The findings of the re-licensure survey, conducted 07/29/24 through 08/01/24, 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

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 re-licensure survey of 08/01/24, conducted on 11/13/24, are documented in this report. It was determined the facility was in compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004

Based on observation, interview, and record review, it was determined the facility failed to notify SPD related to suspected abuse for 1 of 1 sampled resident (#5) reviewed with an allegation of abuse. Findings include, but are not limited to:

Resident 5 was admitted to the facility in 12/2023 with diagnoses including bipolar disorder and major depressive disorder recurrent.

During an observation and interview with Resident 5 on 07/30/24 at 11:40 am, the following was noted:

During an interview with Resident 5 on 07/30/24 at 11:40 am, s/he was observed sitting in a recliner with his/her feet elevated. The resident reported s/he was having a difficult time talking about incidents that had occurred with an employee, which s/he wanted to share with the surveyor. The resident was observed to be tearful and had to take several deep breaths before s/he could continue. The following was revealed by the resident:

* A staff member started visiting the resident frequently, entering his/her apartment and sitting on the bed to visit without permission.

* Resident 5 began receiving gifts from the staff member every day, as well as receiving frequent hugs.

* The staff member was calling every day, even on their days off, to inquire about the status of the resident.

* The staff member was sharing personal information about other staff members with the resident.

* The staff member started saying, "I love you," upon departure from the resident's room.

Resident 5 stated s/he felt "abused" by the staff member and had reported the incidents to the administrator.

In an interview with Staff 1 (ED) on 07/30/24 at 3:15 pm, he acknowledged the resident had made a complaint regarding suspected abuse. Although an internal investigation had been completed and a formal write-up had been documented, there was no documented evidence the allegation of suspected abuse had been reported to the local SPD office.

Staff 1 documented a thorough investigation and reported the incident to SPD on 07/30/24 at approximately 5:30 pm.  Staff 1 verified the staff member had received a formal write-up and was directed to not have any contact with the resident, including visiting, phone calls, and/or text messages.

The need to notify SPD immediately of any incident of abuse or suspected abuse was discussed with Staff 1 on 07/30/24 at 3:15 pm.  Staff acknowledged SPD had not been notified of the situation.

1) Abuse and Neglect reporting requirements training for all staff regarding mandatory reporting, timely reporting and contact/investigation procedures to be provided.

2) Abuse and Neglect reporting requirements refresher training added to annual training schedule to ensure staff stay aware of process.

3/4) Business office manager in conjunction with RN/ED to review annual staff training each year to ensure Abuse and Neglect is covered appropriately.

Based on observation, interview, and record review, it was determined the facility failed to update an acuity-based staffing tool (ABST) to have an accurate number of minutes for 2 of 6 sampled residents (#s 3 and 4) whose ABST was reviewed.  Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 06/2019 with diagnoses including anxiety and multiple sclerosis.

The resident's 06/25/24 service plan, progress notes dated 04/01/24 through 07/29/24, and Resident 3's ABST data was reviewed. Staff were interviewed and observations were made of the resident.

The following areas were not reflective of the resident's current ADL assistance:

* How much time was spent monitoring behavioral conditions or symptoms;

* How much time was spent monitoring physical conditions or symptoms;

* How much time was spent cueing or redirecting due to cognitive impairment or dementia; and

* How much time was spent with bathing.

The need to ensure the ABST tool addressed the amount of staff time needed to provide care was discussed with Staff 1 (ED), Staff 2 (Health Services Administrator), and Staff 12 (Regional VP) on 08/01/24 at 10:30 am. They acknowledged the findings.

2. Resident 4 was admitted to the facility in 01/2021 with diagnoses including alcohol dependence and osteoarthritis.

The resident's 07/23/24 service plan, progress notes from 04/01/24 through 07/25/24, and Resident 4's ABST data was reviewed. Staff were interviewed and observations were made of the resident.

The following areas were not reflective of the resident's current ADL assistance:

* How much time was spent responding to call lights;

* How much time was spent monitoring behavioral conditions or symptoms; and

* How much time was spent cueing or redirecting due to cognitive impairment or dementia.

The need to ensure the ABST tool addressed the amount of staff time needed to provide care was discussed with Staff 1 (ED), Staff 2 (Health Services Administrator), and Staff 12 (Regional VP) on 08/01/24 at 10:30 am. They acknowledged the findings.

1) Staff RN and ED reviewing all resident ABST profiles compared with service planned care to ensure minutes are accurately and appropriately designated for each resident.

2)Staff RN will be proctoring the ABST tool for residents at minimum at time of admit, for quarterly assessments, C.O.C. and other appropriate and necessary situations.

3/4) RN/ED will review at minimum at time of new admit, quarterly assessments, C.O.C.

Based on observation and interview, it was determined the facility failed to ensure all interior materials and surfaces were kept clean and in good repair. Findings include, but are not limited to:

The facility was toured throughout the survey from 07/29/24 to 08/01/24. The following issues were identified:

*  There were gouges and scratches to the wood paneling in the elevator. The laminate on the elevator walls was chipped and broken in multiple areas;

* There were spots and stains on the rugs in the hallway near room 112; and

*  All the settees on the first, second, and third floors had stains on them.

On 07/31/24 at 1:30 pm, the areas needing cleaned or repaired were reviewed with Staff 1 (ED) and Staff 3 (Maintenance Director). They acknowledged the areas needing cleaning and repair.

1) The interior of the elevator in areas noted on SOD will be repaired, patched, painted, covered to restore a level of cleanable surface. All benches will be cleaned, painted, repaired and/or replaced as necessary. Spots and stains on carpet near apartment #112 will be corrected by carpet dye, patch or other appropriate action.

2) All bleach containing cleaning solutions have been removed from housekeeping carts and replaced with appropriate analogs to ensure no further bleaching of carpet occurs.

3/4) Maintenance Director will ensure no bleach containing chemicals are used, will monitor flooring, elevator and furniture for necessary maintenance/cleaning at least monthly.