The findings of the re-licensure survey, conducted 01/09/23 through 01/12/23, 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 OARs 411 Division 004 for 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

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 first revisit to the re-licensure survey of 01/12/23, conducted 05/15/23 through 05/16/23, 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 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 reasonable precautions were exercised against any condition that could threaten the health, safety, or welfare of residents for 1 of 1 sampled resident (#1). Resident 1 was sent unaccompanied via public transportation when s/he displayed an onset of neurological symptoms which necessitated immediate medical attention. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 02/2020 with diagnoses including hypertension.

The resident's 09/08/22 through 01/08/23 service plans, temporary service plans, hospital discharge summaries, and progress notes were reviewed, and facility staff were interviewed.

In a progress note dated 10/10/22 at 7:44 pm, facility staff documented the resident displayed the following symptoms "around 1PM":

* "[Signs and symptoms] of confusion and disorientation";

* "Unable to complete sentence";

* "Was unsure of where [s/he] was supposed to be going, or how to explain what [s/he]  was supposed to be doing.";

* "Resident stated [s/he] had numbness in [his/her] hands in the morning"; and

* "Was shaking when assessed by med tech."

Staff documented the resident had a scheduled a physician's appointment at 2:45 pm. The facility had the resident transported unaccompanied via public transportation to the physician's office. The resident was subsequently transported via ambulance, at the request of the physician, to the local hospital and admitted for assessment for "a possible stroke." The resident was released from the hospital on 10/11/22 with diagnoses of a mass in his/her upper lung, transient ischemic attack, and dysphasia.

The facility's failure to provide immediate medical attention when Resident 1 exhibited a sudden change in neurological symptoms placed the resident's health, safety, and welfare at risk.

The documentation related to the events identified above was reviewed with Staff 1 (Executive Director) and Staff 2 (Wellness Director/LPN) on 01/11/23. The failure to exercise reasonable precautions when the resident displayed neurological symptoms which necessitated immediate medical attention was discussed with them at that time. No further documentation was provided.

Plan of correction for tag C 160

1. The resident needs were evaulated by the hospital, upon return needs were evaluated by nursing and a plan of care was updated and implemented based on new care needs. All staff will be trained by 3/13/23 in change in condition and emergency response and transfer.

2. Changes in condition will be assessed timely. Staff will initiate ermegency medical services if conditions needing immediate medical attention.

3. Timely in response to each incident

4. Wellness Director or Executive Director

Based on observation, interview, and record review, it was determined the facility failed to ensure 1 of 1 sampled resident (#1) was treated with dignity and respect. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 02/2020 with diagnoses including hypertension.

Review of the resident's 09/08/22 through 01/08/23 progress notes, the 11/22/22 service plan, and interviews with staff and the resident revealed the following:

During an interview with the resident on 01/09/23, when asked how s/he was doing, the resident replied that s/he wasn't doing very well because staff "won't let me get out of bed."

Instructions to staff reviewed in Resident 1's 11/22/22 service plan stated, "Staff are not to transfer [Resident 1] if [s/he] is unable to hold [his/her] weight up when standing. Staff are to provide care in bed if [Resident 1] is not able to transfer."

In an interview with Staff 13 (CG/MT) on 01/09/23, she confirmed staff were instructed not to get the resident up if s/he was unable to bear weight.

A discussion related to the above was conducted on 01/09/23 with Staff 1 (Executive Director) and Staff 2 (Wellness Director/LPN). They acknowledged the resident's right to be treated with dignity and respect, and to get out of bed if s/he chose.

Plan of correction for tag C 200

1. Resident's care plan was updated to support resident's rights and plan for transfers per resident request.

2. Facility will ensure all resident rights are upheld and a plan is in place for resident's transfer needs and ability to move about the community.

3. Quarterly

4. Executive Director or Wellness Director

Based on interview and record review, it was determined the facility failed to ensure incidents of abuse or suspected abuse were investigated to rule out abuse for 1 of 1 sampled resident (#1) reviewed with incidents. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 02/2022 with diagnoses including hypertension.

