The findings of the Change of Owner survey conducted 06/25/24 through 06/27/24 are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 for Home and Community Based Services Regulations.

Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

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 re-visit to the change of owner survey of 06/27/24, conducted 10/23/24, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.

2. Resident 2 was admitted to the facility in 02/2024 with diagnoses including type 2 diabetes mellitus, aphasia post cerebrovascular accident, dementia, and hypertension.

Clinical records, including the current service plan, dated 06/20/24, alert charting, progress notes from 03/26/24 through 06/24/24, and outside provider notes were reviewed, and interviews with facility staff were conducted.

The following short-term changes of condition lacked documentation the facility determined what resident-specific action or intervention was needed for the resident, communicated the determined action or intervention to staff, and/or documented weekly progress until the condition resolved:

* 03/28/24: progress note recorded "UA dip was done, it appeared positive for a UTI [urinary tract infection].";

* 04/01/24: progress note recorded "urine sample delivered today was negative for infection but did now glucose >1000 mg/dl.";

* 04/23/24: progress note recorded " ...has not been on insulin while [hospitalized].";

* 05/10/24: progress note recorded "Bad diarrhea (straight liquid) ...";

* 05/11/24: alert charting recorded "Resident's glucose is high 440 at 7:30 pm.";

* 05/12/24: progress note recorded "Resident unstable [and] a little bit dizzy when first getting out of bed this morning.";

* 05/14/24: alert charting recorded " 2 am Resident has had loose stool today x 2. Gait is still unsteady.";

* 05/19/24: progress note recorded " ...shaking more than usual ....[Resident] was taken to hospital by ambulance ...was back at 1:30 am. The ER [Emergency room] couldn't find anything. .. [S/he] was dehydrated. Push fluids.";

* 05/26/24: progress note recorded "Resident unstable on [his/her] feet.";

* 06/12/24: progress note recorded " Received orders to re-start Lantus insulin ...Ozempic [for hypoglycemia] has been discontinued.";

* 06/17/24: progress note recorded " Resident drowsy throughout the day."; and

* 06/20/24: progress note recorded "Received orders to discontinue lisinopril 20 mg [for blood pressure] and start lisinopril 10 mg daily [for blood pressure]."

The need to ensure the facility evaluated the resident and determined what resident-specific action or intervention was needed following a short-term change of condition, communicated the determined action or intervention to staff, and documented progress until the condition resolved was reviewed with Staff 1 (Administrator) and Staff 2 (RN) on 06/26/24 at 4:00 pm. They acknowledged the findings. No further information was provided.

Based on observations, interview and record review, it was determined the facility failed to determine resident-specific actions or interventions needed for residents following a short-term change of condition, communicate the determined actions or interventions to staff, and document progress until the condition resolved for 2 of 2 sampled residents (#s 1 and 2) who experienced changes of condition. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 08/2022 with diagnoses including hypertension and major depressive disorder.

Observation of Resident 1, interviews with staff, and review of the resident's 05/30/24 service plan that included long term and short term service plans, 03/12/24 through 06/24/24 progress notes, alert charting and incident investigations were reviewed. Resident 1's progress notes and alert charting revealed the following:

* 03/12/24: Medication dosage change for fluoxetine (for depression);

* 03/29/24: Resident 1 stood in front of another resident preventing them from standing up;

* 04/07/24: Cough;

* 04/18/24: Physician order for oxycodone (for severe pain);

* 05/02/24: Fall out of bed with left toe pain;

* 05/13/24: Cough;

* 05/20/24: Resident 1 became agitated, "flipped a dining room chair and table over"  and resulted in an emergency room visit;

* 06/08/24: Non-injury fall outside in backyard; and

* 06/20/24: Fall with superficial wound to scalp.

The above short-term changes of condition lacked documentation the facility determined what resident-specific action or intervention was needed for the resident, communicated the determined action or intervention to staff, or documented weekly progress until the condition resolved.

On 06/26/24 at 5:15 pm and 06/27/24 at 12:55 pm the need to ensure the facility determined what resident-specific action or intervention was needed for the resident following a short-term change of condition, communicated the determined action or intervention to staff, was implemented and reviewed for effectiveness, and documented progress until the condition resolved was reviewed with Staff 1 (Administrator) and Staff 2 (RN). They acknowledged the findings. No further information was provided.

1. RN reviewed/updated/resolved Alert/TSP charting.

2. Updated Alert charting policy and charting form- See attached policy & form

3. Moved all Alert charting to a separate Alert binder so all Alerts are easily found and understood.

4. Trained all staff on new process.

5. All Alerts will be reviewed by Administrator 3x a week and by RN 2x a week. Alerts will be resolved as soon as possible.

6. RN & Administrator are responsible for assuring compliance.

Based on interview and record review, it was determined the facility failed to ensure an RN assessment was completed for 1 of 1 sampled resident (# 1) who experienced a significant change of condition. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 08/2022 with diagnoses including hypertension and major depressive disorder.

A review of the resident's clinical record between 03/12/24 and 06/24/24 identified Resident 1 had a fall on 04/14/24 that resulted in a right clavicle fracture.

The right clavicle fracture constituted a significant change in condition requiring a facility RN assessment.

There was no documented evidence the facility RN conducted an assessment which included documentation of findings, resident status, and interventions made as a result of the assessment.

On 06/26/24 at 5:15 pm, Staff 2 (RN) confirmed an RN assessment had not been completed because she did not believe a clavicle fracture was considered a significant change of condition.  

The need to have an RN assessment for a significant change of condition was reviewed with Staff 1 (Administrator) and Staff 2 on 06/26/24. They acknowledged the findings.

