The findings of the re-licensure survey, conducted 03/04/24 through 03/05/24, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 Home and Community Based Services Regulations.

Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.

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 03/05/24, conducted on 05/08/24, 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 observation, interview, and record review, it was determined the facility failed to ensure a minimum of two direct care staff were scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs. Findings include but are not limited to:

The facility was home to 17 memory care residents at the time of the  licensure survey.

During the acuity interview on 03/04/24, and observations on 03/04/24 and 03/05/24, the facility was noted to have three residents with high ADL care needs including one who required two staff for transfer/mobility assistance and meal assistance to eat.

The facility MCC staffing plan, staff schedule, and number of staff observed during the survey revealed the following discrepancies:

The MCC staffing plan identified one Caregiver and one Medication Aide scheduled on day shift (6:00 am - 2:00 pm) and swing shifts (2:00 pm - 10:00 pm), and one Caregiver or one Medication Aide for the overnight shift (10:00 pm - 6:00 am).

The facility had an exception to share staff with the attached ALF. The ALF had one Caregiver or Medication Aide scheduled for the overnight shift.

In an interview with Staff 1 (Administrator) on 03/04/24, she acknowledged two direct care staff were not scheduled and available in the MCC at all times to account for a resident requiring the assistance of two direct care staff for scheduled and unscheduled needs.

Resident requiring 2 staff is no longer living in community.

Staffing needs will be reviewed and scheduled to meet resident needs

Upon change of condition or as needed for scheduling

Administrator and Resident care coordinator

Based on interview and record review, it was determined the facility failed to ensure all residents' acuity was reviewed no less than quarterly and the Acuity Based Staffing Tool (ABST) was updated. Findings include, but are not limited to:

Review of the facility's ABST, CommuniCare, revealed not all residents had been reviewed or updated quarterly. Three unsampled residents lacked evidence of their acuity being reviewed since 10/2023.

The need to ensure all resident acuity was reviewed and updated in the tool at least quarterly was reviewed with Staff 1 (Administrator) and Staff 4 (RCC) on 03/05/24.  They acknowledged the findings.

ABST was updated to reflect current resident needs

Per policy, ABST will be updated and reviewed

at least quartly or upon change of condition

Will be monitored monthly

Administrator and Resident care cordinator  

Based on interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to C 360 and C 361.

Refer to c-360 and c-361