The findings of the re-licensure survey conducted 08/14/23 through 08/17/23 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, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.
Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.
Abbreviations possibly used in this document:
ADL:activities of daily living
bid:twice a day
CBG:capillary blood glucose or
blood sugar
CG:caregiver
cm:centimeter
ED:Executive Director
F:Fahrenheit
HH:Home Health
LPN:Licensed Practical Nurse
MA: Medication Aide
MAR:Medication Administration
Record
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 08/17/23, conducted 01/02/24 through 01/05/24, 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, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.
Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.
Abbreviations possibly used in this document:
ADL:activities of daily living
bid:twice a day
CBG:capillary blood glucose or
blood sugar
CG:caregiver
cm:centimeter
ED:Executive Director
F:Fahrenheit
HH:Home Health
LPN:Licensed Practical Nurse
MA: Medication Aide
MAR:Medication Administration
Record
MCC:Memory Care Community
mg:milligram
ml:milliliter
MT:Medication Technician
OT:Occupational Therapist
PT: Physical Therapist
PRN:as needed
qd:every day or daily
qid:four times a day
QI: quality improvement
RCC: Resident Care Coordinator
RN: Registered Nurse
TAR: Treatment Administration
Record
tid: three times a day
A situation was identified during the survey where failure of the facility to comply with the Department's rules was likely to cause residents serious harm. An immediate plan of correction was requested in the following area:
OAR 411-054-0025 (4) Reasonable Precautions
The facility put an immediate plan of correction in place during the survey and the situation that could cause residents serious harm was abated.
The findings of the 2nd revisit to the re-licensure survey of 08/17/23, conducted 04/03/24 through 04/04/24, 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, Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.
Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.
Abbreviations possibly used in this document:
ADL:activities of daily living
bid:twice a day
CBG:capillary blood glucose or
blood sugar
CG:caregiver
cm:centimeter
ED:Executive Director
F:Fahrenheit
HH:Home Health
LPN:Licensed Practical Nurse
MA: Medication Aide
MAR:Medication Administration
Record
MCC:Memory Care Community
mg:milligram
ml:milliliter
MT:Medication Technician
OT:Occupational Therapist
PT: Physical Therapist
PRN:as needed
qd:every day or daily
qid:four times a day
QI: quality improvement
RCC: Resident Care Coordinator
RN: Registered Nurse
TAR: Treatment Administration
Record
tid: three times a day
The findings of the third revisit to the re-licensure survey of 08/17/23, conducted on 05/15/24, 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 Division 57 for Memory Care Communities.
Based on observation, interview, and record review, it was determined the facility failed to exercise reasonable precautions against any condition which could threaten the health, safety or welfare of residents for 3 of 3 sampled residents (#s 8, 9, and 10) who received inaccurate fluid consistencies. Residents received inaccurate fluid consistencies, placing them at risk for aspiration, choking and/or death. Findings include, but are not limited to:
During the survey on 01/02/24, three sampled residents were identified as requiring modified texture meals and/or modified liquid consistencies.
Resident 8, 9, and 10's clinical records were reviewed. Resident 8 had a physician order dated 12/14/23 for nectar thick consistency liquids. Resident 10 had a signed physician order, dated 11/25/22, indicating s/he required pureed textures and nectar thick liquids. Resident 9 had a physician order dated 10/09/23 for regular/thin diet and fluid consistency.
Resident 8, 9, and 10's service plans revealed the following:
*Resident 8's current service plan dated 11/21/23 noted the resident had a history of swallowing difficulties and required a pureed texture diet with pudding thick liquids.
*Resident 9's current service plan dated 12/21/23 noted the resident was on a mechanical soft texture diet and no specifications for fluid consistency.
*Resident 10's clinical record and current service plan dated 11/15/23 noted the resident was on a puree diet texture with nectar thick liquids.
During meal observations of Resident 8, 9, and 10 and interviews with staff on 01/02/24 between 11:47 am and 1:15 pm, the following was noted:
* Resident 8 required assistance to eat and drink during the noon meal;
* Resident 8 had non-thickened water served at his/her place setting;
* Staff 19 and 24 (CGs) were not able to state what fluid consistency the resident required;
* Staff 24 removed the non-thickened water from the resident and served the resident nectar thick juice;
* Staff 24 stated the resident needed "really" thick liquids and added approximately 1/4 cup of thickening agent to the juice;
* Staff 19 (CG) spoon fed the juice with "pudding like consistency" to the resident;
* Resident 10 required assistance to eat and drink during the noon meal;
* Resident 10 had non-thickened water served at her/his place setting;
* Staff 19 (CG) was not able to state what fluid consistency Resident 10 required;
* Staff 24 (CG) removed the non-thickened water and stated Resident 10 was on a "thick liquid";
* Prior to lunch being served, Resident 9 would stand up from the table and walk around the dining room and attempted to take other residents' silverware and/or drinks. Staff observed to intervene and give resident non-thickened glasses of water while walking around and/or when seated at the table. Resident 9 drank three glasses of non-thickened water prior to the noon meal.
* Resident 9 required assistance to eat during the noon meal;
* Staff 19 (CG) stirred a glass of water and gave to Resident 9 while s/he was eating. Staff 19 confirmed she had added powdered thickener to Resident 9's water but could not state what fluid consistency the resident required;
* Staff 24 (CG) stated Resident 9 was nectar thick; and
* Resident 9 was observed to drink the water provided by Staff 19.
Resident 8, 9 and 10 either received thickened liquid without an order or received the incorrect fluid consistency. Staff 19 and 24 were unaware of what consistency the resident's required and were not clear on how much thickening agent to add to liquids. The facility failed to ensure residents who required modified fluid consistencies were served the appropriate fluid as evaluated or prescribed. This placed the residents at risk for choking, aspiration, and/or death.
On 01/02/23 Staff 27 (Lead Cook) stated that the facility used pre-thickened water but the facility currently did not have any. Staff 3 (Lead Med Tech) stated the facility started using the powdered thickening agent "last week" when the pre-thickened water was not delivered by the food company. She acknowledged the staff should have received some training in using the powder to thicken liquids.
The need to ensure the facility exercised reasonable precautions against any condition which could threaten the health, safety, or welfare of residents was discussed with Staff 1 (ED) on 01/02/24 at 1:25 pm.
An immediate plan of correction was requested by the survey team on 01/02/24 at 2:30 pm. The IJ plan of correction was presented to the surveyors and approved on 01/02/24 at 3:35 pm. The situation was abated.
* What actions will be taken to correct the rule violation for providing appropriate thickened liquids;
1.Staff training was provided for all staff in attendance today by Executive Director, Beth Jones.
2.The Executive Director and lead med tech will monitor for appropriate diets and feeding techniques until all staff have received training and competency verified starting today.
3.Pre-thickened liquids are available as of today to eliminate care staff need to mix fluids.
