The findings of the re-licensure survey, conducted  08/08/22  through 08/09/22 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

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 first re-visit to the re-licensure survey of 08/09/22, conducted on 01/12/23, 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.

Based on 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 the condition was monitored at least weekly to resolution 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 May 2022 with diagnoses including stroke.

Observations of the resident, interviews with staff, review of the service plan dated 06/23/22, temporary service plans and progress notes dated 05/08/22 through 08/08/22 were reviewed. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness and/or lacked resident-specific directions to staff in the following areas:

* Blurry vision and burning eyes;

* New move in;

* Severe diarrhea and medication changes;

* Behaviors including agitation;

* Itchy hands and headache; and

* Neck pain and pressure in the chest.

The need to ensure short-term changes of condition had documentation to reflect monitoring to resolution at least weekly and provided clear, resident-specific directions to staff was discussed with Staff 1 (Administrator) on 08/09/22. She acknowledged the findings.

2. Resident 2 was admitted to the facility in 08/2020 with diagnoses including heart disease.

The resident's 05/16/22 through 08/08/22 progress notes and 06/03/22 service plan were reviewed.

Documentation revealed the resident had experienced short-term changes of condition related to skin. There was no documented evidence the facility determined and documented what actions and interventions were needed for the resident and monitored the conditions at least weekly through resolution.

The need to ensure that short-term changes were monitored to resolution with actions and interventions determined and documented was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 8/09/22. They acknowledged the findings.

1)Resident 1- Chart was reviewed with Physician and ensured that she had been seen for concerns.

Resident 2- Residents skin issue had resolved itself, however staff were instructed on reporting in a timely manner and policy/procedure changes listed below would have prevented the rule violation.

2)Change of condition reporting and monitoring policy is being reviewed and revised. Once it is complete staff will be retrained. In the meantime, administration is reviewing resident charts daily and has provided instructions and visual aids to medication techs as to monitoring/reporting's/and following up. Training to be reviewed on Incident reporting, Basic investigations, Team Huddle/Fact gathering, APS reporting, Reporting to RN/Admin, what it means to monitor to resolution.

3)The change of conditions will be reviewed daily at Stand-Up meetings (M-F) with administration, med techs will review at change of shift, and charting will also be reviewed by administration M-F and weekend charting will be reviewed on Monday. This will occur until our team has shown improvement and has a clear policy and procedure for monitoring to resolution.

4)The RN Manager will be responsible to see that the corrections are completed/monitored in conjunction with the Administrator.