The findings of the re-licensure survey, conducted 07/10/23 through 07/13/23, 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.

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 revisit to the re-licensure survey of 07/13/23, conducted 09/11/23 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 and Home and Community Based Services Regulations OARs 411 Division 004.

2. On 07/12/23 at 3:24 pm, the acuity-based staffing tool (ABST) was reviewed with Staff 1 (Health and Wellness Director/RN) and Staff 2 (Health and Wellness Coordinator/LPN) and revealed the following:

a. Resident 4 was admitted to the facility in 11/2015 and his/her ABST had not been reviewed and updated quarterly since 02/13/23.

b. Resident 6 was admitted to the facility in 01/2014 and his/her ABST had not been reviewed and updated quarterly since 02/13/23.

The need to ensure the facility's ABST was updated no less than quarterly was reviewed with Staff 1 and Staff 2 on 07/12/23. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure the Acuity-Based Staffing Tool (ABST) was updated no less than quarterly and accurately reflected resident care needs for 3 of 6 sampled residents (#s 1, 4, and 6) whose ABST data was reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 12/2020 with diagnoses including anxiety and difficulty walking.

Review of the resident's service plan dated 06/08/23, progress notes dated 04/10/23 to 07/10/23, interviews with staff, and interviews and observations of the resident revealed ABST entries were not reflective of the current care needs in the following areas:

* Monitoring behavioral conditions or symptoms;

* Ensuring non-drug interventions for behaviors; and

* Assistance with ambulation, including escorting to and from meals and activities.  

The ABST data reflected zero minutes when the resident required staff assistance with the above areas.

The need to ensure the ABST reflected resident care needs was discussed with Staff 1 (Health and Wellness Director/RN) and Staff 2 (Health and Wellness Coordinator/LPN) on 07/12/23. They acknowledged the findings.

Administrator reviewed resident's service plan for Resident #1 on 7/27/23 and 7/28/23.  Administrator discussed service plan and findings with the nursing team on 7/27/23.  The ABST for Resident # 1 was updated to reflect team member time monitoring behavioral conditions, ensuring non-drug interventions for behaviors; and assistance with ambulation, including escorting to and from meals and activities.

Administrator reviewed service plan for Resident #4

and Resident #6 on 7/28/23 and will be completing the update on the ABST on 8/2/2023 after conferring with the nursing team.

Administrator and nursing team have scheduled weekly ABST meetings at 9:30 am each Wednesday to review updated care plans, any COC and update the ABST accordingly.

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 resident rooms 221, 223, 227, and 230 identified:

* Stained carpets throughout in all apartments;

* Damage to entry and bathroom door frames in 221 and 230;

* Damage to bathroom walls in 221 and 223; and

* Damage to bedroom/living room walls in 230.

The areas in need of cleaning and repair were reviewed with Staff 1 (Health and Wellness Director/RN), Staff 2 (Health and Wellness Coordinator/LPN), and Staff 3 (Maintenance Director) on 07/11/23 and 07/12/23. They acknowledged the findings.

Administrator scheduled replacement of all flooring in resident room 223 on 7/26/23.  Flooring as well as all repairs to bathroom walls and door frame completed 7/27/23.  Administrator scheduled flooring replacement for apartment 230 on 8/2/23.  Maintenace team is repairing damage to living room walls, entry and bathroom door frames and will be completed by 8/3/23. Flooring for entire apartment 221 is scheduled for replacement on 8/9/23.  Repairs to entry and bathroom walls for Apartment 221 was completed 7/28/23.

Administrator retrained leadership team on identifying repairs and the reporting process in electronic TELS maintenance system on 7/27/23.

Administrator held a Town Hall meeting for residents on 7/27/23 and trained on the process for initiating apartment repairs.  Administrator and marketing team established daily building walk through schedule beginning 7/31/23.  Administrator training at All Staff 8/10/23 on reporting building and apartment repairs.