The findings of the re-licensure survey, conducted 05/16/23 through 05/18/23, 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 for 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

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 revisit to the re-licensure survey of 05/18/23, conducted 03/12/24 to 03/14/24, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for 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 second re-visit to the re-licensure survey of 05/18/23, conducted 06/27/24, 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 resident evaluations contained all required elements and were updated within 30 days of move-in to the facility for 1 of 1 sampled resident (#2) whose new move-in evaluation was reviewed. Findings include, but are not limited to:

Resident 2 was admitted in 03/2023.

The new move-in evaluation, completed on 03/23/23 and 03/28/23, failed to address the following areas:

* Customary routine: bathing;

* Interests, hobbies, social, and leisure activities;

* Spiritual, cultural preferences and traditions;

* Mental Health issues: Presence of depression, thought disorders, behavioral or mood problems, history of treatment, and effective non-drug interventions;

* Personality, including how a person copes with change or challenging situations;

* Housework and laundry;

* Nutrition habits, fluid preferences, and weight if indicated;

* List of treatments: type, frequency, and level of assistance needed;

* Emergency evacuation ability;

* Complex medication regimen;

* Recent losses;

* Unsuccessful prior placements; and

* Environmental factors that impact the resident's behavior including noise, lighting and room temp.

Additionally, the initial evaluation was not updated as needed during the 30 days following the resident's move into the facility.

The need to ensure new move-in evaluations contained all required elements and were updated within 30 days following the resident's move into the facility was discussed with Staff 1 (Administrator) on 05/18/23 at 8:50 am. She acknowledged the findings.

The pre-move in evaluation form was reviewed and updated to assure all elements are incorporated in the evaluation process.  

The 30 day assessments that were previously being noted in the progress notes, are being done through the evaluation forms.  

All changes and information from the evaluation process was put onto the care plans and staff was inserviced on all changes.

The evaluation form will be completed by the Administrator and nursing staff before resident is admitted to facility as well as 30 days, change of condition, and Quarterly reviews.   

Based on interview and record review, it was determined the facility failed to ensure initial evaluations contained all required elements for 1 of 1 sampled resident (#4) whose new move-in evaluation was reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 4 was admitted in 12/2023.

The new move-in evaluation, completed on 11/28/23, failed to address the following areas:

* Customary routine: eating and bathing;

* Eating: dental status and assistive devices;

* Housework and laundry;

* Pain: how a person expresses pain or discomfort;

* Fall risk or history;

* History of dehydration or unexplained weight loss or gain; and

* Unsuccessful prior placements.

The need to ensure new move-in evaluations contained all required elements was discussed with Staff 1 (Administrator) on 03/13/24 at 9:00 am. She acknowledged the findings.

A new form was created to incorporate all elements of the move-in and evaluation process. The form will be updated and modified within the first 30 days of move-in, as well as quarterly, and for any change of condition. Resident 4, 5 and 6 were updated with the new updated forms.  All missing information has been completed on the new updated forms.    

The RN-LPN and Administrator will be monitoring the form and doing all updates and revisions as required and needed.  

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 updated as appropriate within the first 30 days of move-in for 1 of 3 sampled residents (#2) whose service plans were reviewed. Findings include, but are not limited to:

Resident 2 was admitted to the facility on 03/27/23 with diagnoses which included dementia and was receiving hospice services.

Interviews with care staff and family, and observations of Resident 2 during the survey revealed s/he was incontinent, dependent on staff for ADL care, did not use a call light to summon assistance, needed meal assistance, used side rails and was bedbound.

Resident 2's service plan, dated 03/23/23, revealed it was not reflective of the resident's needs and lacked clear direction regarding the delivery of services in the following areas:

* Pain;

* Use of a hospital bed and side rails;

* Falls;

* Oral care;

* Bowel and bladder management;

* Bed bound status;

* Floating heels;

* Dressing status;

* Use of an air mattress;

* Decline in cognition; and

* Risk for choking.

Additionally, the service plan had not been reviewed and updated as appropriate within the first 30 days of move-in.

The need to ensure the service plan was reflective of Resident 2's current care needs, provided clear direction to staff, and was reviewed and updated within the first 30-days of move-in was discussed with Staff 1 (Administrator) during an interview on 05/18/23 at 8:50 am. She acknowledged it had not been reviewed within 30 days of move-in and needed to be updated. No further information was provided.