Review of incident investigations, dated 10/08/22 through 01/08/23, temporary service plans, and progress notes revealed the following:

In an incident investigation dated 11/18/22, staff documented Resident 1 sustained bruises to his/her left upper arm, "around the whole knee," and bruising to his/her left shin, when his/her scooter "tipped slightly" while s/he was being transported in the facility van 11/17/22.

During an interview, Staff 17 (Van Driver) confirmed that even though he had secured Resident 1's scooter with straps, when he turned a corner the resident's scooter tipped "partially" over. While recounting the incident in the van, Staff 17 demonstrated resident's position after the incident and stated s/he was "kind of hanging."

The facility investigation indicated abuse was ruled out as the resident was "tilted too far over in [his/her] chair."

There was no documented evidence the facility immediately investigated whether or not Resident 1's scooter had been secured properly in the van or if the resident had sustained any injuries as a result of "partially" tipping over. The investigation failed to include the response of staff at the time of the event and follow-up actions.  

On 11/18/22 the resident was transported to the emergency department "due to not being able to put pressure on the left leg. Resident was complaining of pain from [his/her] knee to [his/her] hip." Review of the after-visit summary from the emergency department indicated the  resident was diagnosed with a fall and traumatic ecchymosis (bruise) of the left lower leg.

The need to ensure all incidents of abuse or suspected abuse were immediately investigated to rule out abuse and document follow-up actions related to the event was discussed with Staff 1 (Executive Director) and Staff 2 (Wellness Director/LPN) on 01/10/23 and 01/11/23. They acknowledged the lack of documentation related to the incident.

Plan of correction for tag C231

1. Resident was sent to ER for evaluation upon discovery of injury. Incident was reviewed and documented on. Van driver was trained and properly demonstrated securing residents in vehicle on 11/18, including appropriate wheelchairs that can be secured in the van. Training will be conducted 2/22 with ED/WD regarding timely assessment, investigation and documentation of incidents.

2. All incident will be timely investigated and reviewed, including documentation of incident and implementation of updated careplan and interventions. Suspected abuse / neglect will be reporting approrpaitely per Abuse and Neglect Reporting Guidelines.

3. As incidents occur and prior to deadline for reporting suspecte abuse.

4. Executive Director or Wellness Director

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of resident care needs and provided clear direction to staff for 1 of 4 sampled residents (#1). Findings include, but are not limited to:

Resident 1 was admitted to the facility in 02/2020 with diagnoses including essential hypertension.

Review of the resident's 11/21/22 service plan and outside provider notes, observations of the resident, and interviews with staff revealed the following:

* The service plan instructed staff to "provide escort in manual WC [wheelchair] to all meals and activities." A wheelchair was not observed in the resident's room during an interview with him/her on 01/09/23. Staff 13 (CG/MT) stated the resident did not have a manual wheelchair.

* Review of hospice provider notes from 11/22/22 through 01/09/23 revealed hospice provided a bath aide for the resident. There was no indication of this on the service plan.

* The service plan indicated the resident had a hospital bed and urinary catheter. The service plan lacked direction to staff related to the hospital bed and care of the catheter.

The need to ensure the service plan was reflective of the resident's current care needs and provided clear direction to staff regarding the delivery of services was discussed with Staff 1 (Executive Director) and Staff 2 (Wellness Director/LPN) on 01/11/22 and 01/12/22. They acknowledged the deficiencies in the service plan.

Plan of correction for tag C 260

1. Resident #1 care plan was updated in all of cited areas listed. RN consultant is auditing current care plans to ensure that they reflect current care needs.

2. Consultant is providing training on how to ensure accurate service plans that reflect all resident needs. Consultant has provided service plan checklist for nursing to utilize to capture all care needs. All service plans will be reviewed by ED, WD and RN upon admission, at the 30 days, quarterly and with any significant change of condition.

3. Resident admission, 30 day review, quarterly and significant change in condition.

4. Executive Director, Wellness Director

Based on interview and record review, it was determined the facility failed to ensure significant changes of condition were evaluated and referred to the RN, and short-term changes had actions and interventions determined, documented, communicated to staff on all shifts, made part of the resident record, and with weekly progress noted through resolution for 1 of 1 sampled resident (#1). Findings include, but are not limited to:

Resident 1 was admitted to the facility in 02/2022 with diagnoses including hypertension.

Review of the resident's facility records identified the following:

a. In a progress note dated 10/10/22, facility staff documented the resident experienced increased confusion, language difficulties, and numbness in his/her hands. This constituted a significant change of condition as it was a major deviation in the resident's health.

There was no documented evidence the facility evaluated the resident and referred him/her to the RN.

Refer to C160.

b. An 11/18/22 incident investigation stated the resident's scooter partially tipped over in the facility van on 11/17/22, and the resident sustained bruises on his/her left upper arm, knee, and shin.

An 11/18/22 progress note indicated Resident 1 was transported to the emergency department "due to not being able to apply pressure on the left leg. Resident was complaining of pain from [his/her] knee to [his/her] hip." Review of the after-visit summary from the emergency department indicated the resident was diagnosed with a fall and traumatic ecchymosis (bruise) of the left lower leg.

There was no documented evidence the facility evaluated the resident after the incident, developed actions and interventions related to the resident's care, communicated them to staff on all shifts, updated the service plan, and monitored the bruises at least weekly to resolution.

c. A 12/30/22 incident investigation indicated Resident 1 had a documented fall from bed on that day, hit his/her head, and sustained a bruise on his/her right forearm. Latent bruising on the resident's right shoulder and arm was documented by the hospice nurse on 01/03/23.

There was no documented evidence the facility determined and documented what actions and interventions were needed for the resident after s/he sustained the injuries, and communicated them to staff on all shifts.

The need to ensure significant changes of condition were evaluated and referred to the RN, and short-term changes had actions and interventions determined, documented, communicated to staff on all shifts, made part of the resident record, and with weekly progress noted through resolution was discussed with Staff 1 (Executive Director) and Staff 2 (Wellness Director/LPN) on 01/10/23 and 01/11/32. They acknowledged the lack of documentation related to Resident 1's medical condition.

Plan of correction for tag C270

1. Resident #1 was sent to hospital and assessed for change in condition after incident. Resident has currently been assessed and actions and interventions have been determined, documented, and communicated to staff on all shifts, made part of the resident record, and will be weekly assessed with progress note until deemed stable/resolved or updated actions/interventions and documentation are required. Training was provided by March 3, 2023 regarding change in condition moniroting and seeking emergency response.

2. Changes in condition will be assessed timely. Changes identified as signficant as outlined in OARs, will be notied to RN for assessment. Documentation will be timely.

3. Timely as changes occur.

4. Executive Director, Wellness Director and RN as applicable

2. Resident 1, admitted to the facility in 02/2020, was identified during the acuity interview to be receiving hospice services.

Review of the resident's 11/23/22 service plan, 11/23/22 through 01/08/23 temporary service plans, progress notes, hospice visit summaries, and the 12/01/22 through 01/08/22 MAR revealed there was no documented evidence the facility implemented the following recommendations or updated the service plan as applicable:

* 12/1/22: "Apply cool wet washcloth to left knee for comfort";

* 12/2/22: "Recommend offering pain medications and administer prior to any ADL cares to maintain comfort ...and improve participation in ADL cares";

* 12/7/22: Resident reported "pain in shoulders and heel ... displays signs of pain when moving right leg ... Premedicate with PRN pain meds prior to repositioning/brief changes if indicated. Continue to use cold wash cloth on knee for pain";

* 12/11/22: "Give PRN Miralax today";

* 12/18/22: "Give PRN Miralax today";

* 12/19/22: "Apply cream to bilateral LE's [lower extremities] BID ... Continue to monitor superficial open area to gluteal cleft. ... Monitor to ensure catheter is secured to thigh";

* 12/23/22: "Encourage fluids";

* 12/28/22: "Encourage fluids"; and

* 01/03/23: "Monitor discoloration to R [right] shoulder and arm. Notify hospice of increased pain."

