The findings of the Change of Ownership Survey, conducted 04/11/22 through 04/13/22, 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 for 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 re-visit to the re-licensure survey on 04/06/22, conducted 06/15/22 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 and Home and Community Based Services Regulations OARs 411 Division 004.

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

Resident 4 moved into the facility in March 2022.

The resident's move-in evaluation was reviewed, and the following required elements were not addressed:

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

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

The need to ensure new move-in evaluations address all required elements was discussed with Staff 1 (ED) and Staff 3 (Health Services Director) on 04/12/22. They acknowledged the findings.

1.  Resident 4 will be evaluated for these two missing components.

2.  Our community uses an evaluation tool (form) in which these two components were added so that the person performing the evaluation with a potential resident will answer or complete these two components.

3. and 4.  The area needing correction will be evaluated by the Health Services Director after each new move in evaluation to all components are completed.  The Administrator will evaluate quarterly to ensure this new system is successful and corrections are completed.    

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:

On 4/12/22, the facilities Fire and life safety records were reviewed.  The records revealed fire and life safety instructions were not provided to staff on alternating months from the fire drills.

In an interview on 04/12/22, Staff 1 (ED) acknowledged the facility failed to provide life safety instructions to staff on alternate months from fire drills.

1.  Life safety instructions were provided to staff on an alternating month from fire drills beginning in March 2022.  

2.  Our Maintenance Director will continue to perform this life safety instructions to staff during the all staff meeting on alternating months from fire drills.  

3.  and 4.  This area will be evaluated quarterly by the Administrator to ensure corrections are completed and there is ongoing compliance.