The findings of the Change of Ownership survey, conducted 05/28/24 through 05/30/24, 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

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 05/30/24, conducted on 09/04/24, 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 1 sampled resident (#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 03/2024 with diagnoses including Alzheimer's and had a fractured left ankle.

Resident 2 had orders for Oxycodone 2.5 mg as needed for severe pain.

Review of Resident 2's Controlled Substance Disposition Logs, 05/01/24 to 05/28/24 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 2 (Regional Director of Operations) on 05/29/24. She acknowledged the discrepancies.

1. All residents have been audited to ensure correct documentation in electric medication administration record and Narcotic book.

2.Will Audit/cross reference electronic medication administration to narcotic book daily and address concerns with staff

3. Daily for 2 weeks and weekly after

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

Based on interview and record review, it was determined the facility failed to notify the physician when a resident refused consent to an order, for 1 of 1 sampled resident (#2) with multiple medication and treatment refusals. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 03/2024 with diagnoses including Alzheimer's dementia.

Resident 2's physician's order and MARs, from 05/01/24 through 05/28/24, were reviewed.

Resident 2's practitioner had requested to be notified if orders had been refused for three or more days consistently.

Resident 2 had orders for:

*Clobetasol Prop 0.05% shampoo to be applied to the scalp every day;

*Estradiol 0.01% vaginal cream to be used three times weekly;

*Aquaphor ointment to be applied twice daily;

*Miconazole AF 2% powder to be applied twice daily for 10 days;

*Polyethylene glycol twice daily for three days; and

*Nystatin powder to be applied three times daily.

Resident 2 refused some or all of the medications and treatments for 24 days.

There was no documented evidence each incident of Resident 2's multiple treatment and medication refusals had been reported to the practitioner.

The need to notify the practitioner when Resident 2 refused ordered medications and treatments was reviewed with Staff 1 (ED) and Staff 2 (Regional Director of Operations) on 05/29/24. They acknowledged the physician had not been informed of the refusals.

All residents primary care provider's have been faxed to obtain medication refusal orders and will be added to electronic medication administration record upon receiving orders

2. Medication refusal orders have been added to community new move in orders and get added to electronic medication administration record prior to move in.

3.Upon move in and quarterly with 90 day physician orders

4. Executive Director, Assistant Executive Director

Based on observation and interview, the facility failed to take measures to prevent the entry of insects. Findings include, but are not limited to:

The facility was toured with Staff 1 (ED) and Staff 2 (Regional Director of Operations) on 05/28/24.

Multiple small flying insects were noted in resident bathrooms and window sills, and in common bathrooms.

Staff 1 and 2 acknowledged the presence of the insects.

Pointe Pest was called and came out on 5/30/24 and sprayed inside and outside of the community as well as laid granular bait around the community.

2. Pointe Pest will come on a quarterly basis and as needed

3. Every quarter and as needed.

4. Executive Director, Regional Director of Operations

During the survey, concerns were identified in the following area and the facility was provided with technical assistance:

(2) Provider owned, controlled, or operated residential settings must have all of the following qualities:

(b) The setting is physically accessible to an individual.

Based on observation and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to C 510.

Refer to C510

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 305.

Refer to C302 and C305