The findings of the re-licensure survey, conducted 10/17/23 through 10/20/23, 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 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 10/20/23, conducted on 02/05/24 through 02/06/24, 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 move-in evaluations addressed all required elements and were updated and modified as needed during the 30 days following the resident's move into the facility for 1 of 1 sampled resident (#4) whose move-in evaluation was reviewed. Findings include, but are not limited to:

Resident 4 was admitted to the facility in 08/2023 with diagnoses including chronic pain syndrome.

The resident's Functional Evaluation, dated 08/04/23, and Clinical Comprehensive Assessment, dated 08/04/23, were reviewed.   

a. The following elements were not addressed in Resident 4's initial move-in evaluation:

* Customary routines related to eating;

* Personality, including how the person copes with change or challenging situations;

* Assistive devices used for eating;

* Transportation;

* Non-pharmaceutical interventions for pain and how a person expresses pain or discomfort;

* Nutrition habits, fluid preferences and weight if indicated;

* Complex medication regimen; and

* Environmental factors that impact the resident's behavior including, but not limited to: noise, lighting, room temperature.

b. The facility lacked documented evidence the resident's Functional Evaluation and Clinical Comprehensive assessment, both dated 08/04/23, were updated and modified as needed during the 30 days following admission to the facility.

The need to ensure move-in evaluations addressed all required elements and were updated and modified as needed during the 30 days following the resident's move into the facility was discussed with Staff 1 (Administrator), Staff 15 (ED), Staff 2 (Wellness Director), Staff 12 (LPN) and Staff 14 (RN Consultant) on 10/20/23. They acknowledged the findings.

1. Resident #4 will have a new move-in evaluation completed to ensure it includes all required components.

2. Evaluation tool will be modified to ensure it includes all required components.

3. Random audits of move-in and 30-day evaluations will be conducted monthly by the administrator or desginee to ensure continued compliance.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of the current resident status as identified in the evaluation, were updated following a significant change of condition, and provided clear direction to staff regarding the delivery of services for 2 of 3 sampled residents (#s 1 and 4) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 09/2014 with diagnoses including hypertension, depression, and osteoporosis.

Review of Resident 1's most recent service plan, dated 09/25/23, revealed several areas where information differed from the quarterly evaluation, dated 08/31/23. The contradictory findings included the following:

*The quarterly evaluation indicated the resident used no side rails or other devices with restraining qualities. The service plan documented the resident used quarter length side rails bilaterally on the bed. Observations were made of the side rails in Resident 1's apartment; and

*The evaluation indicated the resident had experienced no confusion or memory loss, and was alert and oriented x 4 (person, place, time, situation). The service plan indicated Resident 1 had displayed deficits in judgement, and required safety checks every hour at night.

On 10/20/23, the need to ensure service plans were reflective of residents' needs and preferences as identified in their evaluations, was discussed with Staff  1 (Administrator), Staff 15 (ED), Staff 2 (Wellness Director), Staff 12 (LPN) and Staff 14 (RN Consultant). They acknowledged the finding

2. Resident 4 was admitted to the facility in 08/2023 with diagnoses including chronic pain syndrome and cellulitis of left upper limb.

The resident's service plan dated 10/17/23 was reviewed, and observations and interviews with staff and Resident 4 were completed during the survey.

The service plan was not reflective of the resident's current status and did not provide clear direction to staff in the following areas:

* Upper and lower extremity ulcers;

* Toileting assistance required with hygiene and pant management;

* Ambulation status;

* Prosthesis and related equipment status following recent amputation;

* Reading glasses;

* Preferences around dining in apartment;

* Behaviors toward other residents; and

* HH PT and RN services, including who provided services, frequency of visits, and the role of the caregiver and med tech when issues with bandages or changes to ulcerations occurred.

b. The facility lacked documented evidence the resident's service plan was reviewed and updated following a significant change of condition related to  stage two upper extremity blisters identified on 09/15/23.

The need to ensure service plans were reflective of residents' current needs, included a written description of who shall provide the services and what, when, how, and how often the services shall be provided, and was reviewed and updated as needed following a significant change was discussed with Staff 1 (Administrator), Staff 15 (ED), Staff 2 (Wellness Director), Staff 12 (LPN) and Staff 14 (RN Consultant) on 10/20/23. They acknowledged the findings.

1. Residents #1 & 4 will have new evaluation completed and service plans reviewed and updated to ensure accuracy.  

2. Evaluation tool will be updated to prompt updates to the service plan.  Facility leadership team will be educated on the completion of person-centered service plans.

3. Random audits of service plans will be conducted by the administrator or designee quarterly to ensure continued compliance.

