The findings of the re-licensure survey, conducted 08/21/23 through 08/23/23, 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

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the revisit to the re-licensure survey of 09/23/23, conducted on 01/17/24, are documented in this report. It was determined the facility was in compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004.

Based on interview and record review, it was determined the facility failed to ensure residents' MARs provided clear instructions and parameters for administration of PRN medications for 3 of 4 sampled residents (#s 1, 2, and 3) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 12/2022 with diagnoses including a traumatic brain injury.

Resident 1's 08/01/23 through 08/21/23 MARs and current physician's orders were reviewed.

Resident 1 had physician's orders for:

* Milk of Magnesia 30 ml as needed for constipation or no bowel movement (BM) in two days;

* Polyethylene Glycol 17 grams as needed for constipation; and

* Senna 8.6 mg as needed for constipation.

There were no resident specific parameters to guide non-licensed staff in the administration of these three as needed bowel medications.

2. Resident 2 was admitted to the facility in 05/2022 with diagnoses including Alzheimer's and pain.

Resident 2's 08/01/23 through 08/21/23 MARs and current physician's orders were reviewed.

Resident 2 had physician's orders for:

* Acetaminophen 500 mg as needed for mild pain;

* Ibuprofen 600 mg as needed for pain with guidance to "Try Tylenol first."; and

* Naproxen 500 mg tablet as need for mild to moderate pain.

There were no resident specific parameters to guide non-licensed staff in the administration of these three as needed pain medications.

3. Resident 3 was admitted to the facility in 2/2021 with diagnoses including anxiety, gout, and joint pain.

Resident 3's 08/01/23 through 08/21/23 MARs and current physician's orders were reviewed.

Resident 3 had physician's orders for:

* Bisacodyl EC 5 mg tablet three tablets as needed for constipation;

* Bisacodyl Laxative 10 mg suppository as needed for constipation on day 3; and

* Milk of Magnesia 30 ml as need for constipation or no BM in two days.

There were no resident specific parameters to guide non-licensed staff in the administration of these three as needed bowel medications.

* Oxycodone HCI 5 mg 2 tablets as needed for pain; and

*Tylenol 325 two tablets as need for pain.

There were no resident specific parameters to guide non-licensed staff in the administration of these two as needed pain medications.

The electronic MARs for Residents 1, 2, and 3 were reviewed with Staff 8 (RCC) on 08/22/23. She acknowledged there were no resident specific parameters to guide non-licensed staff in the administration of the multiple PRN medications.

The need to ensure MARs included resident specific parameters to guide non-licensed staff in the administration of PRN medications was reviewed with Staff 2 (Interim RN) and Staff 4 (Regional Director of Nursing) on 08/22/23 and 08/23/23. They acknowledged the findings.

1.  MAR for residents # 1, 2 and 3 have been reviewed and corrections made to ensure accuracy of medication orders and clear, resident-specific parameters for PRN medications, multiple PRN medication for similar use, PRN parameters related to pain scale and documentation of effectiveness

2. Orders/MAR will undergo triple review process upon move-in (Licensed Nurse,RCC and RCC2 or MA) all orders will undergo the same process

3. Licensed Nurse and ED will review the process monthly

4. Licensed Nurse and ED

Based on interview and record review, it was determined the facility failed to ensure PRN psychotropic medications used to treat residents' anxiety had written, resident-specific parameters and non-drug interventions for staff to attempt prior to administering the medication for 2 of 2 sampled residents (#s 1 and 4) who were prescribed PRN medication to address anxiety. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 12/2022 with diagnoses including a traumatic brain injury.

Review of the resident's 08/01/23 through 08/21/23 MAR and current physician orders revealed an order for Lorazepam 0.5 mg (a psychotropic medication) one tablet every 12 hours as needed for anxiety.

The facility administered the Lorazepam to the resident on eleven occasions in August 2023.

The MARs lacked resident specific parameters for staff describing how the resident expressed anxiety. Additionally, there was no documentation of what non-drug interventions were to be attempted prior to administration of the medication.

2.  Resident 4 was admitted to the facility in 12/2022 with diagnoses including schizophrenia.

Review of the resident's 08/01/23 through 08/21/23 MAR and current physician orders revealed orders for:

* Lorazepam 0.5 mg (a psychotropic medication) one tablet as needed for anxiety; and

* Lorazepam 0.5 mg as needed for insomnia.

The MARs lacked resident specific parameters for staff describing how the resident expressed anxiety. Additionally, there was no documentation of what non-drug interventions were to be attempted prior to administration of the medication for anxiety.

The electronic MARs for Residents 1 and 4 were reviewed with Staff 8 (RCC) on 08/22/23. She acknowledged there were no resident specific descriptions of anxiety and no non-drug interventions to attempt prior to administering the medications for anxiety.

The need to ensure there were resident-specific descriptions of how the residents expressed anxiety and that non drug interventions were attempted and documented as not effective prior to administration of the medication was discussed with Staff 2 (Interim RN) and Staff 3 (Regional Director of Nursing) on 08/22/23 and 08/23/23. They acknowledged the findings.

