The findings of the re-licensure survey, conducted 04/24/23 to 04/26/23, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004.

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 revisit to the re-licensure survey of 04/26/23, conducted 07/27/23 are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

2. Resident 2 was admitted to the facility in 03/2023 with diagnoses including edema to the lower legs.

The resident's 04/11/23 service plan, Care Plan Updates, 03/16/23 through 04/02/23 Progress Notes, and MARs were reviewed.

On 04/06/23 the resident was noted to have an "Open area: Right lower leg" and a treatment was instituted on the MAR.

There was no documented monitoring at least weekly until resolution of the change in condition.

Staff 3 (Resident Service Coordinator) and Staff 2 (RN) both indicated the resident did not have a current wound or open area.

The need to ensure short-term changes of condition had documentation to reflect monitoring to resolution at least weekly and provided clear, resident-specific directions to staff was discussed with Staff 1 (Administrator), Staff 2, and Staff 3 on 04/25/23 and 04/26/23. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to evaluate, determine resident specific interventions, communicate instructions to staff, document on the progress of short-term changes in condition with weekly progress noted until the condition resolved, and monitor residents consistent with their evaluated needs for 2 of 4 sampled residents (#s 2 and 4) who were reviewed for changes of condition. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 08/2021 with diagnoses including major depressive disorder and history of falls.

Resident 4's clinical record and charting notes, reviewed from 01/22/23 through 04/23/23 and Care Plan Updates for the same time period identified the following changes of condition:

* 03/26/23 - Non-injury fall;

* 03/28/23 - Non-injury fall;

* 03/28/23 - Hip pain and inner left groin pain;

* 03/30/23 - Return from hospital;

* 04/03/23 - Non-injury fall;

* 04/03/23 - PT recommendation to monitor for increase in depression;

* 04/06/23 - Non-injury fall;

* 04/07/23 - Care Plan Update to provide hydration three times per day; and

* 04/21/23 - Change in ambulation and transfer ability.

Observations and an interview with the resident and private caregiver on 04/24/23 identified the resident had right leg and lower back pain and needed assistance with transfers and walking. The private caregiver stated she "started working with [him/her] on 04/21/23 and needed assistance with mobility since she started working with [him/her]."

The facility failed to evaluate, determine resident specific interventions needed for falls, change in mobility and an increase in depression, communicate the interventions to staff and monitor the effectiveness of the interventions. The facility failed to monitor the resident for increased depression with progress of the condition documented at least weekly until resolved.

The need to ensure the facility evaluated, determined resident specific interventions needed, communicated the instructions to staff and documented on the progress of short-term changes in condition with weekly progress noted until the condition resolved was discussed with Staff 1 (Administrator), Staff 2 (RN) and Staff 3 (Resident Services Coordinator) on 04/26/23 at 10:15 am. They acknowledged the findings.

1. What actions will be taken to correct the rule violation: The RN will complete a significant change of condition for depression and mobility, falls.

How will the system be corrected: Ongoing education will be provided to staff regarding process of monitor for changes in medications, following up on outside provider recommendations, alert charting and temporary service plans.

How often will this area be evaluated: This will be reviewed quarterly.

Who will be responsible: The Administrator, Registered Nurse, and Resident Service Coordinators are responsible to make sure that the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to have a system in place for tracking controlled substances and for the disposal of all unused, outdated, or discontinued medications administered by the facility for 1 of 1 sampled resident (#4) whose MARs and Controlled Substance Disposition logs were reviewed for accuracy. Findings include, but are not limited to:

Resident 4's physician orders, dated 04/04/23, 04/01/23 through 04/24/23 MAR, and controlled substance disposition logs were reviewed and identified the following deficiencies:

On 04/17/23, Tramadol, as needed, was dispensed, and documented on the disposition log.

Review of the current signed physician orders and 04/01/23 through 04/24/23 MAR identified Resident 4 didn't have an active order for as needed Tramadol.

During an interview on 04/26/23 with Staff 2 (RN), it was reported the Tramadol order was discontinued in October 2022; however, the medication was still in the medication cart and had not been disposed.

On 04/26/23 the requirement to have a system in place for accurately tracking controlled substances administered by the facility and to ensure disposal of discontinued controlled substances was discussed with Staff 1 (Administrator), Staff 2, and Staff 3 (Resident Services Coordinator). They acknowledged the findings.

1. What actions will be taken to correct the rule violation: End of each shift - print MAR report listing each resident with controlled substances.

2. How will the system be corrected: Compare MAR against the narcotic book as the count is being performed, add into supplementary documentation, space to verify most current count of each controlled substance.

3. How often will this area be evaluated: The RN will review monthly in the narcotic book for clipped pages, missing pages, staff not counting expired or discontinued controlled substances, missing signatures, need for disposal of discontinued substances, index pages up to date. The RN is to sign monthly on the count verification form the date it was done.

4. Who will be responsible: The Administrator and Registered Nurse are responsible for making sure that the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) that met the regulation. Findings include, but are not limited to:

ABST tool must address all the required ADLs for each resident and the amount of staff time needed to provide care.

The facility tool grouped residents and tasks, not addressing the residents individually.

The need to use an ABST tool that addressed all the ADLs for each resident and the amount of staff time needed to provide care by resident, was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 3 (Resident Service Coordinator) on 04/26/23.

1. What action to correct the rule violation: We will be using the ODHS approved tool, until Point Click Care can alter their tool to meet the ODHS requirements.

2. How will the system be corrected: We will start entering all of our current residents into the ODHS approved tool. Going forward, all new residents will be entered as well.

3. How often will the area be evaluated: at move-in, 30 day, quarterly, and significant change of condition.

4. Who will be responsible: The Administrator via the Resident Service Coordinator.

Based on interview and record review, it was determined the facility failed to provide documentation of fire drills being conducted every other month, and fire and life safety instruction for staff was provided on alternate months. Findings include, but are not limited to:

On 04/24/23, fire drill and fire and life safety training records from September 2022 through March 2023 were reviewed and identified:

*There was no documented evidence unannounced fire drills were conducted and recorded every other month at different times of the day, with residents being relocated; and

*There was no documented evidence fire and life safety instruction to staff was provided on alternate months.

In an interview on 04/25/23, Staff 14 (Director of Plant Operations) acknowledged not having any documented evidence of fire and life safety instruction being conducted on alternating months of fire drills.

On 04/26/23, the requirements regarding fire drills and fire and life safety instruction for staff were reviewed with Staff 1 (Administrator). She acknowledged the findings.

1. What actions will be taken to correct the rule violation: The Executive Director holds monthly All-Staff Meetings. Fire and Life Safety Instruction will be conducted every other month during Veranda Park's All-Staff Meetings. The next meeting is scheduled for Friday, May 19th at 1:00pm. The topic is Fire Extinguisher Use and Safety. On alternating months, the Plant Operations Manager will conduct unannounced fire drills. These drills will take place at different times of the day and involve residents being relocated.

2. How will the system be corrected: Fire and Life Safety trainings will be incorporated into our All-Staff Meetings. Fire Drills will be conducted every other month.

3. How often will this area be evaluated: This will be reviewed monthly.

4. Who will be responsible: The Administrator, Executive Director, and Plant Operations Manager