Based on observation, interview, and record review, it was determined the facility failed to ensure short-term changes of condition had actions or interventions determined and were monitored until resolution for 3 of 3 sampled residents (#s 1, 3, and 4) who experienced short-term changes of condition. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 05/2023, with diagnoses including heart disease and chronic pain.

The resident's service plan, dated 09/25/23, progress notes, dated 07/09/23 through 10/17/23, skin assessment notes, and interim service plans were reviewed.

A progress note dated 08/05/23 documented "resident has open wounds on the front of both legs, cleaned the area and applied a bandage. Notified RN"

There was no documented evidence actions or interventions had been determined or the wounds had been monitored until resolution.

The need to ensure actions or interventions for short-term changes of condition were documented and the changes of condition were monitored, at least weekly, through resolution was discussed with Staff 1 (Administrator), Staff 15 (ED), Staff 2 (Wellness Director), Staff 12 (LPN) and Staff 14 (RN Consultant) on 10/20/23. They acknowledged the findings.

2. Resident 1 was admitted to the facility in 09/2014, with diagnoses including hypertension, depression, and osteoporosis.

The resident's service plan, dated 09/25/23, progress notes, dated 07/09/23 through 10/17/23, skin assessment notes, and interim service plans were reviewed. The progress notes included the following short-term changes:

*07/09/23- A caregiver found "blood on [his/her] bottom", and applied cream; and

*08/06/23- "Resident has a pea-size open sore next to an already pre-existing sore. Barrier cream was applied".

In the four week period between these two identified skin issues there was no documented evidence of monitoring or progress noted, and subsequent documentation confirmed the issues had not resolved.

On 10/20/23, the need to ensure short term changes of condition had documentation to reflect monitoring at least weekly, to resolution was discussed with Staff 1 (Administrator), Staff 15 (ED), Staff 2 (Wellness Director), Staff 12 (LPN) and Staff 14 (RN Consultant). They acknowledged the findings.

3. Resident 4 was admitted to the facility in 08/2023 with diagnoses including chronic pain syndrome.

Observations of the resident and interviews with staff were completed. The resident's service plan, dated 10/17/23, skin assessment notes and progress notes, dated 08/08/23 through 10/17/23, were reviewed. The following was revealed:

a. The following short-term changes of condition lacked documentation of actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts and progress noted, at least weekly, through resolution:

* 08/08/23 - Moved to the facility;

* 08/09/23 - Pre-move in surgical wound to chest;

* 08/09/23 - Lower extremity blisters;

* 08/28/23 - Resident complaints of being "drug sick";

* 09/03/23 - Resident concerns of overdosing;

* 09/04/23 - Lethargy and "jumbling words together"; and

* 09/15/23 - Complications from an off-site CT scan which resulted in blisters to left upper extremity.

b. The following short-term change of condition lacked documentation of actions or interventions needed for the resident and the communication of the determined actions or interventions to staff on all shifts:

* 09/22/23 - Start of antibiotics.

c. The following short-term change of condition lacked documentation of progress noted, at least weekly, through resolution:

* 08/22/23 - Fall from wheelchair during self-transfer.

The need to ensure actions or interventions for short-term changes of condition were documented and communicated to staff on each shift and the changes of condition were monitored, at least weekly, through resolution was discussed with Staff 1 (Administrator), Staff 15 (ED), Staff 2 (Wellness Director), Staff 12 (LPN) and Staff 14 (RN Consultant) on 10/20/23. They acknowledged the findings.

1. Residents #1, #3, and #4 will have an interim service plan completed with actions or interventions and wounds will be monitored weekly until resolution.  Actions or interventions will be communicated to staff on all shifts.

2. Residents experiencing a short-term change of condition will be evaluated, actions and interventions identified and communicated to staff through an Interim Service Plan. Residents experiencing a change of condition will have progress documented weekly until resolved.

3. Audits of change of conditions will be conducted weekly by the executive director or designee and results reported to the Quality Assurance Committee.

Based on interview and record review, it was determined the facility failed to coordinate on-site health services with outside providers and have policies to ensure outside service providers left written information in the facility that addressed the on-site service being provided, for 1 of 2 sampled residents (#1) who received Home Health services. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 09/2014 with diagnoses including hypertension, depression, and osteoporosis.

During the acuity interview on 10/17/23, Resident 1 was identified as receiving HH nursing services.

In another interview on 10/19/23, Staff 3 (LPN) stated all outside provider visit notes were kept in accessible binders in each of the three assisted living buildings on site.

The binder for Building D (in which Resident 1 resided) was reviewed. The only recorded HH visit for the resident was an RN note for skin monitoring, performed on the previous day (10/18/23).

On 10/19/23, Staff 1 (Administrator) and Staff 4 (Med Aide) stated there was no further outside provider documentation available, including a record of the date HH services where initiated for Resident 1.

