The findings of the relicensure survey, conducted 12/06/21 through 12/08/21, 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

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 first re-visit to the re-licensure survey of 12/08/21, conducted 03/01/22 through 03/02/22, 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

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 second re-visit to the re-licensure survey of 12/08/21, conducted 04/27/22, 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 third re-visit to the re-licensure survey on 12/08/21, conducted  06/15/22, 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.

Based on observation and interview, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents. Findings include, but are not limited to:

Oregon Department of Human Services infection control guidelines, which were established to protect the facility staff and residents from the spread of COVID-19 and made available to all facilities, were reviewed during the survey. An Executive Letter dated 03/16/20 defines "screening" as "the evaluation by facility staff of every individual entering the facility consistent with the screening criteria." The following deficiencies were identified:

Upon the survey team's arrival on 12/06/21 at 10:00 am, the facility was having visitors take and record their own temperature, self-screen for COVID-19 symptoms and fill out a screening form themselves at the main entrance to the building. No facility staff person reviewed the documentation or screened visitors for COVID-19 symptoms.

A surveyor met with Staff 1 (Administrator) on 12/06/21 at 1:00 pm and reviewed the required guidance provided by the Oregon Health Authority regarding the need for facility staff to screen visitors and care staff upon entrance to the facility. Staff 1 acknowledged the findings.

On 12/07/21 at 3:00 pm, a visitor was observed entering the unit through the north entrance. She asked if she needed to "sign the form." Two unit staff both told her she did. However, the visitor only signed the visitor log - she did not take her temperature or complete the self-screening form. No facility staff screened her for COVID-19 symptoms or reviewed her documentation.

On 12/08/21, three surveyors entered the building through the north entrance between 8:00 am and 8:45 am. Again, no facility staff was present to screen the surveyors for COVID-19 symptoms.

The need to ensure the facility was screening all visitors and staff upon entering the building was reviewed on 12/08/21 with Staff 2 (ED) and Staff 6 (Executive Manager). They acknowledged the need to revise the facility's screening process and shared the steps they had already begun to take to address the issues.

Staff are now assigned to the check-in table to screen all incoming staff and visitors.

Upon Screening, visitors allowed into the building will wear a sticker designating they have completed the screening / approval process.

When the table is not staffed, entry doors will be locked requiring on-duty staff to answer door and complete the screening process.

This will be monitored daily during business days by the Administrator.

This correction wil be made on or before 02/06/21.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:

The building consisted of independent living apartments and the assisted living (AL) unit. Food was prepared in a main kitchen and then transported to the assisted living unit kitchen to be served. AL residents dined on the unit.

The kitchens were toured on 12/06/21 at 10:30 am. The following areas in the main kitchen needed cleaning or repair:

* There was dust on the top of the commercial ice machine and the ice scoop was left on the top of the ice machine rather than in a scoop holder;

* The wooden wall cabinets behind the tray line had areas where paint was chipped or worn, exposing bare wood;

* The wall on the right side of the warewashing counter had black mold and food splatter;

* There was black mold beginning to grow along the grout line of the warewashing counter;

* There was accumulated grease in the grease gutter of the stove hood;

* A wire wall shelf above the three-compartment sink in the warewashing area was covered in brown, rusty debris;

* The wall and paper towel dispenser above the three-compartment sink were covered with greasy build-up;

* The backsplash and the wooden wall cabinet next to the bread oven had food splatter;

* The red Kitchen Aid stand mixer and the large commercial stand mixer had dried debris on the underside of the motor housing and on the arms where the mixing bowl rested;

* The wood floor of the walk-in freezer was worn, exposing bare wood, which was an uncleanable surface;

* The door to the walk-in refrigerator above and below the handle was grimy;

* Fan grates in the walk-in refrigerator were covered with lint/dust and there was a rolling cart with several trays of uncovered slices of cake and pie;

* Two large ceiling exhausts had lint/dust on the vents;

* The entry and exit doors and frames had damaged paint; and

* The temperature gauges on the warewashing machines were not operating.

The following areas in the AL unit kitchen needed repair:

* Laminate was missing or detached along part of the rear cabinet countertop and along the counter above the steam table.

The areas needing cleaning or repair were reviewed with Staff 7 (Food Services Director) and Staff 16 (Cook) on 12/06/21. They acknowledged the findings.

oFacility will clean and sanitize kitchen appliances, grease trays and paint walls and ceiling with washable paint. Shelving to be replaced with stainless steel surfaces to ensure cleanable surfaces. Overhead cabinets to be sanded and painted, exterior door jambs to be painted to allow washable surface. Food service manager will assure continued compliance with food service staff providing ongoing cleanliness of kitchen sanitation. Maintenance director will ensure compliance corrections to be completed in a timely manner on or before Feb 6th, 2022.

Based on interview and record review, it was determined the facility failed to ensure the move-in evaluation addressed all required elements for 1 of 1 sampled resident (#1) who was recently admitted to the facility. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 11/2021. The move-in evaluation, dated 10/20/21, failed to address the following required elements:

* Interests, hobbies, social, leisure activities;

* Spiritual, cultural preferences and traditions;

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

* How the resident expresses pain;

* Nutrition habits, fluid preferences, and weight if indicated;

* List of treatments: type, frequency, and level of assistance needed; and

* Environmental factors impacting the resident's behavior, including, but not limited to, noise, lighting, and room temperature.

The need to ensure all required elements were addressed in the move-in evaluation was discussed with Staff 1 (Administrator) and Staff 3 (LPN) on 12/07/21. They acknowledged the findings.

Administrator will, upon completing Oregon Screening Tool during evaluation, complete all sections, not leaving any area blank.

In the absence of the administrator, the LN completing the screening tool will ask all questions and include answers even if answer is "none" or "not applicable."

