR 411-054-0060 Restraints and Supportive Devices Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07 This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure a thorough assessment had been completed by an RN, PT or OT, and caregivers had been instructed on the correct use and precautions related to the use of devices with restraining qualities for 1 of 1 sampled resident (# 1) who used siderails. Findings include, but are not limited to: Resident 1 was identified during the acuity interview on 03/10/25 to have siderails on their bed. The resident’s bed was observed to have two half side rails in the up position throughout survey. A review of Resident 1’s clinical record revealed the following were lacking from the record: *An RN, PT or OT assessment; and *Documented instructions for staff on the correct use and precautions related to the use of the device. The need to complete all required elements related to use of an assistive device with restraining qualities was discussed with Staff 1 (Administrator), Staff 2 (Corporate Director of Health Services), Staff 3 (Resident Services Coordinator) and Staff 6 (Alternate Administrator) on 03/12/25 pm. They acknowledged the findings. Staff 2 completed an RN assessment of device and instructions were provided for staff on 03/12/15.

The Facility Nurse completed a side rail assessment for Resident 1 on March 13th. A thorough assessment will be conducted whenever a new order for side rails is placed, and quarterly thereafter. Caregivers will be instructed on the correct use and precautions of side rails, with documentation in the resident’s record. The RSC will coordinate with the RN for new orders, and the Administrator will ensure timely and accurate assessments and training. An audit has been initiated and will be completed to ensure ongoing compliance. RSC, RN and Administrator

OAR 411-054-0060 Restraints and Supportive Devices Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07 This Rule is not met as evidenced by:

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure residents were instructed on fire and life safety procedures within 24 hours of admission. Findings include, but are not limited to: Facility fire and life safety records were reviewed on 03/11/25. The facility lacked documented evidence residents were instructed on general safety procedures, evacuation methods, and responsibilities within 24 hours of admission. The need for residents to be instructed in fire and life safety procedures within 24 hours of admission was discussed with Staff 1 (Administrator), and Staff 20 (Maintenance Director on 03/12/25. They acknowledged the findings.

The facility will ensure that all new residents receive fire and life safety orientation within 24 hours of move-in. The Resident Services Coordinator (RSC) will conduct the orientation, and documentation will be maintained for each resident. Move- In checklist has been updated to include this training item. The Administrator will oversee timely and effective implementation, with regular audits during health services meetings to ensure compliance. RSC and Administrator

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure residents were instructed on fire and life safety procedures within 24 hours of admission. Findings include, but are not limited to: Facility fire and life safety records were reviewed on 03/11/25. The facility lacked documented evidence residents were instructed on general safety procedures, evacuation methods, and responsibilities within 24 hours of admission. The need for residents to be instructed in fire and life safety procedures within 24 hours of admission was discussed with Staff 1 (Administrator), and Staff 20 (Maintenance Director on 03/12/25. They acknowledged the findings.

The facility will ensure that all new residents receive fire and life safety orientation within 24 hours of move-in. The Resident Services Coordinator (RSC) will conduct the orientation, and documentation will be maintained for each resident. Move- In checklist has been updated to include this training item. The Administrator will oversee timely and effective implementation, with regular audits during health services meetings to ensure compliance. RSC and Administrator

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by: