The findings of the Change of Ownership survey, conducted 04/15/24 through 04/16/24, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, 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 re-visit to the re-licensure survey of 04/16/24, conducted on 07/12/24, 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, Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004.

Based on observation, 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 2 sampled residents (#2) whose medications, MARs, and Controlled Substance Drug Disposition logs were reviewed for accuracy. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 05/2023 with diagnoses including anxiety and congestion.

Resident 2 had orders for:

* Lorazepam 0.25 mg as needed for anxiety; and

* pseudoephedrine 60 mg, three times daily for nasal congestion.

Review of Resident 2's Controlled Substance Disposition Logs, 03/01/24 to 04/15/24 MARs, and pills, revealed multiple occasions when the disposition logs did not match the MARs. The medication count matched the dispensation logs.

The inconsistencies between the MARs and Controlled Substance Disposition logs were reviewed with Staff 1 (Regional Director of Operations) on 04/16/24. She acknowledged the discrepancies.

Executive Director and Assistant Executive Director will do a daily MAR to cart to Narcotic book audit on all residents.

By auditing daily and addressing any concerns with staff.

Daily for the next 30 days.

Executive director, Assistant Executive Director and Regional Director of Operations

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

Resident 2 was admitted to the facility in 05/2023 with diagnoses which included anxiety.

Resident 2's 03/01/24 to 04/15/24 MARs and current orders were reviewed.

Resident 2 had orders for:

* Hydroxyzine HCL 25 mg twice daily as needed for anxiety; and

* Lorazepam 0.25 mg as needed for panic attack, use Hydroxyzine first.

There were multiple occasions when the Lorazepam was given before administering the Hydroxyzine, as ordered.

The need to ensure orders were followed was reviewed with Staff 1 (Regional Director of Operations). She acknowledged the findings.

All PRN have been audited to ensure sequencing is in place. Med tech training done on 4/19/24.

Executive director will review PRN's given weekly and address any concerns with staff.

Regional Director of Operations will review.

Executive Director, Assistant Executive Director and Regional Director of Operations.  

Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to C 302 and C 303.

Refer to C302 and C303.

Based on observation and interview, it was determined the facility failed to ensure fences surrounding the perimeter of the outdoor recreation area were no less than six feet (or 72 inches) in height. Findings include, but are not limited to:

The facility was toured on 04/15/24. Sections of fencing surrounding the perimeter of the outdoor recreation area did not meet the six foot height requirement. The surveyor measured several sections of the fence. Measurements included areas as low as 65 inches, or five feet five inches, in height.

The facility had cameras to monitor the courtyard. The door alerted staff when residents exited the facility into the courtyard.

The need to ensure fences surrounding the perimeter of the outdoor recreation area were no less than six feet (or 72 inches) in height was discussed with Staff 1 (Regional Director of Operations) on 04/15/24. She acknowledged the findings.

Quotes are being obtained. Door alarm on back door when residents go outside/inside let's staff know resident is going out/in and there are cameras in the back yard to monitor residents.

We have a company making a model of what an extension would look like to reach height requirement.

Until extension or repair is made to current fencing.

Executive Director, Assistant Executive Director and Regional Director of Operations.