The findings of the re-licensure survey conducted 08/29/22 through 09/02/22 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 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 first re-visit to the change of ownership survey of 09/02/22, conducted 08/07/23 through 08/09/23 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.
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 09/02/22, conducted 01/08/24 through 01/11/24 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.
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 third re-visit to the re-licensure survey of 09/02/22, conducted 04/16/24 through 04/18/24, 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.
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 fourth re-visit to the re-licensure survey of 09/02/22, conducted from 08/26/24 through 08/28/24, 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 observation, interview, and record review, it was determined the facility failed to provide effective administrative oversight to ensure quality of care and services rendered in the facility. Findings include, but are not limited to:
During the second revisit of the re-licensure survey, conducted 01/08/24 through 01/11/24, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number and severity of citations.
Refer to deficiencies in the report.
1. The management company is in partnership with a 3rd party entity for oversight of operations on a weekly basis to ensure standards of the OARs are met. The management company hired on a short term basis, an operations specialist for the community to ensure that the facility complies with all OARs and Company policies and procedures on a continuous basis.
2. Daily Clincial meetings with clincal team
3. At a minimum, the operational standards will be evaluated monthly.
4. Flagstone Executive Director and/or designee with the oversight of the Milestone Regional Operations Specialists.
Based on observation, interview, and record review, it was determined the facility failed to provide effective administrative oversight to ensure quality of care and services rendered in the facility. This is a repeat citation. Findings include, but are not limited to:
During the third revisit of the re-licensure survey, conducted 04/16/24 through 04/18/24, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number and severity of citations.
Refer to deficiencies in the report.
1. The management company is in partnership with a 3rd party entity for oversight of operations on a weekly basis to ensure standards of the OARs are met. The management company hired on a short term basis, an operations specialist for the community to ensure that the facility complies with all OARs and Company policies and procedures on a continuous basis.
2. Daily Clincial meetings with clincal team
3. At a minimum, the operational standards will be evaluated monthly.
4. Flagstone Executive Director and/or designee with the oversight of the Milestone Regional Operations Specialists.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to implement effective methods of responding to and resolving resident complaints. Findings include, but are not limited to:
1. Individual resident interviews were conducted between 01/08/24 and 01/10/24. Multiple alert and oriented residents provided information on services received in the community. Residents expressed concerns in the areas including but not limited to long delays for call light response times, inadequate staffing, housekeeping and medication administration, ordering of incontinent supplies and confusing billing practices. Responses included:
"It's not uncommon to wait 45 minutes to an hour for a call light to be answered"; and
"We run out of "depends" and have to rely on the facility emergency supply until our products are ordered."
Call light reports between 12/01/23 and 01/10/24 were reviewed and confirmed the lengthy response times. The call logs showed call light response times in excess of 20 minutes occurred more than 30 times with some call response time exceeding one hour. On 01/10/24, Staff 26 (ED) stated the facility was planning to get a new call system as the current system did not always work when the "WiFi" system signal was limited. Staff 26 confirmed the system for tracking and resolving resident grievances needed improvement.
2. The "Resident Council Meeting Minutes" dated 10/18/23 and 11/15/23 were reviewed. Comments included:
* On 10/18/23- "washing machines need to be deep cleaned, ... dryer vents cleaned" and " med techs could visit less with each other and focus more on the job for residents"; and
* On 11/15/23- "concerned and upset about staffing issues, invoices are never correct," and "washing machine still isn't working, ... returns clothes looking dingy," and "rooms haven't been cleaned in over a month ..., med techs letting meds run out ..."
Although there was a documented response to the concerns about housekeeping and laundry room floors after the 10/18/23 meeting, housekeeping and laundry continued to be a problem brought forward at the next Resident Council meeting on 11/15/23. The meeting minutes lacked documentation of resolution of agenda topics from the previous month.
The need to ensure the facility implemented effective methods of responding to and resolving resident complaints was discussed with Staff 26 (ED) on 01/11/24. She acknowledged the findings.
1. Review of resident council meeting minutes at monthly QA meeting. Review of resident concerns during daily stand up meeting.
2. Training by Milestone regional staff, in partnership with 3rd party entity consultants will be provided to Flagstone on a continuous basis until standards are upheld to Milestone expectations.Immediate concerns will be discussed in daily stand-up meetings.
3. During this plan of correction period, A dedicated regional specialist will oversee comprehension and compliance of Flagstone staff. Intermittent Audits of comprehension of the training, ongoing assessment of staff comprehension will continue as Milestone standard. Reviewed monthly during QA meeting.
4. The Flagstone Executive Director and/or designee with oversight from the Milestone Dedicated Regional Operation Specialists.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to develop and conduct ongoing quality improvement programs that evaluated services, staff performance, resident outcomes and resident satisfaction. Findings included, but are not limited to:
During the third revisit to the relicensure survey of 09/02/22, conducted 04/16/24 through 04/18/24; quality improvement and oversight to ensure adequate resident care, services and satisfaction was found to be ineffective based on the number of repeat citations and the number and severity of new citations during the third revisit survey.
During an interview on 04/17/24, Staff 34 (Administrator) reported the facility had a quality assurance (QA) program to evaluate services, resident outcomes and satisfaction. The team reportedly met at various intervals to review quality metrics. Staff 34 provided a copy of the minutes of a quality assurance meeting conducted 04/03/24. There were no other QA meeting minutes available to review.
The need to ensure the facility conducted an ongoing quality improvement program that evaluated services, resident outcomes, and resident satisfaction was discussed with Staff 34 on 04/18/24. He acknowledged the findings.
1. Monthly QA will be held to review departmental audits for compliance including review of resident council meeting minutes and metrics for continued quality improvement. Identified areas will be tracked and reviewed per Milestone's policy. Immediate concerns will be discussed in standup for resolutions.
2. Training by Milestone regional staff, in partnership with 3rd party entity consultants will be provided to Flagstone on a continuous basis until standards are upheld to Milestone expectations.Immediate concerns will be discussed in daily stand-up meetings.
3. A dedicated regional specialist will oversee comprehension and compliance of Flagstone staff. Audits of comprehension of the training will be ongoing assessment of staff comprehension will continue as Milestone standard. Results of audits monthly during QA meeting.
4. The Flagstone Executive Director and/or designee with oversight from the Milestone Dedicated Regional Operation Specialists.
There are no detail notes for this visit.
Based on observation, interview and record review, it was determined the facility failed to exercise reasonable precaution against a condition that could threaten the health, safety or welfare of a resident. Resident 19 accidentally ingested a toxic substance and no safety plan was implemented to ensure there would not be a reoccurrence. This placed the resident's health and safety at risk of harm. Findings include, but are not limited to:
Resident 19's current service plan, last updated 02/26/24, progress notes from 02/24/24 through 04/16/24, interim service plans (ISPs) and incident reports were reviewed. Resident 19's service plan and ISP's indicated the resident was dependent on staff for assistance with grooming and oral care and had increased confusion and poor short term memory.
On 03/14/24 progress notes documented the resident was "added to alert for ingesting denture cleaning tablets". The notes indicated emergency services arrived to assess the resident, poison control was consulted and advised to "push fluids". The note documented the resident stated his/her stomach had been upset and the resident thought the tablets were antacid tablets, when s/he "realized they weren't [antacids], they tried throwing it up and let care" staff know.
The record lacked documentation that the resident's physician was notified following the incident or that staff on all shifts were instructed to "push fluids" following the ingestion. There was no documentation that the incident was investigated and a safety plan or changes to the service plan were made to ensure the resident did not accidentally ingest the denture cleaner or other non-edible substances.
On 04/16/24 at 4:15 pm, a full, opened box of denture cleaning tablets was observed next to the sink in Resident 19's bathroom. Staff 27 (RN) was informed the denture cleaner was on the sink and easily accessible to the resident. This put the resident at risk of harm for ingestion of the tablets. A safety plan was requested.
At 4:45 pm the same day, Staff 27 confirmed the dental cleaning tablets were removed from the room and would be stored in the medication cart with instructions to staff to request one tablet daily from medication technician to clean the resident's dentures.
On 04/17/24 at 8:45 am, Staff 27 provided documentation, dated 04/16/24, including an incident report, notification to the physician and Adult Protective Services (APS) of the incident, and changes made to the resident's service plan with interventions to prevent accidental ingestion.
In an interview on 04/17/24, the need to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents was discussed with Staff 34 (Administrator), Staff 27, and Witness 1 (Consultant). They acknowledged the findings.
1. Investigation of reasonable precaution concerns involving resident #19 case was reviewed by Milestone Regional Clinical Team. ISP was put in place and tablets were locked in a secure location.
2. Flagstone Clinical team will be trained on Milestone Policy and/or Procedures for reasonable precautions to ensure safety of residents, regarding 24 hour book reporting, progress notes, investigation follow up and ISPs and continued education and revied during daily clinical meeting will ensure staff understand and follow training on identifying reasonable precautions for safetly of residents.
3. During the plan of correction period, Milestone will partner with 3rd party entity for clinical oversight to ensure compliance with following Milestone policies & procedures. Clinical team will review 24-hour notes and progress notes daily in clinical meeting for ensured safetly of residents and ensured investigations completed. Random audits of Flagstone will be performed by DHW or designee for sustained compliance and results reviewed in QA for 3 months and as needed afterwards
4. The Executive Director is responsible for ensuring that Flagstone meets all OAR and Licensure expectations. The DHW is responsible for following all existing Clinical OARs and Milestone Clinical policies.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure incidents were promptly investigated to rule out abuse and neglect and failed to report possible neglect for 1 of 1 sampled resident (#4) whose record indicated multiple medication errors. Findings include, but are not limited to:
Resident 4 was admitted to the facility on 07/27/20 with diagnoses including dementia and diabetes.
Progress notes dated 06/01/22 through 08/30/22, MAR dated 08/01/22 through 08/30/22 and incident reports dated 08/16/22 and 08/30/22 for Resident 4 were reviewed and revealed the following:
a. Resident 4 had a physician's order to administer sliding scale Novolog insulin (for diabetes management). The following medication errors were noted:
* On 08/16/22 at 9:00 am, Resident 4 received two units instead of three according to a CBG of 161;
* On 08/25/22 at 4:00 pm, Resident 4 received five units instead of six units according to a CBG of 302; and
* On 08/27/22 at 12:00 pm, Resident 4 received three units instead of four units according to a CBG of 236.
b. On 6/19/22 Resident 4 received 44 units instead of the prescribed 40 units of the routine insulin Lantus Solostar (for diabetes management).
c. On 08/30/22 Resident 4 missed a dose of Lantus Solostar due to the facility not ordering the medication in a timely fashion.
During an interview, 09/02/22 at 9:44 am, Staff 1 (ED) confirmed the medication errors on 06/19/22 and 08/30/22 were investigated, however, the remaining errors had not been investigated prior to the relicensure survey. Staff 1 also confirmed all the medication errors listed above had not been reported to the local SPD office.
The facility was directed to self-report the incidents to the local SPD office. Confirmation of the reporting was received on 09/02/22 at 10:16 am.
No negative outcome to the resident was identified as a result of the medication errors.
The need to promptly investigate and report medication errors that could have a negative effect on the resident, was discussed with Staff 1 on 09/02/22. She acknowledge the findings.
1. The action taken to correct the rule violation for resident 4 was documented, investigated and promptly reported to Adult Protective Services (APS) by licensed administrator upon discovery. Full Medication Administration Record (MAR) audit to be completed on all residents.
2. Any incidents of suspected abuse or neglect including but not limited to critical med errors will be documented, investigated and promptly reported to APS. Licensed Nurse and Licensed Administrator to review Medication Dashboard for any critical meds that may have been missed, held, or had an incorrect dose administered. Full MAR audit on all residents.
3. Medication Dashboard for critical meds to be reviewed weekly. MAR audit to be completed 1x/month by the 5th of each month for the prior months MAR's.
4. Licensed Administrator and Licensed Nurse will be responsible to see that the corrections are completed/monitored.
There are no detail notes for this visit.
2. Resident 11 moved into the facility in 05/2019 with diagnoses including stroke with right side paralysis. The resident required staff assistance with transfers and toileting care.
The resident's 11/12/23 through 01/07/24 progress notes were reviewed. On 11/12/23, staff documented, "Resident was sent up to ER [emergency room] for bruising of [his/her] right hand middle finger."
During the survey, documentation related to the injury was requested. On 01/09/24 at 12:25 pm, Staff 26 (ED) and Staff 27 (RN) reported there was no incident report and they did not investigate the bruise, including the cause the injury.
The need to investigate injuries of unknown cause and to report the incident when the facility's investigation was unable to rule out abuse or neglect was discussed on 01/09/24 with Staff 26 and Staff 27. They acknowledged the findings.
On 01/10/24 at 4:40 pm, the survey team received a copy of confirmation the incident was report to local SPD.
Based on observation, interview, and record review, it was determined the facility failed to investigate injuries of unknown cause and an allegation of suspected abuse and failed to report the incident to the local Seniors and People with Disabilities (SPD) office for 2 of 2 sampled residents (#s 11 and 16) who were identified to have a physical injury of unknown origin and experienced an incident of suspected abuse by staff. Resident 16 experienced verbal abuse resulting in emotional harm. Findings include, but are not limited to:
1. Resident 16 moved into the facility in 07/2020 with diagnoses including diabetes.
During an interview on 01/10/24, a medication aide described an incident which occurred on 12/31/23, when Resident 16 stated s/he no longer wanted a caregiver to provide his/her care or to "come to my room." The medication aide stated the caregiver then confronted Resident 16, who had reported the caregiver had been taking his/her personal food and drink items without permission. The incident occurred in the first floor dining area, in front of other residents, staff and visitors. The caregiver reportedly yelled at Resident 16 and stated s/he was "lying" and was "trying to get [him/her] in trouble." Following the incident on the first floor, the caregiver reportedly returned to the resident's room to "convince the resident not to report [him/her]".
The medication aide stated the incident was reported to the oncoming shift and to the ED and Resident Care Director (RCD) the following day.
On 01/10/24 at 3:50 pm, Resident 16 was interviewed about the incident. Resident 16 was able to recall the incident and stated the caregiver would "help [him/her self] to my soda and chips" and stated the caregiver "hollered at me about it downstairs." Resident 16 stated the staff was no longer working and that s/he would not want to receive care from the staff in the future, and stated "It's been hard feelings between us." Resident 16 stated the caregiver delivered some cans of soda to his/her room following the incident.
Reviewed the facility's records and on 01/02/24 staff documented on the record that Resident 16 confirmed s/he did not want the staff to provide care to him/her and "described the resident as being very fearful appearing."
On 01/10/24, during an interview, Staff 26 (ED) confirmed being informed of the incident that occurred on 12/31/23, however the incident had not been reported to SPD and there was no documented investigation. The surveyor requested Staff 26 report the incident to local SPD office. Documentation was provided to the survey team to confirm it had been reported to the local SPD office on 01/11/24.
The failure to report the incident of suspected abuse and investigate the report of abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse resulted in emotional harm to Resident 16.
The need to ensure incidents of suspected abuse were reported to the local SPD and investigated to protect residents and prevent the reoccurrence of abuse was discussed with Staff 26 and Staff 27 (RN) on 01/11/24. They acknowledged the findings.
1. Resident #16 were reported to SPD office on 01/11/24. Resident #11 incident was reported to local SPD office suvery team received a copy on 1/10/24.
2. Flagstone staff will receive additional training and compliance monitoring from Milestone regional staff as well as oversight by dedicated regional operations specialist and 3rd party entity to ensure reporting and investigations are met related to abuse and neglect
3. Flagstone new hires will complete abuse and neglect training upon hire. Current Flagstone staff will complete training on a quarterly basis during the Plan of Corrections period, and semi-annually thereafter.