This process will be audited by the Administrator, using a move in review tool that has been developed as of 12/22/21.  This review tool will be completed in tandem with other admission paperwork, and will be an integral part of the move-in process.

The administrator will be responsible for the completion of this review tool.

Based on interview and record review, it was determined the facility failed to ensure service plans provided clear direction to staff for 1 of 5 sampled residents (#4) whose service plans were reviewed. Findings include but are not limited to:

Resident 4 admitted to the facility in 2019 with diagnoses included hypothyroidism, multiple mental health disorders and an eating disorder.

Review of Resident 4's clinical records indicated the resident had ongoing severe fluctuations in weight and food intake.

Resident 4's current service plan instructed staff to notify the facility RN if the resident displayed "odd eating behaviors" and make a progress note for the RN if the resident had a "big increase in appetite".

There was no documented evidence that clarified Resident 4's baseline appetite for staff to determine if there was an increase in appetite or how the resident might display "odd eating behaviors".

The need to ensure the service plan provided clear direction to staff was discussed with Staff 1 (Administrator) and Staff 3 ( LPN) 12/08/21. They acknowledged the findings.

Resident 4's care plan has been updated to indicate her normal pattern of eating, and to clearly define what "odd eating behaviors" the caregivers should be monitoring for and reporting up the chain of command.

I top-down review will be conducted by 02/06/21 of all current service plans to ensure compliance.

During quarterly service plan reviews, the LN and the Administrator will collaborate and audit said service plans to ensure continued compliance.

Care plan update is completed by LPN and reviewed by Administrator and RN.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents needs and failed to provide clear instructions regarding the delivery of services for 2 of 3 sampled residents (#s 2 and 9). Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 04/2019 with diagnoses including congestive heart failure.

Observations and interviews with staff and the resident were conducted during the survey. The current service plan dated 01/14/22 and temporary service plans from 02/06/22 through 03/01/22 were reviewed.

The service plan was not reflective and did not provide clear instructions in the following areas:

* Side rails on bed;

* CPAP machine;

* Evacuation plan from the second floor;

* Right leg brace;

* Compression stockings; and

* Edema.

The need to ensure service plans were reflective and provided clear instruction was discussed with Staff 18 (Interim Administrator), Staff 3 (LPN) and Staff 4 (RCC) on 03/02/22. They acknowledged the findings.

2. Resident 9 was admitted to the facility in 07/2020 with diagnoses including osteoarthritis.

Observations and interviews with staff and the resident were conducted during the survey. The current service plan dated 01/22/22 and temporary service plans from 02/06/22 through 03/01/22 were reviewed.

The service plan was not reflective and did not provide clear instructions in the following areas:

* Safe transfers;

* Bed mobility;

* Continence;

* Skin injuries; and

* History of falls.

The need to ensure service plans were reflective of the resident's current status and provided clear instructions to staff was discussed with Staff 18 (Interim Administrator), Staff 3 (LPN) and Staff 4 (RCC) on 03/02/22.  They acknowledged the findings.

Residents' assessment and service plan have been reviewed and updated to indicate current care needs (which includes DME).

During EHR conversion (currently in progress) all service plans/assessments are being reviewed for accuracy.

Service plans will be reviewed at 30 days, quarterly, and with any significant change of condition.

Service plan update is completed by LPN and reviewed by Administrator and RN.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective, updated and provided clear instruction to staff for the provision of care for 2 of 4 sampled residents (#s 12 and 13) whose facility records were reviewed.  This is a repeat citation.  Findings include, but are not limited to:

1. Resident 12 was admitted to the facility in 03/2022 with diagnoses including venous insufficiency.

Review of the 03/15/22 service plan and interviews with staff and the resident revealed the following:

During the acuity interview, Resident 12 was identified to have a stasis ulcer for which s/he received home health RN services.

Resident 12 stated during an interview on 04/27/22 that s/he had a wound on his/her right shin. A dressing was observed through the resident's sock.

Review of the 03/15/22 service plan revealed it was not updated to reflect the development of the wound, failed to provide clear direction to staff related to care of the wound, and did not identify that the resident was receiving home health services related to the wound.

The need to ensure service plans were updated as needed, reflective of the resident's status and care needs, and provided clear direction to staff was discussed with Staff 18 (Administrator), Staff 3 (LPN) and Staff 4 (RCC). They acknowledged the findings.

2. Resident 13 was admitted to the facility in 03/2022 with diagnoses including left hip osteoarthritis.

Resident 13 was identified during the acuity interview to have a pressure ulcer on his/her left hip.

Review of the resident's 04/26/22 service plan revealed it was not updated to reflect the development of the wound and failed to provide clear direction to staff for the care of the resident related to the wound.

The need to ensure service plans were updated as needed, reflective of the residents' status and care needs, and provided clear direction to staff was discussed with Staff 18 (Administrator), Staff 3 (LPN) and Staff 4 (RCC). They acknowledged the findings.

Med aids/RCC/Administrator/LPN will ensure all wounds have a temproray care plan, upon being notified of wound, and placed on alert charting.

Then LPN/RN will do assesment for what further action is required.

Upon notifications of any wounds

Determined by LPN/RN

LPN/RN

2. Resident 3 was admitted to the facility in 02/2020 with diagnoses including osteoarthritis, transient ischemic attack, diverticulitis and knee pain.

Over the past three months, the resident had been hospitalized for COVID-19 symptoms, had a decline in physical and cognitive functioning, experienced repeated falls, and had been admitted to hospice services.

Progress notes, "Event Reports," service plans, Temporary Care Plans, the resident's weight record and the alert charting log were reviewed during the survey. The following deficiencies were identified:

a. Resident 3 was found on the floor on 11/15/21 and 11/20/21, reporting s/he had fallen off the couch while reaching for something and had "just sat on the floor," respectively.

