The findings of the re-licensure survey, conducted 01/30/23 through 02/01/23 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 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 02/01/23, conducted 04/26/23, 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.

Based on observation and interview, it was determined the facility failed to establish and maintain infection prevention and control protocols for incontinence care for 2 of 2 sampled residents (#s 3 and 5) whose care was observed. Findings include but are not limited to:

Residents 3 and 5 were dependent on staff for ADL care. During the survey, separate observations of each resident were made of incontinence care on 01/31/23 and 02/01/21. During both observations, care staff removed the resident's soiled brief, provided perineal care, and proceeded to put a clean brief on the resident without removing the soiled gloves or performing hand hygiene. When staff were finished with incontinence care, they removed their gloves but did not perform hand hygiene.

The need to ensure staff utilized effective infection control practices during incontinence care was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 02/01/23. They acknowledged the findings.

Direct care staff will have increased access to hand sanitizer. We will increase access by adding additional hand sanitizer stations and provide personal hand sanitizer bottles. We will implement a hand hygeine observation audit tool. Inservice training on infection control to direct care staff  was completed on 2/24/23.

The hand hygeine audit tool will be used monthly to observe direct care staff practicing infection control, while providing resident care. This audit tool will give us opportunities for improvement and continuing education.

The Infection control Specialist will be responsible to see that corrections are implemented and monitored.