4. Flagstone Business Office Manager and the Executive Director are responsible for correction completion. Milestone Regional team will monitor for compliance thereafter.
Based on observation and interview, it was determined the facility failed to ensure food was prepared in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:
Observations of the kitchen, food storage, prep, and service areas were made on 08/29/22 and 08/30/22. The following was observed:
a. Food Storage
* The door leading into the walk-in cooler had built-up debris present;
* The fan inside the walk-in cooler was dusty;
* The racks inside the walk-in cooler had debris present throughout;
* The walk-in freezer had frozen food on the floor;
* The dry storage floor was in need of deep cleaning; and
* The reach in refrigerator had food debris on the outside of the door and inside on the bottom shelf.
b. Food Service
* Staff did not use alcohol wipes after taking the temperature of the food, they wiped it with a cloth out of a sanitation bucket;
* Staff were observed to unwrap frozen chicken fried steaks, push the garbage down into the receptacle, take a chicken fried steak out of a metal container located in the steam table, cut up the steak then placed the food on a plate, this was done wearing the same pair of gloves; and
* Observations were made of staff touching a garbage can with her bare hands, getting tongs and then serving fruit with the tongs in bowls without washing her hands after touching the garbage can.
c. Sanitation and Equipment
* The attached cutting board on the cold food storage unit had gouges and knife score marks present;
* All four drawers had built up debris inside and outside in the back of the kitchen's food prep area;
* The sugar and potato bins had debris on the inside and outside;
* The flour and oatmeal bins had debris on the outside;
* There was debris on the standing mixer, the guard and the table it was sitting on;
* The oven, stove and hood were in need of deep cleaning;
* The shelf directly above the food storage area in the steam table had food debris under it;
* The lower shelf to the left of the stove had debris on it:
* There was brownish black matter in the drain to the left of the stove;
* There were multiple areas in the janitorial closet in need of cleaning and repair;
* Observations of staff who were washing dishes touched the dirty dishes, sprayed them with water, then took clean plates out of the clean warewasher rack and put them away without washing her hands;
* The warewashing machine did not get up to sanitizing temperature and the strips to test the chemicals did not work for the machine;
* There was black matter in the drain under the warewashing machine;
* The walls throughout the area were in need of cleaning and repair;
* The windowsill had dust and debris on it and there was blue tape on the window;
* The vent on the ice machine had built up dust present;
* Garbage cans were not covered;
* There was brownish black matter throughout the kitchen's tile baseboards;
* Kitchen doors (e.g. office, exits, janitorial closet, dry storage) were in need of cleaning, painting and repair; and
* There were multiple cutting boards that were gouged, had knife scores and were stained.
The areas in need of cleaning and repair and infection control practices were reviewed with Staff 1 (ED) and Staff 6 (Director of Culinary Services) on 08/29/22 and 08/30/22. They acknowledged the findings.
1. The action taken to correct the following rule violations are as follows:
a. Food Storage:
* Areas were promptly cleaned including the removal of built-up debris in various food storage areas including the walk-in freezer, walk-in fridge, reach-in fridge, and dry storage area.
* The walk-in cooler fan and racks were cleared of dust or built-up food debris.
* Frozen food was removed from the walk-in freezer floor.
b. Food Service:
* All kitchen staff were immediately trained on glove use and disposal, hand-washing, and cross contamination.
* Kitchen staff were provided with alcohol swabs for cleaning thermometers.
c. Sanitation and Equipment:
* Cutting board for cold food storage to be repaired and gouges removed
* Kitchen food prep including drawers were cleansed of debris inside and outside.
* Sugar and Potato bins were cleansed of debris inside and outside
* Flour and oatmeal bins were washed on outside
* Oven, Stove and Hood were deep cleaned.
* Shelf above food storage area in the steam table was washed and all debris removed
* Janitorial closet was cleaned to best of community capability - Restoration company scheduled to clean and make necessary repairs to closet.
* Education to staff provided on clean to dirty process for dish pit.
* Warewashing machine was serviced by contractor
* Black matter that was observed on kitchen tile, baseboards, grout, drain under ware washing machine and drain to left of stove will be cleaned by professional floor cleaning contractor.
* Walls will be cleaned and repaired on a schedule with Maintenance Department.
* Windows immediately dusted and debris removed, as well as blue tape.
* Vent on ice machine was promptly cleaned
* Garbage lids were promptly found and put in place.
* Kitchen doors are on schedule to be cleaned, painted and repaired.
2. To ensure the system is corrected cleaning task lists have been implemented for culinary staff including; task, frequency of completion, and person responsible.
3. This will be evaluated every 2 weeks
4. Director of Culinary Services and Executive Director will be responsible to see that the corrections are monitored/evaluated.
Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required components for 1 of 1 sampled resident (#7). Findings include, but are not limited to:
Resident 7 was admitted to the facility on 08/30/22 with diagnoses including dementia.
Resident 7's move-in evaluation failed to address:
* Spiritual, cultural preferences and traditions; and
* Interests, hobbies, social and leisure activities.
The need to ensure new move-in evaluations included all required components was discussed with Staff 1 (ED) on 09/01/22 at 11:46 am. She acknowledged the findings and provided no additional documents.
1. Action taken to correct the rule violation for resident 7, resident 7 was interviewed and missing components were added to service plan. Audit will be performed on all other resident records to ensure that all elements specified in OAR 411-054-0034 section (5) of the rule have been addressed in the evaluation and have been incorporated into the resident's service plan.
2. Community move-in evaluation has been corrected to ensure all components are included in accordance with OAR 411-054-0034.
3. The area needing correction will be evaluated and monitored for each move-in to ensure that the evaluation is complete and accurate.
4. The Licensed Administrator and Executive Director will be responsible to see that the corrections are completed/monitored.
There are no detail notes for this visit.
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 were being followed for 2 of 6 sampled residents (#s 5 and 6) whose service plans were reviewed. Findings include, but are not limited to:
1. Resident 5 was admitted to the facility in 04/2017 with diagnoses including edema.
The resident's 06/14/22 service plan was reviewed and staff were interviewed. The service plan was not accurate and lacked clear caregiving instruction in the following areas:
* Skin issues and what to monitor for;
* Outside provider services;
* Behavior triggers; and
* Behavior interventions.
The need to ensure the resident's service plan was reflective of the resident's needs and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 3 (Staff Nurse) on 09/02/22. They acknowledged the findings.
2. Resident 6 was admitted to the facility in 02/2017 with diagnoses including Type 2 Diabetes, history of urinary tract infections and dementia.
The resident's 07/20/22 service plan and Interim Service Plans (ISPs) were reviewed. Staff was interviewed. Resident 6's service plan was not reflective or lacked clear caregiving instruction in the following areas:
* Documentation of hourly checks;
* A communication plan to assist the resident;
* Where the resident prefers to sleep;
* The use of a wound vac;
* Behavior interventions relating to "reorienting" versus "embracing the moment the resident is in";
* Leaving the apartment without spouse;
* Fall interventions;
* Evacuation assistance needed;
* Daily use of wheelchair;
* Night care assistance needed;
* Nurse to administer insulin;
* No longer going outside to visit the outdoor cat;
* Toileting assistance needed;
* Transfer assistance needed; and
* Being an elopement risk.
The need to ensure the resident's service plan was reflective of the resident's needs, being followed and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 3 (Staff Nurse) on 09/02/22. They acknowledged the findings.
1. Action taken to correct the rule violation on residents 5 and 6. Resident service plans were reviewed and updated to reflect residents' needs and provide clear direction for staff regarding delivery of services to said residents.
2. To ensure accuracy of service plan staff will be interviewed. Nurse and Resident Care Director will review final service plan to ensure accuracy.
3. The area needing correction will be evaluated monthly during Quality Improvement Meetings.
4. Executive Director and Resident Care Director will be responsible to see that the corrections are completed/monitored.
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, were updated quarterly, and/or were available to staff for 2 of 3 sampled residents (#s 8 and 10). This is a repeat citation. Findings include, but are not limited to:
1. Resident 8 was admitted to the facility in 02/2016 with diagnoses including diabetes mellitus and cognitive development delay.
a. Resident 8's most recent service plan, ADL Service Checkoff List, and staff interviews identified the service plan was not reflective of the resident's status or lacked clear direction to staff in the following areas:
* Mobility;
* Shower refusals;
* Outside services;
* Skin monitoring; and
* Frequency of blood sugar checks.
b. Resident 8's service plan had last been reviewed on 03/28/23, not completed quarterly as required.
On 08/09/23, the need to ensure service plans were reflective of resident needs, provided clear direction to staff, and were reviewed quarterly was discussed with Staff 18 (RCC/Administrator Designee). She acknowledged the findings.
2. Resident 10 was admitted to the facility on 06/23/23 with diagnoses including unspecified dementia without behavioral disturbance and anxiety disorder.
The resident's service plan was reviewed during the survey. The service plan was dated 06/27/23. There were two staff signatures acknowledging review of the service plan, both signatures were dated 06/28/23. In an 08/08/23 interview with Staff 18 (RCC/Administrator Designee), she stated she was unsure as to why the resident's service plan was completed and made available to staff four days after the resident was admitted to the facility.
The need to ensure service plans were completed before a resident moves into the facility and readily available to staff to provide clear direction regarding the delivery of services was discussed with Staff 17 (Interim EM/MCC) and Staff 18. They acknowledged the findings.
1. Resident 8 and 10 will receive chart review to ensure residents updated evaluation and service plan via service plan tea. Resident Service plans will continue to be updated per OARs.
VP of Health and wellnesss will conduct EHR review of atrium residents that are due/pass due for their OR evaluation/service plan. Regional nurse will be notified of VP of Health and Wellness audit results. Regional nurse will review audit and collaborate with community RN to ensure OR evaluation/service plans are updated. EHR will be set up to notify clincal team of OR evaluation/service plans due.
3. Administrator will review OR evaluation/service plans due with community nurse during 1:1 weekly meeting.
4. Administrator and/or designee.
3. Resident 11 moved into the facility in 05/2019 with diagnoses including stroke with right side paralysis.
Resident 11's 12/29/23 service plan, Interim Service Plan (ISPs), and staff interviews identified the service plan was not reflective of the resident's status or lacked clear direction to staff in the following areas:
* Transfer status, one person versus two person assistance;
* Use of a raised toilet seat; and
* Toileting status, one person versus two person assistance.
On 01/10/24, the need to ensure service plans were reflective of resident needs and provided clear direction to staff was discussed with Staff 18 (RCD), Staff 26 (ED) and Staff 27 (RN). They acknowledged the findings.
4. Resident 14 moved into the facility in 03/2012.
Resident 14's 10/03/23 service plan and resident and staff interviews identified the service plan was not implemented in the following areas:
* Laundry services.
On 01/11/24, the need to ensure service plans were implemented was discussed with Staff 26 (ED). She acknowledged the findings.
Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of resident's current health status, needs and preferences, provided clear direction to staff or were followed for 4 of 4 sampled residents (#s 11, 12, 13 and 14) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:
1. Resident 12 moved into the facility in 06/2019 with diagnoses including spinal pain and depression and had a recent history of falls and skin wounds. The most recent service plan, dated 12/29/23, and interim service plans were reviewed. The service plan did not provide clear direction to staff or was not being followed in the following areas:
* Interventions to attempt when the resident was resistive to treatments or toileting;
* Interventions to attempt when the resident refused medications;
* Application of barrier cream to buttocks; and
* Emergency evacuation needs and instructions.
2. Resident 13 moved into the facility in 03/2023 with diagnoses including hypertension and spinal stenosis. The most recent service plan, dated 09/14/23 was reviewed and did not include resident preferences or was not being followed in the following areas:
* Preference for only female caregivers for showers, personal care;
* Housekeeping services of cleaning, dishes, dusting;
* Daily weights;
* Bed making daily and washing bed linens weekly;
* Escorts to the dining room for lunch and dinner meals daily;
* Night time safety checks.
In an interview on 01/09/24, Resident 13 stated his/her service plan was not followed when "no one shows up to assist me to the dining room, I get too short of breath to get there without assistance." Resident 13 had requested only female care staff for showers, however, his/her shower days were "assigned" to evenings when there was only a male caregiver. As a result, the resident frequently refused showers. Resident 13 reported s/he routinely had to ask caregivers to make his/her bed as it was not done unless s/he asked and the resident had been taking his/her own weight daily as "care staff never do it."
The need to ensure service plans were reflective of resident needs, included clear direction to staff, information on resident preferences and were followed was discussed with Staff 26 (ED)and Staff 27 (RN) on 01/11/24. They acknowledged the findings.
1. Residents #:11,12,13, and 14 service plans will be audited, then updated to ensure staff have a clear direction to staff specific to resident's current needs and preferences.
2, Flagstone will comply with Milestone process and policy of service plan development: Preadmission, within first 30days, quarterly, and with significant change of condition. Staff will have service plans readily avaiable for review.
3. Service Plans will be reviewed within 30days of move in, quarterly, and with significant change of condition for accuracy. Oversight via scheduled and unscheduled audits during the correction period and ongoing thereafter.
4. The Flagstone Executive Director, and during the Plan of Correction period by 3rd party entity then thereafter by Milestone Regional staff on a quarterly basis.
Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of the resident's needs and preferences, provided clear direction regarding the delivery of services, and were implemented, for 2 of 3 sampled residents (#s 18 and 19) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:
1. Resident 18 was admitted to the facility in 01/2024 with diagnoses including Alzheimer's disease and chronic urinary retention requiring a suprapubic catheter.
The current service plan, dated 03/15/24, and Interim Service Plans (ISPs) from 02/28/23 to 04/11/24 were reviewed, observations of Resident 18 and interviews with staff were completed during the survey.
The service plan was not reflective of the resident's current status, did not provide clear direction to staff, and was not implemented in the following areas:
* Fall status including interventions;
* Bowel management status;
* Grooming and personal hygiene status including brushing teeth;
* Pain status;
* Hydration status;
* Stoma care instructions;
* Unexplained weight gain status;
* Use of a cushion while on wheelchair; and
* Catheter bag care instructions.
The need to ensure service plans were reflective of the resident's current needs and preferences, provided clear direction regarding the delivery of services and were implemented was discussed with Staff 27 (RN), Staff 34 (Administrator), Staff 35 (Resident Care Director), and Witness 1 (Consultant) on 04/17/24. They acknowledged the findings.
2. Resident 19 moved into the facility in 10/2021 with diagnoses including dementia and venous stasis in lower extremity.
Resident 19's service plan, last updated 02/26/24, Interim Service Plan (ISPs), and staff interviews identified the service plan was not reflective of the resident's status or lacked clear direction to staff in the following areas:
* Skin conditions requiring monitoring and treatment; and
* Weight changes and interventions.
On 04/18/24, the need to ensure service plans were reflective of resident needs and provided clear direction to staff was discussed with Staff 34 (Administrator), Staff 27 (RN) and Witness 1 (Consultant). They acknowledged the findings.
1. Residents #:18 and 19 service plans will be audited, then updated to ensure staff have a clear direction to staff specific to resident's current needs and preferences.
2. Flagstone will review and implement Milestone process and policy of service plan development: Preadmission, within first 30days, quarterly, and with significant change of condition to complt with OARs requiements. Staff will receive education to policies and Staff will have service plans readily avaiable for review with signature lines for ensured review and understanding of service plan. Audits of service plans will be conducted and results reviewed in QA meeting for ongoing completion and compliance
3. Service Plans will be reviewed within 30days of move in, quarterly, and with significant change of condition for accuracy. Tracking tool created and reviewed in morning meeting for ongoing compliance of clear direction of resident's needs and preferences and signatures.