The facility failed to determine and document what actions or interventions were needed for the resident following these changes of condition.

b. Resident 3 triggered for a significant weight loss over the past three and six month periods on 11/15/21 as follows:

* Between 8/15/21 and 11/15/21, Resident 3 lost 14.9 pounds or 8.75% body weight; and

* Between 5/15/21 and 11/15/21, Resident 3 lost 17.7 pounds or 10.23% body weight.

This represented a significant change of condition.

The facility failed to evaluate the resident, refer to the facility RN, document the change of condition and update the service plan as needed.

In an interview on 12/07/21, Staff 14 (CG) reported the resident ate independently, continued to have a good appetite and consumed almost 100% of all his/her meals. The surveyor confirmed with staff following each meal during the survey that the resident had eaten his/her meal. In an interview on 12/07/21, Resident 3 stated s/he liked the meals served by the facility, got enough food to eat and "didn't have any issues with the food."

The need to ensure the facility determined and documented what was needed in response to a short term change of condition, and followed-up appropriately in response to a significant change of condition was reviewed with Staff 1 (Administrator) and Staff 3 (LPN) on 12/7/21. They acknowledged the facility failed to document what staff should do following Resident 3's falls and Staff 3 acknowledged she did not have an adequate process for reviewing weight data and referring to the facility RN for further assessment as needed.

4. Resident 5 was admitted to the facility in June 2020 with diagnoses including a history of myocardial infarction.

During the acuity interview, Resident 5 was identified to have had multiple changes of condition which included two hospitalizations and involvement in a motor vehicle accident. It was reported that s/he had experienced a decline in her functional status.

The resident's 09/06/21 through 12/06/21 progress notes, incident reports, hospital discharge summaries, current service plan and temporary service plans, physician orders and MARs were reviewed. Facility staff and the resident were interviewed.

Review of the above revealed the following:

a. On 10/03/21, the resident's daughter called the facility to inform them Resident 5 had been a passenger in a motor vehicle accident. Staff indicated that the resident complained of pain "on the right side of [his/her] ribs" and indicated the resident had declined to go to the emergency department following the accident.

Resident 5 was hospitalized 10/24/21 through 10/26/21 with acute hypoxemic respiratory failure and 11/11/21 through 11/13/21 with acute exacerbation of pulmonary fibrosis.  

Resident 5 visited the emergency department of a local hospital on 11/30/21 related to hip and knee pain.

During interviews with Staff 11 (Medication Aide) and Staff 14 (CG) on 12/06/21, they reported the resident had been independent with her ADLs and mobility prior to the accident and hospitalizations, but now needed assistance with toileting and mobility from the bathroom. Staff 1 (Administrator) reported on 12/06/21 that the resident also required assistance for bed mobility.

During an interview on 12/06/21, Resident 5 reported s/he had right-sided rib pain following the accident. The resident indicated s/he was independent with ADLs and mobility prior to the accident, but now required assistance with clothing management and mobility following toileting and intermittent assistance to dress. The resident indicated s/he slept in his/her recliner secondary to discomfort and required assistance to sit up from lying down.

There was no documented evidence the facility evaluated the resident following the motor vehicle accident or the hospitalizations, referred the resident to the facility nurse, updated the service plan when the resident experienced significant changes related to pain, ADLs and mobility and monitored the resident consistent with his/her evaluated needs.

b. A progress note dated 09/23/21 indicated the resident had been erroneously administered mirtazapine 45 mg (depression) and atorvastatin 80 mg (cholesterol) which were not prescribed for him/her. There was no documented evidence the facility provided specific monitoring instructions to staff following the medication error.

c. A progress note dated 11/28/21 indicated Resident 5 was erroneously administered 15 units of humulog (insulin) at 8 pm instead of the physician ordered 10 units. There was no documented evidence the facility provided specific monitoring instructions to staff following the medication error.

The need to ensure actions and interventions were developed for residents who experience short-term changes of condition, communicated them to staff on all shifts, with updates to the service plan and that residents who experienced a significant change of condition were referred to the RN for assessment and monitored based on their evaluated needs was discussed with Staff 1 (Administrator) and Staff 3 (LPN) on 12/07/21. They acknowledged the findings.

3. Resident 4 admitted to the facility in 2019 with diagnoses including hypothyroidism, multiple mental health disorders, and an eating disorder.

Clinical records and interviews with staff indicated the following:

Resident 4's current service plan included interventions dated 05/12/19 which stated the resident had a diagnosis of an eating disorder and staff were to notify the facility RN if the resident displayed "odd eating behaviors". Interventions added to the service plan on 05/12/21 instructed staff to make a progress note for the RN if the resident had a "big increase" in appetite.

Faxed notifications to the resident's physician dated 05/13/21, 07/14/21, 09/22/21, and 11/10/21 and an RN progress note dated 01/27/21 sated Resident 4 had an ongoing history of displaying extreme food and exercise related behaviors and severe weight fluctuations.

Weight records for 06/01/21 through 12/01/21 indicated Resident 4 experienced the following significant weight fluctuations:

*  06/01/21- 07/01/21: The resident gained 10.2 lbs or an 8.9% increase in total body weight over one month;

*  09/01/21 - 10/01/21: The resident lost 16.4 lbs or a 12.3% loss in total body weight over one month;

*  10/01/21- 11/01/21: The resident gained 15.6 lbs or a 13.13% increase in total body weight over one month; and

*  06/01/21- 12/01/21: The resident gained 15.4 lbs or a 13.4% increase in total body weight over six months.

There was no documented evidence the facility monitored the effectiveness of previous interventions for an ongoing eating disorder and severe weight fluctuations or determined and documented necessary interventions when the resident had significant weight fluctuations 06/01/21 - 12/01/21.

