Inland Point Retirement Community

The findings of the re-licensure survey conducted 01/03/23 through 01/05/23 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 Home and Community Based Services Regulations. Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day
The findings of the revisit to the re-licensure survey of 01/05/23, conducted on 05/10/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs Division 54 for Residential Care and Assisted Living Facilities.

Based on interview and record review, it was determined the facility failed to ensure pre-service dementia care training had been completed, with certification, prior to staff providing direct care to residents, for 4 of 4 newly hired staff (#s 6, 10, 11 and 12). Findings include, but are not limited to:The facility's training records reviewed on 01/04/23 revealed:Staff 6 (CG), hired 07/14/22, Staff 10 (Cook), hired 10/11/21 Staff 11 (CG), hired 10/04/22 and Staff 12 (CG), hired 12/08/22, lacked documented evidence they had completed the required pre-service infection training prior to providing direct care to residents.Requirements for pre-service training were reviewed with Staff 1 (ED) on 01/05/23. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired direct care staff (#s 6, 11 and 12) demonstrated competency of skills in all assigned job duties within 30 days of hire. Findings include, but are not limited to:Training records were reviewed on 01/04/23 and identified the following:Staff 6 (CG) hired 07/14/22, Staff 11 (CG) hired 10/04/22 and Staff 12 (CG) hired 12/08/22 lacked documentation of demonstrated competency in changes associated with normal aging and first aid/abdominal thrust.The need to ensure staff demonstrated competency in all assigned job duties within 30 days of hire was discussed with Staff 1 (ED) on 01/05/23. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure documented evidence of the required 12 hours of annual in-service training, including six hours of dementia care training, was completed for 3 of 3 long term staff (#s 5, 7 and 8) whose training records were reviewed. Findings include, but are not limited to:Staff training records were reviewed on 01/04/23. Annual training records, provided through online training courses and monthly staff meetings, based on anniversary date of hire, for Staff 5 (CG) hired 01/27/21, Staff 7 (MT) hired 10/02/17 and Staff 8 (CG) hired 10/10/18 were reviewed. The records indicated Staff 5, 7 and 8 did not complete all twelve hours of in-service training on topics related to dementia care or community based care.The need to ensure direct care staff completed the required annual training was reviewed with Staff 1 (ED) on 01/05/23. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure all required elements were documented for fire drills in accordance with Oregon Fire Code (OFC) and fire and life safety instruction was provided on alternate months. Findings include, but are not limited to:Review of fire drill and fire and life safety records from 06/18/22 through 12/22/22 identified the following:a. The facility failed to provide fire and life safety instruction to staff on alternate months.b. The facility failed to document the following required elements on firs drills;* Escape route used;* Problems encountered, comments relating to residents who resisted or failed to participate in the drill;* Number of occupants evacuated; and* Alternate routes used during fire drills were not documented.The need to ensure the facility documented all required elements for fire drills and fire life safety training was completed on alternate months was reviewed with Staff 1 (ED). She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to instruct new residents on fire and life safety within 24 hours of admission and provide Fire and Life Safety instruction to residents annually. Findings include, but are not limited to:Fire drill records, from 06/2022 through 12/2022, were reviewed on 01/04/23 with Staff 1 (ED) and revealed the following: * There was no documented evidence new residents were instructed on fire and life safety within 24 hours of admission; and* Staff 2 stated the facility was not providing or documenting annual instruction for residents 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. The requirements for Fire and Life Safety instruction for residents were reviewed with Staff 1 on 01/04/23. She acknowledged the findings.