The findings of the re-licensure survey, conducted 02/06/23 through 02/08/23, are documented in this report. The survey was conducted to determine compliance with 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 revisit to the re-licensure survey of 02/08/23, conducted on 06/13/23, are documented in this report. It was determined the facility was in 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 interview and record review, it was determined the facility failed to ensure it had a trained and designated Infection Control Specialist. Findings include, but are not limited to:

In an interview on 02/16/23 Staff 1 (ED) stated the facility did not have a designated Infection Control Specialist.

On 02/06/23 the need to designate an Infection Control Specialist, who had completed all required training, was reviewed with Staff 1. He acknowledged the findings.

C 295

1.The Executive Director will complete the Infection Control Specialist Training by 3/3/2023

2.The community has identified an additional associate who has complete required training to ensure coverage.

3.The Executive Director or designee will maintain compliance with Infection Control Specialist training as changes in training and guidelines occur.  

4.The Executive Director and/or designee is responsible for this plan of correction.

Based on observation, interview and record review, it was determined the facility failed to ensure MARs included specific instructions for PRN medications for 3 of 6 sampled residents (#s 1, 5 and 6) whose medications were reviewed. Findings include, but are not limited to:

1. Residents 2's 01/01/23 through 02/06/23 MARs were reviewed.

Resident 2 had physician's orders for:

*Enulose as needed for constipation;

*Miralax as needed for constipation; and

*Senna as needed for constipation.

There were no resident specific parameters directing non-licensed staff on the administration of the three bowel medications.

The need for resident specific parameters for PRN medications to guide non-licensed staff was reviewed with Staff 1 (ED) and Staff 2 (RN) on 02/07/23. They acknowledged the findings.

2. Resident 5's 01/01/23 through 02/06/23 MARs were reviewed.

Resident 5 had physician's orders for:

*Acetaminophen 650 mg as needed for pain;

*Methocarbanol 500 mg as needed for pain; and

*Oxycodone 5 mg as needed for pain.

There were no resident specific parameters directing non-licensed staff on the administration of the three pain medications.

The need for resident specific parameters for PRN medications to guide non-licensed staff was reviewed with Staff 1 (ED) and Staff 2 (RN) on 02/07/23. They acknowledged the findings.

3. Resident 6's 01/01/23 through 02/06/23 MARs were reviewed.

Resident 6 had physicians' orders for:

*Acetaminophen 650 mg as needed for pain;

*Ibuprofen 200 mg as needed for pain;

*Senna 8.8 mg as needed for bowel care;

*Magnesium Hydroxide 30 ml as needed for bowel care for constipation;

*Polyethylene Glycol 17 mg scoop as needed for constipation; and

*Sodium Phosphates Enema as needed for constipation.

There were no resident specific parameters directing non-licensed staff on the administration of the two pain medications and four bowel medications.

The need for resident specific parameters for PRN medications to guide non-licensed staff was reviewed with Staff 1 (ED) and Staff 2 (RN) on 02/07/23. They acknowledged the findings.

C 310

1.  The Medication Administration Record for Resident 1, 5 and 6 were reviewed and updated to include special instructions for as needed medications.

2.  Remaining resident medication orders will be reviewed to assure presence of special instructions for as needed medications.  The clinical team has been trained by district team members on proper resident specific parameters for as needed medications.

3.  Medication orders will be monitored through the triple check process and during the quarterly medication review process.  Executive Director and/or designee will randomly audit 5 resident MARs a week for 60 days to assure ongoing compliance.

4.  The Executive Director and/or designee is responsible for this plan of correction..