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

Based on observation, interview, and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities was assessed by an RN, PT or OT,  less restrictive alternatives prior to use were documented, instruction was provided to caregivers on the correct use of and precautions for the device, and use of the device was documented in the resident's service plan for 1 of 1 sampled resident (#2) who had side rails on his/her bed. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 09/2021 with diagnoses including Alzheimer's Disease.

Observation of the resident's room 09/11/23 revealed bilateral half-length side rails on the resident's bed. During an interview on 09/12/23, Staff 4 (Med Tech) stated the resident used the side rails for bed mobility.

There was no documented evidence the following required elements were completed:

* Thorough assessment by an RN, PT or OT;

* Documentation of less restrictive alternatives evaluated prior to use of the device;

* Instruction provided to staff on the correct use and precautions related to the device; and

* Documentation of side rails in the resident's service plan.

The need to ensure the use of a supportive device with potentially restraining qualities was assessed by an RN, PT or OT, included documentation of all required elements and was included in the resident's service plan was discussed with Staff 1 (Administrator) on 09/13/23. She acknowledged the findings, and no additional documents were provided.

The facility nurse has completed a thorough assesment of the supporive device and caregivers have been instructed on proper use. Care plan has been updated. In addition, we have audited to ensure additional residents with siderails have appropriate assessments and care planning.

We have reviewed our policies related to supportive devices with restraining policies and our assessment tool. No changes are needed at this time. However, we have established a communication system to inform our nurse of needed assessments when a siderail is requested by the family or determined to be needed for the resident.

We will evaluated quarterly, by performing an audit of residents with siderails and then examining the clinical record and care plan to ensure our policies are followed.

Our Administrator in collaboration with our nurse.

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 09/12/23.

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

The need to have all required ADLs listed separately on the ABST was discussed with Staff 1 (Interim Administrator) and Staff 2 (RN Administrator) on 09/12/23 and 09/13/23. They acknowledged the findings.

No specific residents were cited. We will consider all residents at risk related to this citation

We are adopting the State ABST tool and are in the process of developing policies based on the requirements as well as using the facility resident evaluations to assist with completion of the tools and analyzing our staffing based on the tool.

As per requirements, every quarter with service planning, with each admission and with each resident change of status.

The Administrator is responsible.

Based on observation, interview, and record review, it was determined the facility failed to ensure compliance with licensing rules related to Residential Care and Assisted Living regulations. Findings include, but are not limited to:

Refer to C340 and C361.

Refer to C340 and C361.