Harmony Living

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST.

Based on interview and record review, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) data was updated no less than quarterly for 13 unsampled residents, failed to enter ABST data for 1 of 1 sampled resident (#3) prior to admit, and failed to remove an unsampled resident from the ABST who was out of the facility at the hospital during the survey. Findings include, but are not limited to: The facility used the Department ABST, and it was reviewed on 03/09/26 at 1:10 pm. The following was identified: a. Thirteen of 16 resident records had not been updated within the last 90 days. b. One resident was out of the facility at the hospital and his/her data was still active in the ABST. c. Resident 3 was admitted to the facility on 01/05/26, and his/her ABST record was not created until 01/20/26. The need to ensure residents’ ABST data was updated no less than quarterly at the time of their quarterly service plan update, to ensure residents were removed from the ABST when they were out of the facility due to hospitalization, and ensure new resident’s ABST record was created prior to their admission to the facility was discussed with Staff 1 and Staff 2 (Operations Manager) on 03/11/26 at 10:25 am. They acknowledged the findings.

To correct this deficiency, the facility has incorporated the Acuity-Based Staffing Tool (ABST) into our pre- admission checklist, ensuring all evaluations are completed prior to move-in. This addition will prevent any new residents from being overlooked in staffing assessments. Additionally, the administrator will update the ABST at minimum quarterly, as well as with any changes of condition. The administrator will also adjust the ABST accordingly when residents are out of the facility. The ABST will be evaluated daily to identify and address any deficiencies or necessary adjustments. The facility administrator will oversee this process to ensure continued adherence to OAR 411- 054-0037 and the successful completion of this correction.

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST.

Based on observation, interview and record review, it was determined the facility failed to ensure residents who had short-term changes of condition were evaluated, resident-specific instructions or interventions were developed and reviewed for effectiveness and progress monitored to resolution at least weekly for 2 of 2 sampled residents (#s 1 and 2) who experienced changes of condition. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 12/2022 with diagnoses including Schizoaffective Disorder. Interviews with staff and review of the resident's 12/04/22 service plan, 12/07/22 through 01/31/23 progress notes, hospital visit notes and incident investigations were completed. During the acuity interview on 01/31/23, Staff 1 (Administrator) reported the resident was independent with ambulation using a walker on admission, although within weeks of admission had declined in his/her ability to ambulate and was now using a wheel chair for mobility. She stated the resident had been to the emergency department and there had not been a medical cause identified for the decline. Resident 1 was observed using a wheel chair for mobility with staff assistance when in the common areas during survey. The resident experienced multiple short-term changes related to falls, without documented monitoring of progress until resolution, and interventions were not reviewed for effectiveness and/or lacked resident-specific directions to staff related to the following: * 12/30/22 - Found on floor crawling to the bathroom; * 01/12/23 - Non-injury fall in the bathroom; and * 01/24/23 - Non-injury fall. The need to ensure there was documentation for short-term changes of condition which reflected monitoring of progress to resolution at least weekly and provided resident-specific directions to staff was discussed with Staff 1 and Staff 2 (LPN) on 02/02/23. They acknowledged the findings. 2.  Resident 2 was admitted to the facility in 06/2016 with diagnoses including Schizophrenia and Chronic Obstructive Pulmonary Disease. The resident was receiving hospice services and had sustained severe weight losses. Observations of the resident, interviews with staff and review of the resident's 11/20/22 service plan, 10/11/22 through 01/31/23 progress notes, hospice visit notes and physician communications were completed. The resident experienced multiple short-term changes without documented monitoring of progress for the conditions at least weekly until resolution, and interventions lacked resident-specific directions to staff related to the resident's condition in the following areas: * 12/30/22 - A red area to the thoracic spine and blister wound to the coccyx; * 01/07/23 - Zithromax (antibiotic) ordered for suspected pneumonia; and * 01/13/23 - Increase dosage of scheduled Morphine Sulphate (for pain), and a new order for Prednisone daily for five days. The need to ensure there was documentation reflecting monitoring of progress through resolution and resident-specific directions to staff for short-term changes of condition was discussed with Staff 1 (Administrator) and Staff 2 (LPN) on 02/02/23. They acknowledged the findings.

