The findings of the re-licensure survey, conducted 05/21/24 through 05/23/24, 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, Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.

Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities 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 first re-visit to the re-licensure survey of 05/23/24, conducted 08/13/24, are documented in this report. It was determined the facility was in substantial 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 for Home and Community Based Services Regulations.

Based on interview and record review, it was determined the facility failed to ensure the preparation, completeness, accuracy, and preservation of resident records for 1 of 5 sampled residents (#4) whose records were reviewed. Findings include, but are not limited to:

Resident 4 was admitted to the facility in 09/2023 with diagnoses including dementia and adult failure to thrive.

Review of the resident's facility record, including progress notes dated 02/01/24 through 05/20/24, was completed, and staff were interviewed. The following was identified:

* On 04/29/24 Staff 2 (RN) documented the resident ". . . was seen holding hands and walking with another female resident  .... residents were seen kissing on the lips."

Survey requested a copy of the facility's investigation of the incident on 05/22/24 at 1:50 pm. At 4:17 pm the facility provided a document dated 04/29/24 which was a brief synopsis of the actions taken by Staff 2 at the time of the incident. When questioned, Staff 2 reported the information was actually written on 05/22/24, not on 04/29/24.

The need to ensure resident records were complete, accurate, and dated at the time of completion was discussed with Staff 1 (ED) and Staff 12 (Regional Director of Operations) on 05/23/24. They acknowledged the findings.

1) Document was updated with correct date of creation during survery on 5/25/24

2) ED and or desegnee will be ensuring all appropriate documentation for any changes in condition of occurences are captured around the date of occurance

3) ED or designee will host a weekly meeting with MCD and RN to ensure proper documentation is completed for any occurances or changes in condition that have happened in the last 7 days

4) ED or designee

Based on interview and record review, it was determined the facility failed to ensure that all incidents of abuse or suspected abuse were immediately reported to the local Seniors & People with Disabilities (SPD) office and were promptly investigated for 1 of 1 sampled resident (#4) whose record was reviewed. Findings include, but are not limited to:

Resident 4 was admitted to the facility in 09/2023 with diagnoses including dementia and adult failure to thrive.

A review of the resident's facility record, including progress notes and temporary care plans dated 02/01/24 through 05/20/24, was completed, and staff were interviewed. The following was identified:

* On 04/29/24 Staff 2 (RN) documented the resident ". . . was seen holding hands and walking with another female resident  .... residents were seen kissing on the lips."

* Staff 2 noted the resident's family was notified of the incident and s/he was placed on alert charting. A temporary care plan was created instructing staff ". . . to redirect the residents if observed kissing."

* Alert charting for the incident was ended on 04/30/24 by Staff 2 because there were "no further observations of kissing" and the other resident was ". . . moving out of the community . . ." that day.

There was no documented evidence this incident was promptly investigated at the time it occurred to rule out abuse, nor that it was reported to the local SPD office if abuse could not be ruled out.

The need to ensure all incidents of abuse or suspected abuse were immediately reported to the local SPD office and were promptly investigated was discussed with Staff 1 (ED) and Staff 12 (Regional Director of Operations) on 05/23/24. They acknowledged the findings.

1) For sampled residents, the occurance was self reported to APS on 5/25/24

2) All Occurences will be revieved daily at stand up and as needed by ED, MCD, RN and Designee

Will report any reportable events within the 24 hour window

ED to complete training on abuse and neglect reporting with all management and employee's weekly for 4 weeks

3)ED MCD, RN or desegnee will monitor daily

4)MCD, RD, ED and or Designee

Based on observation, interview, and record review, it was determined the facility failed to ensure an RN assessment was completed timely and documented findings, resident status, and interventions made as a result of the assessment for 2 of 2 sampled residents (#s 3 and 4) who experienced significant changes of condition. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 01/2024 with diagnoses including Alzheimer's disease and seizures.

Review of the resident's service plan, dated 05/01/24, and progress notes, physician communications, hospice visit notes, and weight records dated 02/01/24 through 05/21/24 was completed.

The resident required full assistance from staff for ADL care, fall safety interventions, meal assistance, redirection for behavior concerns, and wandering into other residents' spaces.

Multiple observations of the resident between 05/21/24 and 05/23/24 showed the resident pacing the facility for extended periods. Staff encouraged the resident to take rest periods but were not often successful. The resident would sit for very brief periods of time and attempts were made by staff to get the resident to eat and drink at those times. Staff would also provide the resident with items s/he could take along as s/he continued to wander the facility. The resident had numerous resident-to-resident altercations and a few falls between February 2024 and May 2024. The resident had a private caregiver who worked with only the resident for approximately eight hours per day. The private caregiver was observed with the resident throughout the survey and would switch out with another staff if she needed to take her break. The resident had no safety awareness, spatial awareness, or personal space awareness. The resident could make very minimal needs known to staff.

