The findings of the re-licensure survey conducted 03/07/22 through 03/08/22 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

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 first re-visit to the re-licensure survey of 03/08/22, conducted 05/25/22 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.

Based on interview and record review, it was determined the facility failed to ensure new move-in evaluations addressed all required elements for 1 of 1 sampled resident (# 4) who was recently admitted to the facility. Findings include, but are not limited to:

Resident 4 moved into the facility in 02/2022.

The move-in evaluation failed to address the following areas:

* Spiritual, cultural preferences;

* Effective non-drug interventions for mental health issues;

* Ability to manage medications;

* Activities of daily living including housework and laundry;

* Personality, including how the person copes with change and challenging situations;

* Pain including pharmaceutical and non-pharmaceutical interventions;

* Complex medication regimen;

* Elopement risk or history; and

* Environmental factors that impact the resident's behavior including but not limited to: noise, lighting, room temperature.

The need to ensure move-in evaluations included all required elements was discussed with Staff 1 (Administrator) on 03/08/22. She acknowledged the findings.

A revision of our Resident Move-in Evaluation to include all objectives from OAR 411-054-0034 (5) by 05/07/2022. From this point forward, all admission will use our updated Resident Move-in Evaluation to ensure this will not happen in the future.

All current residents records will be reviewed and updated to our new standard immediately, then quarterly or when changes occurs.

Administrator or designee will review all Resident Move-in Evaluations, current and future, to assure that all components are addressed and/or completed prior to resident move-in.

For redundancy, Our Resident Care Managers will review all pages of the Resident Move-in Evaluation to ensure all components are addressed and/or completed prior to filing in resident records and developing Service Plans.

Based on interview and record review, it was determined the facility failed to provide life safety instruction to staff on alternating months from fire drills. Findings include, but are not limited to:

Fire and life safety records, reviewed between 09/2021 and 03/2022, revealed that

fire and life safety instructions were not provided to staff on alternating months from the fire drills.

In an interview on 03/08/22, Staff 1 (Administrator) acknowledged the facility failed to provide life safety instructions to staff on alternate months from fire drills.

With the decrease in COVID directives and the ability to gather staff in larger groups, our Fire, Life and Safety instruction for staff will immediately resume during our monthly mandatory staff meetings. The Fire, Life and Safety instruction will alternate months to coincide with fire drills.

McKenzie Living-Eugene's Safety Committee will ensure both fire drills are completed and recommend Fire, Life and Safety training topics to be taught during our monthly mandatory meetings.   

Assistant Administrator or designee will ensure compliance of OAR 411-054-0090 (1)(a-d) by auditing fire drills and staff instruction quarterly.

Based on observation and interview, it was determined the facility failed to ensure courtyards, pathway edges and sidewalks did not contain drop-offs to prevent a tripping hazard for residents. Findings include, but are not limited to:

The facility consisted of five houses. The outdoor courtyard/patio areas, pathways and sidewalks were toured on 3/7/22 and 3/8/22. Drop-offs were observed along the sidewalks and in each of the courtyard and patio areas of all houses.

The need to ensure all exterior sidewalks and pathways were maintained free of drop-offs was discussed with Staff 1 (Administrator) on 3/8/22. She acknowledged the findings.

Administrator contacted our landscape provider, while surveyors were present, and instructed them to put gravel alongside the walkway/pathway edges to reduce the tripping hazard. Then more mulch will cover the gravel for esthetic purposes.

Maintenance personnel will ensure that the landscapers check the depths monthly and add both gravel and mulch as needed to ensure there are no tripping hazards.

Administrator will add pathway drop off to our monthly building/grounds checklist to ensure compliance of OAR 411-054-0200 (3) when inspecting the grounds.