1. MAR for residents 1 and 4 have been reviewed and corrections have been made to ensure accuracy of medication orders and clear, resident specific parameters for PRN medications, resident specific information regarding how they express anxiety, resident-specific non-pharmacological interventions and documentation of effectiveness.

2. Orders/MAR will undergo triple review process upon move-in (Licensed Nurse, RCC and RCC2 or MA) all orders will under go the process.

3. Licensed Nurse and ED will review this process monthly.

4. Licensed Nurse and ED.

Based on observation, interview, and record review, it was determined the facility failed to ensure all residents were entered into the staffing tool, the tool was reviewed no less than quarterly, and Acuity Based Staffing Tool (ABST) entries were reflective of the resident's current care needs for 5 of 5 residents reviewed (#s 1, 2, 3, 4, and 5). Findings include, but are not limited to:

1. Sample Residents 1, 4, and 5 were not entered into the ABST used by the facility to generate the staffing plan.

2. Observations of Resident 2, interviews with staff, and review of the resident's records noted ABST entries were not reflective of the resident's current care needs.  

A review of Resident 2's ABST, revealed an inaccuracy of minutes assigned in the following areas:

* Personal hygiene;

* Grooming;

* Dressing;

* Transferring;

* Repositioning;

* Medication administration;

* Redirecting due to cognitive impairment or dementia;

* Providing treatments;

* Assisting with leisure activities; and

* Monitoring physical conditions.

Resident 2's ABST entries had last been updated in 07/2022.

3. Observations of Resident 3, interviews with staff, and review of the resident's records noted ABST entries were not reflective of the resident's current care needs.  

A review of Resident 3's ABST, revealed an inaccuracy of minutes assigned in the following areas:

* Personal hygiene;

* Grooming;

* Dressing;

* Bowel and bladder management;

* Repositioning in bed;

* Medication administration;

* Providing treatment;

* Monitoring physical conditions or symptoms; and

* Providing additional care services, such as pet care.

Resident 3's ABST entries had last been updated in 07/2022.

4. Review of the current census revealed not all facility residents were entered in to the ABST, and former residents were still in the system.  

Inaccuracies on resident entries for the ABST tool, not including all residents in the tool, and potential inaccurate staffing calculations were discussed with Staff 1 (Executive Director) on 08/21/23. She acknowledged the findings.

1.ABST for residents 1, 2, 3, 4 and 5 have been reviewed and corrections made to ensure accuracy of care, resident-specific needs, and time spent for included ADLs. All current residents have been added to ABST and all past residents removed.

2.ED or designee will ensure new residents are added

to ABST upon move-in as well as removing any residents at move-out appropriately. ED or designee will assure ABST reviewed no less than quarterly.

3.ED and designee will review this at least quarterly or upon change in census.

4. ED and/or designee.

Based on interview and record review, it was determined the facility failed to ensure pre-service Infectious Disease Prevention training was completed for 2 of 2 sampled staff (#s 12 and 13) whose training records were reviewed. Findings include, but are not limited to:

Staff training records were reviewed with Staff 6 (Business Office Manager) on 08/22/23.

Staff 12 (CG), hired 01/11/23, and Staff 13 (CG), hired 05/17/23, lacked documented evidence of having completed pre-service Infectious Disease Prevention training.

Staff 6 acknowledged the training had not been done.

The need for staff to complete Infectious Disease Prevention training before working with residents was reviewed with Staff 1 (ED) on 08/22/23. She acknowledged the findings.

1. All staff training records have been reviewed and any staff missing required pre-service orientation (Pre-service infection control) per state regulation have been brought into compliance.

2. New-hire check list will be utilized and signed off on to ensure each new staff member has completed the required pre-service training prior to start of on-the-floor training.

3.BOM and ED will review this process quarterly.

4. BOM and ED.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 caregiving staff (#s 12 and 13) completed First Aid training and demonstrated satisfactory performance in all job duties within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed with Staff 6 (Business Office Manager) on 08/22/23.

There was no documented evidence Staff 12 (CG), hired 01/11/23, and Staff 13 (CG), hired 05/17/23, had demonstrated competency in Changes associated with normal aging and completed First Aid training.

Staff 6 acknowledged the training had not been done.

The need to ensure staff had demonstrated competence in all job duties within 30 days of hire and completed First Aid training was reviewed with Staff 1 (ED) on 08/22/23. She acknowledged the findings.

1. All staff training has been reviewed and any staff missing required training within 30 days of hire (including first aid and changes in normal aging), per state regulations, have been brought into compliance.

2. New-hire checklist will be utilized and signed off on to ensure each new staff member has completed the required training prior to start of the on-the-floor training.

3. BOM, ED and Licensed Nurse will review this process at least quarterly.

4. BOM and ED

Based on record review and interview, it was determined the facility failed to complete annual training on infectious disease outbreak and infection control for 2 of 2 (#s 10 and 11) staff whose yearly training records were reviewed. Findings include, but are not limited to:

Staff training records were reviewed with Staff 6 (Business Office Manager) on 08/22/23.