4.Simple directions for mixing thickened liquids will be posted for care staff with glass size to ensure correct thickness in case of emergency with no pre-thickened liquid available.
5.Staff will receive training on Friday 01/05/2024 in an all staff meeting on providing appropriate thickened liquids. Those not in attendance will not assist in the dining room until training is documented. This training will be provided by Exec Director, Beth Jones. Janelle Asai, RD, or Vicki Pardon LD with Crandell Dietitians have been requested to provide in-service. ED will update if dietitians are unavailable for that date.
6.The Executive Director will maintain the correct inventory of thickened liquids.
*How will the system be corrected so this violation will not happen again;
1.Care staff will be trained in modified fluid textures at time of hire by qualified staff member. Competency will be verified prior to feeding residents.
2.All new staff who assist in the dining room will receive training on modified diets and thickened liquids prior to assisting residents in the dining room.
3.After initial training, training on proper textures and diets will be conducted quarterly via all staff meetings.
4.Diet orders will be reviewed quarterly and with Change of Condition by the service planning team (ED, Food Service Director, RSC and lead Med Tech).
*How often will the area needing correction be evaluated; and
1.The Executive Director will watch a meal service (random Breakfast, Lunch, Dinner), snack time to monitor for safety or staff training needs for 6 weeks and twice monthly after that.
2.The Executive Director will assign appropriately trained Med Tech, Lead Med tech or RSC on each shift is trained to assure quality control during all mealtimes starting today.
*Who will be responsible for seeing that the corrections are completed?
1. The Executive Director, Lead Med Tech and Food Service Director will be responsible.
There are no detail notes for this visit.
Based on observation and interview, it was determined the facility failed to ensure resident's right to privacy and dignity was maintained related to providing ADL care for 1 of 3 sampled residents (# 8) whose ADL care was observed. Findings include, but are not limited to:
Resident 8 was admitted to the facility in 08/2023 with diagnoses including vascular dementia and shared an apartment with a non-sampled resident.
Observation and interviews with staff during the survey identified Resident 8 as dependent on staff for ADL care. Resident 8 required two person assist with ADL care including incontinent care which was provided while the resident was in bed.
During an ADL observation on 01/03/24 at 1:28 pm in the resident apartment, Staff 24 (CG) and Staff 25 (Life Enrichment Coordinator) provided the following:
* Two person transfer lifting the resident from a wheelchair into bed;
* Cueing and directions regarding incontinency care was provided;
* The resident's pants were removed and then the soiled incontinent brief was removed;
* Perineal care was provided using multiple incontinency wipes;
* Clean incontinent brief was put on the resident; and
* Resident 8 was repositioned in bed and a blanket was used to cover his/her lower body.
The ADL care was provided in the resident apartment in the presence of the roommate and a lack of a privacy curtain.
The need to ensure privacy and maintain resident dignity while providing incontinent care for Resident 8 was discussed with Staff 24 and Staff 25. Staff acknowledged the lack of privacy and stated they would utilize a privacy curtain.
A privacy curtain was observed in Resident 8's room on 01/04/24 at 10:00 am.
The lack of privacy and dignity afforded to Resident 8 was reviewed with Staff 1 (Executive Director) and Staff 18 (LPN Resident Services Coordinator) on 01/04/24 at 11:40 am. Staff acknowledged the finding.
A privacy curtain was provided for the resident receiving care to preserve her dignity and privacy.
Retraining was provided for all staff regarding resident privacy and dignity. Staff were asked to provide privacy curtain for any resident they are providing care for if they are unable to provide care behind closed door or without the roommate leaving the room to protect privacy.
RSC, Lead Med Tech and ED will audit this on each shift at least 3 times weekly for 1 month and then weekly thereafter to ensure resident rights are being observed and dignity and privacy are being provided.
ED will be responsible for ensuring this is completed/monitored.
There are no detail notes for this visit.
3. Resident 3 was admitted to the facility in 07/2019 with diagnoses including dementia.
Interviews with care staff and observations of Resident 3 during the survey revealed they had recently suffered an upper extremity fracture that required staff assistance to don and doff a wrist brace, and also received weekly outside provider visits.
Resident 3's current service plan, dated 07/16/23, failed to provide specific instruction to staff in the following areas:
* Presence of wounds and healing upper extremity fracture;
* Home Health wound care treatments in and out of facility; and
* Instructions for assisting with upper extremity brace.
4. Resident 2 was admitted to the facility in 08/2023 with diagnoses including dementia.
Interviews with care staff and observations of Resident 2 during the survey revealed they had started receiving home health services for a toe wound, however, the service had not been added to Resident 2's service plan.
The need to ensure service plans provided clear direction to staff and were reflective of resident's needs and services was discussed with Staff 1 (ED) and Staff 2 (RN/Resident Services Coordinator) on 08/17/23 at 11:45 am. The findings were acknowledged.
Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current status and care needs and provided clear instruction to staff for 4 of 4 sampled residents (#s 1, 2, 3, and 4) whose service plans were reviewed. Findings include, but are not limited to:
1. Resident 1 was admitted to the facility in 06/2020 with diagnoses including dementia.
Interviews with care staff and observations of Resident 1 during the survey revealed s/he was incontinent, dependent on staff for ADL care, and did not use a call light to summon assistance.
Resident 1's current service plan, dated 06/09/23, failed to provide specific instruction to staff in the following areas:
* Toileting;
* Evacuation;
* Life Enrichment;
* Bathing;
* Dressing/Undressing; and
* Personal hygiene/oral care.
The need to ensure service plans provided clear direction to staff was discussed with Staff 1 (ED) on 08/17/23 at 12:45 pm. The findings were acknowledged.
2. Resident 4 was admitted to the facility in 08/2018 with diagnoses including dementia.
Interviews with care staff and observations of Resident 4 during the survey revealed s/he was incontinent and dependent on staff for ADL care.
Resident 4's current service plan, dated 06/28/23, lacked specific instruction to staff in the following areas:
* Toileting;
* Evacuation;
* Life Enrichment;
* Bathing;
* Dressing/Undressing; and
* Personal hygiene/oral care.
The need to ensure service plans provided clear direction to staff was discussed with Staff 1 (ED) on 08/17/23 at 12:45 pm. The findings were acknowledged.
Service plans updated for each resident to reflect all changes. Details have been added to ensure care staff are aware of changes and aware of how to address changes with each resident.
Caregiver/med tech-to-management communication book has been established and training has been provided to ensure that care staff and med tech's are able to communicate changes as they occur to enable service plans to reflect accurately.
This will be audited weekly by both Executive Director and Resident Services Coordinator to ensure that all changes have been addressed and service plans are accurate.
