The findings of the relicensure 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 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 revisit to the re-licensure survey of 02/01/23, conducted 05/02/23 through 05/03/23, 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.

2. Resident 3 was admitted to the facility in 04/2022 with diagnoses including type II diabetes.

Resident 3 was observed to utilize a wheelchair for mobility.

Observations of the resident, interviews with staff, review of the current 12/14/22 service plan and clinical records during the survey revealed Resident 3's service plan was not reflective of his/her status and did not provide specific directions to staff in the following areas:

* Home Health service;

* Use of cushion while in wheelchair; and

* Use of brace on the right leg.

The need to ensure the service plan provided clear instruction to staff and was reflective of the resident's needs was discussed with Staff 1 (ED), Staff 2 (Registered Nurse) and Staff 3 (Resident Service Coordinator) on 01/31/23 and 02/01/23. They acknowledged the findings.

3. Resident 4 was admitted to the facility in 10/2021 with diagnoses including right foot drop and multiple sclerosis.

Interviews with care staff and observation of Resident 4 during the survey revealed s/he was incontinent and dependent on staff for ADL care.

Resident 4's current service plan, dated 12/20/22,  revealed it was not reflective of the resident's needs and lacked clear direction regarding the delivery of services in the following areas.

* Use of Ted hose/compression stockings;

* Transfer status; and

* Toileting status.

The need to ensure the service plan provided clear instruction to staff and was reflective of the resident's needs was discussed with Staff 1 (ED), Staff 2 (Registered Nurse) and Staff 3 (Resident Service Coordinator) on 01/31/23 and 02/01/23. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction regarding the delivery of services and were followed for 3 of 4 sampled residents (#s 1, 3 and 4) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the ALF in 01/2020 with diagnoses which included dementia and COPD.

Interviews with care staff during the survey revealed s/he used a wheelchair in his/her apartment, had hallucinations, used a side rail for mobility, received bathing assistance from an outside provider, and was dependent on staff for incontinence episodes. S/he was independent with denture care, transfers, hair care and dressing.

Resident 1's service plan, dated 01/06/23, was not reflective of the resident's needs and lacked clear direction regarding the delivery of services in the following areas:

* Assistance required for: transfers and wheelchair mobility, dressing ability, denture care and hair care;

* Monitoring for depression and hallucinations;

* Instructions for safe use of side rails;

* Bathing preferences; and

* Incontinence care and toileting ability.

The need to ensure the service plan was reflective of Resident 1's current care needs and provided clear direction to staff was discussed with Staff 1 (Administrator), Staff 2 (RN) and Staff 3 (Resident Service Coordinator) on 01/31/2023. They acknowledged the findings. No further information was provided.

Resident #1's service plan was updated by RSC on 2/1/2023. Resident #3's service plan was updated by RSC on 2/1/2023. Resident #4's service plan was updated by RSC on 2/14/2023. In our system PCC there are prompts during the evaluation to seek out information to individualized service plans.

Training has been provided to the RSC to use those prompts to seek out information to individualize the service paln. Director of Health Services and Health Services Administrator will be responsible to see that the corrections are completed/monitored.   

Based on interview and record review, it was determined the facility failed to ensure on-site and off-site outside provider information/interventions were communicated to staff and the service plan adjusted if necessary for 2 of 3 sampled residents (#s 2 and 3) who received outside services. Findings include, but are not limited to:

1. Resident 2 was admitted in 05/2020 with diagnoses which included congestive heart failure and had a urinary catheter.

A review of outside provider documentation, from 11/01/22 through 01/30/23, revealed the following home health recommendations lacked evidence they were communicated to staff and the plan of care updated:

* 01/07/23:

- "Patient to elevate bilateral lower extremities as much as possible";

- "Catheter care daily. Make sure catheter is not leaving pressure mark to skin and pressure areas";

- "Avoid tight underwear and tight pants"; and

- "Monitor for skin infections/UTI."

* 01/26/23: "RLE [right lower extremity] skin tears:"

- "Gently wash with soap/water. Baby soap/shampoo is a gentle, skin friendly option";

- "Cover open wounds with non-adherent dressing such as oil emulsion or Viscopaste [zinc based bandage]";

- "Cover with silicone foam border"; and

- "Change 2X weekly and PRN [as needed] exudate [wound drainage]."

In an interview on 02/01/23 at 10:15 am, Staff 1 (Administrator) reviewed the outside provider recommendations and stated they should have been communicated to staff and added onto the MAR or service plan. No further information was provided.