The hospice provider visit notes were reviewed with Staff 1 (Executive Director) and Staff 2 (Wellness Director/LPN) on 01/11/23. They acknowledged the deficiencies identified above.

Based on interview and record review, it was determined the facility failed to coordinate on-site health services with outside service providers, by failure to incorporate recommended interventions into the service plan for 3 of 3 sampled residents (#s 1, 4, and 5) who received outside services. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 12/2021, with diagnoses of heart disease, osteoporosis, and lumbar fracture.

Resident 4's service plan, dated 12/01/22, temporary service plans (TSPs), progress notes, and outside provider notes, dated 10/11/22 through 01/09/23, were reviewed.

The records indicated Resident 4 had received outside services for Occupational Therapy (OT), Physical Therapy (PT), and Home Health Nursing. The outside provider notes included the following recommendations:

* 01/06/23: "Assist in HEP [home exercise program] with yellow theraband";

* 12/26/22: "Please encourage [him/her] to get into [his/her] wheel chair for seated exercises";

* 12/21/22: "Use antipressure booties to float heels while in bed"; and

* 12/21/22: "Please assist with exercises, and stabilize feet at ankles and knees during bridging. Also help [him/her] scooting to HOB [head of bed] with BLE [bilateral lower extremities] bent, and [s/he] assists by 'walking' self up."

There was no documented evidence any of these outside provider recommendations were addressed in TSPs or incorporated into Resident 4's service plan.

In an interview on 01/12/23, Staff 1 (Executive Director) acknowledged the lack of continuity of care regarding provider recommendations. Staff 1 stated, "Yes, we are aware of the problem with the system and are working on it."

On 01/12/23 the need to add recommended interventions to the resident's service plan was discussed with Staff 1 (Executive Director), Staff 2 (Wellness Director/LPN), and Staff 3 (RN). They acknowledged the failure to include outside provider recommendations in the resident's service plan.

3. Resident 5 was admitted to the facility in 10/2019 with diagnoses including history of cerebral infarction.

The resident's record, including the current service plan and temporary service plans (TSPs), progress notes, and outside provider notes dated 10/03/22 through 01/09/23, were reviewed, and the resident and staff were interviewed. The following was identified:

* The resident experienced a stroke on 10/03/22 and was admitted to the hospital, after which s/he was sent to a rehab facility. The resident returned to the facility from rehab on 11/04/22.

* Home health services, including PT and speech therapy, began in 11/2022.

* Between 11/09/22 and 01/02/23 there were 14 home health visits.

* On nine of the 14 home health visits, the PT or speech therapist made recommendations related to resident care. There was no documented evidence the recommendations were communicated to staff or implemented.

On 01/11/23, Staff 1 (Executive Director) and Staff 2 (Wellness Director/LPN) explained they used TSPs to communicate and implement outside provider recommendations. In interviews on 01/12/23, Staff 1 and Staff 2 both reported they were unable to locate any TSPs which corresponded with the recommendations made by home health on the nine occasions noted above.

The need to follow through on recommendations made by outside providers was discussed with Staff 1 and Staff 2 on 01/11/23 and 01/12/23. They acknowledged they had not followed-up on PT and speech therapy recommendations. No further information was provided.

Plan of correction for tag C 290

1. All outside provider current recommendations will be added to resident care plans.

2. Outside service forms will be reviewed timely for changes to plan of care. Temporary service plans and training will be implemented as needed per outside service recommendation.

3. Third party notes will be reviewed on working days. Careplans will be updated with permanent changes at the 30 days, 90 day and for change in condition.