3. Resident 9 was admitted to the facility in 08/2021 with diagnoses including dementia with behavioral disturbance.
Observations of the resident, interviews with staff and review of the most current service plan, dated 12/21/23, showed the service plan was not reflective of the resident's current care needs and/or did not provide clear direction to staff in the following areas:
* Diet texture and assistance with eating;
* How the resident expressed pain including non-verbal expressions and location of pain;
* Behavioral issues and interventions in the dining room;
* Scoop mattress;
* Skin monitoring including type, frequency and location of cream applied;
* Two person assist with bed mobility and toileting; and
* Medication management including crushing medications.
The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (Executive Director) and Staff 3 (Lead Med Tech). They acknowledged the findings.
2. Resident 10 was admitted to the facility 4/2018 with diagnoses including dementia.
Observations of the resident, interviews with staff and review of the most current service plan, dated 11/15/23, showed the service plan was not reflective of the resident's current care needs and/or did not provide clear direction to staff in the following areas:
* Cognition, including orientation, confusion and decision making;
* Impaired communication, including non-verbal and staff to anticipate resident's needs;
* Dressing assist, including two-person assist;
* Transfer assist, including two-person assist and gait belt;
* How the resident expressed pain with non-verbal expressions;
* Falls, including fall interventions; and
* Evacuation assistance.
The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (Executive Director) and Staff 3 (Lead Med Tech). Staff 1 acknowledged the findings.
Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and provided clear direction to staff regarding delivery of services for 3 of 3 sampled residents (#s 8, 9, and 10) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:
1. Resident 8 was admitted to the facility in 08/2023 with diagnoses including vascular dementia.
Observations of the resident, interviews with staff and review of the most current service plan, dated 11/21/23, showed the service plan was not reflective of the resident's current care needs and/or did not provide clear direction to staff in the following areas:
* Two person transfers;
* Two person assist with mobility, dressing, bathing and toileting; and
* Diet texture including fluid consistency and assistance with eating.
The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (Executive Director) and Staff 18 (LPN Resident Services Coordinator). Staff acknowledged the findings.
SP will be reviewed with each resident surveyed and remaining residents.
SP will ensure all care & health needs, diet texture, nutrition & hydration plan, preferences, outside services provided, laundry & bathing schedule are accurate and are provided in the service plan for staff direction. SP team will ensure that the plan is reflective of the care needs, provides clear direction to staff and includes the what, when, how and how often the services should be provided.
This will be audited weekly by Resident Service Coordinator and Lead Med Tech as needed to ensure that Service Plan is accurate and information is being provided to care staff.
Executive Director will be responsible for ensuring this is completed/monitored.
There are no detail notes for this visit.
Based on interview, and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that included the resident, the resident's legal representative if applicable, any person of the resident's choice, the Administrator or designee, and at least one other staff person who was familiar with or who was going to provide services to the resident for 4 of 4 sampled residents (#s 1, 2, 3, and 4) whose service plans were reviewed. Findings include, but are not limited to:
Resident 1, 2, 3, and 4's current service plans were reviewed during the survey.
On 08/16/23 at 1:50 pm, Staff 1 (ED) confirmed the facility lacked documented evidence of a Service Planning Team to develop the individual service plan.
The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 on 08/17/23 at 12:45 pm. She acknowledged the findings.
Service Plan Acknowledgement forms have been re-implemented. These will be signed by all members of the service planning team and management will document who is involved and any distribution of service plan to family, POA or guardian if not available to sign. This will be kept in a binder located in the Executive Director's office.
This will be audited weekly by Resident Service Coordinator and Executive Director and as needed to ensure that Service Plan team is documented accurately and timely.
There are no detail notes for this visit.
Based on observation and interview, it was determined the facility failed to establish and maintain infection prevention and control protocols to provide a safe and sanitary environment. Findings include, but are not limited to:
During the survey, multiple meal observations were made of staff providing meal assistance to residents. Staff were observed wearing gloves, touching wheelchairs, cellular phones, their hair, faces and then continued to provide meal assistance without having changed their gloves.
The need to ensure universal precautions for infection control were exercised, including appropriate hand hygiene, while providing meal assistance to residents, was discussed with Staff 1 (ED) on 08/17/23 at 12:45 pm. The findings were acknowledged.
All-staff retraining on infection control and hand-washing will be held on 9/1/2023 by Executive Director and Resident Services Coordinator. On-going training in Relias Learning will be assigned quarterly.
The sink was returned to the dining room on 8/21/2023 which assists with handwashing during serve-out.
Hand-washing/infection control will be observed minimum 5 days a week for 4 weeks and 2 times a week ongoing.
This will be completed by Executive Director, Resident Services Coordinator, or Lead Med Tech for at least one meal. This will be documented and kept in the Executive Director's office.
1. Resident 8 was admitted to the facility in 08/2023 with diagnoses including vascular dementia.
During interviews and observations from 01/02/24 through 01/03/24, Resident 8 was noted to require two person assist for mobility, toileting, dressing and required assistance with eating.
During an ADL observation on 01/02/24 at 12:50 pm the following was noted:
* Two staff donned gloves and assisted the resident with incontinence care which included cueing, wiping and clothing adjustment;
* Two staff rolled the resident side to side to provide assistance with removal of a soiled depend;
* One staff provided perineal care, then touched a clean incontinence brief, blanket and repositioned the resident using the soiled gloves;
* The staff member removed the soiled gloves and did not perform hand hygiene.
Maintaining effective infection prevention and control while providing incontinence care was discussed with the staff member after the ADL observation.
The observation was reviewed with Staff 1 (Executive Director) and Staff 18 (LPN Resident Services Coordinator) on 01/04/24. Staff 1 acknowledged the finding.
2. Resident 10 was admitted to the facility in 4/2018 with a diagnoses including dementia.
During interviews and observations from 01/02/24 through 01/03/24, Resident 10 was noted to require 2 person assist for mobility, toileting, dressing and required assistance with eating.
During an ADL observation on 01/03/24 at 11:18 am the following was noted:
* Two staff donned gloves, removed the resident's blankets, adjusted her/his clothing and transferred the resident into her/his wheelchair.
* A staff member then assisted Resident 10's roommate wearing the same gloves.
The observation was reviewed with Staff 1 (Executive Director) and Staff 3 (Lead MT) on 01/04/24. Staff 1 acknowledged the finding.
Based on observation and interview, it was determined the facility failed to establish and maintain infection prevention and control protocols to provide a safe and sanitary environment for 3 of 3 sampled residents (#s 8, 9, and 10) during ADL care and meal service. This is a repeat citation. Findings include, but are not limited to:
3. Resident 9 was admitted to the facility in 08/2021 with diagnoses including dementia with behavioral disturbance.
During interviews and observations from 01/02/24 through 01/03/24, Resident 9 was noted to require two person assist for toileting and bed mobility.
a. During an ADL observation on 01/03/24 at 1:05 pm the following was noted:
* Two staff donned gloves without hand hygiene first and assisted the resident with incontinence care which included cueing, wiping and clothing adjustment;
* Both staff assisted removed the soiled brief and assisted the resident onto the toilet;
* One staff provided perineal care, then both staff touched a clean incontinence brief, hip protection underwear, pants, shirt, bed linens, and the bed controller while they assisted resident off the toilet and into bed, all while using the soiled gloves;
* The staff members removed the soiled gloves and then performed hand hygiene after leaving the resident's room.
