The findings of the re-licensure survey, conducted 10/24/23 through 10/26/23, 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 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

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 revisit to the re-licensure survey of 10/26/23, conducted on 12/27/23, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities

Based on interview and record review, it was determined the facility failed to implement an Acuity-Based Staff Tool (ABST) by July 1, 2022 to determine appropriate staffing levels for the facility. Findings include, but are not limited to:

On 10/26/23, Staff 1 (Administrator) was asked to provide evidence the facility had implemented an ABST tool to determine appropriate staffing levels for the facility. Staff 1 stated she had created an ODHS ABST account but had not added resident information into the system.

The need to ensure the facility implemented an ABST was reviewed with Staff 1 on 10/26/23. She acknowledged the findings.

ID PREFIX TAG: C361 - Acuity-Based Staffing Tool

Provider's Plan of Correction regarding ID PREFIX TAG: C361: Acuity-Based Staffing Tool:

"Mountain View Administrator Sandra Arevalo-Vargas is overseeing and monitoring the plan of correction for C361: Acuity-Based Staffing Tool, in order to be within compliance in 60 days, by 12/25/2023. The ABST has been completed online for each current resident at Mountain View Residential Care Facility and has addressed each resident's activities of daily living and other tasks related to care, in order to accurately calculate the amount of staff time needed during each shift. The administrator has been in communication with Katie Gaffney: ABST Policy Analyst, at the Safety, Oversight and Quality Unit, in the Oregon Department of Human Services. Katie has acknowledged the online completion of the ABST. Katie has responded to the email and informed that "The next steps will come from Kelsie Norton who is the ABST corrective action coordinator" (see attached email thread). The administrator is currently still waiting to receive the next steps from Kelsie Norton. To correct the system so that this violation will not happen again, the administrator will ensure that the ABST updates will be routinely conducted each quarter concurrently with the service plans for each resident, as well as any time there is a significant change of condition for a resident. Additionally, ABST updates will be completed within 30 days of any new resident that is admitted to the facility in the future. The administrator will utilize the ABST to effectively staff the facility according to the 24-hour scheduled and unscheduled needs of residents. The administrator will also ensure to provide the Department with the current ABST at the time of any Department assessment of facility staffing levels."

Based on observation and interview, it was determined the facility failed to ensure all exterior pathways were maintained in good repair. Findings include, but are not limited to:

The rear outdoor walking path was toured on 10/26/23 at 10:00 am. The following issues were identified:

* The walking path had a raised area of approximately three inches where seams in the cement met. The uneven surface created a tripping hazard for residents.

* There were drop-offs along the pathway of approximately three and four inches from the pathway surface to the planting bed. This created a potential hazard for residents.

The hazards were discussed with Staff 1 (Administrator) on 10/26/23 at 10:20 am. They acknowledged the findings.

ID PREFIX TAG: C510 - General Building Exterior

Provider's Plan of Correction in regard to ID PREFIX TAG: C510: General Building Exterior

"Mountain View Administrator Sandra Arevalo-Vargas is overseeing and monitoring the plan of correction for C510: General Building Exterior, in order to be within compliance in 60 days, by 12/25/2023. The following hazards were acknowledged for the exterior rear outdoor walking pathway: a 3-inch raised area in between the cement seams that created a tripping hazard, and drop-offs along the pathway ~3-4 inches from the pathway surface to the planting bed that created a hazard. A plan of correction has been initiated by the administrator and these hazards will be fixed. The administrator has contacted Meghan McClain: Operations and Policy Analyst, at the Safety, Oversight and Quality Unit, in the Oregon Department of Human Services, for guidance on how to correct the issue, as these pathways with these specific hazards are not in common walking areas for staff, residents, or family/friends of residents, only for facility building maintenance staff to manage/maintain exterior landscape and building. Meghan has approved our request to build a fence and gate with a sign that warns staff, residents, and family/friends of residents that the pathway is uneven and not accessible, only be maintenance staff (see attached email thread). The administrator has hired an independent contractor to build the fence, gate, and sign, which will be built and completed by 12/25/2023. To correct the system so that this violation will not happen again, the administrator will ensure that facility building maintenance and housekeeping staff will routinely (monthly) evaluate the exterior of the facility with the supervision of the administrator to ensure there are no hazards on the exterior pathways for the facility residents or staff, and that the pathways are in good repair. Additionally, the administrator will ensure all facility staff is aware of this exterior change, that it will not be accessible to staff, residents, or family/friends of residents, so that they may effectively communicate this to residents and family/friends of residents if they ask."

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

Observations of the facility on 10/25/23 and 10/26/23 revealed the following:

* Rooms S-10, S-11, S-17, S-18, and S-20 had scraped doors and/or jambs;

* The entrance door to the living room had a scraped door and jamb;

* The living room had several walls that were gouged or scraped;

* Room N-3 had gouges and scrapes in the wall and corner near the closet;

* The common bathroom near Room N-3 had a scraped door and jamb, and two of four light bulbs were burnt out in the fixture over the sink;

* The common bathroom near Room S-14 had a hole in the ceiling above the transfer pole, and black matter in the caulking along the shower transition strip;

* The common bathroom near Room S-19 had light bulbs missing from the fixture above the sink, and black matter in the caulking surrounding the toilet; and

* White, painted baseboards throughout the facility had a layer of dust and dirt on the top edge and several scraped areas.

The surveyor toured the environment with Staff 1 (Administrator) on 10/26/23 at 08:50 am. She acknowledged the above areas needed to be cleaned and repaired.

ID PREFIX TAG: C513 - Doors, Walls, Elevators, Odors

Provider's Plan of Correction in regard to ID PREFIX TAG: C513: Doors, Walls, Elevators, Odors

"Mountain View Administrator Sandra Arevalo-Vargas is overseeing and monitoring the plan of correction for C513: Doors, Walls, Odors, in order to be within compliance in 60 days, by 12/25/2023. The administrator acknowledged that the following interior areas of the facility need to be cleaned and repaired: rooms S-10, S-11, S-17, S-18, and S-20 doors and jambs with scrapes, living room entrance scraped door and jamb, living room walls with gouges and scrapes, room N-3 wall and corner gouges and scrapes, common bathroom near room N-3 scraped door and jamb and two burnt light bulbs, common bathroom near room S-14 ceiling hole and black matter in caulking, and common bathroom near room S-19 missing light bulbs and black matter in caulking, and lastly, the dust and dirt along the white painted baseboards throughout the facility. A plan of correction has been initiated by the administrator in which these areas will be cleaned and repaired. The administrator has contacted an independent contractor to repaint the interior areas of the facility that have gouges and scrapes by 12/25/2023, which as of today (11/08/2023) is 50% completed. Additionally, the administrator has tasked the facility building maintenance and housekeeping staff with replacing the light bulbs in the common bathrooms and re-caulking the shower transition strip and toilet, all of which will be completed by 12/25/2023. To correct the system so that this violation will not happen again, the administrator will ensure that facility building maintenance and housekeeping staff will routinely (monthly) evaluate the interior of the facility with the supervision of the administrator to ensure there are no areas of the interior of the facility (like ceilings, walls, baseboards, doors, jambs, or light fixtures) that need to be fixed; and that the interior of the facility is in good repair. Additionally, the housekeeping staff will conduct 2 x weekly cleanings of the interior of the facility."