The findings of the change of ownership licensure survey, conducted 06/20/23 through 06/22/23, 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 first re-visit to the re-licensure survey of 06/22/23, conducted on 08/29/23, 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 service plans were reflective of residents' needs and provided clear direction regarding the delivery of services for 1 of 3 sampled residents (# 2). Findings include, but are not limited to:

Resident 2 was admitted to the facility in 06/2021 with diagnoses including chronic pain.

Observations of the resident apartment, interviews with the resident and staff from 06/20/23 to 06/21/23, review of the evaluation and service plan dated 02/08/23, and June ADL sheets, showed the service plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas:

* Use of a 1/2 side rails on the bed, including risks and precautions; and

* The use of a commode chair for toileting.

The need to ensure residents' service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (ED) Staff 2 on 06/21/23. She acknowledged the findings.

First, we did an audit of all residents who are using side rails for mobility or attached call light cord. We are updating all service plans to reflect resident teaching with verbalized understanding of risks and precautions of use of side rails. We are following that up with training for staff to understand risks and precautions for use as well as instructions on notifying the nurse on duty if there is a change in the residence use of side rails.

Resident number two service plan nursing assessment and ADL she has been updated with current needs regarding toileting/ commode use.

The Service Plan Team will do this and evaluate every 90 days of change in condition.   

Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) that met the regulation. Findings include, but are not limited to:

There was no documented evidence the facility was using an ABST that included all the required ADL elements.

The requirements of the ABST were discussed with Staff 1 (ED) on 06/20/23 and 06/21/22. She acknowledged the current acuity tool in use by the facility did not address all the required activities of daily living.

After discussion with surveyor and clarification that our acuity tool in current use was not satisfactory to the requirements, we drafted a template that used all the current required ADL elements. Our old acuity tool, our draft and our old matrix for staffing considerations have been sent to the CBC correction team for review.

We will take any advice that they give and we will implement that acuity-based staffing tool for further assessment of staffing considerations.

The RCF Administrator and Resident Care Manager will finish this and update monthly and as needed.   

Based on observation and interview, it was determined the facility failed to ensure the glass and area surrounding the fireplace did not exceed 120 degrees F. Findings include, but are not limited to:

On 06/20/23, observation during the survey revealed a gas fireplace was located in the living room.  When in operation, the glass face of the unit  was measured and exceeded 150 degrees F.

The need to ensure fireplace glass and the area surrounding the fireplace did not exceed 120 degrees F was discussed with Staff 1 (ED) on 06/20/23. She acknowledged the findings.

The fireplace remained off during the survey.

Temporary lock has been placed on the switch that turns the fireplace on to ensure that staff can protect safety during the investigation phase.  

We have looked at some alternatives including a type of barrier that would not heat up, a new glass piece that would provide space to prevent the outward glass reaching 120 degrees Fahrenheit or decommissioning our gas fireplace and replacing with a modern low temp version.

The RCF Administrator and Facilities Manager will complete this.