Maintaining effective infection prevention and control while providing incontinence care was discussed with the staff members after the ADL observation.
b. A med tech was observed providing wound care to Resident 9's hand at the lunch table. No hand hygiene was observed prior to or following the care. The med tech sprayed the Resident's hand, wiped the area and placed a Band Aid on the wound. No observation the table was cleaned prior to serving food.
The observations were reviewed with Staff 1 (Executive Director) and Staff 3 (Lead Med Tech) on 01/04/24. Staff 1 acknowledged the findings.
4. During the revisit survey, multiple meal observations on 01/02/24 through 01/04/24 were made of direct care staff providing meal service to residents. The following was noted:
* Staff were observed setting tables, serving meals, and pouring beverages without wearing aprons or other barriers to prevent contamination between clothing and food;
* Staff were observed entering and exiting the MCC kitchen and changing tasks without performing hand hygiene;
* Meals and beverages on the food cart were not consistently covered to prevent contamination during delivery.
* A staff member was observed providing one-to-one feeding assist with his mask below his nose, touching his face and hair without performing hand hygiene.
* A med tech was observed in the dining room during the noon meal and provided an insulin injection to a resident. The med tech wiped the glucometer, needle capsule and her hands with the same sanitizer wipe.
Maintaining effective infection prevention and control while providing meal service, food delivery and ADL care was reviewed with Staff 1 (Executive Director), Staff 3 (Lead Med Tech) and Staff 18 (LPN Resident Services Coordinator) on 01/04/24. Staff acknowledged the findings.
Aprons were provided for all staff serving food to residents. Staff were immediately retrained on covering food when delivering from the food cart for both meals and snack.
Retraining on proper handwashing, use of gloves, and infection control for all staff completed and retraining .
Retraining was provided on proper dining room hygiene and use of covering food on the food cart at all times.
The Executive Director, properly trained Lead Med Tech or RSC will watch a meal service (random Breakfast, Lunch, Dinner), snack time, and resident personal care to monitor for infection control and training needs for 6 weeks and twice monthly after that.
The Executive Director, Lead Med Tech and RSC will be responsible for ensuring completion and monitoring.
There are no detail notes for this visit.
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 2 of 2 sampled residents (#s 3 and 4) whose MARs and Controlled Substance Drug Disposition logs were reviewed for accuracy. Findings include, but are not limited to:
1. Resident 3 was admitted in 07/2019 and had diagnoses which included dementia.
a. Resident 3 had an order for hydrocodone-acetaminophen (narcotic analgesic) 5-325 mg, one tablet every four hours PRN for pain.
Resident 1's Controlled Substance Disposition Logs and MARs, reviewed from 07/01/23 to 07/31/23 , revealed five occasions when staff signed on the drug disposition log that the hydrocodone was taken out of the locked storage to administer. However, the MAR lacked documentation that the resident received the medication.
b. Resident 3 had an order for morphine 7.5 mg tablet (narcotic analgesic), every eight hours PRN for pain.
Resident 1's Controlled Substance Disposition Logs and MARs, reviewed from 07/01/23 to 07/31/23 , revealed three occasions when staff signed on the drug disposition log that the morphine was taken out of the locked storage to administer. However, the MAR lacked documentation that the resident received the medication.
Inconsistencies between the MARs and Controlled Substance Disposition logs were reviewed with Staff 1 (ED) and Staff 2 (RN/Resident Services Coordinator) on 08/17/23. They reviewed the documentation and acknowledged the discrepancies.
2. Resident 4 was admitted to the facility in 08/2023 and had diagnoses which included dementia.
Resident 4 had a physician order for PRN morphine, 0.25 ml to be given by mouth or under the tongue every one hour as needed for pain or dyspnea.
Resident 4's 07/01/23 through 08/14/23 Controlled Substance Disposition Logs and MARs were reviewed and revealed the following:
Between 08/01/23 through 08/14/2023 there were two occasions staff signed the drug disposition log. However, the MAR lacked documentation the medication was administered on 08/09/23.
Inconsistencies between the MAR and Controlled Substance Disposition logs were reviewed with Staff 3 (Lead MT) and the explanation offered was the MT who signed the disposition log was a new employee and she "wasn't sure why he didn't sign out on the MAR".
The need to ensure the facility had a system for tracking controlled substances was discussed with Staff 1 (ED) on 08/17/23. The findings were acknowledged.
Re-training on proper Administration and documentation of controlled substances was completed with each med tech individually.
On-going audits of the Controlled Substance Disposition Log vs. the MAR will be completed 4 times weekly by Lead Med Tech to ensure that all Controlled Substances are documented correctly.
Resident Services Coordinator will audit twice monthly in addition to lead med tech and document findings.
Executive Director will be responsible for ensuring that audits are completed.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure written, signed physician orders were documented in the resident's facility record for all medications and treatments the facility was responsible to administer for 1 of 5 sampled residents (# 7) whose orders were reviewed. Findings include, but are not limited to:
Resident 7 was admitted to the facility in 02/2022 with diagnoses including Type II diabetes mellitus.
Resident 7's MAR, dated 07/01/23 through 08/15/23 and prescriber orders were reviewed on 08/15/23. Resident had a physician's order for Novolog (insulin) to be administered before meals according to a sliding scale dosage. The facility did not have a signed physician's order for the resident's current sliding scale dosage.
Staff 2 (RN/Resident Services Coordinator) was interviewed on 08/16/23 and was not able to locate the current signed order for the sliding scale doses. Staff 2 stated she had contacted the resident's PCP and was awaiting the order. No additional information was provided.
The need to ensure the facility had signed physician's orders for all medications administered by staff was discussed with Staff 1 (ED) and Staff 2 on 08/17/23. They acknowledged the findings.
Current and correct order for resident's insulin was received on 8/18/23. Additional training was completed with each med tech regarding correct orders and notifying RSC or Lead Med Tech when orders are not matching, not complete, or not correct.
Lead Med Tech and Resident Services Coordinator will review and approve orders prior to administration. If order is incorrect, MD will be contacted and med will not be administered until corrected order is in place.
This will be documented in binder in ED office and findings will be reviewed minimum of once weekly with Executive Director, Resident Service Coordinator and Lead Med Tech.
