The findings of the ABST inspection, conducted on 08/11/22, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004.

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 revisit to the ABST inspection of 08/11/22, conducted 02/28/23, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004. The facility was found to be in substantial compliance.

Based on observation and interview, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety, or welfare of residents. Findings include, but are not limited to:   

During the survey, conducted 08/11/22, Oregon Department of Human Services infection control guidelines, which were established to protect the facility staff and residents from the spread of COVID 19 and made available to all facilities, were not being followed by the facility.

On 08/11/22 at 8:50 am, when the surveyor entered the facility, observations were made of two facility staff members not wearing masks while providing resident care.

On 08/11/22, the need for proper wearing of required protective facemask's by all staff was discussed with Staff 1 (Administrator) and Staff 2 (Owner). They acknowledged the findings.

1. Infection control has always been one of our top priorities and this can be evidenceced by the fact that Forest Meadows has never had a case of flu or covid since the outbreak began. It is the policy of Forest Meadows to follow all state rules, regulations and guidelines. Even though the state mask mandate has been lifted, this does not apply to medical facilities. Even though Forest Meadows is a Home like enviornment and it feels like a home, it is still a medical faciliy and must maintain the mask mandate. Immediately all employees will be informed they must wear the face mask as discribed in OAR 411-054-0025.

2.The next inservice training meeting, an overview of the rules and regulations will be presented and all employees will sign an acknoledgement of the rules and agree to follow them.

3. Visual  observation will be done daily

4. Administrator

Based on observation, interview and record review, it was determined the facility failed to have sufficient number of caregiving staff to meet the 24-hour scheduled and unscheduled needs of residents to compensate for staff duties beyond direct resident care. Findings include, but are not limited to:

Observations, interviews and record review during the survey revealed the following:

*The facility utilized Universal Workers whose job duties included passing medications, providing care and services to residents, housekeeping, laundry, cooking and activities.

*Observations on 08/11/22 revealed one universal worker on day shift with a census of 15 residents. Interview with Staff 3 (Universal Worker) revealed she was the only staff member on the floor.

*Review of the staffing schedule and interview with Staff 1 (Administrator) during the survey revealed the facility had one staff scheduled at a time during evening and night shifts.

The need to increase staffing levels to compensate for increased staff duties and unscheduled resident needs was discussed with Staff 1 on 08/11/22. She acknowledged the need for increased staff.

1. Our Staffing plan has been the same since 2004 and is displayed in our uniform disclosuer statement which was last approved in 2018. A copy of the uniform discloser statement and the past survey is out and available at all itmes. Staffing is defined by the number of direct care hours detirmined by the ABST. Having the ABTS really helps to define these hours, and we use this tool to obtain the exact direct care hours so we are able to discern our staffing needs and adjust as needed. A copy of the 2018 and 2022 revised Uniform Disclosure Statement are attached.

2. We have added the ABST to our system to verify we have adequate staffing based on occupancy and acuity

3. We look at our staffing needs constantly and are always looking for a new quality person to add to the team.

4. Administrator/Owners

Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) that met the regulation. Findings include, but are not limited to:

On 08/11/22, the ABST was requested from Staff 1 (Administrator). She reported the facility had not yet implemented the ABST.

There was no documented evidence the facility was using an ABST that would determine a staffing plan reflective to meet the 24-hour scheduled and unscheduled needs of residents.

The need to implement an ABST was discussed with Staff 1 (Administrator) and Staff 2 (owner) on 08/11/22. They acknowledged the findings.

1. We have decided to adopt the DHS-ABST and implemented it immediately.

2. We have inputted all residents into the system and answered questions to determine the amount of direct care needed per day, per resident. We created a book which can be reviewed easily and it can be updated with major change of conditions.

3. We will review the direct care hours every month after resident 90 day review, with new resident admit, and the 30 day reviews.

4 Administrator/owners