4. The Flagstone Executive Director, and during the Plan of Correction period by 3rd party entity then thereafter by Milestone Regional staff on a quarterly basis.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure residents who had changes of condition were evaluated, resident-specific instructions or interventions were developed and communicated with staff and the condition was monitored for 3 of 5 sampled residents (#s 4, 5 and 6) who experienced short-term changes of condition. Findings include, but are not limited to:
1. Resident 5 was admitted to the facility in 04/2017 with diagnoses including edema. Progress notes dated 06/24/22 through 08/31/22, skin impairment logs and skin integrity monitoring forms dated 08/09/22 through 08/13/22 were reviewed. Staff were interviewed. The following was identified:
a. On 07/24/22 documentation revealed an open area on the resident's right foot, plantar area. A progress note dated 07/24/22 reflected the facility was going to refer the skin issue to a HH RN to follow for wound care and the facility RN would also monitor these issues. Although there were some notes relating to Resident 4's right foot, the notes were not documented by the facility RN weekly and per interview, had not resolved. There was no evidence the facility had implemented interventions per the resident's evaluated needs.
On 08/09/22 documentation revealed the resident returned from the emergency room with cellulitis and an antibiotic was started. The note stated, "RN to monitor." Although there were some notes relating to Resident 4's open area from the edema, the notes were not documented weekly by the facility RN. There was no evidence the facility had implemented interventions per the resident's evaluated needs.
An interview with Staff 1 (ED) on 08/31/22 at 2:30 pm confirmed that the facility RN didn't know she had to document on the skin issues weekly through resolution nor did she know she needed to document when the resident refused to have the RN look at the areas. The interview also confirmed that Resident 5 did not doff his/her compression stockings each evening and had refused to allow staff to assist. On 09/02/22 at 9:58 am, Staff 6 (RCC) confirmed the resident's skin issues were not resolved.
b. On 08/08/22, documentation revealed Resident 5 went to the emergency room relating to edema and returned to the facility the same day. There was no documented evidence the facility monitored the return through resolution.
The need to ensure residents who had changes of condition were evaluated, resident-specific instructions or interventions were developed and communicated with staff and the condition was monitored was discussed with Staff 1 and Staff 3 (Staff Nurse) on 09/02/22. They acknowledged the findings.
2. Resident 6 was admitted to the facility in 02/2017 with diagnoses including Type 2 Diabetes, spinal stenosis and dementia. The resident's 07/20/22 service plan, Interim Service Plans (ISPs), progress notes dated 06/04/22 through 08/26/22, and Resident Incident Reports were reviewed. Staff were interviewed. The following was identified:
a. The resident's record revealed the following falls:
* 03/31/22 - witnessed fall with no injury ;
* 07/02/22 - fall with lower extremity skin laceration;
* 07/27/22 - fall without injury;
* 07/29/22 - unwitnessed fall, no injury;
* 08/08/22 - non-injury fall; and
* 08/10/22 - non-injury fall.
On 07/23/22 the facility implemented safety checks and repositioning as fall interventions, however there was no documented evidence the interventions were monitored for effectiveness. There was no documentation reflecting new interventions based on evaluated needs for the fall on 07/27/22, and the falls after 07/27/22.
b. Resident 6's record revealed the following skin issues:
* 07/02/22 - Lower extremity skin laceration;
* 07/19/22 - Two open areas on buttocks;
* 07/20/22 - Right lower extremity skin tear;
* 07/23/22 - Skin tear to left upper extremity;
* 08/16/22 - Two cuts on knees which resulted when a dog jumped on the resident; and
* 08/22/22 - Right ankle laceration.
An interview with Staff 1 (ED) on 08/31/22 at 2:30 pm confirmed that the facility RN didn't know she had to document on the skin issues weekly through resolution nor did she know she needed to document when the resident refused to let the RN look at the areas. On 09/02/22 at approximately 9:58 am, Staff 6 (RCC) confirmed the Resident 6's skin issues were not resolved.
Although the facility's Skin Integrity Monitoring Form reflected both the HH RN and the facility RN would be monitoring the skin issues mentioned above, there was not consistent documentation that the facility RN was looking at these areas.
The need to ensure residents who had changes of condition were evaluated, resident-specific instructions or interventions were developed and communicated with staff and the condition was monitored to resolution was discussed with Staff 1 and Staff 3 (Staff Nurse) on 09/02/22. They acknowledged the findings.
3. Resident 4 was admitted to the facility in 07/2020 with diagnoses including diabetes and dementia.
Progress notes dated 06/01/22 through 08/30/22, incident reports, interim service plans and the MAR dated 08/01/22 through 08/30/22 were reviewed. Staff members were interviewed. The following was identified:
a. Resident 4 had a physician's order to administer sliding scale Novolog insulin (for diabetes management) per unit according to the residents CBG reading.
Resident 4 received the incorrect dose of Novolog insulin on the following dates:
* 08/16/22 9:00 am dose;
* 08/25/22 4:00 pm dose; and
* 08/27/22 at 12:00 pm.
During an interview, 09/01/22, Staff 2 (Director of Health and Wellness), confirmed she only monitored resident's insulin dosing on an "as needed basis", and relied on MTs to generate incident reports and notify her when a medication error occurred.
There was no documented evidence the RN had consistently monitored the residents insulin administration.
b. Resident 4 had a physician's order to monitor his/her CBGs four times a day. The following was documented in the MAR:
* 08/15/22 at 8:00 pm glucometer read "HI" with no CBG documented.
In an interview, 09/01/22 at 11:43 am, Staff 6 (RCC) and Staff 9 (MT) confirmed a "HI" reading indicated the resident's CBG was too high for the glucometer to read, and further stated MT's were to alert the on-call nurse and doctor for further instruction.
There was no documented evidence the high CBG was reported to the on-call nurse or physician and no evidence the resident was monitored following the high reading.
The need to ensure residents who had changes of condition were evaluated, resident-specific instructions or interventions were developed and communicated with staff and any condition requiring monitoring was monitored by the facility was discussed with Staff 1 and Staff 2 on 09/02/22. They acknowledged the findings.
1. The action taken to correct the rule violation for residents 5 included placing the resident on weekly skin tracking by facility nurse and updating service plan with interventions. The action taken for resident 6 was placing the resident on weekly skin tracking by facility nurse, updating service plan with specific review to recent falls and fall interventions. The action taken for resident 6 included updating medication orders for CBG or insulins with specific parameters of when to notify the Licensed Nurse and Physician.
2. To ensure that this violation will not happen again the system has been corrected by implementation of the following forms: med tech to med tech communication log which includes alert charting, end of shift report, and Temporary Service Plans that instruct staff on problem/need, goals, approaches/interventions and who provides the care. Staff will be responsible to alert chart once per shift when resident experiences a short term change of condition. Licensed nurse to document once weekly on residents with a significant change of condition.
3. The area needing correction will be evaluated weekly.
4. The Licensed Nurse and Executive Director will be responsible to see that the corrections are completed/monitored.
Based on interview and record review, it was determined the facility failed to communicate interventions to staff on each shift, evaluate implemented interventions for effectiveness and monitor conditions with progress noted at least weekly through resolution for 2 of 2 sampled residents (#s 8 and 9) who experienced changes of condition. This is a repeat citation. Findings include, but are not limited to:
1. Resident 9 was admitted to the facility in 07/2021 with diagnoses including frequent falls.
The resident's progress notes, dated 05/03/23 through 08/01/23 and service plans were reviewed and revealed the following:
a. 05/12/23 - The resident experienced a fall and sustained bruising to the greater portion of the face.
The 05/02/23 service plan noted the resident was independent with mobility and was at risk for falls. Interventions included instructions for staff to remind the resident to move slowly and to encourage the resident to put on supportive shoes with all walking.
The facility lacked documented evidence the previously implemented interventions for the resident's falls were evaluated for effectiveness or if new interventions needed to be developed, and monitoring of the resident for the fall with weekly progress noted at least weekly through resolution.
b. 07/20/23 - Progress note: " ...findings on resident with alarm pendant being 'too tight' around left wrist...area where pendant was placed is slightly red with some blue/purple discoloration."
In an 08/08/23 interview with Staff 18 (RCC/Administrator Designee), she reported she had developed interventions to prevent the resident's skin condition from reoccurring including instructions for staff to rotate placement of the resident's wrist pendant on alternate wrists.
The facility lacked documented evidence the interventions were communicated to staff on each shift.
On 08/09/23, the need to ensure interventions for Resident 9's short-term changes of condition were communicated to staff on each shift, previously implemented interventions were evaluated for effectiveness or if new interventions needed to be developed, and conditions were monitored with progress noted at least weekly until resolved was discussed with Staff 17 (Interim ED/MCC) and Staff 18. They acknowledged the findings.
2. Resident 8 was admitted to the facility in 02/2016 with diagnoses including cognitive development delay and diabetes mellitus.
Resident 8's progress notes, dated 05/03/23 through 08/07/23, current service plan dated 03/23/23, and incident reports were reviewed.
Between 04/01/23 and 08/07/23 the resident experienced the following falls:
* On 04/23/23 staff documented in a Resident Incident Report resident was found on the floor in his/her bathroom and "resident stated [s/he] was trying to use the bathroom and forgot to lock [his/her] wheelchair brakes when [s/he] was transferring."
* On 08/04/23 staff documented in a Resident Incident Report that the resident was "found on [his/her] back in the living room floor yelling" and "resident states [s/he] was getting out of [his/her] recliner to sit in wheelchair when the chair rolled out from under [him/her]."
There was no documented evidence the facility had evaluated the falls in relation to the resident's condition, developed interventions, or monitored fall interventions for effectiveness.
In an interview with Staff 18 (RCC/Administrator Designee) on 08/09/23, she reported that the facility's intervention for resident falls was to "have staff check on them more frequently."
No fall interventions were documented in the resident's service plan, including temporary care plans.
The need to implement a system for responding to resident changes of condition, such as falls, which included determining and documenting what interventions were needed for the resident, communicating those interventions to staff on all shifts, evaluating the interventions for effectiveness, and ensuring the documentation was made a part of the resident's record was discussed with Staff 18 on 08/09/23. She acknowledged the findings.
1.Resident change of condition will be completed for residents 8 and 9. Resident service plans will be updated and reviewed. Staff have to review the service plan binder daily, prior to start of shift for all changes to resident service plans.
2. Clinical team will review residents for change of condition. Staff will be inserviced on conducting a service plan review prior to start of shift. The RN and LPN have been trained by the regional clinical nurse per OAR and Milestone clinical standards in regards to COC's documentation and monitoring.
3. Weekly and as needed per OARs.
4. Administrator, Community Licensed Nurse, and/or designee.
Based on interview and record review, it was determined the facility failed to ensure resident-specific instructions or interventions were determined and documented, communicated to staff on each shift and the conditions were monitored, consistent with his or her evaluated needs for 2 of 2 sampled residents (#s 11 and 12) who experienced short-term changes of condition. This is a repeat citation. Findings include, but are not limited to:
1. Resident 11 moved into the facility in 05/2019 with diagnoses including stroke with right side paralysis.
The resident's progress notes, dated 11/12/23 through 01/07/24, and interim service plans (ISPs) were reviewed and showed the following:
* 12/04/23: Returned to the facility after 11 days of hospital stay with a diagnosis of pneumonia; and
* 12/29/23: Increased cough and required two person assistance with transfers.
There was no documented evidence the facility determined and documented what action or interventions were needed, communicated actions or interventions to staff on each shift and monitored the conditions, consistent with the resident's evaluated needs at least weekly to resolution.
b. The resident's clinical records were reviewed and revealed the following:
* 11/12/23: Emergency room visit due to bruise on the right middle finger;
* 11/20/23: Emergency room visit due to cough;
* 11/21/23: Swollen fingers;
* 12/05/23: Received flu shot;
* 12/08/23: A newly prescribed pain medication; and
* 12/09/23: Rash on groin area.
There was no documented evidence the facility monitored the conditions at least weekly to resolution.
On 01/09/24, the need to ensure resident-specific instructions or interventions were determined and documented, communicated to staff on each shift and the conditions were monitored, consistent with resident's evaluated needs and were monitored with progress noted, at least weekly, until resolved was discussed with Staff 26 (ED) and Staff 27 (RN). They acknowledged the findings.
2. Resident 12 moved into the facility in 06/2019 with diagnoses including spinal pain and depression.
a. The resident's progress notes, dated 10/31/23 through 01/08/24, and interim service plans (ISPs) were reviewed and showed the following:
* 11/01/24: the resident had a fall;
* 11/04/24: the resident experienced a fall and went to the emergency department for evaluation;
* 11/11/24: the resident had a fall; and
* 11/15/24: the resident had a fall.
There was no evidence the facility determined and documented what action or interventions were needed for the resident, communicated actions or interventions to staff on each shift and monitored the conditions, at least weekly, to resolution.
b. The resident's clinical records were reviewed and revealed the following changes of condition were identified:
* 11/10/23 and 11/18/23: redness and irritation to skin folds; and
* 11/20/23: two new wounds to gluteal folds (Stage 2).
There was no documented evidence the facility monitored the conditions, at least weekly, to resolution.
Resident 12's skin conditions were discussed with Staff 27 (RN) on 01/10/24. Staff 27 had evaluated the chronic skin redness to folds and the new wounds, but acknowledged there was no documentation of the conditions being monitored at least weekly.
On 01/10/24, the need to ensure the short-term changes of condition were monitored and the facility had a system to determine and document what action or interventions were needed for the resident, communicate actions or interventions to staff on each shift and monitor the conditions, at least weekly, to resolution was discussed with Staff 26 (ED) and Staff 27. They acknowledged the findings.
1. Residents #11, and #12 will be re-evaluated for current condition status. Service plans will be reviewed and updated accordingly based on resident evualtion
needs. Changes to service plan will be communicated to staff on each shift. Alert charting and ISP will be initatied based on evaluation. DHW follow up as appropriate.
2. Flagstone clincial team will be in-serviced on Milestone expectations regarding identifying, communicating and documenting observed changes in condition (physical, emotional, and mental functioning) of residents.
3. Routine monitoring of change in condition will be ongoing utilizing Milestone policy and processes. Clincial team and/or designee to review daily.
4. The Director of Health and Wellness will follow Milestone policy of daily monitoring of Alert status residents using Milestone tools and systems with supervision by the Executive Director. Milestone regional team will conduct unscheduled and scheduled audits of alert charting practices, Ongoing monthly audits of alert charting will be conducted by Milestone regional clinical team.
2. Resident 18 was admitted to the facility in 01/2024 with diagnoses including Alzheimer's disease and chronic urinary retention requiring suprapubic catheter.
Resident 18's 03/15/24 service plan, Interim Service Plans (ISPs), 02/20/24 through 04/16/24 progress notes, 02/28/24 physician orders, and 02/2024 through 04/2024 weight records were reviewed and showed the following:
The following short-term changes lacked documented evidence the resident's conditions were monitored until resolution:
* 02/25/24: Start a new ointment treatment as needed for rash;
* 03/07/24: Start an antibiotic to treat urinary tract infection following return from hospital;
* 03/08/24: A diagnosis of COVID positive;
* 03/13/24: Non-injury fall;
* 03/16/24: Aggressive behaviors;
* 03/24/24: Left leg pain;
* 03/28/24: Start a new dose of an anti-depressant medication;
* 04/01/24: Start an antibiotic to treat urinary tract infection following return from hospital;
* 04/05/24: Start a new dose of an anti-depressant medication; and
* 04/07/24: Missing antibiotic medication.
On 04/17/24, the need to monitor the resident's conditions through resolution, with at least weekly documentation, was discussed with Staff 27 (RN), Staff 34 (Administrator), Staff 35 (Resident Care Director) and Witness 1 (Consultant). They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to determine and document what actions or interventions were needed, communicate the interventions to staff, and/or monitor the conditions to resolution for 3 of 3 sampled residents (#s 14, 18 and 19) who experienced changes of condition. This is a repeat citation. Findings include, but are not limited to:
1. Resident 14 moved into the facility in 03/2012 with diagnoses including generalized anxiety disorder and chronic obstructive pulmonary disorder.