4. Executive Director, Wellness Director

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

During the re-licensure survey, conducted 01/09/23 through 01/12/23, the medication system was found to be ineffective in the following areas:

1. Multiple instances were identified where 2 of 4 sampled residents (#s 4 and 5) did not receive prescribed medications for up to eight days because the facility was waiting for the pharmacy to deliver the medication.

2. Administrative oversight of the medication administration system was found to be ineffective based on deficiencies identified in the following areas:

* C302 Systems: Tracking Control Substances;

* C303 Systems: Treatment Orders; and

* C310 Systems: Medication Administration.

The need to ensure a safe medication system and to ensure adequate professional oversight was discussed with Staff 1 (Executive Director) and Staff 2 (Wellness Director/LPN) on 01/10/23. They acknowledged the lack of a safe medication system and professional oversight.

Plan of correction for tag C 300

1. Resident #4 and 5 MARS were reviewed for accuracy and to ensure all medications were available and accessible to be given as ordered. Community is receiving medications via on-demand process to ensure medications are available for administration.

2. Missed medication report reviewed  by med techs prior to completing shift. Routine audits for 7 day supply will be conducted twice weekly. All med orders will be reviewed through three check system, which includes checking availability or investigating barriers to availability. All follow up with be documented.

3. Weekly and quarterly.

4. Executive Director, Wellness Director, Resident services director

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 2 sampled residents (#1) whose MARs and Controlled Substance Disposition logs were reviewed. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 02/2022 with diagnoses including hypertension.

Review of Resident 1's 01/01/23 through 01/09/23 Controlled Substance Disposition logs and MARS, revealed seven doses of morphine sulfate solution were initialed as given on the MAR, but were not reflected on the disposition log.

The MAR and Controlled Substance Disposition Logs were reviewed with Staff 1 (Executive Director) and Staff 2 (Wellness Director/LPN) on 01/12/23. They acknowledged the discrepancies between the two documents. The need to ensure an accurate narcotic disposition log was maintained for all controlled substances was discussed at that time. Staff 1 and Staff 2 acknowledged the findings.

Plan of correction for tag C 302

1. Documentation will be reviewed for accuracy in both the MAR and the controlled substance log. On the spot immediate training was provided to med techs on how to accurately dispense controlled substances. Medtech meeting completed 1/25.

2. Monthly med tech meeting completed on 1/25 and appropriate administration of controlled substances reviewed. Elderwise consultant will provide controlled substance audit. Routine audit of narc book to MAR for accuracy. All discrepancies will be reported to WD per protocol.

3. Quarterly and and as needed

4. Wellness Director, RSD

2. Resident 1 was admitted to the facility in 02/2020 with diagnoses including hypertension.

Review of the resident's 12/02/22 physician orders, the facility's bowel tracking log, and the 12/02/22 through 01/08/23 MARs revealed the following:

* Cavilon barrier cream (for skin breakdown) and fluticasone nasal spray were ordered to be administered daily, but listed as PRN on the MAR. The medications were not administered to the resident during the time frame reviewed.

* There was no documented evidence of a physician order in the resident's facility record for PRN Milk of Magnesia (for constipation), which was administered on 12/24/22 and 01/04/23.

* Physician orders for PRN bowel medications for constipation indicated staff were to administer Miralax on day two without a bowel movement, Senna on day three without a bowel movement, and a bisacodyl suppository on day four.

Documentation on the MAR indicated the medications were not administered to the resident in the time frame ordered by the physician on multiple occasions.

The MAR and physician orders were reviewed with Staff 1 and Staff 2. They acknowledged the discrepancies documented above. The need to ensure there were signed physician orders in the resident's facility record for all medications the facility was responsible to administer and orders were carried out as prescribed was discussed with and acknowledged by Staff 1 (Executive Director) and Staff 2 (Wellness Director/LPN) on 01/11/23.

3.  Resident 4 was admitted to the facility in 12/2021 with diagnoses of heart disease, osteoporosis, and lumbar fracture.  