During an interview with Resident 4 on 12/06/21 s/he stated no concerns with the food served by the facility and stated the facility provided alternate options if s/he did not like what was on the menu. Additionally, the facility had a snack bar that was always available. During observations of the lunch meals in the dining room on 12/06/21 and 12/07/21 staff offered the residents a choice of two main dish options. Resident 4 did not require staff assistance with eating meals and ate about 75% of the meals. During observation made throughout the survey the snack bar was noted to be stocked with a variety of packaged snacks, fresh fruit and a variety of beverages

The need to ensure the facility determined, documented and monitored interventions for effectiveness at least weekly through condition resolution when residents experienced changes in condition was discussed with Staff 1 (Administrator) and Staff 3 (LPN) on 12/08/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to identify changes of condition, determine and document what actions or interventions were needed for the resident, communicate these to staff, refer significant changes to the facility RN and monitor the conditions to resolution for 4 of 4 sampled residents (#s 3, 4, 5 and 6) who experienced changes of condition. Findings include, but are not limited to:

1. Resident 6 was admitted to the facility in 08/2019 with diagnoses including chronic obstructive pulmonary disease (COPD), renal failure and depression.

Review of Resident 6's weight record identified a weight loss of 16.2 pounds, or 11.1 % of body weight over a three month period, from 08/15/21 to 11/15/21. This constituted a severe weight loss, and represented a significant change of condition.

On 12/07/21 Staff 3 (LPN) was asked to obtain a current weight for Resident 6, to determine if further weight loss had occurred. Staff 3 attempted to obtain the resident's weight several times, but the resident refused.

In an interview on 12/06/21 Resident 6 stated that the food "was pretty good", and she usually "ate ok".  The resident stated that staff made snacks and extra servings available upon request, and denied having any difficulty eating without assistance.

On 12/06/21 and 12/07/21 Resident 6 was observed eating lunch. In both instances, the resident consumed approximately 50% of the meal, and showed no difficulty with eating.

In an interview on 12/07/21, Staff 11 (CG/MA) stated that Resident 6 "Sometimes only eats a little bit at meals, but will often have an extra drink or snack afterwards". Staff 11 confirmed the resident needed no assistance with eating.

The resident's progress notes, service plan, temporary care plans and alert charting log were reviewed. There was no documented evidence the facility identified the weight loss, referred the change of condition to the facility RN, developed interventions or monitored the condition to resolution.

On 11/08/21 the need to identify changes of condition, determine and document what actions or interventions were needed for the resident, refer significant changes to the RN and monitor the conditions to resolution was discussed with Staff 1 (Administrator) and Staff 3 (LPN). They acknowledged the findings, and Staff 3 confirmed the need to develop an updated system for documentation and management of weight changes.

oWeight changes that indicate a significant gain or loss will be reviewed once per month at a nurses meeting with facility LPNs and the RN.  This review will include discussion of interventions already implemented (and if they are effective), as well as the next intervention to be started to manage the weight change.  

oThe interventions implemented will be documented on a temporary care plan (TCP).  If these interventions are effective, then the TCP will become part of the current care plan.

oThe LPNs and RN will collaborate on intervention implementation but the LPNs will write and disseminate the TCPs to the appropriate care plan books for caregivers to review.

oSome interventions (such as weekly weights or caloric supplements-health shakes) will be documented on the MAR.

oChanges of condition d/t alteration in ADL functioning will be communicated by caregiver up the chain of command.  

oLPN will review reported changes to ADL status and update RN at the weekly nurses meeting.

oChanges in functional ability will generate a TCP providing instruction to caregivers for additional support that the resident requires.

oIf the above interventions are not of short duration, they will be incorporated into the resident's permanent care plan by either the LN or the administrator.

oDeclines in functional ability will be reported to the resident's PCP.

oMedication errors discovered at the time of error will be reported to the LN (either the nurse assigned to the unit, or the on-call nurse if after hours), who will provide verbal instruction to the MA as well as create a written TCP instructing staff in what to observe for during the alert observation period.  

oAfter hours, it will be the MA's responsibility to print out the TCP once the LN has written it, and then place it in the TCP book.

oObservation of adverse effect (or none) to medication error will be documented by the MA on the daily log each shift during the alert monitoring period.

oDaily log will be reviewed each business day morning by admin and LPN.

Based on interview and record review, it was determined the facility failed to ensure residents who had short-term changes of condition were evaluated, had resident-specific instructions or interventions developed and reviewed for effectiveness and the condition was monitored to resolution at least weekly for 2 of 3 sampled residents (#s 8 and 9) who experienced changes of condition. Findings include, but are not limited to:

1. Resident 8 was admitted to the facility in February 2022 with diagnoses including hyperparathyroid and kidney disease.

Review of the resident's physicians orders, 02/06/22 through 03/01/22 progress notes, current service plan, 02/06/22 through 03/01/22 temporary care plans and interviews with staff were completed.

The following medications were ordered on 02/17/22 and administered without monitoring for effectiveness and/or potential adverse effects:

* Melatonin 4 mg at daily at bedtime for insomnia;

* Magnesium Oxide 400 mg daily; and

* B Complex with Folic Acid 0.4 mg daily.

The need to ensure short-term changes of condition had documentation to reflect monitoring to resolution at least weekly was discussed with Staff 18 (Interim Administrator), Staff 3 (LPN) and Staff 4 (RCC) on 03/02/22. They acknowledged the findings.

2. Resident 9 was admitted to the facility in July 2020 with diagnoses including  osteoarthritis and anxiety.

Review of the resident's physicians orders, 02/06/22 through 03/01/22 progress notes, current service plan, 02/06/22 through 03/01/22 temporary care plans, incident and event reports and interviews with staff and resident were completed.