The resident's clinical record, including progress notes, Interim Service Plans, and incident reports, were reviewed and interviews were conducted. The following was identified:
a. There was no documented evidence the facility determined what resident-specific actions or interventions were needed for the resident, communicated the determined actions or interventions to staff, or documented weekly progress through resolution for the following short-term changes of condition:
* 03/30/24 and 04/08/24 - Incorrect dosage administered of hydroxyzine.
b. There was no documented evidence short-term changes of condition were monitored, with progress documented at least weekly through resolution for the following:
* 03/29/24 - Started three new medications (including antibiotics); and
* 04/02/24 - Incorrect dosage administered of prednisone.
The need to ensure resident-specific actions or interventions for short-term changes of condition were determined, documented, and communicated to staff on each shift and the changes of condition were monitored, at least weekly, through resolution was discussed with with Staff 27 (RN), Staff 34 (Administrator), Staff 35 (Resident Care Director) and Witness 1 (Consultant) on 04/17/24 at 3:30 pm. They acknowledged the findings.
3. Resident 19 moved into the facility in 10/2021 with diagnoses including dementia and a history of venous stasis to the lower extremity.
Resident 19's service plan, Interim Service Plans (ISPs), 02/24 through 04/16/24 progress notes, and physician communications were reviewed and showed the following:
The following short-term changes lacked documented evidence the facility determined and documented what action or intervention was needed for the resident, the determined action or intervention was communicated to staff on each shift and was made part of the resident record with weekly progress noted until the conditions resolved:
* 03/14/24: accidental ingestion of a toxic substance and recommendations to push fluids;
* 03/21/24: rash to back;
* 04/03/24: new antibiotic started following return from hospital;
* 04/04/24: symptoms of gastric bleeding following return from hospital;
* 04/11/24: rash to back; and
* 04/13/24: neck wound.
On 04/17/24, the need to determine and document what action or interventions were needed for the resident, communicated to staff on each shift and document at least weekly progress noted until the conditions resolved was discussed with Staff 27 (RN), Staff 34 (Administrator), Staff 35 (Resident Care Director) and Witness 1 (Consultant). They acknowledged the findings.
1. Residents #14, #18 and #19 will be re-evaluated for current condition status. Service plans will be reviewed and updated accordingly based on resident evualtion
needs. Changes to service plan will be communicated to staff on each shift. Alert charting and ISP will be initatied based on evaluation. DHW follow up as appropriate.
2. Flagstone clincial team will be in-serviced on Milestone policy regarding identifying, communicating and documenting observed changes in condition (physical, emotional, and mental functioning) of residents. Service plans will be reviewed by clinical team and signed for understanding and meeting the care needs identified in the ISP.
3. Daily review of 24 hour report, alert charting and ISP will be reviewed by DHW and/or Designee for Change of Condition and updates to services plans will be communicated to care staff. Randon audits will be conducted monthly and as needed by DWH or designee and reviewed in QA for sustained improvement
4. The Director of Health and Wellness will follow Milestone policy of daily monitoring of Alert status residents using Milestone tools and systems with supervision by the Executive Director. The Executive Director is responsible for continued compliance.
There are no detail notes for this visit.
2. Resident 18 was admitted to the facility in 01/2024 with diagnoses including Alzheimer's disease.
Observations of the resident and interviews with staff during the survey, 04/16/24 through 04/18/24, revealed the resident required an escort to the dining room and the resident was able to eat independently after set up.
Resident 18's weight record was reviewed during the survey and revealed the following:
* 02/2024 - 123.2 pounds;
* 03/2024 - 131.6 pounds; and
* 04/2024 - 146.4 pounds.
From 02/2024 to 03/2024, Resident 18 had weight gain of 8.4 pounds or 6.81 % of his/her body weight in a month and from 02/2024 to 04/2024, the resident had weight gain of 23.2 pounds or 18.83 % of his/her weight, which represented a significant change of condition.
There was no documented evidence the RN completed an assessment of the resident's condition which included findings, resident status and interventions made as a result of the assessment to address the significant weight changes.
On 04/18/24, the above findings, lack of an RN assessment and continued weight gain were shared with Staff 27 (RN). She acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to ensure an RN assessed significant changes of condition that included documented findings, resident status, and interventions made as a result of the assessment for 2 of 3 sampled residents (#'s 18 and 19) who were reviewed for significant changes. Findings include, but are not limited to:
1. Resident 19 moved into the facility in 10/2021 with diagnoses including dementia, hypertension and a history of venous stasis to lower extremity. The resident was receiving a diuretic daily, per physician's orders.
The resident's clinical record was reviewed and revealed Resident 19 experienced weight gain from 03/25/24 through 04/15/24. The resident was having his/her weight taken weekly. Weight records showed the following:
* 03/18/24: 136 pounds;
* 03/25/24: 135 pounds;
* 04/04/24: 118.8 pounds; (identified as an incorrect weight)
* 04/08/24: 152.8 pounds; and
* 04/15/24: 158 pounds.
From 03/18/24 through 04/15/24, Resident 19 gained 17.5 pounds in one month, or 12.96% of body weight. This constituted a significant change of condition requiring an RN assessment.
On 04/16/24, the facility RN completed a "late entry for 04/05/24" assessment note dated 04/16/24. The assessment documented weight loss and referred to "a short ER visit on 04/13/24 for a skin infection and exacerbation of venous stasis (leg swelling)". The assessment documented weight loss and did not document weight gain. The assessment did not include information on the resident's status, and the interventions made as a result of the assessment were related weight loss and not weight gain.
The need to ensure an RN conducted an assessment that included findings, status and interventions when a resident experienced a significant change of condition was reviewed with Staff 34 (Administrator), Staff 27 (RN) and Witness 1 (Consultant). They acknowledged the findings.
1. RN completed significant change of condition and service plan update for resident 18, 19 for recent change. Clinical team will provide training to staff on significant change of condition and when to notify the regional clinical team. The regional clinical team will provide training to the RN and managers on significant change of condition assessment requirements.
2. Clinical meetings for review of change of condition will occur multiple times per week. ISPs and alert charting will be reviewed in the clinical meeting. The regional clinical team will provide training to the RN in how to follow OARs and Milestone clinical standards changes of condition. Med techs, RCD, and LPN will be trained on responding to changes of condition.
3. Daily, weekly.
4. Administrator and Registered Nurse.
There are no detail notes for this visit.
2. Resident 6 was admitted to the facility in 02/2017 with diagnoses including Type 2 Diabetes.
On 08/31/22 at 3:06 pm, Resident 6's 08/2022 MAR was reviewed and revealed the resident was an insulin dependent diabetic. Per record review, the facility RN completed a diabetic assessment on 08/30/2022. A diabetic assessment for 05/2022 was requested from Staff 1 (ED) on 09/02/22 at 10:38 am. She provided me with the last assessment done for Resident 6, which was dated 02/15/2021. When asked about the delegation records for the resident, Staff 1 confirmed there would be the same issues with delegation as for Resident 4.
The need to ensure staff who administered insulin injections was delegated in accordance with OSBN Division 47 Rules was discussed with Staff 1 (ED) on 09/02/22. She acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules, for 2 of 2 sampled residents (#s 4 and 6) who received insulin injections by unlicensed facility staff. Findings include, but are not limited to:
According to OSBN Division 47 Administrative Rules, delegation means an RN authorizes an unlicensed person to perform tasks of nursing care and indicates the authorization in writing. The delegation process includes nursing assessment of the client in a specific situation, evaluation of the ability of the unlicensed persons, teaching the task and observing the staff demonstrate the task.
1. During the acuity interview on 08/31/22, Resident 4 was identified to be administered insulin injections by non-licensed staff.
Resident 4's MAR dated 08/01/22 through 08/30/22 was reviewed and revealed insulin had been given by Staff 7 (MT), Staff 17 (MT) and Staff 18 (MT) on multiple occasions.
Initial delegations for Staff 7 completed 04/18/22, Staff 17 completed 05/20/22 and Staff 18 completed 05/25/22 lacked documentation in the following areas:
* A nursing assessment and condition of the client;
* The rationale the task can be safely delegated to an unlicensed CG;
* The skills, ability and willingness of the unlicensed CG;
* Written instructions that include risks, side effects, risk factors and whom to report the same;
* The frequency client should be reassessed, including rationale; and
* The rationale for how frequently the CG should be supervised and re-evaluated.
Re-delegations for Staff 7 completed 06/13/22, Staff 17 completed 07/20/22 and Staff 18 completed 07/23/22 lacked documentation in the following areas:
* Nursing assessment and condition of the client; and
* How frequently the unlicensed person should be supervised and re-evaluated, including rationale for the frequency based on the competency of the caregiver.
The need to ensure staff who administered insulin injections was delegated in accordance with OSBN Division 47 Rules was discussed with Staff 2 (Director of Health and Wellness) on 09/02/22 at 8:51 am and with Staff 1 (ED) on 09/02/22 at 9:44 am. They acknowledged the findings. No additional information was provided.
1. The action taken to correct the rule violation for each example/resident includes the implementation of new forms that will document all required components in accordance with regulation and in accordance to OSBN Division 47. The delegating RN was in the process of transferring delegations to staff nurse during the time of survey. New delegating RN completed all appropriate documentation on each resident and delegated staff member.
2. The use of the following forms will assure that the system for RN delegation has been corrected and the violation will not happen again.
* Initial Evaluation of Caregiver Competence for Delegation
* RN Delegation Assessment Evaluation
* RN Reevaluation - Supervision of Caregiver's Competence for Delegation
* RN Delegation Insulin Pen
* RN Delegation Glusose Measurement Related to Insulin Administration
3. The area needing correction will be evaluated every 60 days.
4. The Director of Health & Wellness will be responsible to see that the corrections are completed/monitored.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to coordinate care with outside providers in order to ensure the continuity of care, for 1 of 1 sampled resident (# 11) who received Home Health services. Findings include, but are not limited to:
Resident 11 moved into the facility in 05/2019 with diagnoses including stroke with right side paralysis.
During the acuity interview on 01/08/24, the resident was identified to receive outside provider services.
The resident's outside provider's visit notes, dated 12/18/23 through 12/29/23, service plan dated 12/29/23 and Interim Service Plan (ISPs) were reviewed and revealed the following recommendations made by Home Health providers:
* Needs a shower at least weekly;
* Clean under peri-area daily and apply zinc paste; and
* Clean buttocks daily and apply zinc paste.
There was no documented evidence these recommendations were communicated with staff in an effort to coordinate care.
On 01/09/24 at 4:50 pm, the need to ensure on-going coordination of care was discussed with Staff 26 (ED) and Staff 27 (RN). They acknowledged the findings. No additional information was provided.
1. Resident #11 current condition and orders will be reviewed. Service plan will be updated with needs reflected. Service plan updates will be communicated to staff on each shift. Flagstone clincial team will collaborate with outside providers.
2. Flagstone clincial team will be inserviced on Milestone protocols of processing medical orders via 3-step process, updating service plans, implementing ISPs, and communicating changes to staff in writing to ensure implementation.
Resident charts will be audited to ensure EHR reflects provider orders and/or recommendations.
3. Flagstone staff will verify changes in orders, and document occuring to ISP and/or service plan on each shift following Milestone policy. Milestone regional staff will complete frequent audits of ISPs and Service Plans, provider orders, communication with third party providers, and documentation for compliance.
4. The Director of Health and Wellness and Milestone Regional team.
Based on interview and record review, it was determined the facility failed to ensure information and interventions provided by on-site by outside providers were communicated to staff and service plans adjusted if necessary, for 1 of 2 sampled residents (#18) who received outside services. This is a repeat citation. Findings include, but are not limited to:
Resident 18 was admitted to the facility in 01/2024 with diagnoses including Alzheimer's disease.
Resident 18 was identified during the acuity interview on 04/16/24 as receiving home health services.
Review of progress notes from 02/20/24 through 04/16/24 and "Outside Agency Documentation" from 02/22/24 through 03/07/24 included the following information made by the provider:
* 03/07/24: "Please make sign for bathroom. insertion site. OK to swab [with] betadine daily to dry out. Cover site [with] split gauze [and] tape on top only."; and
* 03/23/24: Clean catheter bag with "distilled white vinegar [and] water day and night shift...".
The 03/07/24 outside provider recommendation was not communicated to staff until 04/07/24. There was no documented evidence the 03/23/24 information was communicated to staff or the service plan was adjusted to ensure continuity of care.
The need to ensure staff were informed of on-site, outside provider information and interventions and the service plan adjusted if necessary was reviewed with Staff 27 (RN), Staff 34 (Administrator) and Staff 35 (Resident Care Director) during the survey. They acknowledged the findings.
1. Resident #18 current condition and orders will be reviewed. Service plan will be updated with needs reflected. Service plan updates will be communicated to staff on each shift. Flagstone clincial team will collaborate with outside providers.
2. Flagstone clincial team will be inserviced on Milestone protocols of processing medical orders via 3-step process, updating service plans, implementing ISPs, and communicating changes to staff in writing to ensure implementation.
Resident charts will be audited to ensure EHR reflects provider orders and/or recommendations.
3. Flagstone staff will verify changes in orders, and document occuring to ISP and/or service plan on each shift following Milestone policy. Milestone regional staff will complete frequent audits of ISPs and Service Plans, provider orders, communication with third party providers, and documentation for compliance.
4. The Director of Health and Wellness and Milestone Regional team.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure a safe medication system and adequate professional oversight of the medication and treatment administration systems. Findings include, but are not limited to:
Administrative oversight of the medication administration system was found to be ineffective based on deficiencies identified in the following areas:
C 282: RN Delegation and Teaching;
C 303: Systems: Medication and Treatment Orders;
C 305: Systems: Resident Right to Refuse; and
C 310: Systems: Medication Administration.
The requirement to ensure a safe medication system and adequate professional oversight of the medication administration system was discussed with Staff 1 (ED) on 09/02/22. She acknowledged the findings.
1. The action taken to correct the rule violation for each example/resident will be a MAR audit on all residents.
2. Medication Dashboard will reviewed for accuracy and monitored including but not limited to: documentation of refusals, missed meds, held meds, PRN, medications, treatments, MAR audit will be completed routinely.
3. Medication Dashboard will be reviewed by ongoing and offgoing med tech prior to end of shift. MAR audit will be completed montly by the 5th of the month on prior months MAR's.
4. Executive Director and Director of Health & Wellness will be responsible to see that the corrections are completed/monitored.
Based on interview and record review, it was determined the facility failed to ensure a safe medication and treatment system was in place and failed to ensure adequate professional oversight of the medication and treatment administration systems. This is a repeat citation. Findings include, but are not limited to:
Administrative oversight of the medication administration system was found to be ineffective based on deficiencies identified in the following areas:
C 303 and C 310.
On 08/09/23 the need to ensure a safe medication system was discussed with Staff 17 (Interim ED/MCC) and Staff 18 (RCC/Administrator Designee). They acknowledged the findings.
See citations C-303 and C-310
Based on interview and record review, it was determined the facility failed to ensure a safe medication administration system was in place and failed to ensure adequate professional oversight of the medication and treatment administration system, for 2 of 2 sampled residents (#s 15 and 16). The facility's failure to ensure medications were administered as ordered put Resident 15 at risk for overdose of pain medication. This is a repeat citation. Findings include, but are not limited to:
During the survey, conducted 01/08/24 through 01/11/24, concerns were identified in medication administration system, including medication errors, following physician's orders and tracking of controlled substances records.