The resident experienced a significant change related to an increase in confusion, behaviors, and an overall decline. The resident experienced two seizures in February 2024 prior to hospice admission.

The resident was admitted to Hospice services on 02/24/24.

The facility failed to ensure an RN assessment was completed related to the resident's decline and admission to Hospice services, which documented findings, resident status, and interventions made as a result of the assessment.

The need to ensure an RN assessment was completed which documented findings, resident status, and interventions made as a result of the assessment was discussed with Staff 1 (ED), Staff 2 (RN), and Staff 12 (Regional Director of Operations) on 05/22/24 and 05/23/24. The staff acknowledged the findings.

2. Resident 4 was admitted to the facility in 09/2023 with diagnoses including dementia and adult failure to thrive.

During the acuity interview on 05/21/24, Resident 4 was identified to have been placed on hospice over three months prior related to refusing to eat. The resident was also identified as likely to become agitated and have an increase in behaviors if surveyors were to ask him/her questions or be too physically close.

A review of the resident's facility record, including 02/01/24 through 05/20/24 progress notes, temporary care plans (TCPs), hospice visit notes, and 10/2023 through 05/2024 weight records, was completed, and staff were interviewed. The resident was not observed to leave his/her unit until surveyors were exiting the facility on 05/23/24, when s/he was observed eating dinner in the dining room at 5:00 pm.

The resident's weights were identified as:

*11/08/23 - 150 pounds; and

* 05/08/24 - 119 pounds.

In the six month period between 11/08/23 and 05/08/24, the resident lost a total of 31 pounds, or 20.67% of his/her totally body weight, which constituted a significant change of condition.

Progress notes included "RN Weight Assessment" entries on 02/25/24 and 05/12/24. These assessments did not include findings, resident status, and interventions made as a result of the assessment.

There was no further evidence documented that the facility RN had completed a significant change of condition assessment for the resident's weight losses in a timely manner.

TCPs showed hospice prescribed dexamethasone (later discontinued) and cannabis tincture (THC) to stimulate the resident's appetite.

Staff interviews between 05/21/24 and 05/23/24 revealed the resident frequently paced the hallways in the evenings and didn't like it when staff "bothered" him/her while walking, staff frequently had to feed the resident to get him/her to eat, the resident had refused to eat "since last year" but his/her appetite had improved since hospice prescribed THC, and s/he didn't eat a lot of "regular food" but would eat snacks. On 05/23/24, Staff 5 (CG) reported she had been able to "distract" the resident enough so that s/he ate his/her entire lunch that day.

On 05/23/24 at 2:13 pm, Staff 4 (MT/CG) was asked to weigh Resident 4. At 2:39 pm, Staff 4 reported the resident weighed 125 pounds. This was an increase of six pounds since 05/08/24.

The need to ensure an RN assessment was completed in a timely manner for all significant changes of condition was discussed with Staff 1 (ED) and Staff 12 (Regional Director of Operations) on 05/23/24. The staff indicated they were unaware assessments were not being completed in a timely manner related to significant changes of condition. Staff 1 and Staff 12 acknowledged the findings.

1)Bonaventure RNC completed change of contidion inservice training RN on change of condition policy on 5/24

2) ED MCD or Designee will complete charge note audit for the last 24 hours daily to ensure any potential change in conditions are addressed timely by community RN or designee for the next 90 days

Inservice staff to complete inservice with staff on proper steps to communicate potential changes in condition. Inservice to be completed by 6/30/2024

3) Reveiwed daily by ED, MCD, RN or designee

4) RN, ED, and or designee

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 2 of 2 sampled residents (#s 3 and 4 ) whose MARs and Controlled Substance Drug Disposition logs were compared for accuracy. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 01/2024 with diagnoses including Alzheimer's disease and seizures. The resident's physician orders, the Controlled Substance Disposition logs, and the MAR dated 05/01/24 through 05/21/24, were reviewed.

a. Resident 3 was prescribed routine morphine, 0.5 ml by mouth three times a day. The May 2024 MAR specified the scheduled administration times as 8:00 am, 3:00 pm, and 8:00 pm.

The following inaccuracies were identified between the resident's MAR and the Controlled Substance Disposition log:

* On 05/01/24, 05/02/24, 05/03/24, 05/07/24, 05/09/24, and 05/17/24, the 3:00 pm and 8:00 pm doses were signed as administered on the MAR, but were not signed out on the disposition log;

* On 05/04/24, 05/08/24, and 05/13/24, the 3:00 pm dose was signed as administered on the MAR, but was not signed out on the disposition log;

* On 05/05/24, 05/06/24, and 05/18/24, the 8:00 pm dose was signed as administered on the MAR, but not signed out on disposition log;

* On 05/10/24, the 8:00 am dose was signed out twice on the disposition log, and the 3:00 pm and 8:00 pm doses were signed as administered on the MAR, but not signed out on the disposition log;