On 10/20/23 the need to ensure outside service providers left written information in the facility that addressed the on-site services being provided was discussed with Staff 1, Staff 15 (ED), Staff 2 (Wellness Director), Staff 12 (LPN) and Staff 14 (RN Consultant). They acknowledged the findings.

1.  Resident #1 is receiving home health services and provider has been educated to provide notes in the facility provider communication binder.  

2.  Residents receiving services from an outside provider will have notes left in the facility provider communication binder and will be reviewed by the nurse or designee daily.

3. Audit of outside provider communication will be done by the administrator or designee and results reported to the executive director monthly.

Based on observation, interview, and record review, it was determined the facility failed to ensure a safe medication and treatment administration system, and failed to ensure adequate professional oversight of the systems. Findings include, but are not limited to:

During the re-licensure survey, conducted 10/17/23 through 10/20/23, professional oversight of the medication and treatment administration system was found to be ineffective, based on deficiencies in the following areas:

* C 302: Tracking Controlled Substances;

* C 303: Medication and Treatment Orders;

* C 305: Resident Right to Refuse;

* C 325: Self Administration of Medications; and

* C 330: PRN Psychotropic Medications.

During the exit meeting on 10/20/23 Staff 1 (Administrator), Staff 2 (Wellness Director), Staff 12 (LPN), Staff 13 (Regional Representative), Staff 14 (RN Consultant) and Staff 15 (Executive Director) were informed the overall medication administration system was determined to be inadequate based on the number of deficiencies related to the above medication areas. They acknowledged the findings.

1.  New facility RN is in place full-time and will be scheduled to take the next Role of the RN course.

2.  All medication technicians will be in-serviced on tracking controlled substances, medication and treatment orders, resident right to refuse, self administration of medications, PRN psychotropic medications and parameters.

3. Audits will be conducted per plans of correction for C302, C303, C305, C325, and C330.  

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 (#4) whose MARs and Controlled Substance Disposition logs were reviewed for accuracy. Findings include, but are not limited to:

Resident 4 was admitted to the facility in 08/2023 with diagnoses including chronic pain syndrome.

The resident's physician orders, the Controlled Substance Disposition logs and the MAR, dated 10/01/23 through 10/17/23 were reviewed.

Resident 4 had physician orders for the following controlled medications:

* Alprazolam 0.5 mg - Take one tablet orally in the evening for anti-anxiety;

* Alprazolam 0.5 mg - Take one to two tablets by mouth nightly as needed for anxiety or sleep;

* Morphine 15 mg - Take three tablets by mouth two times daily for pain; and

* Oxycodone 15 mg - Take one tablet by mouth every eight hours as needed for severe pain.

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

* 10/01/23 - Resident 4's scheduled morphine was documented as administered at 8:00 am and 8:00 pm in the Controlled Substance Disposition log, but it was not documented in the MAR;

* 10/02/23 - Resident 4's scheduled morphine was documented as administered at 8:00 am and 8:00 pm in the Controlled Substance Disposition log, but it was not documented in the MAR;

* 10/05/23 - Resident 4's PRN alprazolam was documented as administered at 8:00 pm in the Controlled Substance Disposition log, but it was not documented in the MAR;

* 10/05/23 - Resident 4's PRN oxycodone was documented as administered at 12:50 pm in the Controlled Substance Disposition log, but it was not documented in the MAR;

* 10/13/23 - Resident's 4's PRN oxycodone was documented as administered at 5:31 pm and 11:32 pm in the Controlled Substance Disposition log, but it was not documented in the MAR; and

* 10/18/23 - The Controlled Substance Disposition log indicated there were 16 oxycodone pills remaining in the medication bubble pack; however, there were 15 doses remaining.

The need to ensure the facility had an effective system for tracking controlled substances was discussed with Staff 1 (Administrator), Staff 15 (ED), Staff 2 (Wellness Director), Staff 12 (LPN) and Staff 14 (RN Consultant) on 10/20/23. They acknowledged the findings.

1. Resident #4 will have a medication error report completed.

2. Narcotic book and MARs will be reconciled weekly by administrator or designee until ongoing compliance is achieved.

3. Staff will be re-educated on the importance of documentation in the MAR and narcotic book simultaneously and accuracy of the narcotic counts.       

Based on observation, interview, and record review, it was determined the facility failed to ensure written, signed physician orders were documented in the resident's facility record for all medications and treatments the facility was responsible to administer, and that medication orders were carried out as prescribed for 5 of 5 sampled residents whose orders were reviewed (#s 1, 2, 3, 4, and 5)  Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 09/2023 with diagnoses including heart failure and lower extremity fracture.  

Resident 2's 10/2023 MAR indicated they administered their own medications.