1. Resident 15 moved into the facility in 07/2023 with diagnoses including adult failure to thrive. During the survey, it was reported Resident 15 had received double doses of pain medication.
a. The resident's 12/01/23 through 01/09/24 MARs, signed physician orders and tracking of controlled substances records were reviewed and showed the following:
* 11/27/23 physician's order indicated to administer oxycodone, 2.5 mg, as needed for severe pain;
* The MAR showed the resident received the pain medication several times;
* The tracking controlled substances record showed the resident received 5.0 mg of pain medication instead of 2.5 mg as prescribed on multiple occasions;
* The medication error was reported to Staff 27 (RN) on 12/01/23, but action for the medication error was not taken until 12/29/23; and
* Between 12/01/23 and 12/29/23, the resident continued to receive 5.0 mg of oxycodone eight times in error.
The repeated medication administration errors represented an unsafe medication administration system. The facility failed to address the medication errors timely which resulted in Resident 15 continuing to receive an incorrect dose of pain medication, placing the resident at risk of overdose.
b. The MAR read to administer Tylenol, 325 mg, as needed for pain and oxycodone 2.5 mg as needed for severe pain;. The MAR further directed "when resident is in pain and requests medication, please start with Tylenol, then Flexeril, then Oxycodone." There was no order for Flexeril on the MAR which provided inaccurate direction to staff. Staff documented on the MAR they administered oxycodone on multiple occasions, prior to trying Tylenol first as directed on the MAR. Therefore, staff failed to follow the directions as indicated on the MAR.
On 01/11/24 at 2:00 pm, the above findings were shared and the need to ensure adequate professional oversight for a safe medication system, address medication errors in a timely manner to prevent further medication errors and following physician orders as prescribed was discussed with Staff 26 (ED) and Staff 27. They acknowledged the findings.
2. During the survey, it was reported the facility routinely ran out of lancets and diabetic supplies, to obtain blood sugar readings which resulted in staff being unable to administer insulin as prescribed to Resident 16. Reportedly, the concern was expressed to Staff 18 (RCD), Staff 26 (ED) and Staff 27 (RN) repeatedly, but the issue was not addressed in a timely manner.
Resident 16's 12/01/23 through 12/31/23 MARs and 12/31/23 through 01/01/24 progress notes were reviewed. The MAR showed staff did not obtain blood sugar levels on 12/31/23. Staff documented on the progress note, "Resident was not able to get 11:30 am insulin for lunch due to facility being out of lancets."
On 01/11/24 at 2:00 pm, the above findings were shared and the need to ensure adequate professional oversight for a safe medication system and provide medical supplies as required to follow physician orders was discussed with Staff 26 and Staff 27. They acknowledged the findings.
3. The facility pharmacy audit reports were obtained and reviewed. The report, dated 10/13/23, showed several recommendations, including tracking of controlled substance documents. There was no documented evidence the recommendations were implemented.
On 01/09/24 at 12:09 pm, Staff 26 (ED) and Staff 27 (RN) confirmed they had not yet implemented the pharmacist recommendations.
4. During the survey, administrative oversight of the medication and treatment administration systems were found to be ineffective based on deficiencies in the following areas:
* C 302: Tracking Control Substances;
* C 303: Medication and Treatment Orders; and
* C 310: Medication Administration.
The need to ensure the facility had a safe medication administration system and the overall medication and treatment administration systems were reviewed with Staff 18 (RCC), Staff 26 (ED) and Staff 27 (RN) on 01/11/24. They acknowledged the findings.
1. Investigation of med management concerns involving #15 and #16 resident cases was conducted by Milestone regional clinical team. Resident #15 and #16 physician orders will be sent to PCP for review and signature.
2. Flagstone clinical team will be re-trained on Milestone policies and/or procedures regarding medication management, including but not limited to: medical order processing, documentation of orders, Diabetic supply ordering, medication supply management and ordering, tracking of controlled substances and investigations into Medication Errors.
Director of Health and Wellness to attend Leading Age Nurse training program for clinical best practices.
Pharmacy audit will be conducted.
3. During the plan of Correction, Milestone will partner with a 3rd party entity for clinical oversight and auditing of practices to ensure best practices in medication management. Weekly for 2 weeks and then every 2 weeks thereafter until resolution.
4. The Executive Director is responsible for ensuring the corrections are completed. The Milestone regional team in partnership with the 3rd party oversight entity will monitor during the plan of correction period, then thereafter Milestone regional team will continue to monitor.
Based on interview and record review, it was determined the facility failed to have a safe medication and treatment system in place and to ensure adequate professional oversight of the medication and treatment administration systems. This is a repeat citation. Findings include, but are not limited to:
Administrative oversight of the medication administration system was found to be ineffective based on repeat deficiencies identified in the following areas:
C 302, C 303, and C 310.
On 04/18/24 the need to ensure a safe medication system with adequate professional oversight was discussed with Staff 34 (Administrator) Staff 27 (RN) and Witness 1 (Consultant). They acknowledged the findings.
1. Investigation of med management concerns involving #14, #1, #19 and #20 resident cases was conducted by Milestone regional clinical team. Resident #14, #18, #19 and #20 physician orders will be sent to PCP for review and signature.
2. Flagstone clinical team will be re-trained on Milestone policies and/or procedures regarding medication management, including but not limited to: medical order processing, documentation of orders, Diabetic supply ordering, medication supply management and ordering, tracking of controlled substances and investigations into Medication Errors.
Director of Health and Wellness to attend Leading Age Nurse training program for clinical best practices.
Pharmacy audit will be conducted.
3. During the plan of Correction, Milestone will partner with a 3rd party entity for clinical oversight and auditing of practices to ensure best practices in medication management. Weekly for 2 weeks and then every 2 weeks thereafter until resolution.
4. The Executive Director is responsible for ensuring the corrections are completed. The Milestone regional team in partnership with the 3rd party oversight entity will monitor during the plan of correction period, then thereafter Milestone regional team will continue to monitor.
There are no detail notes for this visit.
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 (# 15) whose records were reviewed. Findings include, but are not limited to:
Resident 15 moved into the facility in 07/2023.
Resident 15 had signed physician orders on 11/27/23 for oxycodone 2.5 mg as needed for severe pain.
Resident 15's 12/01/23 through 01/09/24 MAR and the Controlled Substance Disposition Log were reviewed and revealed the following:
* The Controlled Substance Disposition log showed the oxycodone was administered on 58 occasions between 12/01/23 and 01/08/24, however, the MAR showed only 40 occasions the medication was administered to Resident 15.
Inconsistencies between the MAR and Controlled Substance Disposition logs were reviewed on 01/11/24 with Staff 26 (ED) and Staff 27 (RN). They reviewed the documentation and acknowledged the discrepancies.
1. Medication cart audit to include controll substances will be completed for community.
2. Medication technicians to be re-trained on Milestone policies and processes for management of controlled substances not limited to education on medication orders, documentation of controlled substance disposition (disposition logs), and safe destruction of medications.
DHW will complete re-training on Milestone expectations in oversight responsibilities as RN, reporting expectations, investigation expectations, and timely communication expectations.
ED will compelte re-training on Milestone expectations in investigation and reporting expectations, and timely communication expectations.
3. During the plan of correction period, Milestone will partner with a 3rd party Entity for clinical oversight and assurance of compliance 8 hours per week. Thereafter, Milestone will monitor and provide oversight to ensure compliance with systems in place.
4. The Executive Director is responsible for ensuring that Flagstone meets all OAR and licensure expectations, the DHW is responsible for following all existing clinical OARs and Mielstone clinical policies
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 (# 20) whose records were reviewed. This is a repeat citation. Findings include, but are not limited to:
Resident 20 moved into the facility in 04/2024 with diagnoses including chronic pain.
The 04/09/24 through 04/17/24 MAR directed staff to administer tramadol 50 mg as needed for pain.
Resident 20's 04/09/24 through 04/16/24 MAR and the Controlled Substance Disposition Log were reviewed and revealed the following:
* The Controlled Substance Disposition log showed the tramadol was administered on five occasions between 04/09/24 and 04/16/24, however, the MAR showed only four occasions the medication was administered to Resident 20.
* The Controlled Substance Disposition log lacked clear information on how many tablets of the medication were received on 04/09/24. There were three different quantities on the record; and
* The Controlled Substance Disposition was not documented in chronological order.
Inconsistencies between the MAR and Controlled Substance Disposition logs were reviewed and the need to have a system in place for accurately tracking controlled substances administered by the facility was discussed on 04/17/24 and on 04/18/24 with Staff 27 (RN), Staff 34 (Administrator) and Witness 1 (Consultant). They reviewed the documentation and acknowledged the findings.
1. Medication cart audit to include controll substances will be completed for community.
2. Medication technicians to be re-trained on Milestone policies and procedures for management of controlled substances not limited to education on medication orders, documentation of controlled substance disposition (disposition logs), and safe destruction of medications.
DHW will complete re-training on Milestone expectations in oversight responsibilities as RN, reporting expectations, investigation expectations, and timely communication expectations.
ED will compelte re-training on Milestone expectations in investigation and reporting expectations, and timely communication expectations.
3. During the plan of correction period, Milestone will partner with a 3rd party Entity for clinical oversight and assurance of compliance 8 hours per week. Thereafter, Milestone will monitor and provide oversight to ensure compliance with systems in place.
4. The Executive Director is responsible for ensuring that Flagstone meets all OAR and licensure expectations, the DHW is responsible for following all existing clinical OARs and Mielstone clinical policies
There are no detail notes for this visit.
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 and physician or other legally recognized practitioner orders were documented in the resident's facility record for 2 of 6 sampled residents (#s 4 and 6) whose orders were reviewed. Findings include, but are not limited to:
1. Resident 6 was admitted to the facility in 02/2017 with diagnoses including Type 2 Diabetes and dementia. August 2022 MARs and physician's orders were reviewed. The following orders were not in the resident's record:
* 650 mgs of scheduled acetaminophen (for pain);
* Mylanta (for upset stomach or indigestion);
* Order to leave the calmosptine ointment in the bathroom (for skin); and
* Spouse to take and monitor CBGs in the morning and at night (to report to facility staff relating to diabetes).
The need to ensure orders were carried out as prescribed and the resident had physician or other legally recognized practitioner order were documented in the resident's chart was discussed with Staff 1 (ED) and Staff 3 (Staff Nurse) on 09/02/22. They acknowledged the findings.
2. Resident 4 was admitted to the facility on 07/27/20 with diagnoses including diabetes and dementia. The facility was administering insulin to the resident multiple times daily.
Physician's orders and the MAR dated 08/01/22-08/30/22 for Resident 4 were reviewed and revealed the following:
a. Resident 4 had a physician's order to administer Novolog insulin (for diabetes management) as follows: inject subcutaneously per sliding scale three times daily before meals: 120-150 = two units, 151-200 = three units, 201-250 = four units, 251-300 = five units, 301-350 = six units, 351-400 = seven units.
* On 08/16/22 at 9:00 am the resident's CBG was 161. The physician's order directed staff to administer three units of insulin and per the MAR two units were administered;
* On 08/17/22 at 12:00 pm no CBG was recorded, and no insulin was administered as resident was out of facility with his/her family;
* On 08/17/22 at 4:00 pm the resident's CBG was 228. The physician's order directed staff to administer four units of insulin and per the MAR 228 units were documented. The amount administered is unknown;
* On 08/25/22 at 9:00 am the resident's CBG was 144. The physician's order directed staff to administer two units of insulin and per the MAR no insulin was administered;
* On 08/25/22 at 4:00 pm the resident's CBG was 302. The physician's order directed staff to administer six units of insulin and per the MAR five units were administered; and
* On 08/27/22 at 12:00 pm the resident's CBG was 236. The physician's order directed staff to administer four units of insulin and per the MAR three units were administered.
An interview with Staff 17 (MT) on 09/01/22 at 11:43 am confirmed that diabetic equipment and medications were normally sent with Resident 4 and his/her family when out of the facility. Staff 1 (ED) confirmed on 09/01/22 at 12:16 pm the medications were not sent with the resident on 08/17/22 and the resident did not receive his/her 12:00 pm Novolog dose.
b. Resident 4 had a physician's order to administer Lantus Solostar (for diabetes management) 40 units subcutaneously every night at bedtime. The following error was noted:
* On 08/30/22 the medication was documented as "on hold until available."
In an interview with Staff 6 (RCC) on 09/01/22 at 11:43 am, she confirmed the facility ran out of the Lantus Solostar. The medications were ordered to arrive STAT (within two hours) but they did not arrive until 08/31/22.
There was no negative outcome identified related to the lack of following physician orders related to insulin administration and CBG monitoring.
The need for the facility to ensure medication orders were carried out as prescribed was discussed with Staff 1 on 09/01/22. Findings were acknowledged.
1. The action taken to correct the rule violation for each example/resident is a full Medication Administration Audit for all residents that reside in the community for the month of August and September. In addition a chart review will be completed on each resident and Physician's Orders review to be sent.
2. To ensure the violation will not happen again the system will be corrected by auditing the MAR's and sending reviewed Physicians Order on a routine basis.
3. The area of correction will need to be evaluated on a monthly basis.
4. Licensed Nurse and Executive Director will be responsible to see that the corrections are completed/monitored.
Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 1 of 2 sampled residents (#8) whose physician orders were reviewed. Findings include, but are not limited to:
Resident 8 was admitted to the facility in 02/2016 with diagnoses including cognitive development delay and diabetes mellitus.
Review of Resident 8's signed physician orders and 07/01/23 through 08/07/23 MAR identified the following:
a. The resident had an order for Humalog 100 u/ml 3ml pen (for diabetes) stating it was a change from Aspart 100-u/ml pen (for diabetes), "same dosing instructions".
Prior to the change to Humalog the resident had been receiving both routine Aspart, 3x daily before meals "in addition to sliding scale", and sliding scale Aspart.
The resident began receiving sliding scale Humalog on 07/21/23. The resident did not receive any routine Humalog. The resident's MAR indicated the last routine Aspart was given at 11:00 am on 07/21/23.
In an interview with Staff 19 (LPN) on 08/08/23, she stated she would clarify with the physician what the order was but that she thought there had been a verbal order for the discontinuation of the routine Aspart.
b. The MAR did not have a signature for administration of sliding scale Humalog on 07/22/23 at 11:00 am. It could not be confirmed that the resident had received the medication.
c. The resident had an order for notifying the physician if CBG is greater than 400. The resident's CBG was 441 on 07/03/23 and 436 on 07/12/23. The facility had no documentation of physician notification.
The need to follow physician orders as written was discussed with Staff 18 (RCC/Administrator Designee) on 08/09/23. She acknowledged the findings.
1. Resident 8 medication orders and CBGs sent to PCP for review.
CBG parameters will be clarified with PCP and then added to EMR/EHR by clinical team.
2. New orders will be reviewed by clincial team/designee on a daily basis to ensure accuracy and implementation.
3. Daily and as needed per OARs.
4. Licensed Nurses, RCD's and Administrator and/or Designee.
Based on interview and record review, it was determined the facility failed to obtain written, signed physician or other legally recognized practitioner orders in the resident's facility records and failed to ensure physician orders were carried out as prescribed for 6 of 6 sampled residents (#s 11, 12, 13, 15, 16 and 17) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to:
1. Resident 11 moved into the facility in 05/2019 with diagnoses including stroke with right side paralysis.
a. During the record review, the surveyor noted multiple physician orders were not in the resident's chart. The surveyor requested signed physician orders from the facility then the facility staff obtained the signed physician orders from the pharmacy during the survey.
