The findings of the re-licensure survey, conducted 07/29/24 through 08/01/24, 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

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 08/01/24, conducted on 09/11/24, 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 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 07/30/24 and discussed with Staff 1 (Regional Director of Operations) and Staff 4 (Administrator) on 07/31/24 at 1:40 pm. The facility had implemented the Department's ABST tool.

There was no documented evidence the facility updated the ABST data for each resident whenever there was a significant change of condition and no less than quarterly, nor was there evidence they routinely updated their staffing plan.

The need to ensure residents' ABST was reviewed no less than quarterly and whenever there was a significant change of condition, and the tool was used to develop and update the facility's staffing plan, was discussed with Staff 1 and Staff 4 on 08/01/24 at 11:30 am. They acknowledged the findings.

1. What action will be taken to correct violation: Admin will be using the ODHS, ABST approved tool and updating at move-in, the first 30 day eval, quarterly and with a significant change of condtion.

2. How will this system be corrected: Admin reviewed  Acuity- based Staffing Tool Provider Guide. Admin will enter every resident in on their move in date, update at 30 days, quarterly and significant change of condtion. Open and close each residents ABST even if no changes have occurred, creating a time stamp.

3. How often will the area be evaluated: Move-in, 30 day evaluation, quarterly, and a significant change of condition.

4. Who will be responsible: The Admininistrator will input and update, RN and Care staff will assist with data retrieval. Admin will open and close residents ABST even if no changes have occurred, to create the time stamp.

Based on interview and record review, it was determined the facility failed to ensure 1 of 3 newly-hired direct care staff (#7) demonstrated satisfactory performance in all assigned duties within 30 days of hire. Findings include, but are not limited to:

Training records were reviewed on 07/30/24 at 11:20 am with Staff 3 (Business Office Manager). The following deficiencies were identified:

There was no documented evidence Staff 7 (MT), hired 04/01/24, demonstrated satisfactory performance within 30 days of hire of the following required elements:

* Role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Changes associated with normal aging;

* Identification, documentation and reporting of changes of condition; and

* Conditions that require assessment, treatment, observation, and reporting.

The need to ensure newly-hired direct care staff completed training and demonstrated competence in all assigned duties within 30 days of hire was discussed with Staff 3 on 07/30/24 at 11:20 am and Staff 1 (Regional Director of Operations), Staff 2 (ED), and Staff 4 (Administrator) on 07/31/24 at 12:15 pm. They acknowledged the findings.

1. What action will be taken to correct the rule violation: Administrator and the Business office manager along with each employee will review and verify that the 30-day competency checklist and all pre-service trainings are finished prior to being scheduled to train on the floor.

2.How will the system be corrected so this violation will not happen:  The Administrator, Business office manager and the employeee will work together to review and verify that all pre-service trainings are finished prior to being scheduled to train on the floor.

3.How often will the area needing correction to be evaluated: Prior to being scheduled to train on the floor, at 30 days and once a month. Added to Control calendar upon new hire.

4. Who will be responsible to see that the corrections are completed/monitored: Administrator and Business office manager will review and verify that all pre-service trainings are finished prior to scheduling employee to train on the floor.

Based on observation and interview, it was determined the facility failed to ensure exterior pathways were maintained in good repair. Findings include, but are not limited to:

During a tour of the facility on 07/29/24 at 2:15 pm, the following was identified:

* The interior courtyard and residents' private patio areas contained drop-offs, up to approximately six inches in depth, in the following areas:

    - From the concrete surface to adjacent planting beds, in the private patio areas; and

    - From the concrete pathway to adjacent planting beds, in the interior courtyard.

The drop-offs created a potential tripping hazard for residents who used the courtyard or their private patios.

The drop-offs were shown to and discussed with Staff 1 (Regional Director of Operations), Staff 2 (ED), Staff 4 (Administrator), and Staff 10 (Director of Plant Operations) on 07/29/24 at 3:50 pm. They acknowledged the findings.

1. What actions will be taken to correct the rule violation:

Executive Director and Director of Plant operations have added bark placement onto the control calendar and Maintence calendar for twice a year. Done on 8/5/2024. Administrator and Executive director will conduct a quarterly environmental walk through of the community. Added to control calendar quarterly.

2. How will the system be corrected: On August 5th bark was placed along exterior pathways, to ensure there are no significant drops Administrator and Executive director will conduct a quarterly environmental check of the community grounds, added quarterly to control calendar. Bark is scheduled twice a year added to control calendars.

3. How often will the area needing correction be evaluated? Quarterly walk through with Administrator and Executive director.  Findings will be communicated with Director of plant operations.

4. Who will be responsible: Administrator and Executive director will be responsible for quarterly environmental walk through of grounds of the community, Director of plant operation's will be responsible for executing any finidings that need to be corrected.