Executive Director will be responsible for ensuring that audits are completed.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included resident specific parameters and instructions for PRN medications for 6 of 6 sampled residents (#s 1, 2, 3, 4, 5, and 6) whose MARs were reviewed. Findings include, but are not limited to:
1. Resident 1, 2, 3, 4, and 5's MARs between 07/01/23 through 08/15/23 were reviewed and the following was noted:
a. Residents 3's MARs dated 08/01/23 through 08/14/23 revealed the following:
Multiple incidents of medications including Eliquis (blood thinner), Gentamicin (antibiotic), and Hydroxurea (chemotherapy) with scheduled administration times left blank, failing to document administration of the medications.
b. Residents 2's MARs, reviewed from 08/01/23 through 08/14/23 revealed the following:
Multiple incidents of medications including buproprion (antidepressant), ezetimible (cholesterol lowering), linsinopril (blood pressure), and Insulin (blood sugar metabolism) with scheduled administration times left blank, failing to document administration of the medications.
c. Residents 1's MARs were reviewed from 07/01/23 through 08/14/23 and revealed the following:
Multiple incidents of medications including, but not limited to, quetiapine (for agitation) and sertraline (for restlessness and agitation) with scheduled administration times left blank, failing to document if the medications were administered as ordered.
d. Resident 4's MARs were reviewed from 07/01/23 through 08/14/23 and revealed the following:
Multiple incidents of medications including, but not limited to, divalproex (for agitation), levetiracetam (for controlling seizures), and quetiapine (mood stabilization) with scheduled administration times were left blank, failing to document if the medications were administered as ordered.
e. Residents 5's MAR, dated 07/01/23 through 08/15/23, revealed the following:
Multiple incidents of multiple medications, including but not limited to divalproex (for dementia), mirtazapine (for sleep) and quetiapine (for dementia), with scheduled administration times, were left blank and failed to document if the medications were administered as ordered.
On 08/15/23, Staff 1 (ED) was interviewed regarding the blanks on the MAR for Resident 1, 2, 3, 4, and 5. Staff 1 reported the facility had an inadequate "WiFi" signal to capture electronic administrations in some areas of the unit. The facility did not have an effective system to audit and ensure administrations were being recorded on the electronic MAR.
The need to ensure an accurate MAR was kept for all medications administered by the facility was discussed with Staff 1 (ED) on 08/15, 08/16, and 08/17/23. Staff 1 acknowledged the findings.
2. Resident 6 was admitted to the facility in 04/2023 with diagnoses including vascular dementia and major depressive disorder.
Residents 6's MAR, dated 07/01/23 through 08/15/23, revealed the following:
a. Multiple incidents of multiple medications, including but not limited to citalopram (for depressive disorder), lorazepam (for anxiety) and olmesartan (for hypertension), with scheduled administration times, were left blank and failed to document if the medications were administered as ordered; and
b. Resident 6 had physician's orders including:
*Lorazepam every four hours as needed for agitation/anxiety;
*Haldol every six hours as needed for agitation;
* Morphine every 15 minutes as needed for pain or shortness of breath; and
* Hydrocodone/APAP every four hours as needed for pain.
There were no resident specific parameters and instructions to staff for which medication to administer first when the resident experienced "agitation" or "pain".
On 08/15/23, Staff 1 (ED) was interviewed regarding the blanks on the MAR. Staff 1 reported the facility had an inadequate "WiFi" signal to capture electronic administrations in some areas of the unit. The facility did not have an effective system to audit and ensure administrations were being recorded on the electronic MAR.
The need to ensure an accurate MAR was kept for all medications administered by the facility and included resident specific parameters and instructions for PRN medications was discussed with Staff 1 (ED) and Staff 2 (RN/Resident Services Coordinator) on 08/16/23. They acknowledged the findings.
MAR's were corrected on 8/16/2023.
Ongoing audit of MAR will be conducted at minimum of 4 times weekly by lead med tech and/or Resident Services Coordinator.
This will be documented in binder in ED office and findings will be reviewed minimum of once weekly with Executive Director, Resident Service Coordinator and Lead Med Tech.
Resident Services Coordinator will be responsible to ensure that the corrections are completed and monitored.
2. Resident 10 was admitted to the facility in 04/2018 with diagnoses including dementia.
Resident 10's 12/01/23 through 12/31/23 MAR and current orders were reviewed.
Resident 10 had orders for:
* Acetaminophen 325 mg tablet and acetaminophen 650 mg suppository were both prescribed to treat pain and fever.
There were no specific parameters to guide non-licensed staff on which medication to use first when the resident experienced pain and/or fever.
The need to ensure the MAR included resident-specific parameters and instructions for PRN medications was discussed with Staff 1 (Executive Director) and Staff 3 (Lead Med Tech) on 01/04/24. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included resident specific parameters and instructions for PRN medications for 2 of 3 sampled residents (#s 9 and 10) whose MARs were reviewed. This is a repeat citation. Findings include, but are not limited to:
1. Resident 9's 12/01/23 through 12/31/23 MAR and current orders were reviewed.
a. Resident 9 had the following PRN medications for pain management:
* Acetaminophen 325 two tablets as needed for mild/moderate pain;
* Acetaminophen 650 mg suppository as needed for mild pain; and
* Morphine 20 mg/mL as needed for pain.
The electronic medication record was reviewed with Staff 6 (MT) on 01/03/24. There were no specific parameters to guide non-licensed staff on which pain medication to use first.
b. Resident 9 had the following PRN orders for medications for loose stools listed on the MAR:
* Loperamide 2 mg "one tablet as needed for diarrhea give one tablet after each consecutive loose stool after first loose stool"; and
* Loperamide 2 mg give "two tablet as needed for diarrhea give two tablets after first loose stool".
The electronic medication record was reviewed with Staff 6 on 01/03/24. There were no clear parameters to guide non-licensed staff on which order to follow for bowel medications after loose stools.
c. Resident 9 had a physician order to check blood pressure daily. Twelve of 31 days were left blank, failing to document resident's blood pressure.
On 01/03/24 Staff 6 acknowledged that Resident 9 would not sit still and on those days staff were unable to get a blood pressure reading. She acknowledged the need to document the refusals. No further documentation was provided.
The need to ensure MARs were accurate and included clear parameters to direct non-licensed staff when administering multiple PRN medications for the same condition was discussed with Staff 1 (Executive Director) and Staff 3 (Lead Med Tech) on 01/04/23. Staff 1 acknowledged the findings.
Paramaters were added for residents surveyed.
Retraining was provided with care staff regarding refusals of medications/treatments and the importance of documentation and notification to doctor.
All resident MARs were audited by Regional Director of Operations and Lead Med Tech for missing parameters. Parameters were obtained and entered for all residents.
As orders arrive, they will be reviewed by Med Tech, Lead Med Tech and RSC to ensure accuracy. If paramater is missing, RSC will be notified immediately so this can be obtained and entered in MAR.