Resident 11's current signed physician orders, hospital discharge summary and 12/01/23 through 01/08/23 MAR were reviewed and showed the following:
b. The 12/04/23 hospital discharge summary indicated to discontinue Zolpidem [to treat insomnia] 5.0 mg. The MAR showed the resident received the medication continually and the medication was not discontinued as of 01/07/24.
c. The 12/04/23 physician order indicated to administer Apixaban [to prevent blood clots] 5 mg two times daily. The MAR showed the medication was administered once daily, not two times, as prescribed.
d. The 12/20/23 physician order indicated to administer Fluconazole 100 mg for yeast infection. Further instruction showed to administer 2 tablets of the medication for one day and then 1 tablet of the medication for five days. The MAR showed the medication was administered for seven days, not six days, as prescribed.
e. The 12/13/23 physician order indicated to apply Nystatin powder two times daily. The MAR showed the treatment was not transcribed on the MAR to carry out.
On 01/10/24, the above findings were shared and failure to follow physician orders as prescribed was discussed with Staff 26 (ED) and Staff 27 (RN). They acknowledged the findings.
2. Resident 15 moved into the facility in 07/2023 with diagnoses including adult failure to thrive.
Resident 15's current signed physician orders and tracking controlled substance log, dated 11/25/23 through 01/06/24, were reviewed and showed the following:
* 11/27/23 MD order indicated to administer oxycodone 2.5 mg as needed for severe pain; and
* The Controlled Substance Disposition logs showed oxycodone 5.0 mg was administered, not 2.5 mg, on nine occasions.
On 01/11/24 at 2:00 pm, the above findings were shared and failure to follow physician orders as prescribed was discussed with Staff 26 (ED) and Staff 27 (RN). The findings were acknowledged.
3. Resident 16 moved into the facility in 07/2020 with diagnoses including diabetes mellitus with renal complications.
Resident 16's 12/01/23 through 12/31/23 MAR and 12/31/23 through 01/01/24 progress notes were reviewed and showed the following:
* The MAR directed staff to administer insulin injection three times daily before meals and to hold the insulin for CBG less that 90. The MAR revealed staff did not obtain CBG result and did not administer insulin on 12/31/23 lunch at 11:30 am; and
* Staff documented on 12/31/23 progress note, "Resident was not able to get 11:30 am insulin for lunch due to facility being out of lancets."
On 01/11/24 at 2:00 pm, the above findings were shared and failure to follow physician orders as prescribed was discussed with Staff 26 (ED) and Staff 27 (RN). They acknowledged the findings.
4. Resident 17 moved into the facility in 03/2021 with diagnoses including type II diabetes.
Resident 17's 01/01/24 through 01/09/24 MAR and an incident report, dated 01/02/24, were reviewed and showed the following:
* Staff documented on an incident report the facility received a physician order for Keflex [antibiotic] on 12/15/23, however, the antibiotic was not started until 01/01/24, 17 days after the order was received.
On 01/11/24 at 2:00 pm, the above findings were shared and failure to follow physician orders as prescribed and the antibiotic not being started timely, was discussed with Staff 26 (ED) and Staff 27 (RN). They acknowledged the findings.
5. Resident 12 moved into the facility in 06/2019 with diagnoses including depression.
Resident 12's 12/01/23 through 01/08/24 MARs and current physician's orders were reviewed and showed the following:
* A physician's order, signed 11/15/23, stated to administer paroxetine (a psychotropic medication for major depressive disorder) 40 mg; take 1 tablet by mouth once daily at bedtime; and
* The MARs indicated an order for staff to administer paroxetine 40 mg at 8:00 am and at 8:00 pm.
The facility was unable to provide a physician's order for the 8:00 am dose of the medication and was unable to verify whether the physician had intended to order both an a.m. and p.m. dose. The facility contacted the physician on 01/10/24 to verify.
The need to ensure physician's orders were followed as prescribed was discussed with Staff 26 (ED) and Staff 27 (RN) on 01/10/24 and 01/11/24. They acknowledged the findings.
6. Resident 13 moved into the facility in 03/2023 with diagnoses including hypertension.
In an interview on 01/09/24, Resident 13 reported the facility medication aides had been administering his/her furosemide incorrectly. The resident was able to explain the blood pressure parameters for administering the medication, and stated staff continued to give him/her the medication, even when his/her blood pressure was supposed to be "held".
Resident 13's 01/01/24 through 01/09/24 MAR and current physician's orders were reviewed and showed the following:
* A physician's order, signed 10/26/23, stated to administer furosemide (a diuretic) 20 mg; take 0.5 tablet (10 mg) by mouth every day; hold for systolic blood pressure less than 110;
* The MAR included the order for furosemide and included the parameters to hold the medication for systolic blood pressure below 110; and
* The MAR showed the furosemide was administered to the resident on 01/02/24, 01/06/24 and 01/08/24 when the systolic blood pressure was below 110 and should have been "held".
The need to ensure physician's orders, including resident specific instructions and parameters, were followed was discussed with Staff 26 (ED) and Staff 27 (RN) on 01/11/24. They acknowledged the findings.
1. EMAR audit for residents #11,12,13,14,16 and 17 will be completed to ensure accuracy of medication orders. Residents # above will send medication orders to PCP for review and signature.
2. Med Techs will be re-trained on processing processing physican orders, medication management, following physician orders, ordering supplies. .
3. During the plan of Correction period, the Medication carts will be audited weekly by the DHW or designee and additionally by the 3rd party clinical oversight entity.
pharmacy will conduct medication audit ASAP and quarterly therafter.
4. The Executive Director and the Director of Health and Wellness will ensure the corrections are completed, with oversight from the 3rd party entity and the Milestone regional team.
Based on interview, and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 3 of 3 sampled residents (#s 14, 18 and 19) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to:
1. Resident 18 was admitted to the facility in 01/2024 with diagnoses including Alzheimer's disease and chronic urinary retention requiring suprapubic catheter.
The resident's 03/01/24 through 04/16/24 MARs and physician's orders were reviewed and identified the following:
a. A physician's order, dated 02/28/24, indicated to administer Donepezil (a medication to treat Alzheimer's disease) 10 mg daily.
The MAR showed the medication was not administered from 03/18/24 through 04/15/24, for 29 days.
b. A physician's order, dated 03/05/24, indicated to administer Cipro (an antibiotic to treat infection) 500 mg every 12 hours for 10 days.
The MAR showed the antibiotic was not administered on one occasion on 03/17/24.
c. A physician's order, dated 04/01/24, indicated to administer cephalexin (an antibiotic to treat infection) 500 mg every six hours for seven days.
The MAR showed the antibiotic was not administered on 11 occasions between 04/04/24 and 04/10/24.
On 04/17/24, the physician orders and the MARs were reviewed and the need to ensure physician's orders were administered as prescribed was discussed with Staff 27 (RN), Staff 34 (Administrator), Staff 35 (Resident Care Director) and Witness 1 (Consultant). They acknowledged the findings.
2. Resident 14 was admitted to the facility in 03/2012 with diagnoses including generalized anxiety disorder and chronic obstructive pulmonary disease.
The resident's 03/01/24 through 04/16/24 MARs and physician's orders were reviewed and identified the following:
a. A physician's order, dated 03/21/24, indicated to administer hydroxizine (a medication to treat anxiety) 50 mg tab by mouth every 6 hours as needed for anxiety. Not to exceed three doses in 24 hours.
The MAR showed the medication was administered four times within 24 hours on 03/30/24 with two doses being administered at the same and with the fourth dose being administered within 4.5 hours. The MAR also revealed that on 04/08/24 the medication was administered four times within 24 hours with two doses being administered within one minute.
b. A physician's order, dated 03/29/24, indicated to administer prednisone (a medication to treat chronic obstructive pulmonary disease) one 50 mg tablet by mouth daily for five days.
The MAR showed the medication was administered once on 03/29/24 and twice daily on 03/30/24 through 03/31/24.
c. A physician's order, dated 04/11/24, indicated to administer azithromycin (an antibiotic to treat infection) 250 mg two tablets by mouth for one day and one tablet by mouth every day for four days.
The MAR showed the antibiotic was administered one tablet on day one, three tablets administered on day two and one tablet administered on day three.
On 04/17/24, the physician orders and the MARs were reviewed and the need to ensure physician's orders were administered as prescribed was discussed with Staff 27 (RN), Staff 34 (Administrator), Staff 35 (Resident Care Director), and Witness 1 (Consultant). They acknowledged the findings.
3. Resident 19 moved into the facility in 10/2021 with diagnoses including dementia and a history of venous stasis to the lower extremity.
The resident's 03/01/24 through 04/16/24 MARs and physician's orders were reviewed and identified the following:
A physician's order, dated 04/03/24, indicated to administer docusate sodium [a medication for bowel regularity] 250 mg tab by mouth every two days.
The MAR instructed staff to administer the docusate sodium every day and indicated the medication was being administered daily.
On 04/18/24, the physician orders and the MARs were reviewed and the need to ensure physician's orders were administered as prescribed was discussed with Staff 27 (RN), Staff 34 (Administrator) and Witness 1 (Consultant). They acknowledged the findings.
1. EMAR audit for residents #14,18 and 19 will be completed to ensure accuracy of medication orders. Residents # above will send medication orders to PCP for review and signature.
2. Med Techs will be re-trained on processing physican orders, medication management, following physician orders, and ordering supplies.
3. Medication carts will be audited weekly by the DHW or designee and additionally by the 3rd party clinical oversight entity. Tracking tool created for monitoring accuracy of orders and service plans and reviewed daily with team. Pharmacy will conduct medication audit ASAP and quarterly therafter or as requested by DHW or designeee for sustained compliance. Results of the audits will be reviewed in QA.
4. The Executive Director and the Director of Health and Wellness will ensure the corrections are completed, with oversight from the 3rd party entity and the Milestone regional team.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to notify the physician or other practitioner when a resident refused to consent to medication and treatment orders for 1 of 1 sampled resident (#2) who had documented refusals. Findings include, but are not limited to:
Resident 6 was admitted to the facility in 02/2017 with diagnoses including Type 2 Diabetes and dementia. August 2022 MARs, physician's orders and progress notes dated 06/04/22 through 08/26/22 were reviewed. The following refusals were identified:
* 07/16/22 - refused all medications;
* 07/29/22 - refused the 6:00 am dose of antibiotics (for wound infection);
* 08/01/22 - refused calmoseptine (for skin); and
* 08/28/22 - refused erythromycin (for eye infection).
There was no documented evidence the facility notified the practitioner of the above refusals.
The need to ensure the physician or other prescribing practitioners were notified when a resident refused to consent to orders was discussed with Staff 1 (ED) and Staff 3 (Staff Nurse) on 09/02/22. They acknowledged the findings.
1. The action taken to correct the rule violation for each example/resident was notification made to Physician for each medication refusal.
2. To ensure the violation will not happen again the system was corrected by implementation of audit on medication refusals.
3. The aread of correction will be evaluated monthly.
4. The Resident Care Director and Executive Director will be responsible to see that the corrections are completed/monitored
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was maintained for all facility administered medications, including the initials of the person administrating the medication, for 1 of 6 sampled residents (#6) whose MARs were reviewed. Findings include, but are not limited to:
Resident 6 was admitted to the facility in 02/2017 with diagnoses including dementia.
August 2022 MARs, physician's orders and progress notes dated 06/04/22 through 08/26/22 were reviewed. The following accuracy issues were identified:
A progress note by an MT dated 08/02/22 stated calmoseptine ointment (for skin) was left in the resident's bathroom "available to whomever is able to assist [him/her] with toileting." There were only MT initials on the 08/2022 MAR relating to the administration of the ointment.
An interview with Staff 6 (RCC) on 09/02/22 at 9:58 am verified there was calmoseptine ointment in Resident 6's bathroom for anyone to apply.
There was also a blank on the 08/04/22 entry for the 4:00 pm administration of the calmoseptine ointment.
The need to ensure MARs were accurate and included the initials of the person administrating the medication was discussed with Staff 1 (ED) and Staff 3 (Staff Nurse) on 09/02/22. They acknowledged the findings.
1. The actions taken to correct the rule violation for each example/resident are as follows; education with all medication techs to ensure understanding of a safe medication administration system, 6 rights of medication administration posted on the med carts, medication audit on all residents, and physicians orders review on all residents.
2. To ensure the violation will not happen again the system has been corrected by the reviewal of the medication dashboard at shift change by oncoming and offgoing med techs to follow up on refusals, missed medications, medications with attached documentation, and held medications.
3. The area needing correction will be evaluated at shift change by med techs and weekly by management.
4. Licensed Nurse and Executive Director will be responsible to see that the corrections are completed/monitored.
2. Resident 8 was admitted to the facility in 02/2016 with diagnoses including cognitive development delay and diabetes mellitus.
The resident's current signed physician orders and 07/01/23 through 08/07/23 MAR were reviewed. The following inaccuracies were identified:
a. The MAR included the initials UW corresponding to the signature and title of Universal Worker 1, Medtech, not the name of the person administering the medication, as required. These initials were used 25 times.
b. On 08/06/23 at 8:00 am and 4:00 pm the resident's blood sugar was documented as 0.
c. Staff 23's (MT) initials were signed on Resident 8's MAR eight times for insulin administration. In an interview with Staff 26 (RN) on 08/08/23 she reported that Staff 23 had not yet been delegated to administer insulin. On 08/08/23 Staff 23 reported that she had never administered insulin but had always had someone else administer it. On 08/09/23 Staff 18 (RCC/Administrator Designee) reported that she had administered insulin the day before, when Staff 23 was signed into the MAR. Staff 18 reported she believed this to be the correct process, if there was documentation in a notation field she had administered the medication. She stated that she had forgotten to write in the notation field on previous occasions.
The need to ensure MARs were accurate and included the signature of the person administering the medications was discussed with Staff 18 on 08/09/23. She acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure accurate MARs were kept for any medications and treatments administered by the facility for 2 of 2 sampled residents (#s 8 and 9) whose MARs were reviewed. This is a repeat citation. Findings include, but are not limited to:
1. Resident 9 was admitted to the facility in 07/2021 with diagnoses including vascular dementia.
The resident's 07/01/23 through 08/07/23 MARs were reviewed during the survey. The record review revealed the initials UW in place of staff initials for each of Resident 9's scheduled morning medication administrations on 07/24/23, 07/25/23, 07/27/23, 07/28/23, 08/01/23 and 08/02/23. Further review of the MAR noted the initials UW and the title Universal Worker on the staff initial key.
In an interview on 08/09/23 Staff 17 (RCC/Administrator Designee) reported the facility had staffed temporary Universal Workers employed by the corporate entity to provide staffing relief while the facility was understaffed. Staff 17 stated the facility had entered the title and initials as a staff login in the facility's electronic MAR system and instructed the temporary MT's to chart medication administrations on the MAR using the Universal Worker login.
On 08/09/23 the need to ensure MARs were accurate including the initials of the person who administered medications was discussed with Staff 17 (Interim ED/MCC) and Staff 18. They acknowledged the findings
1. Temporary universal workers have been given their own logins. EMAR will be updated to reflect specific med tech administering resident medications. CBGs will be properly documented in EMAR.
2. Staff training will be completed by regional clinical nurse to ensure the med tech administering resident medication and/or obtaining CBGs per physican orders is documentated.
3. Weekly and as needed per OARs.
4. Licensed Nurse, Administrator, RCD's, and/or designee
Based on interview and record review, it was determined the facility failed to ensure accurate MARs were kept for any medications and treatments administered by the facility for 3 of 4 sampled residents (#s 11, 12 and 15) whose MARs were reviewed. This is a repeat citation. Findings include, but are not limited to:
1. Resident 12 moved into the facility in 06/2019 with diagnoses including depression. The resident was reported to have chronic redness to skin folds, contact dermatitis and two wounds to the buttocks. The 12/01/23 through 01/08/24 MARs and current physician's orders were reviewed and showed the following:
* Clotrimazole 1% cream "topically apply to affected areas 2 times daily until rash resolves"; and
* Desenex 2% powder "topically apply to affected areas every day" for skin.
There were no specific parameters or instructions to guide non-licensed staff as to where to apply the cream or powder on the resident's various skin conditions.