Care plans have been reviewed and updated to reflect all new changes:  including but not limited to:  

Pain, Use of a hospital bed and side rails., falls, oral care, etc.  Clear direction to care givers for all care needs was included in all new changes on care plans.  

Care Plans will be monitored and Quarterly reviews to assure dates remain within the 30 to 90 day window. New 30 day evaluation form will be used for assisting with the 30 day review as well as the 90 day Quarterly.

The LPN, RN and Administator will be monitoring care plans and reviews on scheduled dates and PRN

Based on interview and record review, it was determined the facility failed to ensure residents who had short term changes of condition had weekly progress documented until the condition resolved for 2 of 3 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 07/2021 with diagnoses including COPD (Chronic Obstructive Pulmonary Disease), depression and esophageal reflux.

The resident's 04/10/23 service plan, 02/01/23 through 05/17/23 progress notes, and physician communications were reviewed. The resident experienced multiple short-term changes without weekly progress noted until resolution in the following areas:

* Medication changes;

* ER visit for difficulty breathing and panic attack; and

* Falls.

Although alert monitoring was initiated for the changes, there was no documented monitoring of resident's condition until resolution.

The need to ensure short-term changes of condition had documented resolution was discussed with Staff 1 (Administrator) on 05/16/23 at 10:20 am. She acknowledged the findings.

2. Resident 2 was admitted to the facility on 03/27/23 with diagnoses which included dementia and was receiving hospice services.

Resident 2's clinical record and progress notes, reviewed from 3/27/23 through 5/16/23, revealed the following:

* The resident fell on 05/06/23. Review of the record revealed no documented evidence the facility consistently monitored and documented on the progress of the resident's condition at least weekly until resolved.

On 05/08/23 at 9:00 am, Staff 1 (Administrator) reported she reviewed the resident's record and concluded the short-term change in condition had no documented resolution. No further information was provided.

Policies are in place for monitoring resident for change of condition.  Direct care staff receive training during staff oriendtation on how to idenitity and report a change of condition.  Direct care staff will report changes to facility LPN, RN or Administrator as they occur.  Both LPN and Administrator are avaliable 24 hours a day 7 days a week. RN will be responsible for assessing the change of condition and if further action is required.

All staff were inserviced on monitoring and charting of new admits, change of conditions, Med changes and ER/Hospital visits.  All shifts will monitor for 7 days with progress notes on the electronic records.  New forms  were created to assist with  monitoring from start to resolution of all charting.  

Based on interview and record review, it was determined the facility failed to ensure short term changes of condition were monitored until resolution, interventions were determined, and documented, communicated to staff on each shift, and reviewed for effectiveness for 2 of 2 sampled residents (#s 4 and 5) who experienced short-term changes of condition. This is a repeat citation. Findings include, but are not limited to:

1. Resident 5 was admitted in 07/2022.

Resident 5's clinical record and charting notes, reviewed from 12/21/23 through 03/12/24, revealed the following:

a. Resident 5 fell or was found on the floor 13 times between 12/21/23 and 03/12/24. The facility failed to investigate the circumstances for several of the falls to determine if service-planned interventions were implemented, were effective or if new interventions were needed, and failed to communicate determined actions/interventions to staff on each shift. Additionally, there was no documented evidence the facility consistently monitored and documented on the progress of the resident's condition at least weekly until resolved.

b. Resident 5 had a medication change on 01/26/24. Although alert monitoring was initiated for the change, there was no documented monitoring of resident's condition until resolution.

The need to ensure short term changes of condition were monitored until resolution, interventions were determined, documented, communicated to staff on each shift, and reviewed for effectiveness was shared with Staff 1 (Administrator) and Staff 3 (LPN) on 03/14/24. They acknowledged the findings.

2. Resident 4 was admitted to the facility on 12/04/23.

The resident's current service plan, 12/04/23 through 03/12/24 progress notes, and physician communications were reviewed. The resident experienced multiple short-term changes without weekly progress noted until resolution in the following areas:

* 12/04/23: New move-in;

* 01/05/24: Nasal congestion; and

* 02/26/24: Nausea and vomiting.

Although alert monitoring was initiated for the changes, there was no documented monitoring of resident's conditions until resolution.