Review of Resident 4's MAR, dated 12/01/22 through 01/09/23, and physician orders, dated 12/05/22, identified the following deficiencies:

The following scheduled medications had missed doses on the dates shown, with the reason listed as "awaiting delivery":

* Senna-Time 8.6 mg (for constipation): 12/06/22, 12/07/22, 01/06/23, 01/07/23, 01/08/23;

* Carvedilol 3.125 mg (for heart health): 12/07/22, 12/08/22, 12/09/22, 12/10/22, 01/08/23;

* Oyster Shell Calcium 500 mg (supplement): 12/07/22, 12/08/22, 12/09/22, 12/10/22, 01/08/23;

* Acetaminophen 325 mg (for arthritis): 12/10/22;

* Modafinil 100 mg (for sleep apnea): 12/12/22;

* Clopidogrel 75 mg (for chest pain): 12/14/22, 12/15/22; and

* Atorvastatin 10 mg (for high cholesterol): 01/08/23.

While the facility was awaiting delivery of these medications, the resident was not receiving them, which constituted failure to follow physician orders.

On 01/12/23 the need to ensure all written orders were carried out as prescribed was discussed with Staff 1 (Executive Director), Staff 2 (Wellness Director/LPN) and Staff 3 (RN). They acknowledged the findings, and Staff 2 stated the facility was working to improve the medication systems.

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

1. Resident 5 was admitted to the facility in 10/2019 with diagnoses including diabetes.

Review of the resident's 12/01/22 through 01/09/23 MARs and physician orders revealed the following deficiencies:

a. The resident missed doses of the following scheduled medication on the dates listed, with the reason given as "awaiting delivery":

* Amlodipine Besylate 10 mg (for hypertension): 12/05/22, 12/06/22;

* Atorvastatin 40 mg (for cholesterol): 12/10/22, 12/11/22, 12/12/22, 12/13/22, 12/14/22, 12/15/22, 12/17/22;

* Glipizide 5 mg (for diabetes): 01/04/23, 01/05/23, 01/06/23, 01/07/23; and

* Lisinopril 10 mg (for hypertension): 12/05/22, 12/06/22.

While the facility was awaiting delivery of these medications, the resident was not receiving them, which constituted failure to follow physician orders.

b. The resident had the following orders for Lisinopril (for blood pressure):

* 12/06/22 5 mg once a day;

* 12/08/22 10 mg once a day; and

* 12/13/22 10 mg once a day.

From 12/08/22 through 01/09/23 the resident was administered 5 mg per day of Lisinopril.

In an interview with Staff 2 (Wellness Director/LPN) on 01/10/23, she verified there were discrepancies between physician orders for Lisinopril and what was administered to the resident.

The need to carry out physician orders as prescribed was discussed with Staff 1 (Executive Director) and Staff 2 on 01/10/23. They acknowledged the findings, and both reported they had begun to make changes to the medication administration system.

Plan of correction for tab C 303

1. Resident 1,4 and 5's eMAR's were reviewed for accuracy, current physician orders were obtained for all medications, clarification or discontinuation of orders were obtained and all medications are on site. Facility inplement new ordering system for timely delivery of medications.

2. Missed medication report will be reviewed each shift by med staff and supply availablility reviewed twice a week. Routine audit of MARS for holes and exceptions.

3. Weekly and quarterly.

4. WD and RSD

2. Resident 1 was admitted to the facility in 02/2020 with diagnoses including hypertension.

Review of the 12/01/22 through 01/08/22 MARs and current physician orders revealed the following:

* Quetiapine, Lisinopril, fluticasone lacked reasons for use;

* PRN Senexon (for constipation), discontinued on 12/28/22 by the physician, was still listed on the MAR as of 01/09/23; and

* Multiple bowel medications identified on the MAR to be administered for constipation lacked clear parameters and instructions to staff related to the sequence in which to administer the medications.

The MAR was reviewed with Staff 1 (Executive Director) and Staff 2 (Wellness Director/LPN) on 01/11/23. They acknowledged the deficiencies referred to above. The need to ensure the MAR was accurate and included resident-specific parameters and instructions for PRN medications was discussed with and acknowledged by Staff 1 and Staff 2.  