The need to ensure MARs were accurate including resident specific parameters and instructions for staff to follow was discussed with Staff 26 (ED) and Staff 27 (RN). They acknowledged the findings.
2. Resident 11 moved into the facility in 05/2019 with diagnoses including stroke with right side paralysis and pain in right toes.
The 12/01/23 through 01/08/24 MARs, current physician's orders and Controlled Substance Disposition log were reviewed and showed the following:
* The MAR revealed multiple blanks.
* A physician order indicated to administer oxycodone 2.5 mg, however, staff incorrectly documented on the Controlled Substance Disposition log that they administered 5.0 mg of oxycodone when the oxycodone medication packages were delivered with 2.5 mg doses.
* The 12/20/23 order indicated to administer Fluconazole 100 mg for yeast infection. Further instruction indicted to administer two tablets of the medication for one day and then one tablet of the medication for five days. Staff documented on the MAR that they administered three tablets of Fluconazole, inaccurately, on multiple days.
* The MAR showed Diclofenac sodium 1% gel "topically apply 4gm to affected areas" as needed for moderate pain and Miconazole Nitrate 2 % cream "topically apply to affected areas" as needed for redness. There were no specific parameters or instructions to guide non-licensed staff as to where to apply the gel or cream on the resident's various pain and skin conditions.
* The MAR showed Preparation [for hemorrhoid] ointment "apply to affected areas" as needed for "package directions." There was no reason for use and no specific parameters or instructions to guide non-licensed staff as to when to apply the ointment.
The need to ensure MARs were accurate including blanks on the MARs, the Controlled Substances tracking records and resident specific parameters and instructions were discussed with Staff 26 (ED) and Staff 27 (RN) during the survey. They acknowledged the findings.
3. Resident 15 moved into the facility in 07/2023 with diagnoses including adult failure to thrive.
The resident's 12/01/23 through 01/08/24 MARs, current physician orders and Controlled Substance Disposition log were reviewed and showed the following:
* A physician order indicated to administer oxycodone 2.5 mg, however, Staff incorrectly documented on the Controlled Substance Disposition log that they administered 5.0 mg of oxycodone when the oxycodone medication packages were delivered with 2.5 mg doses.
* The MAR showed to administer Tylenol 325 mg "1-2 tablets" as needed for pain. There was no specific parameters or instructions to guide non-licensed staff as to how many tablets of the medication should be administered.
The need to ensure MARs were accurate including the Controlled Substance tracking records and resident specific parameters and instructions was discussed with Staff 26 (ED) and Staff 27 (RN) during the survey. They acknowledged the findings.
1. Resident charts for #11,12, and 15 will be audited to ensure orders are current and reflected accurately in EMAR. PCP will be sent a requested for a clarification order related to parameters, clear instruction, and/or diagnosis as needed.
2. Med technicians, DHW and RCD re-trained on documentation expectations in EMAR.
DHW re-trained on Milestone procedure for verifying parameters, clear instruction, and dx within orders and MARs routinely.
PCPs will be sent medications orders for review and siganture.
3. EMAR audits to be completed daily per Milestone policy by the DHW with oversight from the 3rd party clinical entity during the Plan of Correction period. Thereafter, Milestone regional team will conduct routine oversight of MAR management per standard processes.
4. The DHW is responsible to see that corrections are completed with oversight by the Executive Director, and Milestone regional team.
2. Resident 18 was admitted to the facility in 01/2024 with diagnoses including Alzheimer's disease.
The resident's 03/01/24 through 04/16/24 MARs and physician's orders were reviewed.
The following PRN medications lacked resident specific parameters or instructions to direct non-licensed staff on which medication should be administered and in what order:
* Miralax for constipation; and
* Milk of Magnesia for constipation.
During an interview on 04/16/24, Staff 38 (Agency MA) confirmed the electronic MAR system did not have instructions for staff to follow regarding which medication should be administered and in what order.
The need to ensure the resident's MAR was accurate and included resident specific parameters and staff instructions was reviewed with Staff 27 (RN), Staff 34 (Administrator) and Staff 35 (Resident Care Director). They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure residents' MARs were accurate, and provided clear instruction and parameters for administration of PRN medications for 3 of 3 sampled residents (#s 14, 18 and 19) whose MARs were reviewed. This is a repeat citation. Findings include, but are not limited to:
1. Resident 14 was admitted to the facility in 03/2012 with diagnoses including generalized anxiety disorder and chronic obstructive pulmonary disease.
Resident 14's 03/01/24 through 04/16/24 MARs and signed physician's orders dated 03/14/24 were reviewed and revealed the following:
* Clotrimazole 1% cream to be applied to affected areas two times daily until rash was resolved.
The MAR did not provide accurate reason for use and information for staff including the cream could be kept at bedside.
The need to ensure the facility kept an accurate MAR, including accurate reason for use, and instruction for staff was discussed with Staff 27 (RN), Staff 34 (Administrator), Staff 35 (Resident Care Director), and Witness 1 (Consultant) on 04/17/24 at 3:30 pm. They acknowledged the findings.
3. Resident 19 moved into the facility in 10/2021 with diagnoses including dementia and a history of venous stasis to the lower extremity.
The resident's 03/01/24 through 04/16/24 MARs and physician's orders were reviewed and identified the following:
* The MARs included instructions for staff as follows: "Abrasion. Check neck wound daily and apply PRN antibiotic ointment. May cover with large bandage." The MAR also included a physician's order for triple antibiotic ointment (neosporin). "Topically apply to skin abrasion 1 to 2 times daily as needed."
The "check abrasion" order was documented daily on the MAR as administered. However, the order lacked clear instruction to staff regarding the signs or symptoms that would indicate when to apply the ointment.
In an interview on 04/18/24, Staff 39 stated it was unclear how to determine when the antibiotic ointment should be admininstered and where to mark it on the MAR.
The need to ensure resident's MARs were accurate and included resident specific parameters and instructions for PRN medications was reviewed with Staff 27 (RN), Staff 34 (Administrator) and Witness 1 (Consultant) on 04/18/24. They acknowledged the findings.
1. Resident charts for #14,18, and 19 will be audited to ensure orders are current and reflected accurately in EMAR. PCP will be sent a requested for a clarification order related to parameters, clear instruction, and/or diagnosis as needed.
2. Med technicians, DHW and RCD re-trained on documentation expectations in EMAR.
DHW re-trained on Milestone procedure for verifying parameters, clear instruction, and diagnosis within orders and MARs routinely.
PCPs will be sent medications orders for review and siganture. Tracking tool created to review and monitoring and will be reviewed daily by clinical team.
3. EMAR audits to be completed daily per Milestone policy by the DHW with oversight from the 3rd party clinical entity during the Plan of Correction period. Audits will be reviewed in QA committee
4. The DHW is responsible to see that corrections are completed with oversight by the Executive Director, and Milestone regional team.
There are no detail notes for this visit.
Based on observation and interview it was determined the facility failed to employ a full-time Administrator scheduled on-site at least 40 hours per week. Findings include, but are not limited to:
In an 08/08/23 interview, Staff 17 (Interim ED/MCC) stated he shared the roles of ALF and MCC administration with the ALF Administrator. Staff 17 reported he and the ALF Administrator rotated every two weeks with each covering both facilities while the other was out of state.
The need to employ a full-time Administrator scheduled to be on-site at least 40 hours per week was reviewed with Staff 17 on 08/10/23. He acknowledged the findings.
1. Adminsistrator has been hired and is on-site 40 hours per week.
2. Regional team to collaborate with administrator on weekly basis for retention
3. Weekly
4. Administrator and Regional team
Based on observation and interview, it was determined the facility failed to ensure a licensed administrator was scheduled to be on-site in the facility at least 40 hours per week. This is a repeat citation. Findings include, but are not limited to:
During an interview on 01/09/23 at 4:00 pm, surveyor shared findings related to ongoing resident concerns related to staffing levels, resident care, medication administration and monitoring of resident changes of condition with Staff 26 (ED) and Staff 27 (RN). A review of the repeat areas cited was discussed. Staff 26 stated "a lot of time was spent addressing the issues with the memory care" over the past few months. Staff 26 confirmed there was not currently an approved Administrator for the (neighboring) memory care unit and the Assisted Living Administrator and Staff 18 (RCC) were providing "support" for the memory care.
The need to have a licensed administrator on-site in the facility at least 40 hours per week was discussed with Staff 26 and Staff 27 on 01/11/24. They acknowledged the findings.
1. Flagstone has a full time ED for the Assisted Living community as well as a separate administrator for the Memory Care setting. Each will ensure that their schedules are posted accurately and consistently.
2. The Flagstone Executive Director will ensure that the hours of administration meet OAR expectations and any alterations are pre-approved by Milestone and the State per OAR requirements.
3. a dedicated Milestone regional staff will be assigned to oversee the adminstrative staff of Flagstone to ensure all Milestone and State expectations are met during the Plan of Corrections period.
4. Milestone Regional Staff will be reponsible to ensure this correction is completed.
There are no detail notes for this visit.
Based on observation, interview, and record review, it was determined the facility failed to have direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident and adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department. Findings include, but are not limited to:
During the entrance conference on 01/08/24 the following was identified:
* The facility had 32 residents residing on two floors of the facility; and
* Two residents needed two-person assistance with transfers and for all or part of their care.
During the survey, staff identified three additional residents who required two person assistance with transfers and some of their ADL care.
The current posted staffing plan was as follows:
* Day shift: 2 CG's and 1 MA;
* Swing shift: 2 CG's and 1 MA; and
* Noc shift: 1 CG and 1 MA.
During the survey, multiple residents who were alert and oriented, reported the facility did not schedule adequate numbers of staff which resulted in staff not responding to call lights in a timely manner and not receiving laundry services as outlined on the service plan. Residents also stated showers were not provided as scheduled "when there was not enough staff."
On 01/10/24, call light logs from 12/01/23 through 01/10/24 were reviewed. The call logs showed call light response times in excess of 20 minutes occurred more than 30 times with some call response time exceeding one hour.
During the survey, multiple staff reported staffing concerns. Medication Aides were reportedly instructed to work in both MCC and ALF during the same shift. Reports indicated there was only one MA and no direct care staff (CG) during the evening shift on 12/15/23 and 12/16/23, 12/22/23 and 12/23/23 and on 12/31/23.
On 01/09/24, Staff 26 (ED) was interviewed regarding staffing levels. Staff 26 acknowledged the facility was routinely unable to provide the number of staff as indicated on the posted staffing plan for the swing shift and routinely scheduled only one staff, a medication aide, on night shift.
The need to ensure the facility had direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident, including fire safety evacuation needs, was discussed with Staff 26 (ED) on 01/10/24. She acknowledged the findings.
*Refer to C 361 Acuity Based Staffing Tool
1. Flagstone will review and update the state provided ABST. Staffing plan will be calculated using the ABST.
2. Execuative Director and Director of Health and Wellness will audit current staffing schedule and compare to ABST to ensure resident scheduled and unscheduled needs are met.
3. ABST and staffing schedule audit to be conducted weekly and/or with ABST update related to service plan updates
4. Execuative Director, Director of Health and Wellness with Milestone regional team oversight.
.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to schedule staffing to the levels, intensity and qualifications indicated by the Acuity Based Staffing Tool (ABST). Findings include, but are not limited to:
The facility was comprised of two floors of resident apartments, divided into four sections - two on the first floor and two on the second floor and was home to 32 residents at the time of the re-visit survey. The facility had five residents who were identified as requiring two person assistance with transfers and ADL care.
The facility's ABST was reviewed with Staff 26 (ED) on 01/09/24. Staff 26 stated the facility was providing two direct care staff (1 CG and 1 MA) on day and swing shifts and one staff (MA) at night. Staff 26 stated this was the number of staff indicated on the facility ABST.
The facility staffing plan was posted in the front lobby and verified by Staff 26 as:
Day Shift: 2 direct care staff and 1 medication aide;
Swing Shift: 2 direct care staff and 1 medication aide; and
Night Shift: 1 direct care staff and 1 medication aide.
The facility ABST tool print-out was provided on 01/09/24 and reviewed. The ABST showed the following:
Day Shift: Monday, 01/08/24: 2.18 staff,
Tuesday, 01/09/24: 2.57 staff,
Wednesday, 01/10/24: 2.32 staff
Swing Shift: Monday, 01/08/24: 1.29 staff,
Tuesday, 01/09/24: 1.36 staff,
Wednesday, 01/10/24: 1.28 staff
Night Shift: Monday, 01/08/24: 0.75 staff,
Tuesday, 01/09/24: 0.73 staff,
Wednesday, 01/10/24: 0.89 staff
Observations of staffing on 01/08/24 and 01/09/24 showed two staff on duty (1 MA and 1 CG). Interviews with multiple care staff and residents confirmed the facility routinely had two direct care staff on duty during the day and swing shifts, and one direct care staff at night.
During an interview on 01/09/24, the discrepancy between the number of staff provided and the number of staff required, as determined by the ABST, was discussed with Staff 26 (ED) and it was determined Staff 26 was not aware that 2.18, 2.57 and 2.32 (respectively, on the ABST schedule) required three staff, and not two. Staff 26 acknowledged the facility was not providing the number of direct care staff indicated by the ABST.
The need to ensure the facility was staffing to the levels, intensity and qualifications indicated by the ABST was discussed with Staff 26 and Staff 27 (RN) on 01/11/24. They acknowledged the findings.
1. Flagstone will review and update the state provided ABST. Staffing plan will be calculated using the ABST.
2. Executive Director and Director of Health and Wellness will audit current staffing schedule and compare to ABST to ensure resident scheduled and unscheduled needs are met
3. ABST and staffing schedule audit to be conducted weekly and/or with ABST update related to service plan updates
4. Executive Director, Director of Heath and Wellness with Milestone regional team oversight
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure all pre-service training had been completed, with certification, prior to staff providing direct care to residents, for 4 of 4 newly hired staff (#s 4, 9, 11 and 12). Findings include, but are not limited to:
The facility's training records reviewed on 09/01/22 revealed:
Staff 4 (Maintenance Director) hired 01/17/22, Staff 9 (MT) hired 01/29/21, Staff 11 (CG) hired 08/08/22 and Staff 12 (CG) hired 07/01/22, lacked documented evidence they had completed the standard precautions for infection control.
Requirements for pre-service training were reviewed with Staff 1 (ED), Staff 3 (Staff Nurse) and Staff 6 (RCC) on 09/02/22. They acknowledged the findings.
1. The action taken to correct the rule violation for each example/resident was the assignment of the following Relias courses to all staff to ensure that all staff have received required training on standard precautions for infection control.
a) Infection Control: Essential Principles [REL-ALL-0-IFEP] [0.5 hr]
b) Personal Protective Equipment [REL-PAC-0-PPE] (0.25 hr]
c) Infection Control: Isolation and Cohorting [REL-PAC-0-ISOCO] (0.5 hr)
d) Transmission-Based Precautions [REL-SRC-0-TBP] (0.5 hr)
2. To ensure that the violation will not happen again the system will be corrected by the assignment and completion of the appropriate training courses upon hire and prior to working with residents.
3. The area needing correction will be evaluated on a monthly basis.
4. Business Office Manager and Executive Director will be responsible to see tha the corrections are completed/monitored.
Based on interview and record review, it was determined the facility failed to ensure 1 of 3 newly hired staff (# 12) had completed all required areas of training within 30 days of hire. Findings include, but are not limited to:
Review of the facility's training records on 08/31/22 at 1:00 pm revealed:
1. There was no documented evidence Staff 12 (CG), hired 07/01/22, had demonstrated competency in all required areas and within 30 days of hire including:
* Identification, documentation and reporting of changes of condition; and
* Conditions that require assessment, treatment, observation and reporting;
The need to document demonstrated competency in job duties within 30-days of hire was discussed with Staff 1 (ED) on 09/02/22. She acknowledged the lack of documented evidence the required training had been provided.