The Administrator and nursing staff are reviewing all current residents and current interventions to ensure interventions are effective and resident specific during February 2023. The Administrator and Nurse will meet regularly each week to review any interventions in place from incident reports and interim service plans to discuss if they are effective and provide further resident-specific instruction to staff as needed. Skin monitoring sheets will be utilized by nursing staff to track any resident skin issues on-going and will be reviewed by the Administrator during regularly meetings to discuss current acuity.

Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused to consent to orders for 1 of 1 sampled resident (#2) who had documented medication refusals. Findings include, but are not limited to: Resident 2 was admitted to the facility in 06/2016 with diagnoses including Schizophrenia. Resident 2's 10/11/22 through 01/31/23 progress notes, physician communications, and 01/01/23 through 01/31/23 MAR were reviewed. The resident's record showed multiple refusals of the following medications: * Quetiapine (for behaviors); * Depakene (for mood); * Milk of Magnesia (for constipation); * Miralax (for constipation); and * Morphine Sulphate (for pain). There was no documented evidence the facility had a system for notifying prescribers  each time the resident refused to consent to orders. The need to ensure the facility notified the physician/practitioner of medication refusals was discussed with Staff 1 (Administrator) and Staff 2 (LPN) on 02/02/23. They acknowledged the findings.

The Administrator contacted the PCP for clarification on when he/she wants to be notified for med refusals for Resident #2 after the survey was completed. The nurse and the Administrator will review with med trained staff the notification procedures for when residents refuse medications as ordered. Administrator and RN will do monthly Inservice Service trainings with med aids on, med administration, notifacations, and the overall roll of the med aids. The Administrator will review the MAR weekly for medication refusals and notifications to the physician/prescriber by staff on-going.

Based on observation and interview, it was determined the facility failed to keep all interior materials and surfaces in good repair. Findings include, but are not limited to: The interior of the facility was toured on 01/31/23. The following deficiencies were identified: * Doors and door frames throughout the facility had multiple scratches and gouges; * Carpet throughout the facility common areas and resident rooms was worn, with frayed and torn areas, and one square area in the middle of the hallway approximately 5 x 6 inches missing carpet; * Vinyl flooring in the kitchen, dining room and laundry room was worn and scratched, with seams pealing up and chipped off in multiple areas. Two areas observed in the kitchen were missing patches of vinyl, exposing bare floor beneath; * Wood doors on the activity cabinets were scratched and the finish worn off, exposing bare wood; * Vinyl on one cushion of the yellow love seat in the television room was cracked; and * The front edge of the counter top in the laundry room was peeled away from the counter face and was being held in place with tape. The areas needing repair were reviewed with Staff 1 (Administrator) and Staff 2 (Regional Director of Operations) on 02/01/23. They acknowledged the items needing repair and reported they were already getting bids to replace the flooring throughout the facility.

Facility doors, door frames, and trim are being repaired and replaced as needed throughout the facility.  Bids were already being done to replace facility flooring including carpet and vinyl; flooring will be replaced throughout facility as needed as soon as it can be scheduled. Any cabinet that needs to be refinished will be or will be replaced by facility maintenance.  The Administrator will review all facility furniture for any cracks and/or tears and will replace furniture as needed during February 2023. Maintenance staff will repair the laundry room countertop where it peeled off during February 2023. The Administrator will conduct a weekly walk through of facility grounds, including exterior and interior of facility and note any repairs that need to be done and schedule maintenance staff to complete.  The Administrator will review work completed by maintenance for completion on-going.

The findings of the re-licensure survey, conducted 01/31/23 through 02/02/23, 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 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 first re-visit to the re-licensure survey of 02/02/23, conducted 07/13/23, 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 and OARs 411 Division 004 Home and Community Based Services Regulations.