Review of Resident 2's record showed the "medication self-administration safety screen" dated 09/13/23 was incomplete, with no information or safety

determination documented. No evaluation of Resident 2's ability to administer their own medications was completed.

A progress note dated 10/17/23 stated "Received orders Resident 2 may not self-administer their own medications"

In an interview on 10/19/23, Staff 18 (Med Aide) confirmed Resident 2 continued to administer his/her own medications and an observation of the med cart showed no medications stored for Resident 2.

The facility had a physician order that Resident 2 was not to self-administer medications, however, interview and record reviewed confirmed Resident 2 continued to keep medications in their room and self-administer.

The need to ensure physician's orders were followed was discussed with Staff 1 (Administrator), Staff 15 (ED), Staff 2 (Wellness Director), Staff 12 (LPN) and Staff 14 (RN Consultant) on 10/20/23. They acknowledged the findings.

2. Resident 3 was admitted to the facility in 05/2023, with diagnoses including heart disease and chronic pain.

Review of Resident 3's 10/2023 MAR and physician's orders showed the following medications were administered without a signed order:

* Duloxetine DR 30 mg cap (anti-depressant);

* Fluconazole 200 mg tab (anti-fungal);

* Spironolcactone 25 mg tab (diuretic);

* Potassium CHL ER 200 MEQ (supplement);

* Trelegy Ellipta 100-62.5 MCG (steroid inhaler);

* Acetaminophen 500 MG 2 tablets (analgesic); and

* Albuterol 90 MCG (asthma inhaler).

In an interview on 10/19/23, Staff 1 acknowledged there were not physician's orders for the medications the facility was administering.

The need to ensure written, signed physician orders were documented in the resident's facility record for all medications and treatments the facility was responsible to administer was discussed with Staff 1, Staff 15 (ED), Staff 2 (Wellness Director), Staff 12 (LPN) and Staff 14 (RN Consultant) on 10/20/23. They acknowledged the findings, and no additional documentation was provided.

On 10/20/23 prior to survey's exit, the facility received signed physician orders from the pharmacy.

3. Resident 5 was admitted to the facility in 10/2022 with diagnoses including Type II Diabetes and hypothyroidism.

Review of Resident 5's 10/2023 MAR and current physician's orders showed the following medications were administered without a signed order:

* Amlipodine 2.5 mg (blood pressure medication);

* Furosemide 40 mg (diuretic);

* Insulin Aspart 100 u/ml injection (anti-diabetic);

* Jardiance 25 mg (anti-diabetic);

* Levothyroxine 112 mcg (thyroid hormone);

* Losartan 50 mg (blood pressure);

* Trulicity 4.5 mg (anti-diabetic);

* Pantoprazole 40 mg (antacid);

* Venlafaxine 75 mg (antidepressant);

* Eliquis 5mg (blood thinner);

* Budesonide 160-4.5mcg (anti-asthma);

* Lantus Solostar pen injection (anti-diabetic);

* Gabapentin 100 MG (analgesic);

* Methocarbamol 750 mg (analgesic); and

* Acetaminophen 500 mg (analgesic).

In an interview on 10/19/23, Staff 1 acknowledged there were not physician's orders for the medications the facility was administering.

The need to ensure written, signed physician orders were documented in the resident's facility record for all medications and treatments the facility was responsible to administer was discussed with Staff 1, Staff 15 (ED), Staff 2 (Wellness Director), Staff 12 (LPN) and Staff 14 (RN Consultant) on 10/20/23. They acknowledged the findings, and no additional documentation was provided.

On 10/20/23 prior to survey's exit, the facility received signed physician orders from the pharmacy.

3. Resident 1's MAR, dated 10/01/23 through 10/17/23, and signed physician orders, dated 10/12/23, were reviewed. The following deficiencies were identified:

There were no written, signed orders for the following medications in Resident 1's record:

* Aspirin (anticoagulant);

* Clobetasol ointment (for irritation);

* Clopidogrel (anticoagulant);

* Multivitamin tab (supplement);

* Nizoral A-D shampoo (for itching);

* Pantoprazole (Gastroesophageal Reflux Disease);

* Potassium Chloride (venous hypertension);

* Amlodipine (hypertension);

* Buspirone (for anxiety);

* Enalapril Maleate (hypertension);

* Gabapentin (for neuropathy);

* PRN acetaminophen (for fever or mild pain);

* PRN barrier cream (for prevention and healing of skin breakdown);

* PRN Bisacodyl supp (constipation);

* PRN Bisacodyl tablet (for no BM, by 4th day);

* PRN calcium carb (Gastroesophageal Reflux Disease);

* PRN clobetasol prop (itchy scaly scalp);

* PRN Corn Remover 40% Pads (corn remover);

* PRN Ibuprofen (for mild to moderate pain or inflammation);

* PRN Ketoconazole 2% shampoo (for dry scalp);

* PRN Milk of Magnesia (for no BM, by 3rd day);

* PRN PEG 3350 Powder (constipation); and

* PRN Preparation H 1% Cream (hemorrhoids).