Staff 10 (MA), hired 06/22/21, and Staff 11 (CG), hired 03/1/17, lacked documented evidence of completing annual training on infectious disease outbreak and infection control.

Staff 6 confirmed the annual training on infectious disease outbreak and infection control had not been done.

The need to ensure staff completed annual training on infectious disease outbreak and infection control was reviewed with Staff 1 (ED) on 08/22/23. She acknowledged the findings.

1. All staff training records have been reviewed and any staff missing required annual infectious disease outbreak and infection control training CEUs per state regulations have been brought into compliance

2. BOM will utilize staff training tracker worksheet to maintain oversight on required annual CEUs for staff. ED and Licensed Nurse will ensure appropriate CEU training subjects are provided during staff training for staff each month/year

3. BOM, ED and Licensed Nurse will review the process at least quarterly.

4. BOM, Licensed Nurse and ED

Based on interview and record review, it was determined the facility failed to provide fire and life safety training and failed to include required components on fire drill records. Findings include, but are not limited to:

Fire and life safety records from 01/2023 to 07/2023 were reviewed with Staff 5 (Maintenance Director) on 08/22/23.

* Fire drill records lacked the following components:

- Escape route used; and

- Number of occupants evacuated.

* Fire and life safety training was not documented as completed every other month alternating with fire drills.

On 08/22/23 the need to document all required fire drill information and provide fire and life safety training was reviewed with Staff 1 (ED). She acknowledged the findings.

1.  Fire drill schedule has been created outlining which months we will have fire drill and the alternating months fire and life safety instructions for staff. Fire drill for September will include escape route used, evacuation time needed, number of residents evacuated, and any problems encountered relating to residents choosing not to participate in drill.

2. Fire drill schedule with alternating month fire and life safety instructions for staff has been created and is kept in Fire and Life safety binder providing full year's schedule

3. ED and Maintenance Director will review fire and life safety on monthly basis.

4. ED and Maintenance Director will ensure corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to instruct residents within 24 hours of admission, and re-instruct residents at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills and designated meeting places outside the building or within the fire safe area in the event of an actual fire. Findings include, but are not limited to:

On 08/22/23, the surveyor discussed the facility's process and documentation for instructing residents on fire and life safety procedures with Staff 5 (Maintenance Director) and Staff 6 (Business Office Director).

Staff 5 reported he did not instruct residents within 24 hours of admission, or re-instruct annually, in general safety procedures, evacuation methods, responsibilities during fire drills and designated meeting places outside the building or within the fire safe area in the event of an actual fire.

Resident admission records were reviewed with Staff 6. There was no documented evidence of instructing residents on fire and life safety procedures with in 24 hours of move in.

The need to ensure residents were instructed within 24 hours of admission, and re-instruct at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills and designated meeting places outside the building or within the fire safe area in the event of an actual fire was reviewed with Staff 5 and 6. They acknowledge the findings.  

1.Fire and life safety training will be provided to all current residents by October 22nd, 2023 and documented to include: general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside of building or within fire safe area in the event of an actual fire. Resident training will continue at least annually going forward.

2. Documentation of residents training will be included in resident move-in packet and documented annual re-training will be kept in fire and life safety training binder. Alternating exit routes will be included on alternating month fire drills.

3. ED and Maintenance Director will review fire and safety monthly.

4. ED and Maintenance Director.

Based on observation and interview, it was determined the facility failed to ensure all exterior pathways and accesses were maintained in good repair. Findings include, but are not limited to:

The exterior of the facility was toured on 08/21/23.

Exterior sidewalks around the facility, sidewalk outside exit doors, and pathways had drop offs up to four inches measured from the concrete to the ground. These drop-offs created potential hazards for residents.

On 08/21/23, the building's exterior was reviewed with Staff 1 (ED). She acknowledged the findings.

1. Exterior sidewalk areas surrounding the building where drop-offs were noted will be filled in to minimize potential hazard to residents--to be completed by October 22nd 2023.

2.  Maintenance Director will make monthly rounds to determine if sidewalk areas are in need of re-fill due to weather, erosion, or water run-off and will make nescessary repairs in the shortest time possible.

3. Monthly review will be completed.

4. Maintenance Director and ED

Based on observation and interview, it was determined the facility failed to ensure the environment was kept clean. Findings include, but are not limited to:

Observations of the facility on 08/22/23 revealed:

* Carpeted columns in dining room had carpet detached and falling off;

* Intake vents on first floor had a build up of dust and debris; and

* Floor fan in use in first floor main corridor had build up of dust and debris on the blades and cage.

The surveyor reviewed the findings with Staff 4 (Regional Director of Nursing) on 08/23/23. She acknowledged the findings.

1.  Carpeted column in the dining room will be repaired by 10/22/23. Intake vents on first floor will be cleaned by 10/22/2023. Floor fan in use in 1st floor corridor will be cleaned by 10/22/23

2. Maintenance Director will make monthly rounds to ensure cleanliness of vent intakes, fans and other cleanliness related issues.

3. Monthly review will be completed.

4.  Maintenance Director and ED