The findings of the initial survey conducted 02/05/24 through 02/07/24 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 02/07/24, conducted on 04/18/24, 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 observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs and provided clear instructions to staff for 1 of 2 sampled residents (#1) whose service plans were reviewed. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 12/2022 with diagnoses including hypertension.

Observations, interviews, and review of the current service plan dated 12/18/23, revealed the service plan was not reflective of the resident care needs and did not provide clear direction to staff which included a written description of who shall provide the services and what, when, how, and how often the services should be provided in the following areas:

* Bathing;

* Bowel and bladder care; and
* Ambulation.

On 02/07/24, the need to ensure service plans were reflective of resident care needs and included a written description of who should provide the services and what, when, how, and how often the services should be provided was discussed with Staff 1 (Executive Director). He acknowledged the findings.

The facility administrator reviewed and updated #1 service plan.The facility administrator reassured all residents service plans are up to date and in compliance with services.Each category of service plans will be updated per the residents' needs.  

Service plans will be reviewed on admission date, 30 day and quarterly bases and change of condition. Staff educated to report to facility administrator if service plan does not match residents's services. The facility administrator to ensure service plans are updated immediately after any change of condition.  

Service plans will be reviewed on admission date, 30 day, quarterly bases and during any change of conditions.

The facility administrator.