Print Inspection: Y0N3

The findings of the relicensure survey conducted 05/01/23 through 05/03/23 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, 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 first revisit to the re-licensure survey of 05/03/23, conducted 07/27/23, 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 57 for Memory Care Communities.

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 second re-visit to the re-licensure survey of 05/03/23, conducted 10/13/23, 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, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.

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

Resident 1 was admitted to the facility in January of 2023. The following required elements were either incomplete or were not included on the evaluation form:

* Mental health issues, including:
a) Presence of depression, thought disorders, behavioral or mood problems;

b) History of treatment;

c) Effective non-drug interventions;

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

* Recent losses.

On 05/03/23, the need to ensure the initial move-in evaluation contained all required elements was discussed with Staff 1 (Memory Care Director) and Staff 3 (LPN). They acknowledged the findings.

An audit will be completed by Memory Care Administrator  for each resident in memory care to ensure each assessment is complete with all the required elements as noted in

OAR 411-054-0034

Upon initial evaluation MC Administrator or LN will use the updated Evaluation form that addresses all the required elements noted in the CBC guide.

Memory Care Administrator  and LN will be responsible in ensuring the above is completed and followed.

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

Resident 1 was admitted to the MCC facility in 07/2023. The following required elements were either incomplete or were not included on the evaluation form:

* Cognition, including decision making abilities;

* Activities of daily living including dental status;

* Fluid preferences; and

* History of dehydration

On 07/27/23, the need to ensure the initial move-in evaluation contained all required elements was discussed with Staff (10) and Staff 3 (LPN). They acknowledged the findings.

The Offline Evaluation tool has been completely revised to update and include all elements required as noted in Re- Survey. The Updated Initial Evaluation will be used with any potential admissions prior to move in date. The Memory Care Administrator will be responsible in monitoring the accurate form is utilized and completed

Based on interview and record review, the facility failed to use the results of an Acuity-Based Staffing Tool (ABST) to develop and routinely update the facility's staffing plan. Findings included, but are not limited to:

Record review on 05/02/23 of the posted staffing plan, the facility's ABST, and the staffing schedule for 04/01/23 to 05/03/23 revealed the scheduled staffing plan was not reflective of the ABST.

In an interview on 05/02/23 with Staff 1 (Memory Care Director) and Staff 10 (ALF Executive Director) it was determined the facility had not been scheduling the number of direct care staff as determined by the ABST.

The need to ensure the facility followed the staffing plan generated by the ABST was discussed with Staff 1 and Staff 10 on 05/03/23. They acknowledged the findings.

This community shall utilize the acuity based staffing tool (ABST) to determine appropriate staffing for the community

as noted in OAR 411-054-0037.

The community will fully implement the ABST selected and complete an ABST assessment for each resident.

The community will update and utilize the ABST tool to develop and routinely update the communities staffing plan to convert evaluated care needs of residents into staff hours to generate a community staffing plan.

Memory Care Administrator will be complete and monitor / update  for accuracy weekly and as needed with any care changes.

Based on interview and record review, the facility failed to use the results of an Acuity-Based Staffing Tool (ABST) to develop and routinely update the facility's staffing plan. This is a repeat citation. Findings included, but are not limited to:

Record review on 07/27/23 of the posted staffing plan, the facility's ABST, and the staffing schedule for 07/02/23 to 07/27/23 revealed the scheduled staffing plan was not reflective of the ABST.

In an interview on 07/27/23 with Staff 10 (ALF Executive Director), it was determined the facility had not been scheduling the number of direct care staff as determined by the ABST.

On 07/27/23 the need to ensure the facility followed the staffing plan generated by the ABST was discussed with Staff 2 (Health Services Director/RN), Staff 3 (Medication Licensed Nurse), and Staff 10. They acknowledged the findings.

The Community will utilize the ABST tool to determine time to meet staff levels and develop a staffing plan to specify the total number of weekly minutes required to meet the 24 HR scheduled and unscheduled needs of residents. This will be evaluated when there is a change in Level of care and/ or new admission. ABST numbers will be printed daily for review during normal business days. This Administrator will report to Kelsie Norton, Corrective Action Coordinator Bi- Monthly to address areas of noted concern, including but not limited to progress of implementation of ABST, barriers , proposed remediation of barriers and timelines for completion. The Memory Care Administrator is responsible to monitor and complete this Plan of Correctio

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted and documented in accordance with Oregon Fire Code (OFC), and fire and life safety instruction to staff was provided and documented on alternate months. Findings include, but are not limited to:

Review of fire drill and fire and life safety records for 11/01/22 through 05/01/23 identified the following:

1. The facility had not documented the following areas related to fire drills conducted:

* Escape route used;

* Problems encountered;

* Comments relating to residents who resisted or failed to participate in the drills;

* Evacuation time period needed;

* Evidence alternate routes were used; and

* Number of occupants evacuated.

2. In an interview conducted 05/02/23 at 1:30 pm with Staff 8 (CG) and Staff 9 (CG), they were unable to clearly state where the designated point of safety was located.

3. The facility did not consistently conduct and document fire and life safety instruction for staff on alternate months.

The need to ensure the facility conducted fire drills per the OFC and provided fire and life safety instruction to staff on alternate months was reviewed with Staff 1 (Memory Care Director) on 05/03/23. She acknowledged the findings.

The community will conduct fire drills and life safety training as required per OAR 411-054-0090

requirements.

The community will conduct fire drills every other month and life safety training on alternate months with complete documentation as required.

All staff in- service on fire drills and life safety will take place on 5/10/23.

Memory care Administrator and ESD will be responsible to oversee and conduct fire drills and life safety trainings.

Based on interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:

Refer to C 252, C 361, Z 142, and Z 162.

Please refer to C252 and C361

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 361 and C 420.

Referral tag, refer to C361 and C420

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

Refer to C 361.

Please refer to C252 and C361

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 252

Referral tag, refer to C252

Based on interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:

Refer to C 252.

Please refer to C252 and C361