* On 05/11/24, 05/14/24, 05/15/24, and 05/18/24, the 8:00 am, 3:00 pm, and 8:00 pm doses were signed as administered on the MAR, but were not signed out on the disposition log;

* On 05/12/24, the 8:00 am and 8:00 pm doses were signed as administered on the MAR, but were not signed out on the disposition log; and

* On 05/20/24, the 8:00 am dose was signed as administered on the MAR, but not signed out on the disposition log.

b. Resident 3 was prescribed morphine 0.25 ml by mouth every hour as needed for pain or shortness of breath. The following inaccuracies were identified between the resident's 05/01/24 through 05/21/24 MAR and the Controlled Substance Disposition log:

* On 05/02/24 and 05/14/24, Resident 3's PRN morphine was documented as administered in the Controlled Substance Disposition log, but it was not documented in the MAR.

In an interview with Staff 1 (ED) on 05/23/24, she verified she was aware their current system for tracking controlled substances needed improvement and that staff needed additional training.

On 05/23/24, the need to ensure the facility had an effective system for tracking controlled substances was reviewed with Staff 1 and Staff 12 (Regional Director of Operations). They acknowledged the findings.

2. Resident 4 was admitted to the facility in 09/2023 with diagnoses including dementia and adult failure to thrive.

The resident's physician orders, the Controlled Substance Disposition logs, and the MAR, dated 05/01/24 through 05/21/24, were reviewed.

a. Resident 4 was prescribed routine morphine, 0.25 ml by mouth, three times daily for pain. The May 2024 MAR specified the scheduled administration times as 6:00 am, 2:00 pm, and 10:00 pm.

The following inaccuracies were identified between the resident's MAR and the Controlled Substance Disposition log:

* On 05/01/24, 05/07/24, and 05/14/24, the 6:00 am and 2:00 pm doses were signed as administered on the MAR but were not signed out on the disposition log;

* On 05/03/24, 05/04/24, 05/10/24, and 05/17/24, the 2:00 pm dose was signed as administered on the MAR but was not signed out on the disposition log;

* On 05/06/24, 05/13/24, and 05/18/24, the 2:00 pm and 10:00 pm doses were signed as administered on the MAR, but were not signed out on the disposition log;

* On 05/08/24, the 10:00 pm dose was signed as administered on the MAR, but was not signed out on the disposition log; and

* On 05/19/24 and 05/20/24, the 6:00 am, 2:00 pm, and 10:00 pm doses were signed as administered on the MAR but were not signed out on the disposition log.

b. Resident 4 was prescribed morphine 0.25 mg every hour as needed for pain or shortness of breath. The resident's 05/01/24 through 05/21/24 MAR and the Controlled Substance Disposition logs were reviewed and identified the following inaccuracies:

* On 05/09/24 Resident 4's PRN morphine was documented as administered in the Controlled Substance Disposition log, but it was not documented in the MAR.

Inconsistencies between the MAR and Controlled Substance Disposition logs and the need to ensure the facility had an effective system for tracking controlled substances was discussed with Staff 1 (ED) and Staff 12 (Regional Director of Operations) on 05/23/24. They acknowledged the findings.

1)ED, MCD, and MED TECH completed a full narcotic audit and reconciled to ensure both Narc log and MAR are matching for the sampled residents

2)ED, RN, and MCD to inservice all med techs weekly for 4 weeks on narcotic storage, administration and documentation

ED MCD, RN or Designee will audit once weekly and as needed review

3)Weekly and as needed by MCD, RN, ED or Desegnee

4)MCD, RN, and ED or designee

Based on interview and record review, it was determined the facility failed to ensure life safety instruction to staff was provided on alternate months to fire drills and staff knew the designated point of safety outside the building. Findings include, but are not limited to:

Fire and life safety records, reviewed between December 2023 and May 2024, revealed the facility failed to provide life safety instructions to staff. The only instruction provided to staff was the facility's "Fire response and Fire drill policy." The same instruction was provided to the staff each month. There was no evidence the facility provided life safety instruction to staff as required.

Interviews with staff between 05/22/24 and 05/23/24 indicated the staff did not know where the designated point of safety was or what to do during a fire drill.

The need to ensure the facility included life safety instruction to staff and that staff were trained on the designated point of safety was discussed with Staff 1 (ED) and Staff 12 (RDO) on 05/23/24. They acknowledged the findings.

1) All active employees will be inservices on fire life safety and evacuation on 6/27/24

2) ED and or Designee will host twice monthly training and fire simulations for the next 90 days to better help staff articulate what to do in an emergency. After 90 days community will continue with monthly audible drills

3) Twice monthly training to occur for 90 days and monthly there after

4)ED or designee

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

Refer to C155, C231, and C420.

Refer to C155, C231, and C420.  

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 C280 and C302.

Refer to C280 and C302.