Additional information was requested from Staff 1 (Administrator) on 03/14/24 at 9:15 am.

On 03/14/24 at 9:15 am, Staff 1 (Administrator) reported she reviewed the resident's record and concluded the short-term changes in condition had no documented resolution.

A complete update was made to the 24-hour shift report sheet.  This ensures appropriate communication between each staff member, LPN, RN and administration.  The updated report sheet now includes a section in which falls for each shift are recorded.  This consists of ensuring staff that found or witnesses a resident fall to complete incident reports and notifying nurse on call of fall or incident.  A section was also added to the report sheet to report any new or medication change for specific resident on specific date.  Information to include when a new med or change was initiated, how resident is tolerating the new or changed medication.  Also, the section included that if adverse reaction is observed , contact was made to nurse on call to take appropriate measures.  The last section added to the report sheet was if a change of condition was noted in a resident.  Education from nursing staff provided to caregivers and med-techs on reporting in this section when a resident has cold/flu symptoms, nausea/vomiting, or condition in which it warrants a PRN medication.

A short term service plan book was implemented to communicate to all staff new actions/interventions initiated for specific residents on a specific situation.  All staff were educated and encouraged to check the book at the beginning of each shift.  A signature section was included for staff to acknowledge awareness of reading and understanding the actions/interventions.  Incident log was created for LPN and RN to ensure a record is kept for changes occurring.  This consists of falls, new or medication changes, skin changes, infections and change of condition.  Log allows nursing staff to ensure follow up is occurring at each shift and resolving when appropriate.

Based on interview and record review, it was determined the facility failed to ensure orders were carried out as prescribed for all medications and treatments the facility was responsible to administer for 2 of 3 sampled residents (#s 1 and 3) whose orders were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 2021 with diagnoses which included hypertension.

a. The resident had an order for Amlodipine 10 mg one tablet daily for high blood pressure. Staff were to hold the medication if the systolic BP (upper number) was less than 110.

Resident 1's MAR, reviewed from 05/01/23 - 05/17/23, revealed the blood pressure was outside the parameters on 05/01/23. Per the physician order, the Amlodipine should have been held, but staff administered it.

b. Resident 1 had an order for Losartan Potassium 100 mg one twice a day. Staff were to hold the medication if the BP was less than 100/60 or pulse was under 50.

According to the MAR, the BP was outside parameters on one occasion and the medication was still administered.

The need to ensure medications were administered as prescribed was reviewed with Staff 1 (Administrator) on 05/18/23 at 10:15 am. She reviewed the MAR and acknowledged the orders were not followed.

2. Resident 3 was admitted in 2016 with diagnoses which included multiple sclerosis.

Resident 3 had an order for Breo Ellipta Aerosol inhaler one puff daily.

According to the MAR, reviewed from 05/01/23- 05/17/23, s/he did not receive the medication between 05/01/23 and 05/17/23 because it was "unavailable".

In an interview with Staff 1 (Administrator) on 05/18/23 at 9:00 am, she verified the medication had not been given as ordered. She said the facility contacted the physician to obtain a re-fill order but had no documentation verifying when the MD had been contacted.

The need to ensure medications were available and administered as prescribed was reviewed with Staff 1 (Administrator), Staff 2 (LPN) and Staff 3 (LPN) during the exit conference on 05/18/23. They acknowledged the findings. No further information was provided.

All Med-Tech staff have been given inservices  regarding parameters of Hypertensive medications.  Vitals will be taken before administration of hypertensive medications.  Hypertensive medication will be kept separate from other medications until it is proven within parameters of giving. If not within parameters vitals will be rechecked in one hour to determine if medication willl be held for that medication pass.

LPN will monitor Mar's weekly

Protcols for re-fill requests have been updated.  LPN or Med-Techs will send a written request via fax to provider for re-fills.  If no response from provider after 48 hours, a follow up telephone call will be made by facility LPN or if directed the Med Tech.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate for 2 of 3 sampled residents (#s 1 and 2) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 2021 with diagnoses which included hypertension.

Residents 1's MARs, reviewed from 05/01/23 through 05/17/23 revealed the following:

* Lack of resident-specific instructions for multiple PRN anxiety medications, including sequence of administration.