Resident 9 experienced the following changes of condition which lacked evaluation, resident-specific instructions or interventions developed and reviewed for effectiveness and monitoring of the change of conditions to resolution at least weekly:

* 02/05/22 Assisted fall during transfer;

* 02/10/22 Assisted fall during transfer; and

* Increased left should pain which resulted in emergency services transport on 02/10/22 and 02/24/22.

The need to ensure changes of condition were evaluated, resident specific instructions or interventions were developed and reviewed for effectiveness and monitored at least weekly to resolution was discussed with Staff 18 (Interim Administrator), Staff 3 (LPN) and Staff 4 (RCC) on 03/02/22.  They acknowledged the findings.  

Any new medication order will elicit a temporary service plan and the resident will be placed on alert charting. Any resident in an observation period for significant (vs. short-term) change of condition will be charted on by the nurse weekly until such time it is determined that the change is 'significant' and then a new assessment and sig change service plan will be completed by the RN.

At weekly nurse meeting potential changes in condition will be reviewed by the nursing staff. If a potential significant change occurs between weekly meetings, the LPN will notify the RN at the time of discovery.

Evaluation will occur with each new medication order, and at weekly nursing meetings to ensure compliance.

LPNs, RN, and administrator are responsible for compliance and monitoring.

2. Resident 3 was admitted to the facility in 2/2020 with diagnoses including osteoarthritis, transient ischemic attack, diverticulitis and knee pain.

Over the past three months, the resident had been hospitalized for COVID-19 symptoms, had a decline in physical and cognitive functioning and had been admitted to hospice services.

Progress notes, "Event Reports," service plans, Temporary Care Plans, the resident's weight record and the alert charting log were reviewed during the survey. The following deficiencies were identified:

* Between 8/15/21 and 11/15/21, Resident 3 lost 14.9 pounds or 8.75% body weight; and

* Between 5/15/21 and 11/15/21, Resident 3 lost 17.7 pounds or 10.23% body weight.

This weight loss represented a significant change of condition for Resident 3 for which an RN assessment was required.

There was no documented evidence the facility RN conducted an immediate assessment of the weight loss which included documentation of findings, resident status and interventions made as a result of this assessment. The resident's service plan was not updated and there was no evidence current interventions were evaluated for effectiveness or new interventions were developed and implemented.

The need to ensure significant changes of condition were assessed and documented by the facility RN, and changes were made to the resident's service plan based on the findings of the assessment, was reviewed with Staff 1 (Administrator) and Staff 3 (LPN) on 12/7/21. They acknowledged the facility RN had not conducted an assessment of Resident 3's weight loss.

3. Resident 5 was admitted to the facility in June 2020 with diagnoses including a history of myocardial infarction and macular degeneration.

Review of the resident's 09/06/21 through 12/06/21 facility record revealed the following:

* 10/03/21: Resident was involved in a motor vehicle accident followed by right-sided rib pain and decrease in functional abilities;

* 10/23/21-10/26/21: Resident was hospitalized with diagnosis of acute hypoxemic respiratory failure due to COVID-19;

* 11/11/21 - 11/13/21: Resident was hospitalized with diagnosis of acute exacerbation of pulmonary fibrosis and discharged with 2L of oxygen for use with activity; and

* 11/30/21: Resident 5 visited the emergency department of the local hospital related to left hip/knee pain.

The resident's increase in pain and decrease in functional status represented a significant change of condition for Resident 5 for which an RN assessment was required.

There was no documented evidence the RN had completed an assessment based on the resident's condition, documented the findings, resident status, and interventions made as a result of the assessment.

The need to ensure an RN completed an assessment based on the resident's condition was discussed with Staff 1 (Administrator) and Staff 3 (LPN) on 12/06/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure an RN completed a significant change of condition assessment which included findings, resident status and interventions made as a result of the assessment for 4 of 4 sampled residents (#s 3, 4, 5, and 6) who experienced significant changes of condition. Findings include, but are not limited to:

1. Resident 4 admitted to the facility in 2019. The resident's diagnoses included hypothyroidism, multiple mental health disorders and an eating disorder.

The following significant changes in weight were documented in Resident 4's weight records dated 06/01/21 through 12/01/21:

*  06/01/21- 07/01/21: The resident gained 10.2 lbs or an 8.9% increase in total body weight over one month;

*  09/01/21 - 10/01/21: The resident lost 16.4 lbs or a 12.3% loss in total body weight over one month;

*  10/01/21- 11/01/21: The resident gained 15.6 lbs or a 13.13% increase in total body weight over one month; and

*  06/01/21- 12/01/21: The resident gained 15.4 lbs or a 13.4% increase in total body weight over six months.

There was no documented evidence the facility RN completed an assessment or determined necessary interventions when Resident 4 experienced the above significant changes in weight.

The need to ensure an RN completed a thorough assessment when residents experienced significant changes in condition was discussed with Staff 1 (Administrator) and Staff 2 (LPN) on 12/08/21. They acknowledged the findings.

4. Resident 6 was admitted to the facility in 08/2019 with diagnoses including chronic obstructive pulmonary disease (COPD), renal failure and depression.

Review of Resident 6's progress notes, service plan, temporary care plans, weight record and alert charting log identified the following deficiencies:

The resident experienced a weight loss of 16.2 pounds, or 11.1 % of body weight in a three month period, from 08/15/21 to 11/15/21. This constituted a severe weight loss, and represented a significant change of condition.

There was no documented evidence the facility RN performed an immediate assessment of the resident's weight loss, including documentation of findings, resident status, and interventions made as a result of the assessment.