1. The action taken to correct the rule violation for each example/resident; staff was trained and competency was documented.
2. To ensure this violation will not happen again the system has been corrected by the use of the onboarding checklist for each employee that will be completed within 30 days of hire date.
3. The area needing correction will be evaluated on a monthly basis.
4. Business Office Manager and Executive Director will be responsible to see that the corrections are completed/monitored.
Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted according to the Oregon Fire Code (OFC), fire and life safety instruction was provided to staff on alternate months and there was documented evidence of changes made to ensure the evacuation standard for residents was being met. Findings include, but are not limited to:
On 09/01/22, review of facility fire drill and fire and life safety instruction records, from 03/2022 through 08/2022, and interviews with staff indicated the facility had not documented;
* The escape route used;
* Problems encountered and comments related to residents who resisted or failed to participate in the drills;
* Number of occupants evacuated; and
* Evidence the facility provided fire and life safety instruction to staff every other month as required.
Additionally there was no documented evidence of the changes the facility made to ensure the evacuation standard was met.
On 09/01/22, the need to ensure fire drills were documented with all required elements, fire and life safety instruction was provided to staff on alternate months and the facility documented the immediate changes they made to meet the evacuation standard was discussed with Staff 1 (ED) and Staff 4 (Maintenance Director). They acknowledged the findings.
1. The action taken to correct the rule violation for each example/resident is added documentation to the fire drill logbook to ensure required documentation is recorded moving forward.
2. The system has been corrected so this violation will not happen again by the addition of required documentation to the Tel's fire drill logbook.
3. The area needing correction will be evaluated on a monthly basis.
4. Maintenance Director and Executive Director will be responsible to see tha the corrections are complete/monitored.
Based on interview and record review, it was determined the facility failed to provide documentation that fire drills included all required components. This is a repeat citation. Findings include, but are not limited to:
Review of fire and life safety records on 08/08/23, for April 2023 through July 2023, identified the following required components were not documented:
*Escape route used;
*Problems encountered, comments relating to residents who resisted or failed to participate in the drills;
*Evacuation time-period needed; and
*Number of occupants evacuated.
On 08/08/23, the need to ensure documentation of fire drills included all required components was discussed with Staff 17 (Interim ED/MCC) and Staff 21 (Maintenance Director). They acknowledged the findings.
1. Fire drills will be completed per OARs.
2. The Maintence Director and Administrator will be inserviced of Fire drills per OAR/OFC by Regional Maintence team.
3. Documentation of fire drills will be reviewed monthly during Administrator and Maintence Director 1:1 weekly meeting.
4. Administrator and/or Designee
Based on interview and record review, it was determined the facility failed to provide documentation that fire drills included all required components. This is a repeat citation. Findings include, but are not limited to:
Review of fire and life safety records on 01/08/24, for October 2023 through December 2023, identified the facility failed to conduct Fire drills every other month.
On 01/08/24, the need to conduct a fire drill every other month and document all required components was discussed with Staff 21 (Maintenance Director) and Staff 26 (ED). They acknowledged the findings.
1. Fire drill will be held this month and documented.
2. The Maintenance Director and Administrator have been trained in how to run, debrief, and document a fire drill including escape route used, problems encountered, evacuation time-period needed and number of occupants evacuated.
3. Monthly per Milestone standards - no less than every other month per OARs.
4. Administrator/Admin designee, DHW, RCD's and Maintenance Director.
There are no detail notes for this visit.
Based on observation, interview, and record review, it was determined the facility failed to ensure their change of ownership survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:
Refer to C 260, C 270, C 300, C 303, C 310, C 420 and C 613.
Refer to C 260, C 270, C 300, C 303, C 310, C 420 and C 613
Based on observation, interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include but are not limited to:
Refer to C 260, C 270, C 300, C 303, C 310, C 350, C 420, and C 613.
Refer to C260, C270,C300, C310,C350,C420, and C613
Based on observation, interview and record review, it was determined the facility failed to ensure their re-visit survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include, but are not limited to:
Refer to C150, C260, C270, C290, C300, C302, C303, and C310.
Refer to C160, C260, C270,C280, C300, C302,C303, C310
There are no detail notes for this visit.
Based on observation and interview, it was determined the facility failed to ensure all exterior pathways and accesses to the facility's common use areas were made of smooth material and maintained in good repair. Findings include, but are not limited to:
The exterior of the facility was toured on 08/31/22 at 1:35 pm. The following issues were noted:
* Pathways on the north and east sides of the building had 1-2.5" drop-offs from pathway to rock bed landscaping; and
* Pathways on the northeast side of the building near the stairs were broken and raised in three places and cracked in one place. Pathways near the raised garden beds were broken and raised in one place. These areas created uneven surfaces and potential tripping hazards.
The need to ensure the common use areas were smooth and free from drop-offs was discussed with Staff 1 (ED) on 09/01/22 at 2:38 pm. She acknowledged the findings.
1. The action taken to correct the rule violation for each example/resident are as follows:
a) To correct drop off from pathway to rock bed contractor has been contacted to fill in rock bed to make even surface with pathway.
b) Contractor has been contacted to repair uneven and broken pathways.
2. To ensure this violation will not happen again the system will be corrected by routine observation of pathways and rock bed with specific awareness to the focus of ensuring there are no uneven surfaces or potential trip hazards.
3. The area needing correction will be evaluated on a monthly basis.
4. Maintenance Director and Executive Director will be responsible to see that the corrections are completed/monitored.
Based on observation and interview, it was determined the facility failed to ensure the environment was kept clean, in good repair and free from unpleasant odors. Findings include, but are not limited to:
The facility was toured on 08/31/22 at 11:54 am. The following areas were observed to need cleaning and/or repair:
* Carpet was frayed, stained, torn and/or covered with tape near rooms 101, 202, 206, 216, 224, 225, 228, 231, near the first floor med room, near the first floor industrial laundry room, near the vending machines, at the entrances of both second floor laundry rooms, near the entrance of the small activity room, near the elevator on the second floor and at the entrance of the 215-223 hallway;
* Rooms 112, 117, 123 and 202 had scraped doors and/or door frames with bare wood exposed;
* Walls near rooms 112, 113, 115, 119, 121, 124, 224, the mailboxes, the foyer, the business office, the first floor community laundry room and the second floor elevator had torn or gouged wallpaper;
* Walls outside room 121 had large scrapes and gouges in the drywall;
* Pillars in the foyer and near both first and second floor elevators were gouged with chipped paint;
* Handrails throughout the facility were scraped, gouged and/or uneven with bare wood exposed;
* Chairs throughout the dining room had scrapes and gouges in the wood;
* Benches near room 116 and across from the small activity room were stained;
* Laundry rooms throughout the facility had stained utility sinks and dust and debris build up on and around the machines;
* Laundry room on the second floor near the stairs had linens, a single glove, lint and stained flooring behind the machines; and
* Urine odors were noted in the hallway near room 125.
The surveyor toured the environment with Staff 1 (ED) on 09/01/22 at 2:38 pm. She acknowledged the above areas needed to be cleaned and repaired.
1. The following actions will be taken to correct the rule violation for each example/resident:
* Carpet replacement of the hallways and common areas by outside contractor.
* Apartment doors and door frames will be repaired and painted to ensure there is no bare wood exposed.
* Walls that have torn or gouged wallpaper will be repaired.
* Pillars will be repaired and painted.
* Handrails will be repaired of scrapes, gouges, and bare wood.
* Chairs will be refinished to correct scrapes and gouges in wood.
* Benches in hallway were shampooed.
* Laundry rooms were deep cleaned; including utility sinks and machines.
* Upstairs laundry room immediately had items removed from behind machines.
* Urine smell in hallway near room 125 addressed by shampooing of carpet and implementation of routine cleaning schedule.
2. To ensure the violation will not happen again the system will be corrected by the implementation of community audit and check off list of buildings general repair needs.
3. The area needing correction will be evaluated on a quarterly basis.
4. Maintenance Director and Executive Director will be responsible to see that the corrections are completed/monitored.
Based on observation and interview, it was determined the facility failed to ensure all interior materials and surfaces were kept clean and in good repair. This is a repeat citation. Findings include, but are not limited to:
Observation during the survey from 08/07/23 through 08/08/23 revealed the following areas in need of cleaning or repair:
1. The staff laundry room had dirt and debris throughout on the floor, linoleum that was torn and gouged making it an un-cleanable surface. There were items being stored there including cardboard boxes and an open container of dirt with moldy substance on top, a mini refrigerator and evidence that staff were eating in the laundry room next to the clean clothes.
2. All three resident laundry rooms had dirt and debris on the floor, linoleum that was stained, torn and dirty. The walls on the second floor laundry rooms had chipped paint. There were multiple boxes of personal supplies being stored there.
3. There was a persistent odor outside Room 118.
In an interview on 08/08/23, the surveyor discussed and reviewed areas that required cleaning or repair with Staff 17 (Interim ED/MCC) and Staff 21 (Maintenance Director). They acknowledged the findings.
1. Resident room, bathrooms, laundry rooms, and pervasive odor will be cleaned, repaired and/or odor deotorized.
2.Administrator and Maintenance Director will ensure interior materials and surface will be kept clean and in good standing by conducting routine walk through out the community
3.Weekly during 1:1 meeting.
4. Administrator and/or Maintenance staff.
Based on observation and interview, it was determined the facility failed to ensure all interior materials and surfaces were kept clean and in good repair. This is a repeat citation. Findings include, but are not limited to:
Observations on 01/08/24 revealed the following areas in need of cleaning or repair:
1. The industrial/staff laundry room linoleum was cracked, torn and gouged making it an un-cleanable surface.
2. Resident laundry rooms on the first and second floors had debris on the floor and dust build up along the walls.
3. The first floor resident laundry room had a broken washing machine and a bucket of yellow liquid against the wall under the soap dispenser.
The need to ensure laundry areas were kept clean and in good repair was discussed with Staff 26 (ED) on 01/11/24. She acknowledged the findings.
1. Laundry room floor is in repair to be cleaned.
Laundry rooms on 1st and 2nd floors will be clean of debris and dust.
1st Floor laundry room laundry machine is repaired.
2. Flagstone will comply with Milestone's preventative maintenance program to ensure that surfaces are cleanable, repairs are managed in the work order system with cleaning schedules managed timely.
Maintenance Director, housekeeping staff will be trained and in-serviced on the work order system, how to ensure damage is reported timely, and proper use of cleaning schedules.
3. The Preventative Maintenance system, the Work Order system will be routinely monitored by the regional maintenance team. Scheduled and unscheduled site audits will be conducted during and past the plan of correction period.
4. the Maintenance Director with the Executive Director are responsible to see that the corrections are completed.
There are no detail notes for this visit.
Based on observation and interview, it was determined the facility failed to ensure operable windows were designed to prevent accidental falls when sill heights were lower than 36 inches and above the first floor. Findings include, but are not limited to:
The facility was toured on 08/31/22. Resident unit windows on the second floor opened vertically, and windowsills were lower than 36 inches. The windows in common areas and resident bedrooms lacked a system which permanently limited how much the window could be opened to prevent accidental falls.
The following windows were observed to have no permanent locking mechanism:
* Room 207;
* Room 220; and
* Large second floor activity room.
The need to ensure operable windows were designed to prevent accidental falls was discussed with Staff 1 (ED) on 09/01/22 at 2:38 pm and she acknowledged windows on the second floor were not designed to prevent accidental falls.
1. The action taken to correct the ruled violation for each example/resident was the immediate implementation of permanent locking mechanism to the activity apartments, room 220 and room 207. Additional locking mechanisms have been purchased for all resident apartments on 2nd floor.
2. To ensure this violation will not happen again the system will be corrected by the addition of checking windows for locking mechanisms on a routine basis.
3. The area needing correction will be evaluated on a quarterly basis.
4. Maintenance Director and Executive Director will be responsible to see that the corrections are completed/monitored.
Based on observation and interview, it was determined the facility failed to ensure the stove in the common area kitchen had a keyed, remote switch or safety device to ensure staff control. Findings include, but are not limited to:
The environment tour on 08/31/22 at 1:12 pm revealed the stove in the small second floor activity room was keyed to ensure staff control. However, the operating key was found in the locking system and no staff member was observed to be using the stove or to be in the activity room.
The need to ensure the stove in the common area activity room had a system to ensure staff control was discussed with Staff 1 (ED) on 09/01/22. She acknowledged the findings.
1. The action taken to correct the rule violation was met by the Executive Director immediately removing the key from the stove area. Keys are to only be held by designated staff.
2. To ensure the system is corrected so his violation will not happen again the keys will be kept only be appropriate directors and directors were trained on specific OAR 411-054-0300(6)(d) regarding cooking stove.
3. The area needing correction will be evaluated weekly.
4. Life and Leisure Director and Executive Director will be responsible to see that the corrections are completed/monitored.
Based on observation and interview, it was determined the facility failed to ensure a one-way flow of soiled linens and soiled clothing from the soiled area to the clean area and soiled clothing and linens were laundered in a washing machine with a minimum rinse temperature of 140 degrees Fahrenheit or with a chemical disinfectant. Findings include, but are not limited to:
During a tour of the four facility laundry rooms on 08/31/22 at 11:49 am, it was observed three of the four laundry rooms had residential washing machines and dryers, one utility sink and one point of entry. The fourth laundry room had industrial machines, a flushing rim clinical sink and two points of entry. Additionally, three different detergents were being used within the community laundry rooms which did not have a chemical disinfectant included.
In an interview with Staff 17 (MT) on 08/31/22 at 1:57 pm, she stated personal soiled linens were washed in the community laundry rooms and soiled bed linens were washed in the laundry room with industrial machines.
In another interview with Staff 5 (Director of Maintenance) on 08/29/22, he confirmed the facility water temperatures were set between 114 and 115 degrees Fahrenheit.
The need to properly launder soiled clothing and linens was reviewed with Staff 1 (ED) on 09/01/22. She acknowledged these findings.
1. The action taken to correct the ruled violation for each example resident is laundry detergent with chemical disinfectant was purchased and will be the only standard used throughout the community and in all laundry rooms.
2. To ensure the violation will not happen again the system will be corrected by routine purchasing of appropriate laundry detergent with chemical disinfectant.
3. The area needing correction will be evaluated on a monthly basis.
4. Maintenance Director and Executive Director will be responsible to see that the corrections are completed/monitored.
Based on observation and interview, it was determined the facility failed to ensure covers, grates or screens of wall heaters did not exceed 120 degrees Fahrenheit (F) when they were installed in locations that were subject to incidental contact by residents or with combustible material. Findings include, but are not limited to:
The building was toured on 08/31/22 at 12:47 pm. An electric wall heater was observed in room 220. When it was turned on and the temperature of the surface of the metal grill was measured with the surveyor's digital thermometer, the temperature was noted to be 364 degrees F.
An immediate plan of action was requested on 08/31/22 at 12:54 pm. Staff 1 (ED) confirmed an audit of all electric wall heaters was completed, all mechanisms were disconnected and documentation was provided to the survey team on 09/01/22 at 2:38 pm.
The need to ensure wall heaters did not exceed 120 degrees F was discussed with Staff 1 on 09/01/22. She acknowledged the findings.
1. Immediate action was taken to correct the rule violation by performing an audit of all electric wall heaters in the community. All mechanisms were disconnected. All cadet wall heaters will be removed as apartments become vacant to ensure that the cadet heaters will not be reconnected.
2. This violation will not happen again as the system was corrected and all mechanisms were disconnected.
3. The area for correction will be evaluated on a quarterly basis.
4. Maintenance Director and Executive Director will be responsible to see that the corrections are completed/monitored.