MAR will be reviewed twice weekly by Lead Med Tech and/or RSC for missing parameters and to ensure all medications and treatments have been given and/or properly documented.
Executive Director will review weekly with RSC to ensure these corrections are being completed/monitored.
Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included resident specific parameters and instructions for PRN medications for 3 of 4 sampled residents (#s 12, 13, and 14) whose MARs were reviewed. This is a repeat citation. Findings include, but are not limited to:
1. Resident 13's 04/01/24 through 04/04/24 MAR was reviewed.
a. Resident 13 had the following PRN medications for pain management:
* Acetaminophen 325 two tablets as needed for pain;
* Acetaminophen 650 mg suppository as needed for pain; and
* Morphine 20 mg/mL .25 ml as needed for pain.
The electronic medication record was reviewed with Staff 1 (Executive Director), Staff 6 (Med Tech), and Staff 28 (Resident Services Coordinator) on 04/04/24. They confirmed there were no specific parameters to guide non-licensed staff on which PRN pain medication to use first.
b. Resident 13's MAR listed the following medications without an indication for use:
* Diltiazem CD 180 mg;
* Metoprolol Tartrate 50 mg;
* Quetiapine 25 mg;
* Hyoscyamine sublingual 0.125 mg; and
* Lorazepam 0.5 mg Tab.
The electronic medication record was reviewed with Staff 1 (Executive Director), Staff 6 (Med Tech), and Staff 28 (Resident Services Coordinator) on 04/04/24. They confirmed there were no indications for use on the MAR.
c. Resident 13's MAR listed the following medications for constipation:
* Senna 8.6 mg PRN "by mouth twice daily as needed for constipation;"
* Polyethylene Glycol 17 gm PRN "take by mouth once daily as needed for constipation;" and
* Bisacodyl 10 mg suppository "every day as needed for constipation."
The electronic medication record was reviewed with Staff 1 (Executive Director), Staff 6 (Med Tech), and Staff 28 (Resident Services Coordinator) on 04/04/24. They confirmed there were no specific parameters to guide non-licensed staff on which PRN bowel medication to use first.
2. Resident 12 was admitted to the facility in 04/2023 with diagnoses including dementia.
The resident's 03/01/24 through 04/04/24 MAR and current physician's orders were reviewed. The following PRN medications lacked resident-specific parameters for administration:
* Acetaminophen 500 mg (for pain); and
* Oxycodone 5 mg (for pain).
The need to ensure the MAR included resident-specific parameters and instructions for PRN medications was discussed with Staff 1 (Executive Director), Staff 6 (Med Tech), and Staff 28 (Resident Services Coordinator) on 04/04/24. They acknowledged the findings.
3. Resident 14 was admitted to the facility in 11/2021 with diagnoses including dementia.
The resident's 04/01/24 through 04/04/24 MAR was reviewed.
The following PRN medications for treating pain lacked resident-specific parameters for administration:
* Acetaminophen 325 mg; and
* Morphine 0.25 ml (5 mg).
The following PRN medications for treating difficult breathing and/or shortness of breathing lacked resident-specific parameters for administration:
* Morphine 0.25 ml (5 mg); and
* Ventolin inhaler.
The need to ensure the MAR included resident-specific parameters and instructions for PRN medications was discussed with Staff 1 (Executive Director), Staff 6 (Med Tech), and Staff 28 (Resident Services Coordinator) on 04/04/24. They acknowledged the findings.
Resident 13's MAR was corrected with accurate diagnosis for medications indications for use on 04/05/2024.
Resident 12, 13, and 14 PRN orders were corrected with parameters by Resident Services Coordinator after order obtained from MD on 4/05/2024
MAR's will be audited twice weekly for diagnosis and parameters by the Resident Services Coordinator and/or the Lead Med Tech. Any missing parameters or diagnosis will be corrected. This will be documented and kept in the RSC office and will be audited monthly by ED.
New orders will be reviewed by med tech, Lead Med Tech and Resident Services Coordinator to ensure that diagnosis and paramaters are included at time of order being entered. A copy of these will be kept in RSC office for review by ED monthly.
All med techs have been re-trained on identifying missing diagnosis and paramaters and on notifying management (RSC or Lead Med Tech) of any missing at time order is received. (Completed by 4/22/2024)
Resident Service Coordinator is enrolled in "The Role of the nurse in CBC" on 4/23-25 and will be completing this class to increase his knowledge of nursing in RCF/ALF.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure non-pharmacological interventions were attempted and documented to be ineffective prior to the administration of psychotropic medications for 1 of 2 sampled residents (#6) who were receiving PRN psychotropic medications. Findings include, but are not limited to:
Resident 6 was admitted to the facility in 04/2023 with diagnoses including vascular dementia and major depressive disorder.
Review of Resident 6's MAR, dated 07/01/23 through 08/14/23, and physician orders revealed the following:
* Resident 6 was prescribed lorazepam 1 mg every four hours as needed for nausea/agitation/anxiety, and it was documented as administered to the resident on eight occasions between 07/22/23 and 08/11/23; and
* Haldol 4 mg every six hours as needed for agitation, and it was documented as administered to the resident on seven occasions between 07/09/23 and 07/31/23.
The facility lacked documented evidence non-pharmacological interventions were attempted and were ineffective prior to administration of the medications and the MAR lacked information on non-pharmacological interventions for staff to attempt.
In an interview on 08/15/23, Staff 3 (Lead MT) confirmed the MAR and electronic system did not have non-pharmacological interventions listed for staff to attempt prior to administering the PRN medications.
On 08/16/23, the need to ensure non-pharmacological interventions were attempted and documented to be ineffective prior to the administration of PRN psychotropic medications was discussed with Staff 1 (ED) and Staff 2 (RN/Resident Services Coordinator). They acknowledged the findings.
All residents non-pharmacological interventions were reviewed by Resident Services Coordinator (RN).
These were implemented in PCC (service plans) in addition to being listed on the MAR in the proper place for documentation.
These will be audited weekly by RSC (RN) and reviewed with Executive Director and Lead Med Tech weekly to ensure Alternative Measures are being used appropriately and their effectiveness.
Documentation of these audits will be kept in Executive Director's office and reviewed monthly by Executive Director to ensure they are being completed.
There are no detail notes for this visit.
Based on observation, interview, and record review, it was determined the facility failed to ensure an assistive device with restraining qualities was assessed by an RN, PT, or OT prior to use, and instruction provided to caregivers on precautions and correct use of the device for 2 of 2 sampled residents (#s 5 and 6) who were reviewed for devices with restraining qualities. Findings include, but are not limited to:
1. Resident 5 was admitted to the facility in 11/2022 with diagnoses including Alzheimer's disease and anxiety disorder.
During the survey, Resident 5 was observed while lying in bed. The bed was equipped with a half-side rail in the up position on one side of the bed. In the resident's room, a "lap buddy" type cushion was observed sitting on the wheelchair. Staff 3 (Lead MT) confirmed the "lap buddy" was obtained by the facility and used by Resident 5 when s/he was up in the wheelchair.