2. Resident 3 was admitted to the facility in 04/2022 with diagnoses including atrial fibrillation, presence of a cardiac pacemaker and heart failure.

Resident 3's clinical records indicated the resident had a scheduled pacemaker replacement at the hospital in 01/2023.

A review of the discharge instructions showed activity conditions and special precautions as follows:

* No lifting more than five pounds for one month;

* No aggressive movement of the affected arm; and

* Need to take precaution around electromagnetic equipment.

The facility developed a temporary service plan to monitor for shortness of breath, fainting, weakness, chest pain and fever. However, there was no evidence the facility communicated the discharge instructions to staff or updated the plan of care.

On 01/31/23 at 4:00 pm,, the need to ensure on-going coordination of care for off-site health services was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (Resident Service Coordinator). They acknowledged the findings.

RSC updated resident's #2 and #3's service plan on 2/01/2023. We have an outsider provider form to fill out for each provider who comes onsite. The RSC reviews these on a daily basis to add to the service plan. The RN views next, for any clinical issues that need to be followed up on. The RSC has been re-trained to the TSL system. Health Services Adminstrator will be responsible to see that the corrections are completed/monitored.

Based on observation and interview, it was determined the facility failed to implement effective methods of infection control for 1 of 1 sampled resident (#4). Findings include, but are not limited to:

Observations were made during the survey to determine adherence to universal precautions for infection control.

On 01/31/23 at approximately 9:30 am, the surveyor obtained permission and observed Staff 9 (CG) and Staff 10 (CG) provide incontinence care to Resident 4. During the observation, Staff 10 failed to change gloves after removing a soiled incontinent product and wiping urine from Resident 4's perineum. Staff 10 applied cream to the resident's bottom and touched the resident's clean blanket and clean incontinent brief while wearing the same soiled gloves.

The need to ensure staff consistently used universal precautions was discussed with Staff 1 (Executive Director), Staff 2 (RN) and Staff 3 (Resident Service Coordinator) on 01/31/23 at 4:00 pm. They acknowledged the findings.

The med-techs will be meeting with the Director of health Services (RN) on 2/22/2023 and they will go over infection control during this time.The caregivers will be assigned a video from our TSL infection control video guide to re-train caregivers on infection control. The Heath Services Administrator will be responsible to see that the corrections are being monitored quaterly.

Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed, for 1 of 5 sampled residents (#4) whose orders were reviewed. Findings include, but are not limited to:

Resident 4 was admitted to the facility in 10/2021 with diagnoses including pain and multiple sclerosis.

The resident's 12/21/22 physician's orders and 12/01/22 through 01/31/23 MARs and TARs were reviewed and revealed the following:

Resident 4 had a physician's order for oxycodone 5 mg two times daily as needed for pain and ibuprofen 800 mg every eight hours as needed for pain when the pain was not relieved by oxycodone.

a. The MAR revealed the ibuprofen was administered five times, 12/14/22, 12/15/22, 12/17/22, 12/30/22 and 01/04/23 when the oxycodone was effective.

b. The MAR revealed four times, 12/12/22, 12/16/22, 12/29/22 and 01/07/23, the ibuprofen was not administered when the pain was not relieved by oxycodone.

The need to ensure physician's orders were carried out as prescribed was discussed with Staff 1 (Executive Director), Staff 2 (RN) and Staff 3 (Resident Service Coordinator) on 01/31/23 at 4:00 pm. They acknowledged the findings.

Director of nursing put clear instructions for the Ibuprofen on resident #4's MARS on 2/14/2023.

The Director of nursing will meet with all med-techs on 2/22/2023 and go over Medication room systems, orders to re-train the med-techs. Any time there is a new order The Director of Nursing will review the order and she will will be responsible to see that the corrections are being complteted and monitored regularly.

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements for residents were met. Findings include, but are not limited to:

Fire drill records from 07/30/22 through 01/30/23 were reviewed on 02/01/23 with Staff 1 (Administrator). The facility lacked documentation of the following required elements:

* Evidence residents were being instructed on fire and life safety procedures (including in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places inside or outside the building) within 24 hours of admission and re-instructed at least annually with a written record including the content and residents attending.

The need to have documented evidence of all fire and life safety training components was discussed with Staff 1 (Administrator) and Staff 6 (Director of Plant Operations) on 02/01/23. They acknowledged the findings.

RSC's are working with each resident to go over the annual fire and life safety instructions. RSC's will go over fire and life safety instructions during their quarterly care conference meetings. The Administrator and RSC will monitor quarterly to ensure the residents are being offered the annual fire and life safety instructions.