On 10/19/23, Staff 1 (Administrator) acquired signed physician's orders for Resident 1's medications before the survey was completed.

On 10/20/23, the need to ensure the facility had written, signed orders in every resident's record for all medications and treatments being administered was discussed with Staff 1, Staff 15 (ED), Staff 2 (Wellness Director), Staff 12 (LPN) and Staff 14 (RN Consultant). They acknowledged the findings.

4. Resident 4 was admitted to the facility in 08/2023 with diagnoses including chronic pain syndrome.

The resident's MAR dated 10/01/23 through 10/16/23 and current physician's orders were reviewed.

a. There was no documented evidence of signed physician orders in the resident's facility record for the following medications:

* Alprazolam 0.5 mg - Take one tablet orally in the evening for anti-anxiety;

* Bactrim DS 800-160 mg - Take one tablet by mouth two times a day for 12 days for cellulitis; and

* Spironolactone 50 mg - take one table by mouth daily as a diuretic, hold until patient completes course of Bactrim.

On 10/20/23 prior to survey's exit, the facility received signed physician orders from the pharmacy.

b. Resident 4 had physician orders for oxycodone 15 mg to be administered every eight hours as needed for severe pain. On 10/11/23, the resident received this medication at 12:02 am, 3:04 am, 7:29 am and 2:44 pm. The medication was given earlier than the prescribed eight hour parameter for all administrations. On 10/19/23 at 2:07 pm, Staff 13 (Regional Representative) confirmed the medication was erroneously set-up in the electronic MAR to allow administration prior to the prescribed parameter. Staff 13 corrected the electronic MAR at that time.

The need to ensure physician orders were in the residents' facility record and medication orders were carried out as prescribed was discussed with Staff 1   (Administrator), Staff 15 (ED), Staff 2 (Wellness Director), Staff 12 (LPN) and Staff 14 (RN Consultant) on 10/20/23. They acknowledged the findings.

1. Resident #2's self-administation safety screen has been updated.  Will work with resident, her physician, and caseworker on an agreeable medication administration plan.

2.  Resident #1, #3 and #5's signed orders were obtained and are in the resident charts.

3. Resident #4's PRN order was updated to reflect the accurate order time frame.  

4. Signed orders will be reviewed by the administrator or designee and obtained for all other residents.

5.  PRN orders will be reviewed by the administrator or designee and corrected as needed for all other residents.

6. Staff have been educated PRN time frames and administration.  

7.  Audits will be conducted of signed orders by the administrator or designee quarterly and findings reported to the Quality Assurance Committee.  PRN orders will be audited by the administrator or designee monthly and findings reported to the executive director.

Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused consent to an order for 1 of 1 sampled resident (#4) who had documented medication refusals. Findings include, but are not limited to:

Resident 4 was admitted to the facility in 08/2023 with diagnoses including chronic pain syndrome.

The resident's MAR, dated 09/01/23 through 09/30/23, was reviewed and revealed facility staff documented Resident 4 refused the following orders:

* Acetaminophen 325 mg (for pain) on ten occasions.

There was no documented evidence the facility notified Resident 4's physician of the refusals.

The need to notify the physician/practitioner when a resident refused consent to orders was discussed with Staff 1 (Administrator), Staff 15 (ED), Staff 2 (Wellness Director), Staff 12 (LPN) and Staff 14 (RN Consultant) on 10/20/23. They acknowledged the findings.

1. Resident #4's physician was notified of resident's refusals of acetamenophen.  Resident's orders will be updated to reflect notification of refusals to physician per physician request.

2. All other residents will be reviewed to ensure direction to staff to notify physician of refusals.

3. Will educate med techs on notification to physician of refusals.

4. Nurse or designee will audit for notification of refusals weekly x 4 then monthly until ongoing compliance achieved.

Based on interview and record review, it was determined the facility failed to ensure residents had a physician's or other legally-recognized practitioner's order of approval for self-administration of prescription medications and were evaluated upon move-in and then at least quarterly to assure ability to safely self-administer medications for 2 of 2 sampled residents (#s 2 and 4) who self-administered their medications. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 09/2023 with diagnoses including heart failure and lower extremity fracture.  

Resident 2's 10/2023 MAR indicated s/he administered her/his own medications.

Review of Resident 2's record showed the "Medication self-administration safety screen" dated 09/13/23 was blank, with no information or safety determination documented. No evaluation of Resident 9's ability to administer their own medications was completed.