The need to ensure there were clear parameters for staff when administering multiple PRN medications for the same condition was discussed with Staff 1 (Administrator) on 05/18/23 at 10:15 am. No further information was provided.

2. Resident 2 was admitted to the facility on 03/27/23 with diagnoses which included dementia and was receiving hospice services.  

Residents 2's MARs, reviewed from 05/01/23 through 05/17/23 revealed the following:

* Lack of resident-specific instructions for multiple PRN medications for pain and anxiety, including sequential order of use.

The need to ensure there were clear parameters for staff when administering multiple PRN medications for the same condition was discussed with Staff 1 (Administrator) on 05/08/23 at 10:15 am. No further information was provided.

Residents with multiple pain and pyschotropic medication PRN orders were updated to reflect in what sequence the each medication would be administered. LPN will monitor new PRN pain and pyschotropic medication orders to ensure that the sequence is noted on the EMAR.

Based on interview and record review, it was determined the facility failed to ensure resident MARs included resident specific parameters and instructions for PRN medications, for 1 of 3 sampled residents (#6) whose MARs included multiple PRN medications used to treat the same condition. This is a repeat citation. Findings include, but are not limited to:

Resident 6 was admitted to the facility in 08/2023.

Residents 6's MARs were reviewed from 03/01/24 through 03/12/24 and the following was noted:

* Lack of resident-specific instructions for multiple PRN pain and anxiety medications, including which one to administer first.

In an interview on 03/13/24 at 12:20 pm, Staff 12 (MA) reviewed the resident's MAR. She confirmed the multiple PRN pain and anxiety medications lacked specific instructions for staff including sequence of administration.

The need to ensure there were clear parameters for staff when administering multiple PRN medications for the same condition was discussed with Staff 1 (Administrator) and Staff 3 (LPN) on 03/14/24. They acknowledged the findings.

We contacted all providers who prescribe pain and anxiety medications to clarify and individualize parameters for each resident who are currently using PRN pain and anxiety medications.

All of our PRN medications used to treat the same condition have been updated and indicated which medication to use first. Parameters have been included for all of our psychotropic and pain medications. We have notified our hospice agencies to remind them that all PRN pain and anxiety medications being used require parameters and specific instructions on sequence of administration. An in-service was held with the med techs regarding parameters and which medications are used first.  The RN,LPN will be responsible for checking to assure medications coming in from physicians are checked for parameters and usage.  Medications are checked through monthly cycle fill.  

Based on interview and record review, it was determined the facility failed to ensure PRN psychotropic medications used to treat a resident's behavior had documentation that non-pharmacological interventions had been tried with ineffective results prior to administering the medications and all direct care staff had knowledge of non-pharmacological interventions for 1 of 2 sampled residents (#1) who received PRN psychotropic medications. Findings include, but are not limited to:

Resident 1 moved into the facility in 07/2021 and had diagnoses which included anxiety.

Review of the resident's service plan, physician orders, and 05/01/23 - 05/17/23 MAR revealed the following:  

Resident 1 was prescribed lorazepam 1 mg (anti-anxiety medication) one tablet every eight hours PRN for anxiety.

The facility failed to ensure the resident's MAR and clinical record included the following required information:

* Documentation that all direct care staff had been informed of non-pharmacological interventions for Resident 1; and  

* Staff administered the PRN lorazepam on 17 occasions without documentation that non-pharmacological interventions were attempted prior to administration of the medication.

During an interview with Staff 10 (MT) on 05/18/23 at 10:10 am, she reviewed the resident's record and confirmed staff had not documented that non-pharmacological interventions had been attempted prior to administering the medication.

The need to ensure the required information for PRN psychotropic medications was documented in the MAR or clinical record was discussed with Staff 1 (Administrator) on 05/18/23 at 10:15 am. She acknowledged the findings. No further information was provided.

All PRN psychoactive medications have been updated with parameters for behavioral use or hospice services.

Parameters also include non-pharmaceutical interventions before medication use, unless residents are able to self direct their own care.  

All Med-tech and direct care staff have been inserviced on non-pharmaceutical interventions and documenting prior to adminstering medications.  All residents have been reviewed and updated to assure medications requiring interventions and non-pharmaceutical interventions were incorporated into their individual records.  

LPN and RN will monitor and maintain MAR's as medication changes occur.    