3. Resident 5 was admitted to the facility in 10/2019 with diagnoses including hypertension and diabetes.

Review of the resident's 12/01/22 through 01/09/23 MARs and physician orders revealed the following:

* On the 12/2022 MAR, two medications lacked reasons for use:

- Preservision AREDs; and

- Warfarin.

* The 12/2022 MAR indicated Atorvastatin had been initialed as administered on 12/16/22, but marked as "awaiting delivery" 12/10/22 through 12/15/22 and on 12/17/22.

* Calmoseptine ointment was ordered to be administered twice daily; the 8:00 pm administration on 12/05/22 was left blank.

* On the 01/01/23 through 01/09/23 MAR Glipizide had been initialed as administered on five occasions between 01/04/23 and 01/07/23 and marked as "awaiting delivery" on three occasions.

* Also on the 01/01/23 through 01/09/23 MAR, three medications lacked reason for use:

- Glipizide;

- Preservision AREDS; and

- Warfarin.

The need to ensure the MAR was accurate was discussed with Staff 1 (Executive Director) and Staff 2 (Wellness Director/LPN) on 01/10/23. They acknowledged the findings and stated they had provided training to MTs about documenting accurately on the MAR and planned to continue the training.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate for 3 of 4 sampled residents (#s 1, 2, and 5) whose MARs and physicians orders were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 09/2022 with diagnoses including chronic viral Hepatitis C and prostate cancer. A review of Resident 2's 12/01/22 through 01/09/23 MAR identified the following medications lacked a reason for use:

* Bupreno-Nalox 2-0.5 mg sl tab;

* Insulin glargine-yfgn U100 pen;

* Loratadine 10 mg tablet;

* Polyethylene glycol 3350 powder;

* Sebex shampoo;

* Simvastatin 20 mg tablet;

* Spironolactone 25 mg tablet;

* Tamsulosin hcl 0.4 mg capsule;

* Venlafaxine hcl 75 mg tablet;

* Wixela 100-50 Inhub; and

* Xtandi 40 mg capsule.

The need to ensure MARs included a reason for use for all medications was discussed with Staff 4 (Regional RN) on 01/09/23 and with Staff 1 (Executive Director), Staff 2 (Wellness Director/LPN), and Staff 3 (RN) on 01/12/23. They acknowledged the deficiencies on the MAR.

Plan of correction for tag C 310

1. Resident's 1,2 & 5 MARS were updated to reflect indications for use. Parameters were written for all PRN medications. Clear parameters and instructions were written related to the sequence in which to administer medications when there are multiple medications with same diagnoses

2. Third checks are performed on each medication order to ensure med process is complete, including PRN parameters and indication for use. Routine clinical meetings are held to verify third check process.

3. Quarterly MAR audits. WD will pull PRN parameter audit weekly.

4. Executive Director, Wellness Director, RN as applicable

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 long-term staff (#s 11, 13, and 15) completed the required minimum 12 hours of in-service training annually. Findings include, but are not limited to:

Staff training records were reviewed on 01/10/23.

There was no documented evidence Staff 11 (MT), Staff 13 (CG/MT), or Staff 15 (CG), hired 03/16/12, 09/22/17, and 03/12/18, respectively, had completed a minimum 12 hours of annual in-service training related to the provision of care, at least six of which needed to be related to dementia care.

The need to ensure all required in-service training hours were completed annually was reviewed with Staff 1 (Executive Director) and Staff 2 (Wellness Director/LPN) on 01/10/23. They acknowledged the lack of annual training hours for long-term staff.

Plan of correction for tag C 374

1. Full training audit completed and training completion in process. All staff training completed 1/25 which included 1.5 hours dementia training.

2. Employee training assigments will be scheduled upon hire and routinely audited for completion.  

3. Quarterly and annually.  

4. Executive Director, Wellness Director and RSD