Print Inspection: YLMN

The findings of the re-licensure survey conducted 03/07/22 through 03/09/22 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

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 second re-visit to the re-licensure survey of 03/09/22, conducted 05/12/22, 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 drill records included documentation of all required elements and fire and life safety instruction to staff was provided on alternate months from fire drills. Findings include, but are not limited to:

On 03/07/22, fire drill and fire and life safety training records from 10/26/21 to 02/28/22 were reviewed. The following deficiencies were identified:

A. Fire drill records lacked documentation of the following required components:

* The escape route used;

* Problems encountered and comments relating to residents who resisted or failed to participate in the fire drills; and

* Number of occupants evacuated.

During an interview with Staff 4 (Maintenance) on 03/08/22 at 11:30 am, he stated the facility was not relocating or evacuating residents during fire drills.

B. The facility did not provide fire and life safety instruction to staff on alternating months from fire drills. Documentation review and interview with Staff 4 on 03/08/22 confirmed the facility was not consistently providing fire and life safety instruction to staff on alternating months from fire drills.

The requirements regarding fire drills and fire and life safety instruction for staff were reviewed with Staff 6 (Riverwood ALF Administrator) and Staff 7 (Corporate) on 03/08/22 at 11:45 am. They acknowledged the findings.

1. Community will provide fire and life safety instructions for staff on alternating months of fire drills and ensure all required components are documented and recorded.

2. Community will continue to conduct monthly fire and life safety training per Prestige Senior Living policy and ensure to meet OAR 411-054-0090 and 411-054-0093. Staff will be trained at newly hired, the following topics every other month; elopment drill, prolonged power failure, earthquakes, extreme heat, wildfires, winter storms and extreme cold, chemical threats, floods, thunderstorms and lightening and bomb threats. Staff will be intereviewed and provided questionnaire form outside of monthly training to ensure each individual is aware and acknowledges importance  of safety escape route that is outlined in our fire and life safety plan.

3. This system will continue to be conducted and monitored each month to ensure staff are in compliance with our safety plan.

4. This system will be monitored monthly by Maintenance Director, Executive Director will be responsible for compliance.