Resident 5's service plan, last updated 03/13/23, stated "uses lap buddy to help prevent falls". The service plan did not include any information on use of the side rail.
Upon request, the facility provided an "assessment of supportive devices with restraining characteristics" completed by an RN on 03/10/23, however, the assessment stated it was a review of a "lap belt". The assessment described a device used for the resident to "hold self up in the chair" and "releas[ing] the belt". During an interview on 08/15/23, Staff 2 (RN/Resident Services Coordinator) stated the document did not appear to be accurate for a "lap buddy" type device. Staff 2 confirmed the current service plan did not include instructions for caregivers on the correct use and precautions related to use of the devices.
There was no assessment available for the side rail.
The need to ensure an assessment and required documentation for devices with potentially restraining qualities was completed was discussed with Staff 1 (ED) and Staff 2 on 08/16/23. They acknowledged the findings.
2. Resident 6 was admitted to the facility in 04/2023 with diagnoses including vascular dementia.
Resident 6 was observed to have a "lap buddy" type cushion. Staff 3 (Lead MT) confirmed the "lap buddy" was obtained by the facility following a recommendation by PT services and used by Resident 6 when s/he was up in the wheelchair.
Resident 6's service plan, last updated 07/17/23, did not include any information on use of the lap buddy.
Upon request, the facility provided an "assessment of supportive devices with restraining characteristics" completed by an RN on 05/30/23, however, the assessment stated it was a review of a "lap belt". The assessment described a device used for the resident to "hold [him/her] in the chair" and "remove the belt on [his/her] own". During an interview on 08/15/23, Staff 2 (RN/Resident Services Coordinator) confirmed the document did not appear to be accurate for a "lap buddy" type device. Staff 2 confirmed the current service plan did not include instructions for caregivers on the correct use and precautions related to use of the device.
The need to ensure an assessment and required documentation for devices with potentially restraining qualities was completed was discussed with Staff 1 (ED) and Staff 2 on 08/16/23. They acknowledged the findings.
All resident rooms have been audited for devices with restraining qualities. Resident's service plans have been updated to reflect these devices. Assessment of supportive devices with restraining characteristics have been accurately completed by facility RN. Clear instructions for use have been included in the service plan.
Staff were retrained to notify management/nursing using the Communication Binder for any use of possible devices with restraining qualities.
Audit will be completed weekly by Resident Services Coordinator or designee of resident rooms to ensure there are no devices with restaining qualities that have been implemented that are not captured previously.
This will be the responsibility of the Executive Director to ensure this is completed and monitored.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to use an acuity-based staffing tool (ABST) that showed all residents with the 22 required care elements with staff time to complete them. Findings include, but are not limited to:
ABST record system was reviewed with Staff 1 (ED) on 08/17/23 at 10:00 am. Staff 1 stated the facility was using "Point Click Care" to record the 22 required care elements and staff time to complete them.
A record review of the ABST information provided by Staff 1 revealed the following:
* ABST did not address all the required activities of daily living (ADLs) for each resident; and
* ABST did not include the amount of staff time needed to provide care for the resident sample picked for the survey.
In an interview on 08/17/23 at 1:30 pm, the need for the ABST tool to show all residents with the 22 required care elements with staff time to complete them, ensuring ABST provided data so the facility could develop a 24-hour schedule and an individualized task list was discussed with Staff 1. She acknowledged the findings.
ABST is updated and accurate on the ODHS provided tool to ensure all 22 required care elements are met.
This will be updated twice weekly by the Resident Service Coordinator or Executive Director during service plan meetings and as needed.
Executive Director to audit weekly to ensure that the corrections are completed and monitored ongoing.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to provide fire and life safety instruction to staff on alternate months from fire drills in accordance with the Oregon Fire Code (OFC), document all required components of the drills and failed to identify residents who were unwilling or failed to participate in drills. Findings include, but are not limited to:
The previous six months of fire drill and fire and life safety training records were reviewed on 08/16/23 with Staff 1 (ED). The following were identified:
a. Fire and life safety training for staff:
* The facility lacked documented evidence of fire and life safety training for staff on alternate months.
b. Fire Drills:
* There was no documentation of problems encountered, comments relating to residents who resisted or failed to participate in the drills;
* There was was no documented evidence the facility had identified residents who were unwilling or failed to participate in fire drills and made immediate changes to ensure evacuation standards were being met.
The need to ensure fire drills were completed and all required components were documented and fire and life safety training for staff was conducted, per the rules, was reviewed with Staff 1 on 08/16/23 and 08/17/23. She acknowledged the findings.
Retraining of Proper Fire Drill documentation was held with Environmental Safety staff and a sample was filled out by ESS to ensure that he understands all the components of Fire Drill Documentation.
Executive Director will be involved in Fire Drills monthly and will audit Fire Drill Documentation with ESS to ensure all requirements are met and to discuss and resolve any issues that may have occurred during drill.
Executive Director will audit drills monthly and ensure these are documented correctly.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure residents were instructed within 24 hours of admission and re-instructed at least annually in general safety procedures, evacuation methods, responsibilities during fire drills and designated meeting places outside the building or within the fire safe area in the event of an actual fire. Findings include, but are not limited to:
On 08/16/23, Staff 1 (ED) was asked to explain the facility's process for providing fire safety training to residents who may be able to retain the information, upon admission and annually. Staff 1 stated there was no documentation of the facility's process and annual training was not provided to residents. No further documentation of resident training was provided.
The need to have a process to identify residents who could retain the information and ensure those residents were trained in fire safety procedures upon admission and at least annually was reviewed with Staff 1 on 08/17/23. She acknowledged the findings.
Environmental Safety staff trained on completing Fire Safety Training that is to take place upon admission in the memory care with all residents and their family.
The Fire Safety Training documentation has been added to the initial move-in paperwork and it is the responsibility of the ESS to ensure this training occurs and is documented within 24 hrs of admission.
Business Office Manager will audit to ensure this occurs with each move-in using the updated "move-in checklist".
Executive Director will ensure this is completed and sign off on the updated "move-in checklist" within 24 hrs of admission.
There are no detail notes for this visit.
Based on observation, 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. Findings include but are not limited to:
Refer to C 260, C 295, C 310, and Z 164.
Refer to C 260, C 310 and Z 164
Based on observation, 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 C310.
Please see our plan of corrections at C310
There are no detail notes for this visit.
Based on observation and interview, it was determined the facility failed to ensure all interior and exterior materials and surfaces were kept clean and in good repair. Findings include, but are not limited to:
The facility had recently renovated eight resident units with hard wood flooring. There were 16 rooms that had not been renovated and had carpet in the units.