On 12/08/21 the need to ensure an RN assessment was performed for all significant changes of condition, including documentation of findings and changes made to the service plan as a result the assessment was discussed with Staff 1 (Administrator) and Staff 3 (LPN). They acknowledged the facility RN had not performed the required assessment for Resident 6's weight loss.

oWeight changes that indicate a significant gain or loss will be reviewed once per month at a nurses meeting with facility LPNs and the RN.  This review will include discussion of interventions already implemented (and if they are effective), as well as the next intervention to be started to manage the weight change.  

oThe interventions implemented will be documented on a temporary care plan (TCP).  If these interventions are effective, then the TCP will become part of the current care plan.

oThe LPNs and RN will collaborate on intervention implementation but the LPNs will write and disseminate the TCPs to the appropriate care plan books for caregivers to review.

oSome interventions (such as weekly weights or caloric supplements-health shakes) will be documented on the MAR.

oSignificant weight gain or loss will generate a significant change of condition assessment completed by RN after collaboration with LPN.

oHospitalizations where resident is out of facility greater than 24 hours will be reported to RN who will complete an evaluation/assessment and document on a significant change of condition care plan which will be printed and disseminated to staff via care plan book.  As residents are not routinely hospitalized, there is no frequency with which this will occur except at the time of hospital discharge back to facility.   

Based on interview and record review, it was determined the facility failed to ensure residents who experienced a significant change of condition were assessed by the RN in a timely manner for 1 of 2 sampled residents (#13) reviewed with a significant change of condition. Findings include, but are not limited to:

Resident 13 was admitted to the facility in 03/2022, with diagnoses including osteoarthritis of the left hip.

Review of 04/16/22 through 4/27/22 progress notes, skin monitoring sheets, RN assessments, and physician faxes and staff interviews conducted 04/27/22 revealed the following:

* During the acuity interview on 04/27/22, Staff 3 (LPN) indicated Resident 13 had a newly-identified pressure ulcer.

* A 04/18/22 fax to the resident's physician references a 4/15/22 skin monitoring note that stated, "RN agrees with this LPN's [Staff 13] evaluation of an unstageable pressure ulcer to the left hip area."

* In an RN assessment dated 04/27/22, identified as a late entry for an assessment completed 04/22/22, the RN confirmed Resident 13 had a left hip pressure ulcer. The assessment was completed seven days after the LPN identified the wound.

The need to ensure RN assessments were completed in a timely manner when residents experienced significant changes of condition was discussed with Staff 18 (Administrator), Staff 3, and Staff 4 (RCC). They acknowledged the findings.

All resident's, upon move-in, and signficant change of condition, will be completed by RN.  With a significant changes of condition, or with service plan updates, the RN will review, sign and date within 48 hours.

Protcol is updated, and in place, ensuring all updates and reviews are completed within 48 hours.

Assesments and sevice plans are reviewed at 30 days, quaterly and with any significant change of condition.

All assesments and service plans are updated by LN and reviewed and activated by Administrator and RN.

Based on interview and record review, it was determined the facility failed to ensure that written, signed physician orders were documented in the resident's facility record for all medications that the facility was responsible to administer and that orders were carried out as prescribed for 2 of 5 sampled residents (#s 5 and 7). Findings include, but are not limited to:

1. Resident 5 was admitted to the facility in June 2020 with a history of myocardial infarction.

Review of the 11/01/21 through 12/06/21 MAR, 11/13/21 physician orders and 09/06/21 through 12/06/21 progress notes and incident reports revealed the following:

* Resident 5 was administered mirtazapine 45 mg (antidepressant) and atorvastatin 80 mg (cholesterol) for which there was not a signed physician order in the resident's facility record.

* Resident 5 had a signed physician order, dated 11/17/21, which instructed staff to administer 10 units of humulin (insulin) at 8 pm daily. The resident was administered 15 units of humulin on 10/23/21 at 8 pm.

The need to ensure the facility had an order for all medications administered and that physician orders were followed as written was discussed with Staff 1 (Administrator) and Staff 3 (LPN)on 12/07/21. They acknowledged the findings.

2. Resident 2 was admitted to the facility in 04/2019 with diagnoses including diabetes.

A review of the resident's 11/2021 MAR and current physician orders revealed the following:

* The resident had a physician order for Insulin Aspart (for diabetes) on a sliding scale before each meal. The order indicated if his/her CBG was between 301 and 350 staff should administer 30 units of insulin.

* On 11/11/21 staff recorded the resident's CBG at 335 at 5:00 pm, before the dinner meal.

* Documentation on the MAR indicated the resident was administered 22 units of insulin, when 30 units should have been administered.

In an interview with Staff 3 (LPN) on 12/07/21, she reported this was a medication error.

The need for physician orders to be followed as written was discussed with Staff 1 (Administrator) and Staff 3 (LPN) on 12/07/21. They acknowledged the finding.

oAll MAs receive training with an experienced MA prior to being allowed to work without direct supervision of experienced MA.

oAll MAs receive training from the LN, reiterating and expanding on training received with MA trainer.

oAll MAs who complete tasks requiring delegation will have training with the RN regarding the task to be delegated, provide return demonstration of the delegated task and be monitored by OSBN standards of delegation.

oAny medication error is investigated by LN, reported to DHS RN, and then reviewed with med aide for cause of error and how he or she will change his or her behavior to prevent the error from occurring again.

oMed aides who show repetitive errors will be reviewed for retraining and/or appropriateness for the job of medication aide.

Based on interview and record review, it was determined the facility failed to ensure orders were carried out as prescribed for all medications and treatments the facility was responsible to administer, for 1 of 2 sampled resident (# 2) whose orders were reviewed. Findings include, but are not limited to:

Resident 2 admitted to the facility in April 2019 with diagnoses to include diabetes and depression.

Resident 2's MAR and physician orders, reviewed from 02/06/22 - 03/02/22, revealed the following:

* The orders instructed staff to follow a hyperglycemia protocol for CBG's (blood glucose levels) greater than 300. Between 02/01/22 and 02/28/22 Resident 2's CBG's were documented to be above 300 on 20 occasions. There was no documented evidence the protocol instructions were followed.

