The findings of the re-licensure survey, conducted 04/29/24 through 05/01/24, 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

MCC:Memory 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 first re-visit to the re-licensure survey of 05/01/24, conducted on 02/05/25, 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 interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) which met the regulation. Findings include, but are not limited to:

The facility's ABST was reviewed on 04/30/24.

There was no documented evidence all 22 required ADLs were addressed separately on the ABST staffing tool the facility was using.

The need to have all required ADLs listed separately on the ABST was discussed with Staff 1 (ED) and Staff 2 (District Director of Operations) on 04/30/24. They acknowledged the findings.

As we continue to partner with DHS on reviewing our ABST tool, we will continue to staff According to our Brookdale acuity based staffing tool.

2. Our home office team will continue to establish proper communication with DHS regarding The ABST tool and the 22 elements that make up the ABST tool, we will continue to staff at or above staffing levels currently identified in our tool.  We will continue our bi-weekly reporting to the department until we have received DHS approval on our ABST.

3.  This will be evaluated by the Health and Wellness Director/Resident Care Coordinator to ensure that proper staffing levels are scheduled according to the 22 elements to ensure the scheduled and unscheduled needs of the residents are being met.

4. The Executive Director is responsible to ensure that our staffing levels are appropriate as defined by our staffing tool      

Concerns were identified and the facility was provided with technical assistance in the following areas:

H1517

(2) Provider owned, controlled, or operated residential settings must have all of the following qualities:

(d) Each individual has privacy in his or her own unit.