A progress note dated 10/17/23 stated "Received orders Resident 2 may not self-administer their own medications"

In interview on 10/19/23, Staff 18 (Med Tech) confirmed Resident 2 continued to administer her/his own medications and observation of the med cart showed no medications stored for Resident 2.

On 10/19/23, the requirement for both a physician's order to self-administer medication, and an RN evaluation of safety before a resident begins to self-administer medications was reviewed with Staff 1 (Administrator). He acknowledged the findings.

2. Resident 4 was admitted to the facility in 08/2023 with diagnoses including chronic obstructive pulmonary disease.

Resident 4's physician orders and Functional Evaluation, dated 08/04/23, were reviewed and revealed the following:

* The resident had an order for albuterol 90 mcg - Inhale two puffs by mouth every six hours as needed for wheezing; and

* Staff were to administer all medications for the resident.

On 10/19/23 at 11:24 am, Staff 16 (Med Aide) confirmed the facility did not administer the resident's albuterol, rather the resident kept it in his/her apartment and self-administered the medication as needed.

A current evaluation of the resident's ability to self-administer prescription medications and a physician order was requested on 10/20/23 at 8:58 am. The facility was unable to provide the requested self-medication evaluation or physician order.

The need to ensure residents who chose to self-administer medications were evaluated for safety and had a physician's written order of approval for the self-administration of prescription medications was discussed with Staff 1 (Administrator), Staff 15 (ED), Staff 2 (Wellness Director), Staff 12 (LPN) and Staff 14 (RN Consultant) on 10/20/23. They acknowledged the findings.

1. Resident #2 and #4's self-administation safety screen will be updated and order obtained as appropriate.

2. All other residents self-administering medications will be reviewed by the nurse or designee to ensure they have been evaluated and there is a physician order for self-administration.  

3. Med techs will be in-serviced on resident self-administration of medications.

4. Audits of residents self-administering medications will be conducted quarterly by the nurse or designee.

Based on interview and record review, it was determined the facility failed to ensure medications that were given to treat a resident's behavior had resident-specific parameters and non-pharmacological interventions were attempted and documented to be ineffective prior to the administration of psychotropic medications for 1 of 1 sampled resident (#4) who was prescribed psychotropic medications. Findings include, but are not limited to:

Resident 4 was admitted to the facility in 08/2023 with diagnoses including anxiety and insomnia.

Review of Resident 4's MAR, dated 10/01/23 through 10/16/23, and physician orders revealed the following:

* Resident 4 was prescribed alprazolam 0.5mg - take one to two tablets by mouth nightly as needed for anxiety or sleep; and

* Alprazolam was documented as administered to the resident on eight occasions between 10/02/23 and 10/16/23.

The facility lacked documented evidence of resident-specific parameters regarding when unlicensed staff were to administer one versus two alprazolam, non-pharmacological interventions were attempted and were ineffective prior to administration of the alprazolam, and the MAR lacked information on which non-pharmacological interventions to attempt.

In an interview on 10/19/23, Staff 16 (Med Aide) confirmed the electronic MAR did not have resident-specific parameters or non-pharmacological interventions listed for staff to attempt prior to administering the PRN medication.

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        The need to ensure medications that treat a resident's behaviors had resident-specific parameters and non-pharmacological interventions were attempted and documented to be ineffective prior to the administration of PRN psychotropic medications was discussed with Staff 1 ( Administrator), Staff 15 (ED), Staff 2 (Wellness Director), Staff 12 (LPN) and Staff 14 (RN Consultant) on 10/20/23. They acknowledged the findings.

1. Resident #4's orders for prn psychotropic medications will be updated to include parameters on when to administer and non-pharmacological interventions that were attempted.  

2. All other residents receiving PRN psychotropic medications will be reviewed to ensure paramaters on when to administer and non-pharmacological interventions.

3. Med techs will be in-serviced on parameters and non-pharmacological interventions prior to PRN administration of psychotropic medications.

4. Audits of PRN psychotropic orders will be conducted by nurse or designee monthly.

Based on observation, interview, and record review, it was determined the facility failed to ensure the Acuity-Based Staffing Tool (ABST) was reviewed before a resident moved into the facility, entries were reflective of the resident's current care needs, and the facility was staffing to the ABST generated staffing level for 2 of 3 residents reviewed (#s 1 and 4) and unsampled residents. Findings include, but are not limited to:

1. A review of the facility's ABST on 10/17/23 and on 10/19/20 with Staff 1 (Administrator) revealed the facility failed to enter all residents prior to move-in and remove residents following discharge from the community.

