Print Inspection: XW0J

The findings of the re-licensure survey, conducted 07/15/24 through 07/17/24, 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 and OARs 411 Division 004 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 revisit to the re-licensure survey of 07/17/24, conducted on 09/19/24, 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.

Based on interview and record review, it was determined the facility failed to ensure implementation of an acuity-based staffing tool (ABST) that included all required ADLs and the amount of staff time needed to provide care. Findings include, but are not limited to:

The facility's ABST was reviewed and discussed with Staff 1 (ED) at 10:00 am on 07/17/24. Staff 1 reported the ABST was driven by the service plan for each resident.

Review of the facility ABST tool revealed there was no documented evidence all 22 of the required ADLs were individually addressed for each resident, nor was the amount of staff time needed for each of the 22 ADL elements.

On 07/17/24, the need to ensure the facility used an ABST which met the regulation was discussed with Staff 1. He acknowledged the findings.

Health and Wellness Director or designee will complete an ABST for all existing residents in the community.  This will be completed on or before September 6th, 2024.  

All new move-ins will have an ABST completed at or before the time of move in.  All existing residents will have his or her ABST updated with each change in condition assessment.

Executive Director or designee will complete a monthly audit to ensure all resident have a current ABST completed.  This will be completed using a resident roster.  

Executive Director will bring the audit to QA quarterly for 3 quarters, beginning in September 2024.

Based on interview and record review, it was determined the facility failed to ensure residents were instructed about the facility's fire and life safety procedures per Oregon Fire Code (OFC) within 24 hours of admission and were 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. Findings include, but are not limited to:

Fire and life safety records were reviewed on 07/15/24.

a. There was documentation some residents were being instructed on fire and life safety procedures within 24 hours of admission; however, there was no documentation of this training for the four sampled residents (#s 1, 2, 3, and 4) whose records were reviewed.

b. There was no documented evidence residents were being re-instructed at least annually in fire and life safety procedures.

In an interview with Staff 2 (Maintenance Director) on 07/15/24 at 1:30 pm, he stated he provided "updates" on fire and life safety procedures at resident council meetings and town hall meetings "as needed," but did not have a system in place to ensure all residents were re-instructed annually. No documentation was provided indicating the topics discussed or the residents in attendance at resident council or town hall meetings.

The need to consistently instruct residents on fire and life safety procedures within 24 hours of admission, to re-instruct residents at least annually, and to keep a written record of fire safety training, including content of the training sessions and the residents attending, was discussed with Staff 1 (ED) on 07/16/24. He acknowledged the findings.

Conducting an annual fire, life and safety re-instruction to be offered 2 different days. This will be held on July 31, 2024 and August 1, 2024. We will go over general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area, in the vent of an actual fire. Any resident who did not attend, will have a separate training with the MD to cover all areas listed.

Upon completion of the annual fire, life and safety drill we will continue to hold this annually on July 2025 and also completing this training within 24 hours of a new resident move in which will be kept on file signed by resident and MD upon date of completion. The 4 residents who were on the confidential list during the survey will get a fire,life/safety training to be completed by 8/15/24 and placed in their file signed by resident and MD.

MD to engage residents with discussions and have a Q/A session prior to closing the training.

We can provide documentation upon request of the trainings, and annual.