Based on observation, interview and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities was assessed by an RN, PT or OT, documentation of less restrictive alternatives prior to use, instruction to caregivers on the correct use of and precautions for the device, and documentation of the use of the device in the resident's evaluation and service plan for 1 of 1 sampled resident (#2) who had side rails on their bed. Findings include, but are not limited to:

Resident 2 was admitted to the facility on 03/27/23 with diagnoses which included dementia and was receiving hospice services.

On 05/17/23 at 10:25 am, the resident's bed was observed to have bilateral half-length side rails in the up position.

There was no documented evidence the device with restraining qualities had been assessed by an RN, PT or OT, documentation of less restrictive alternatives prior to use, instruction to caregivers on correct use and precautions, and documentation of the use of the rails in the resident's evaluation and service plan.

The above information was discussed with Staff 1 (Administrator) on 05/18/23 at 9:00 am. She was unaware the resident had side rails on his/her bed. She acknowledged the resident's record lacked an assessment by an RN, PT or OT, documentation of less restrictive alternatives prior to use, instruction to caregivers on correct use and precautions, and documentation in the evaluation and service plan.

Half rail assessment was completed and added to the quarterly review schedule.  Use of half rail was added to the resident's care plan.  Inservice to direct care staff on correct use and pre-cautions on using half rails.

Based on interview and record review, it was determined the facility failed to ensure an Acuity Based Staffing Tool (ABST) was reviewed and amended for each resident at least quarterly. Findings include, but are not limited to:

Review of the facility's online ABST information with Staff 2 (LPN) on 05/17/23 at 11:45 am revealed the facility was not reviewing and amending the ABST tool for residents at least quarterly.

The need to ensure the facility reviewed the ABST assessments quarterly was discussed during the exit interview with Staff 1 (Administrator) and Staff 2 on 05/18/23. They acknowledged the findings.

Facility has been in contact with DHS regarding the use of the ABST to gain a greater understanding of how to calculate and enter each resident information.  The ABST has been added to the quarterly review schedule to ensure an accurate information and accounting for all residents.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 direct care staff (#s 6, 7 and 8) had documented evidence of completion of First Aid certification and abdominal thrust training within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed on 05/17/23 and revealed Staff 6 (CG) hired 03/01/23, Staff 7 (CG) hired 03/09/23, and Staff 8 (CG) hired 02/01/23, lacked documented evidence they had completed First Aid certification and abdominal thrust training within 30 days of hire.

The need for staff to complete all required training in the specified time frames was discussed with Staff 1 (Administrator) on 05/17/23 at 12:45 pm. She acknowledged the findings.

All current staff have completed the First Aide and Abdominal Thrust course.  Alll new and incoming staff are required to show proof of First Aide and Abdominal Thrust certification or obtain certification prior to being allowed to start employment.  

Based on interview and record review, it was determined the facility failed to ensure residents received fire and life safety training at least annually. Findings include, but are not limited to:

Fire and life safety records were requested during the survey. The following deficiencies were identified:

* Documentation of annual fire and life safety training provided to residents.

The need to ensure residents received fire and life safety training at least annually was discussed with Staff 1 (Administrator) on 05/08/23 at 10:30 am. She acknowledged the findings. No further information was provided.

Resident Annual Fire and Life Safety training was conducted on 6/16/2023.  A floor plan with marked exits is posted in all resident rooms and hallways along with evacuation instructions an procedures.

Based on interview and record review, it was determined the facility failed to ensure their relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:

Refer to C 252, C 270, and C 310.

See plans of correction for C 252, C 270, and C 310.

Based on observation and interview, it was determined the facility failed to ensure pathways were maintained in good repair and did not have potential hazards. Findings include, but are not limited to:

Observations of the outer courtyard surfaces and pathways on 05/18/23 showed the following:

* Multiple drop-offs of 2-5 inches along several pathway edges.

The need to ensure pathways were maintained in good repair and did not have potential hazards was discussed with Staff 1 (Administrator) during a tour of the exterior grounds on 05/18/23 at 11:15 am. The findings were acknowledged.

Decorative bark was ordered and placed in areas around the sidewalk and patio areas to eliminate hazardous drop offs. Maintenance staff will monitor areas and report any hazards to administration in a timely manner.