2. Resident 4 was admitted to the facility in 08/2023 with diagnoses including chronic pain syndrome.

Observations of Resident 4, interviews with the resident and staff, and review of the resident's records revealed ABST entries were not reflective of the resident's current care needs and had an inaccurate number of minutes assigned in the following areas:

* Dressing and undressing; and

* Bowel and bladder management.

3. Resident 1 was admitted to the facility in 09/2014, with diagnoses including hypertension, depression and osteoporosis.

Observations of Resident 1, interviews with the resident and staff, and review of the resident's records revealed ABST entries were not reflective of the resident's current care needs and had an inaccurate number of minutes assigned in the following areas:

* Bowel and bladder management;

* Assisting with communication, assistive devices for hearing, vision and speech;

* Ambulation, escorting to and from meals and activities; and

* Transferring in or out of bed and chair.

4. The facility's posted staffing plan and the ABST generated staffing hours were reviewed with Staff 1 on 10/19/23. It was determined the facility's staffing plan did not consistently meet or exceed the staffing hours generated by the tool.

The need to ensure residents were entered into the ABST system prior to moving into the facility, the entries were reflective of the resident's care needs and the facility was staffing to the staff hours generated by the ABST was discussed with Staff 1, Staff 15 (ED), Staff 2 (Wellness Director), Staff 12 (LPN) and Staff 14 (RN Consultant) on 10/20/23. They acknowledged the findings.

1.  Resident #1 and #4's Acuity-Based Staffing Tool (ABST) has been updated to reflect the resident's current care needs.  

2.  ABST will be updated prior to resident move-in and upon discharge from the community.  

3.  ABST generated staffing hours will be reviewed weekly to ensure facility posted staffing plan is accurate and the staffign plan meets or exceed staffing hours generated by the tool.

4. Administrator will be educated on the timeline and monitoring hours in the ABST.  

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 4, 8 and 9) completed all required pre-service orientation training prior to beginning their job responsibilities. Findings include, but are not limited to:

Staff training records were reviewed on 10/18/23 with Staff 17 (Receptionist) and the following were identified:

a. Staff 4 (Med Aide), hired on 12/05/22, lacked documented evidence pre-service orientation training was completed in the following areas prior to beginning her job responsibilities:

* Resident rights and values of CBC care (completed on 03/07/23);

* Abuse reporting requirements (completed on 03/23/23);

* Infectious Disease Prevention (completed on 03/08/23); and

* Fire safety and emergency procedures (completed on 04/04/23).

b. Staff 8 (CG), hired on 07/13/23, lacked documented evidence pre-service orientation training was completed in the following areas prior to beginning her job responsibilities:

* Resident rights and values of CBC care (completed on 10/15/23);

* Abuse reporting requirements;

* Infectious Disease Prevention (completed 10/12/23); and

* Fire safety and emergency procedures (completed 10/14/23).

c. Staff 9 (CG), hired on 08/21/23, lacked documented evidence pre-service orientation training was completed in the following areas before prior to beginning her job responsibilities:

* Resident rights and values of CBC care (completed 10/09/23);

* Abuse reporting requirements;

* Infectious Disease Prevention (completed 10/10/23); and

* Fire safety and emergency procedures (completed 10/12/23).

The need to ensure newly hired staff completed all required pre-service training's prior to beginning their job responsibilities was reviewed with Staff 1 (Administrator), Staff 15 (ED), Staff 2 (Wellness Director), Staff 12 (LPN) and Staff 14 (RN Consultant) on 10/20/23. They acknowledged the findings.

1.  Staff #4, #8, and #9 have completed the pre-service orientation trainings.  

2.  All newly hired staff will complete all the required pre-service trainings prior to beginning their job responsibilities.

3.  Training records will be reviewed by the administrator or designee for each new hire prior to beginning job responsibilities ongoing.  The executive director or designee will conduct audits quarterly and report results to the Quality Assurance Committee to ensure continued compliance.

4. Administrator and receptionist will be educated on the training requirements.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired direct care staff (#s 4, 8 and 9) demonstrated competency of skills in all assigned job duties within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed on 10/18/23 with Staff 17 (Receptionist) and the following were identified:

a. Staff 4 (Med Aide), hired on 12/05/22, lacked documented evidence of competency within 30 days of hire in the following required topics:

* Role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Changes associated with normal aging;

* Identification, documentation, and reporting changes of condition (completed on 04/04/23); and

* Conditions that require assessment, treatment, observation and reporting.

b. Staff 8 (CG), hired 07/13/23, lacked documented evidence of competency within 30 days of hire in the following required topics:

* Role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Changes associated with normal aging;

* Identification, documentation, and reporting changes of condition (completed on 10/13/23); and

* Conditions that require assessment, treatment, observation and reporting (completed on 10/15/23).

c. Staff 9 (CG), hired 08/21/23, lacked documented evidence of competency within 30 days of hire in the following required topics:

* Role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Changes associated with normal aging;

* Identification, documentation, and reporting changes of condition (completed on 10/10/23); and

* Conditions that require assessment, treatment, observation and reporting (completed on 10/12/23).