* Fluoxatine 40 mg was ordered to be administered daily in the morning for depression. The documented administration time of the medication was 05:00 pm daily.   

* Insulin Aspart subcutaneous injections were ordered on a sliding scale three times a day before meals as needed based on Resident 2's blood glucose level. On 02/23/22 at 08:00 am Resident 2's CBG was 251. The order instructed staff to administer 28 units of insulin  for a CBG between 251 and 300. The documentation indicated that 24 units of insulin was administered.  Four units less than what was ordered.

Resident 2's MARs and orders were reviewed with Staff 3 (LPN)  and Staff 18 (Interim Administrator) on 03/02/22. They acknowledged that staff failed to ensure orders were carried out as prescribed.

1. Medication aides reviewed CBGs and then completed the missing documentation and corrected the insulin dose input error. LPN corrected the administration time of fluoxetine.

2. Medication aides were inserviced about reading MAR to ensure appropriate documentation (e.g. CBG and associated sliding scale insulin dose, resident refusals for prn specialty orders). LPN, RN, and/or admin will review all MARs during current EHR conversion to ensure that order and administration time are not in conflict.

3/4. This will be reviewed during monthly MAR audits by LN or RCC.

Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as written for 1 of 4 sampled residents (#12). This is a repeat citation.  Findings include, but are not limited to:

Resident 12 was admitted to the facility in 03/2022 with diagnoses including venous insufficiency and edema.

The 02/15/22 physician order summary and 04/16/22 through 04/27/22 MAR were reviewed.  

The 02/15/22 physician orders instructed the facility to administer furosemide 40 mg (diuretic) to the resident daily.

Review of the 04/16/22 through 04/27/22 MAR revealed the resident had been administered 20 mg of furosemide daily during that time frame.

The need to ensure physician orders were carried out as prescribed was discussed with Staff 18 (Administrator), Staff 3 (LPN), and Staff 4 (RCC) on 04/27/22. They acknowledged the findings.

All move in medication orders will be reviewed, and placed in eMAR, upon receipt of orders by LPN.  Clairfication faxes will be made out at this time and completed orders/clarifications will be given to RN for review

This will give another review to ensure all medications orders are correct.

Upon every move in and any uncertainly of orders by LPN.

LPN and RN

Based on interview and record review, it was determined the facility failed to ensure residents' MARs provided clear instruction and parameters for administration of PRN medications for 2 of 3 sampled residents (#s 8 and 9) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 8 was admitted to the facility in 09/2021 with diagnoses including right radius fracture and chronic kidney disease.

The 02/01/22 through 02/28/22 MAR and physicians orders were reviewed and identified the following PRN pain medications:

* Acetaminophen 650 mg every eight hours as needed for pain or fever greater than 100 degrees F; and

* Hydrocodone-APAP 5-325 mg, one tablet every six hours as needed for pain.

The MAR lacked clear parameters and instructions for administration of the PRN pain medications.

The need to ensure MARs were accurate and included clear parameters and direction to staff for medication administration was discussed with Staff 3 (LPN) and Staff 18 (Interim Administrator) on 03/02/22. They acknowledged the findings.

2. Resident 9 was admitted to the facility in July 2020 with diagnoses including osteoarthritis.

The 02/1/22  through 02/28/22 MAR and physicians orders were reviewed and identified the following PRN pain medications:

* Acetaminophen 1000 mg every 12 hours as needed for pain;

* Tramadol HCL 50 mg every six hours as needed for pain; and

* Hydrocodone APAP 5-325 mg every four hours as needed for pain.

The MAR lacked clear parameters and instructions for administration of the PRN pain medications, and had no instruction of how many milligrams of Acetaminophen Resident 9 could receive in a 24 hour period.

The need to ensure MARs were accurate and included clear parameters and direction to staff for medication administration was discussed with Staff 3 (LPN) and Staff 18 (Interim Administrator) on 03/02/22. They acknowledged the findings.

1. All MARs reviewed that clear instructions are present for medication aide in the event that there are multiple prn medications ordered for the same indication.

2. Each time a new prn medication is ordered, during transcription to MAR, LN will ensure that if the new medication now creates more than one treatment option for the same indication, that parameters will be listed for which medication to give first unless resident can self-direct. All medication records will also be reviewed with current EHR conversion.

3/4. MAR instructions will be evaluated quarterly during audit provided by contracted pharmacy's RN.

Based on interview and record review, it was determined the facility failed to ensure a self-administration of medication evaluation was completed quarterly and to have a current order from a legally recognized provider for self-administration of prescription medications for 2 of 2 sampled resident (#s 5 and 7) who self-administered their medication. Findings include, but are not limited to:

1. During the acuity interview on 12/06/21, Resident 7 was identified as self-administering his/her medication.

A review of the resident's record revealed there was no physician order for self-administration of medication, nor was there a documented evaluation of the resident's ability to safely self-administer medication.

The need to have an order from a legally recognized prescriber and a documented quarterly evaluation of the resident ' s ability to safely self-administer medication was discussed with Staff 1 and Staff 3 (LPN) on 12/07/21. They acknowledged the findings.

2. Resident 5 was admitted to the facility in June 2020 with diagnoses including macular degeneration.

During an interview with Staff 1 (Administrator) on 12/08/21, he reported the resident self-administered diclofenac sodium gel (pain) and albuterol (respiratory) via inhaler.

The resident's 11/17/21 and 11/19/21 signed physician orders and 11/01/21 through 12/06/21 MAR were reviewed.

An 11/17/21 signed physician order indicated the resident was to be administered albuterol via inhaler every four hours as needed for wheezing or shortness of breath. There was no documented evidence of a physician order for the resident to self-administer the medication located in the resident's facility record.