1. Updated Change of Condition Policy - See attached

2. Updated Incident Report to include the need for change in condition assessment by RN - See attached IR

3. Trained RN and all staff on new process

4. Administrator reviews all IR's and if a change of condition assessment needs to be done Administrator will assure that it is done by RN.

5. Administrator & RN are responsible for assuring compliance.

2. Resident 2 was admitted to the facility in 02/2024 with diagnoses including type 2 diabetes mellitus, aphasia post cerebrovascular accident, dementia, hypertension.

Resident 2's current facility records and MARs from 06/01/24 to 06/25/24 were reviewed.

Resident 2's current facility records included a hospital discharge physician order on 04/23/24 to obtain "daily weights per facility protocol", and on 05/07/24 to change a diet texture "to dysphagia texture: D3-advanced with swallow precaution."

There was no documented evidence the resident's daily weight was obtained, and diet instructions were implemented.

The need to ensure physician or other legally recognized practitioner orders were carried out as prescribed was reviewed with Staff 1 (Administrator) on 06/27/24 at 2:40 pm. She acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure all written, signed orders for medications and treatments from a legally recognized practitioner were documented in resident records and carried out as prescribed for 2 of 2 sampled residents (#s 1 and 2) whose records were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 08/2022 with diagnoses including hypertension and major depressive disorder.

The resident's 06/01/24 through 06/25/24 MAR and physician's orders were reviewed and revealed the following:

a. Resident 1 had physician orders for brimonidine (for glaucoma) eye drops twice daily. The medication was circled four times between 06/11/24 and 06/21/24 and noted as being unavailable. During the same time period, the medication was documented as administered on 15 occasions interspersed between the dates the medication was marked as unavailable.

Observations on 06/27/24 indicated the medication bottle was dated 06/17/24. During an interview on 06/27/24 with Staff 1, she was unsure why the medication was signed as administered when other dates indicated the medication was unavailable.

b. Resident 1 had physician's order for timolol eye drops (for glaucoma) twice daily. On four occasions between 06/22/24 and 06/25/24 the medication was circled but no documentation to indicate the reason.

c. Resident 1 had physician orders for metoprolol (for high blood pressure) twice daily. The physician's order directed the facility to hold the medication if the systolic blood pressure was less than 90 and if the pulse was less than 45. The medication was scheduled for 8:00 am and 8:00 pm. Review of the MAR indicated the resident's blood pressure was taken once daily at noon.  During an interview on 06/26/24, Staff 4 (MT) confirmed the facility only obtained the resident's blood pressure and pulse at noon and did not have documented evidence this was done prior to administering the metoprolol.

d. Resident 1 had physician orders to check blood pressure once daily at noon and directed the facility to notify the physician if the blood pressure was greater than 160/90 or below 100/60. Review of the MAR indicated there were two occasions where Resident 1's blood pressure was less than 100/60. During an interview on 06/27/24, Staff 1 (Administrator) confirmed the facility did not have documented evidence the provider had been notified when the resident's blood pressure was less than 100/60.

The need to ensure the facility administered all medications and treatments as ordered by a legally recognized practitioner was discussed with Staff 1 on 06/27/24 at 12:55 pm. The findings were acknowledged.

1. All defiencies were reviewed with RN and Med Techs.

2. All orders have been corrected/implemented.

3. RN will review all MAR's twice a week and address any issues with the Med Techs.

4. Administrator will review all MARs once a week and address any issues with RN & Med Techs to ensure compliance.

5. Administrator will review all discharge orders to ensure they have been implemented and are signed by the provider.

6. RN/Administrator & Med Techs are responsible for assuring compliance.  

Based on observation, interview and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities had a thorough assessment completed by an RN, PT or OT prior to use, documentation of less restrictive alternatives evaluated prior to use, and instruction to caregivers on the correct use and precautions related to the use of the device included on the service plan for 1 of 1 sampled resident (# 1) who had a side rail on their bed. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 08/2022 with diagnoses including hypertension and major depressive disorder.

During an interview and observation on 06/25/24 at 4:15 pm, Resident 1's hospital bed was observed to have a quarter length side rail in the down position. Staff 4 (MT) confirmed the rail is in the up position when s/he is in bed.

Resident's 1's service plan, dated 05/30/24, was reviewed. There was no documented evidence regarding instruction to caregivers on the correct use and precautions for use of the side rail. Additionally, there was no documented evidence the device with potentially restraining qualities had been assessed by an RN, PT or OT, and documentation of less restrictive alternatives evaluated prior to use.

During an interview on 06/26/24 at 11:15 am, Staff 2 (RN) confirmed there was no documented evidence an assessment of the device with restraining qualities had been completed. She indicated an assessment was completed on 06/26/24 and during an interview she had with Resident 1, s/he no longer wanted the quarter length side rail. The side rail was removed from his/her bed.

The need to ensure the use of a supportive device with potentially restraining qualities included documentation of all required elements and was included in the resident's service plan was discussed with Staff 1 (Administrator) and Staff 2 on 06/26/24 at 5:15 pm. They acknowledged the findings.

1. Rail was removed at the time of finding.

2. Implemented a new assesment for for the RN to use to properly asses the use of devices with potentiall restraining qualities. See assessment form attached.

3.Updated policy.

4. Added assessment to Quarterly Review form to ensure compliance. See attached form.

5.RN is responsible for completing the assessment.

6. Administrator is responsible for assuring compliance.

7. Area will be monitored at 90 days reviews and PRN.  

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to C 270, C 280, C 303, and C 340.

See POC for C 270, C 280, C 303 and C 340