The need to ensure staff had documented evidence of competency demonstration within 30 days of hire was discussed with Staff 1 (Administrator), Staff 15 (ED), Staff 2 (Wellness Director), Staff 12 (LPN) and Staff 14 (RN Consultant) on 10/20/23. They acknowledged the findings.

1. Staff #4, #8, and #9 will demonstrate competency of skills in all assigned job duties.

2. Training records will be audited by the administrator or designee every 30 days for compliance.

4. Administrator and receptionist will be educated on the requirement for competency within 30-days of hire.

Based on interview and record review, it was determined the facility failed to ensure documented evidence of the required 12 hours of annual in-service training, including six hours of dementia care training, was completed for 1 of 2 long-term staff (#11) whose training records were reviewed. Findings include, but are not limited to:

Facility training records were reviewed on 10/18/23 with Staff 17 (Receptionist) and the following was revealed:

Training records for Staff 11 (CG), hired 10/03/18, failed to document evidence of 12 hours of required in-service training, including six hours of training related to the care of residents with dementia, between 10/03/22 and 10/03/23.

The need to ensure staff completed the required 12 hours of annual in-service training, including six hours of dementia care training was reviewed with Staff 1 (Administrator), Staff 15 (ED), Staff 2 (Wellness Director), Staff 12 (LPN) and Staff 14 (RN Consultant) on 10/20/23. They acknowledged the findings.

1. Staff 11 will complete additional in-servicing to ensure that the requirements are met.

2. All other staff with 1 year or more of service will be reviewed to ensure they meet the annual in-service requirements.

3.  Annual in-service training will be audited by the administrator or designee monthly and findings reported to the executive director.

4. . Administrator and receptionist will be educated on the requirement for annual in-service trainings.

Based on observation and interview, it was determined the facility failed to maintain all exterior pathways in good repair, and to ensure all facility grounds were kept orderly and free of refuse. Findings include, but are not limited to:

The exterior of the building was toured on 10/17/23. The following issues were noted:

* Multiple sections of the concrete path that encircled the building which had drop-offs from the surface of the path to the planting bed of greater than two inches. This represented a fall risk for residents; and

* An area observed on the rear grounds which included a mixture of old equipment (medical and exercise), appliances, furniture, tools, and building materials. This area was not kept orderly and presented a potential safety hazard for residents.

On 10/19/23 the need to ensure all exterior areas were maintained in good repair was discussed with Staff 1 (Administrator) and Staff 3 (Maintenance Director). They acknowledged the findings.

1. Planting beds near the concrete path will have material added to minimize drop-offs.

2. The equipment in the rear grounds of the facility will be cleaned up and old equipment removed.

3. Maintenance director will be educated on the requirement to keep the grounds safe, orderly and free of litter and refuse.

4. Administrator or designee will monitor monthly to ensure ongoing compliance.

Based on observation and interview, it was determined the facility failed to keep all interior materials and surfaces clean and in good repair. Findings include, but are not limited to:

The facility's interior was toured on 10/17/23 at 1:15 pm. The following issues were identified:

Common areas:

    * Marks and scrapes on multiple wood doors and frames;

    * Patchy paint on walls in D building;

    * Dark stains and streaks on hallway carpets throughout facility; and

    * Drywall damage and chips on hallway corners in D building.

Resident apartments:

    Room 8B:

    *  Door frame had gouges, scrapes, chipped paint and bare wood exposed;

    *  Baseboard was lifting from the wall in multiple places;

    *  Laminate flooring was uneven by the closet;

    *  Laminate of countertop was chipped with bare wood exposed;

    *  Laminate of shelves near refrigerator was chipped with bare wood exposed; and

    *  Base of kitchen counter was chipped with bare wood exposed.

    Room 9C:

    * Large white stains visible on bedroom carpet; and

    * Water leaking from beneath commode onto bathroom floor.

On 10/19/23 the areas in need of cleaning or repair were discussed with Staff 1 (Administrator) and Staff 3 (Maintenance Director). They acknowledged the findings.

1.  Doors and frames will be touched up with paint.

2.  Walls in building D will have the paint updated to minimize the patches.

3.  Carpets have been cleaned.

4.  Drywall damage in hallway corners will be repaired and painted.

5.  Resident apartment 8B will have door frame touched up, baseboard reglued, laminate repaired/patched.  Resident apartment 9C will have bedroom carpet cleaned.  Leak for commode has been repaired.

6. Maintenance director will be educated on maintenance of the interior of the facility.