Mapleview Manor LLC

The findings of the re-licensure survey, conducted 09/11/23 through 09/13/23 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 Home and Community Based Services Regulations OARs 411 Division 004.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day
The findings of the first re-visit to the re-licensure survey of 09/13/23, conducted 11/07/23, 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 a supportive device with potentially restraining qualities was assessed by an RN, PT or OT, less restrictive alternatives prior to use were documented, instruction was provided to caregivers on the correct use of and precautions for the device, and use of the device was documented in the resident's service plan for 1 of 1 sampled resident (#2) who had side rails on his/her bed. Findings include, but are not limited to:Resident 1 was admitted to the facility in 09/2021 with diagnoses including Alzheimer's Disease. Observation of the resident's room 09/11/23 revealed bilateral half-length side rails on the resident's bed. During an interview on 09/12/23, Staff 4 (Med Tech) stated the resident used the side rails for bed mobility.There was no documented evidence the following required elements were completed:* Thorough assessment by an RN, PT or OT; * Documentation of less restrictive alternatives evaluated prior to use of the device; * Instruction provided to staff on the correct use and precautions related to the device; and* Documentation of side rails in the resident's service plan.The need to ensure the use of a supportive device with potentially restraining qualities was assessed by an RN, PT or OT, included documentation of all required elements and was included in the resident's service plan was discussed with Staff 1 (Administrator) on 09/13/23. She acknowledged the findings, and no additional documents were provided.

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 09/12/23.There was no documented evidence all 22 required ADLs were addressed separately on the acuity-based staffing tool the facility was using.The need to have all required ADLs listed separately on the ABST was discussed with Staff 1 (Interim Administrator) and Staff 2 (RN Administrator) on 09/12/23 and 09/13/23. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure compliance with licensing rules related to Residential Care and Assisted Living regulations. Findings include, but are not limited to:Refer to C340 and C361.