The resident had a signed physician order, dated 11/19/21, to self-administer diclofenac sodium gel as needed every four hours for pain.

There was no documented evidence the facility had evaluated the resident to assure his/her ability to safely self-administer either of the medications.

The need to ensure resident's had signed physician order of approval for self-administration of prescription medications and that residents were evaluated at least quarterly to assure their ability to safely self-administer medications was discussed with Staff 1 and Staff 3 (LPN) on 12/06/21. They acknowledged the findings.

oEach resident who self-administers medications will do so only after RN has completed initial assessment, and then updated it quarterly.

oAdministrator will notify RN the month that the next quarterly care plan update is due so that RN can update the self-medication assessment to coincide with care plan update.

oOnce RN assesses resident to be competent to self-medicate (initially), then she will fax PCP requesting an order that resident may self-administer medications.

oThis self-administration order is added to the top of resident's MAR as information only, and will be reviewed/signed by PCP when 180-day orders are sent for signature.

oIf a resident is assessed to no longer be able to self-medicate, the PCP will be notified, and the MAR and care plan will be updated to reflect that facility staff are now responsible for medication administration.

oA resident who has been deemed competent to have oral medications prepared by the MA and then left in the resident's room for self-administration, will, after self-medication assessment completed by RN and resident approved for this task, have a signed order from the PCP documenting his/her approval of this task.

oEither the unit LPN or the RN will fax PCP with this request.  

oThis assessment will be reviewed quarterly at time of quarterly care plan update; administrator will notify RN at the start of the month that the quarterly care plan is due so that self-medication assessment will coincide with care plan update.

Based on interview and record review, it was determined the facility failed to ensure their relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:

Refer to C260, C270 and C303.

1. Reallocation of administrative staff to place experienced administrator on unit to ensure completion of POC by compliance date.

2. Reallocation of experienced administrator will allow for thorough training of adminitrator candidate.

3/4. Ongoing evaluation by experienced administrator (reporting to Executive Director) until such time as administrator candidate has completed requisite training and passed administrator's exam, as well as  

Based on interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include, but are not limited to:

Refer to C260, C280 and C303.

New adminstrator/RN on unit to ensure completion of POC by compliance date.

New RN to ensure all protcols are met

Ongoing evaluations

Adminstrator reporting to Execuitive Director

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

A tour of the environment on 12/08/21 revealed the following:

* Concrete and asphalt pathways in the front of the building revealed multiple gaps between concrete slabs;

* Raised transitions from concrete to asphalt;

* A concrete slab by the entrance near the dumpster was raised approximately 5 inches; and

* Potholes were noted in the parking lot in front of the ALF entrance and at the end of the asphalt walkway ending at the independent living entrance.

The environment was toured with Staff 1 (Administrator) on 12/07/21. The need to ensure pathways were maintained in good repair and did not create potential tripping hazards was discussed at that time. He acknowledged the findings.  

Facility will have signed repair bid with contractor to repair deficiencies in asphalt areas to be completed when weather/temperature permits proper adhesion and bonding of asphalt. Maintenance director will be responsible for oversight of contractor repairs and ongoing upkeep of driveways. Repair work to be completed as soon as possible weather permitting.

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

A tour of the environment was conducted on 12/06/21. The following issues were identified:

* Wooden doors throughout the facility showed deep gouges and scrapes;

* The resident laundry room had gouges in the floor near the door, black smudges on wall and the coved base of the flooring was pulling away from the wall;

* Black matter was observed inside light fixtures in common areas and resident hallways;

* The carpet outside the elevator on the second floor was stained;

* The light fixture in the elevator had black matter on it; and

* The caulk at the base of the second floor common-use bathroom was cracked.

Multiple areas in the staff laundry room were in need of cleaning and repair, including the following:

* There was brown matter on the wall behind, the light fixture above and on the bowl of the hopper sink;

* The linoleum base of the hopper had gaps where black matter had accumulated and there were gaps in the caulk;

* The wood cabinet next to the hopper had peeling laminate and exposed raw wood;

* The coved base of the flooring in the washer/dryer room had been removed with areas of exposed drywall and peeling paint visible;

* Multiple cabinets, wall mounts and the laundry table had exposed raw wood;

* Multiple ceiling tiles were disintegrating in the corners; and

* Multiple holes in the wall and where paint had peeled off were noted.  

The environment was toured with Staff 1 (Administrator) on 12/08/21. The need to ensure the environment was kept clean and in good repair was discussed at that time. Staff 1 acknowledged the findings.

Floor coverings and cove base surfaces to be replaced in laundry areas to repair gouges and torn flooring by flooring contractor on or before Feb 6th 2022. Walls and holes to be repaired by maintenance director with washable surfaces, ongoing compliance will be completed by care staff and repairs be reported to maintenance director in a timely manner to achieve continued compliance in a clean and efficient manner. Painting and repairs to be completed on or before Feb 6th 2022.

Based on observation and interview, it was determined the facility failed to ensure all exit doors were equipped with an alarm or other acceptable security system to alert staff when residents exited the facility. Findings include, but are not limited to:

During an interview with Staff 1 (Administrator), he reported the exit doors at the end of the two residential wings did not have alarms to alert staff when residents were exiting the building.

On 12/08/21, the need to ensure exit doors were equipped with an alarming device or other acceptable system was discussed with Staff 1.  He acknowledged the findings.

Exit doors to assisted living will have door alarms installed to report exit from facility by residents to pagers that care staff currently use to respond to resident needs. Maintenance director will be responsible for installation of door alarms and care staff to report and malfunction to maintenance department for timely repair of malfunction. Care staff and maintenance dept will assure ongoing compliance with exit alarms. Repairs to be completed on or before Feb. 6th 2022.