The findings of the re-licensure survey, conducted 05/01/23 through 05/03/23, 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 05/03/23, conducted 07/26/23, 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.

Based on interview and record review, it was determined the facility failed to ensure residents with changes of condition were monitored until resolution for 2 of 3 sampled residents (#s 1 and 3) who experienced short-term changes of condition. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 11/2021 with diagnoses including weakness and chronic pain.

Resident 1's 01/30/23 through 05/02/23 progress notes, 02/22/23 through 03/22/23 physician visit notes, and 02/18/23 through 03/28/23 Temporary Service Plans (TSPs) were reviewed during the survey and showed the following:

* 02/18/23: New medication Miralax for 14 days;

* 02/21/23: New medication Norco every six hours as needed for pain;

* 03/03/23: Received steroid injection in the right shoulder;

* 03/14/23: Experienced abnormal walking; and

* 03/28/23: Had gum pain.

There was no documented evidence the resident's status was evaluated and the resident's condition was monitored to resolution.

On 05/03/23, the above information was discussed with Staff 1 (Administrator). Staff acknowledged the findings.

2. Resident 3 was admitted to the facility in 04/2023 with diagnoses including dystonia and major depressive disorder.

Resident 3's 04/04/23 through 05/1/23 progress notes, alert charting, and Temporary Service Plans (TSPs) were reviewed, and staff were interviewed. The following changes of condition were identified:

* 04/04/23: Admission to the facility;

* 04/11/23: Alert for rash discontinued;

* 04/21/23: Diet change; and

* 05/01/23: 30-minute checks discontinued.

There was no documented evidence the changes were monitored through resolution, with progress noted at least weekly.

The lack of documentation of monitoring through resolution was discussed with Staff 1 (Administrator) on 05/03/23. She acknowledged the findings.

1.  RN to assess change of condition and update progress notes for new medications and pain management for Resident 1.  RN to assess change of condition and update progress notes for orientation to facility and staff, any change in skin conditions, diet and safety checks for Resident 3.

2.  Weekly progress notes will be completed by RN for all residents on alert charting to monitor change of conditions until resolution or resident is stable.  Some conditions may require more frequent monitoring and documentation of that monitoring.

Alert charting will be initiated for change of condition. Weekly progress may be documented in progress notes, MAR or TAR, Skin Sheets, Behavior tracking logs or other tracking tools that become part of the resident's record.  

Med tech and resident care coordinator training to document in progress notes for initiation of any change of condition alert will be completed by 6/09/23.

3. Moving forward 3 residents will be audited in Change of Conditions to ensure adequate documentation and monitoring has been completed until condition is resolved or resident is stable.  Audits will be reviewed quarterly at QAPI x3.

4. Administrator

Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility, for 1 of 1 sampled resident (#1) whose MARs and Controlled Substance Disposition logs were compared for accuracy. Findings include, but are not limited to:

Resident 1's 04/01/23 through 05/01/23 MAR and the Controlled Substance Disposition log were reviewed and revealed the following:

* On five occasions; 04/01/23, 04/05/23, 04/06/23, 04/07/23, and 04/29/23, staff documented Tramadol 50 mg were administered on the Controlled Substance Disposition log. There was no documented evidence on the MAR the medication was administered to Resident 1 on those days.

Inconsistencies between the MAR and Controlled Substance Disposition log were reviewed with Staff 1 (Administrator) and Staff 2 (RN) on 05/03/23. They reviewed the documentation and acknowledged the discrepancies.

1. On 5/10/23 RN spoke with med tech, had her correct documentation on MAR for Resident 1 to accurately reflect medications administered.

2.  Complete staff re-training on narcotic medication administration documentation process and complete competency review with current med techs by 6/15/23.  

3. Compare controlled substance disposition log with MAR monthly x3, audits will be reviewed at quarterly QAPI.

4. RN

Based on observation, interview, and record review, it was determined the facility failed to ensure the use of a supportive device with restraining qualities was included in the resident's service plan and failed to instruct caregivers on the correct use of and precautions related to the supportive device for 1 of 2 sampled residents (#3). Findings include, but are not limited to:

Resident 3 was admitted to the facility in 04/2023 with diagnoses including dystonia.

The resident's 04/04/23 through 05/1/23 progress notes, alert charting, and Temporary Service Plans (TSPs) and his/her initial service plan were reviewed, observations were made, and staff were interviewed.

Resident 3 was identified during the acuity interview on 05/01/23 as having side rails on his/her bed.

On 05/02/23 at 10:20 am half side rails were observed on both sides of the resident's bed in the up position.

During observation of a transfer with a Hoyer lift on 05/03/23, the resident was noted to use the side rails for repositioning.

There was no documented evidence the use of side rails was communicated to staff on all shifts, instruction was provided to staff about the use of side rails, or the use of the supportive devices was added to the copy of the resident's service plan to which staff had access.

The need to ensure the use of supportive devices with restraining qualities were added to resident's service plans with instructions for staff on the use of and precautions for supportive devices was discussed with Staff 1 (Administrator) on 05/03/23. She acknowledged the findings.

1.  Temporary service plan initiated for Resident 3's side rail use on 5/3/23.

2. To make service plan available to staff, process for updating resident service plan utilizing the alert card/temporary service plan reviewed with RCC's and RN's.

RN will complete temporary service plan to communicate changes to staff following any changes to side rail use.  

Care coordinators will update current service plans and caregiver charting for staff to check side rail Q shift, that side rail is securely attached to bed and functioning properly, to notify RCC/RN for any concerns.  

Provide staff education on side rail use and specific risks, specifically that RN is the only person authorized to initiate or make any changes to side rail use by 6/15/23.

3. Audit side rail use to residents service plan, audits will be reviewed quarterly at QAPI x3.

4. RN and/or RCC