The findings of the re-licensure survey conducted 06/24/24 through 06/26/24 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 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 06/24/24, conducted on 10/10/24, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004.

Based on observation, interview and record review, it was determined the facility failed to determine, document, communicate to staff what actions or interventions were needed for a resident in response to a change of condition, and monitor and document on the progress of the condition at least weekly until resolved for 1 of 2 sampled residents (#2) with documented short-term changes of condition. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 03/2017 with diagnoses including schizophrenia, chronic heart failure, pain and edema.

Resident 2's record, including progress notes, home health provider notes, the current service plan and the MAR were reviewed during the survey.

The facility RN documented in a progress note on 04/12/24 that the resident complained of pain in his/her lower legs. The RN documented that her evaluation indicated the resident's legs were unwrapped at the time, and were "very swollen" with "small fluid-filled blisters." The RN also documented that home health was doing dressings and that she spoke to the resident about elevating the legs to help with the swelling and pain but the resident was non-compliant with instructions.

There was no documented evidence the facility determined what actions or interventions were needed for the resident, documented the interventions and communicated them to staff, or monitored and documented on the resident's condition at least weekly until resolved as follows:

* The next documentation regarding the resident's condition was made by the facility RN on 05/22/24 where she noted continued edema, some sores on the legs but no drainage, and that the resident stated his/her legs "bother [him/her] and itch." The facility RN made one additional progress note regarding Resident 2's legs on 06/05/24, noting the resident "will not let me do any kind of exam. Will try at another time."

* In an interview on 06/25/24, Staff 2 (Regional Director of Operations) reported that her review of Resident 2's MAR from 04/12/24 through 05/31/24 indicated no topical treatments were implemented for or provided to the resident. The MAR did not indicate the resident requested pain medication for his/her legs. No treatments or medications were requested by or provided to the resident from 06/01/24 through 06/24/24.

* In interview on 06/25/24, Staff 1 (Administrator) acknowledged no updates to the resident's care and service plan were made in response to the resident's complaint of leg pain on 04/12/24.

* The resident's service plan indicated a history of lower leg swelling due to edema with red, cracked skin and occasional weeping from the swollen areas. The service plan directed staff to "encourage [resident] to wear compression socks when [his/her] legs are swollen." There was no documented evidence the facility encouraged the resident to don compression socks.

* Staff 1 also provided home health progress notes that indicated the last care HH provided for the resident's legs was on 04/12/24. The HH provider documented on that date that "Both lower legs continue to have 4+ edema with areas of bright red inflamed tissue." Staff 2 acknowledged the facility did not follow up with HH regarding continued treatment for Resident 2's legs.

During the survey, Resident 2 was observed walking independently around the facility and outside patio using a four-wheeled walker. In interviews during the survey, the resident denied current pain in his/her legs. The resident's lower legs were observed to be more red-colored than the surrounding tissue but with no pitting edema or sores present.

The need to ensure the facility determined, documented, and communicated to staff what actions or interventions were needed for a resident in response to a change of condition and the facility monitored and documented on the progress of the condition at least weekly until resolved, was reviewed with Staff 1 and Staff 2 on 06/25/24. They acknowledged the deficiencies.

Refer to POC for 270

1) What action will be taken to correct the rule violation?

The Administrator along with the community RN will communicate twice a week or as needed regarding change of condition, monitoring and documenting the progress of the change. Staff will be educated on the actions/interventions that are needed for the change.  The Administrator will review the documentation at least twice a week to ensure the condition that is being monitored for the resident is being done as directed. Universal workers will implement temporary service plans if the Administrator is out of the community.  The regional director will provide education to the care staff in regards to what needs to be in a temporary service plan versus permanent update in service plan for a resident.

2)How will this system be correct so this violation will not happeen again?

The Administrator, the assistant of the community and the RN will review the resident along with the concern weekly to ensure the interventions are working, being documented and the progress of the concern.  Once the concern has been resolved, both the RN and Administrator will make documentation of the concern being resolved. If the concern becomes chronic, the service plan will be updated to reflect a permanent change in the resident status.

3) How often will the area needing correction be evaluated?

Short term changes will be monitored per resident need per any new change of condition or change of medication during the weekly 1:1 meeting with the Regional Director. Temporary Service Plans and change of conditions will be reviewed daily by Administrator and weekly by RN.

4) Who will be responsible to see that the correction area is completed/monitored? The Administrator, the assistant, RN and the Regional Director.   

Based on observation and interview, it was determined the facility failed to ensure the proper processing of soiled linens. Findings include, but are not limited to:

During an inspection of the interior environment of the building on 06/25/24, Staff 4 (Universal Worker) was asked to explain the facility's procedure for handling soiled laundry. Staff 4 stated she did not typically handle resident's laundry and was not sure of the proper procedure.

Staff 3 (Assistant Administrator/Universal Worker) volunteered to explain the facility's procedure. During the course of the discussion, the following deficiencies in the procedure were identified:

* Staff did not consistently contain soiled items when transporting them from the resident's room to the laundry room.

* As universal workers, besides handling soiled laundry, the staff also provided personal care to the residents. However, the facility did not provide protective aprons for staff to don while handling soiled laundry to prevent contamination of their own clothing.

* The facility washing machine did not have a hot water rinse cycle and the facility was not using a chemical disinfectant.

The above deficiencies increased the risk that communicable diseases could be spread to residents and staff.

The need to ensure the facility developed and implemented proper soiled linen handling procedures was reviewed with Staff 1 (Administrator) and Staff 2 (Regional Director of Operations) on 06/26/24. They acknowledged the findings.

Refer to POC for C530

1) What action will be taken to correct the rule violation?

Regional Director and the assistant reviewed the requiremets of C530 with all staff. Monthly training of this will continue with daily oversight by the assistant, Administrator and the Regional Director. Community purchased protective aprons for staff to don while handling soiled laundry to prevent contamination of their own clothing.  The community has also put in place the use of the detergent with sanitizer when washing soiled clothing per the recommendation of the surveyors since our washing machines are not commercial machines.

2)How will the system be correct so this violation will not happen again?

Continued training and education to all team members. All resident rooms will have a supply of large trash bags to put soiled laundry in it to transport it from the resident's room to the laundry room. The staff will be monitored to make sure they are using the protective aprons when having to handle soiled laundry. Administrator will monitor to ensure there is plenty of supply of the chemical disinfectant available when doing laundry.

3) How often will the area needing correction be evaluated.

The Administrator and the assistant along with the regional director will monitor it daily.  Community administrator will monitor the supply of the disinfectant weekly when supply orders are being placed.

4) Who will be responsible to see the correction area is completed/monitored for follow up?

The Administrator and the assistant will be responsible for this daily and will report to Regional Director weekly on the process.

Concerns were identified and the facility was provided with technical assistance in the following areas:

(2) Provider owned, controlled, or operated residential settings must have all of the following qualities:

(e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to

access the unit.