During a tour of the facility on 08/14/23 through 08/16/23, multiple resident rooms, including but not limited to, room #s 102, 109, 112 and 114 had large dark stains and black scuffs on the carpets. Room 105 had frayed and worn carpet, exposing the flooring beneath the carpet.
The rooms in need of carpet repair were discussed with Staff 1 (ED) on 08/17/23. She acknowledged the findings.
Room 105, 103 and 107 carpet replaced with flooring. All rooms with carpet to be replaced with flooring unless resident's decline to relocate for flooring replacement.
All rooms with carpet to be placed on a weekly carpet cleaning schedule until carpets can be replaced.
Environmental Safety Services to be responsible for ensuring these are cleaned and cleaning is documented on a weekly basis.
Executive Director will conduct walk-through of each room at least 1 time per week and will document any flooring or other items needing attention.
There are no detail notes for this visit.
H1517: TA was provided to ensure each individual has privacy in his/her own unit.
Refer to C 200.
There are no detail notes for this visit.
Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:
Refer to C361, C420, C422, and C513.
Refer to POC for C361, C420, C422 and C513
Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:
Refer to C 160, C 200, and C 295.
Refer to C 160, C 200 and C 295
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure 1 of 1 newly-hired staff (#16) had the required pre-service dementia training, and 4 of 4 newly-hired staff (#s 13, 14, 15 and 16) completed all required pre-service orientation training prior to beginning their job responsibilities. Findings include, but are not limited to:
On 08/15/23 at 10:30 am, Staff 13 (MT), Staff 14 (CG), Staff 15 (CG), and Staff 16's (Dietary Aide) training records were reviewed. During an interview with Staff 1 (ED), the following was identified:
1. Staff 16 hired on 06/13/23, lacked documented evidence of pre-service dementia care training for topics including:
* Techniques for understanding, communicating and responding to distressful behavioral symptoms; including but not limited to, reducing the use of antipsychotic medications for non-standard uses when responding to distressful behavioral symptoms; and
* Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: identify and address pain; provide food and fluid; prevent wandering and elopement; and use of a person-centered approach.
2. Staff 13 hired on 07/15/23, Staff 14 hired on 03/15/23, Staff 15 hired on 05/17/23, and Staff 16 hired on 06/13/23, lacked documented evidence of Infectious Disease Prevention training approved by the Department prior to performing job duties.
The need to ensure newly-hired staff completed pre-service orientation training prior to beginning their job responsibilities was discussed on 08/16/23 with Staff 1 (ED). She acknowledged the findings.
All required staff training completed for each of the newly-hired staff and existing staff.
Business Office Manager will be responsible for tracking these trainings and ensuring that they are completed prior to bringing their job responsibilities and on-going.
BOM will audit this tracking weekly to ensure all staff have required pre-inservice and on-going training.
Infectious Disease Prevention training template has been updated to reflect all required training and each staff has been assigned and completed training in Relias.
Executive Director will audit Business Office Manager's tracking records going forward on a monthly basis.
There are no detail notes for this visit.
Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:
Refer to C260, C262, C295, C302, C303, C310, C330, and C340.
Refer to POC for C260, C262, C295, C302, C303, C310, C330, and C340
Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:
Refer to C 260 and C 310.
Refer to C 260 and C 310
Based on interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:
Refer to C 310.
Please see our plan of corrections at C310
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure a daily meal program based on resident's preferences and needs that was individualized and documented in the resident's service plan for 2 of 3 sampled residents (#s 8 and 9) whose service plans were reviewed. Findings include, but are not limited to:
Resident 8 and 9's current service plans were reviewed during survey. Each service plan lacked information and staff instructions related to the individualized nutrition and hydration status, preferences, and needs of the resident.
The need to develop a daily meal program based on resident's preferences and needs that was individualized and documented in the resident's service plan was discussed with Staff 1 (Executive Director) and Staff 18 (LPN Resident Services Coordinator) on 01/04/24. Staff acknowledged the findings.
Resident's surveyed service plans were immediately updated with Nutrition and Hydration plans. All remaining resident's service plans will be updated with Nutrition and Hydration plans as well.
SP will ensure all care & health needs, diet texture, nutrition & hydration plan, and preferences are accurate and are provided in the service plan for staff direction. SP team will ensure that the plan is reflective of the daily meal program individualized to each resident and provides clear direction to staff.
This will be audited weekly by Lead Med Tech and Food Service Director and as needed to ensure that Service Plan is accurate and correct information is being provided to care staff.
Executive Director will be responsible for ensuring this is completed/monitored.
There are no detail notes for this visit.
Based on observation, interview, and record review, it was determined the facility failed to ensure activity evaluations addressed all required components and individualized activity plans were developed for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose activity plans were reviewed. Findings include, but are not limited to:
Resident 1, 2, 3, and 4's records were reviewed, and observations were made during the survey. There was no documented evidence activity evaluations addressed the required components, and that service plans had been individualized to reflect the following:
* Current abilities and skills;
* Emotional/social needs and patterns;
* Physical abilities and limitation;
* Adaptations needed to participate;
* Identification of activities for behavioral interventions; and
* There was no specific activity plan which detailed what, when, how and how often staff should offer and assist each resident with individualized activities.
The need to ensure activity evaluations addressed all required components and individualized activity plans were developed was discussed with Staff 1 (ED) on 08/17/23 at 12:45 pm. The findings were acknowledged.
Lifestyle Enrichment Director has ensured all activity evaluations are completed and will be meeting with each resident prior to admit or upon admission to ensure that these individualized activity plans are completed upon Admission and included in the service plan.
Lifestyle Enrichment Director is responsible for ensuring these are completed and documenting completion.
Executive Director and Resident Services Coordinator will audit monthly to ensure these are completed and added to the service plans accurately using PCC.
Based on interview and record review, it was determined the facility failed to ensure all residents were evaluated for activities and/or individualized activity plans were developed for each resident based on their activity evaluation for 3 of 3 sampled residents (#s 8, 9, and 10) whose records were reviewed. This is a repeat citation. Findings include, but are not limited to:
1. Resident 8's service plan offered some information about the resident's interests however, the facility had not completed an evaluation that addressed the following:
* Current abilities and skills;
* Physical abilities and limitations; and
* Adaptations necessary for the resident to participate.
The need to ensure the facility evaluated all residents for activities was discussed with Staff 1 (Executive Director) and Staff 18 (LPN Resident Services Coordinator) on 01/04/24 at 11:40 am. Staff 1 acknowledged the findings.
3. Resident 10's service plan offered some information about the resident's historical interests, however, the facility had not fully evaluated the resident's current abilities and activity needs, including:
* Emotional and social needs;
* Current abilities and skills;
* Physical abilities and limitations; and
* Adaptations necessary for the resident.
There was no specific activity plan that detailed what, when, how and how often staff should offer and assist the resident with individualized activities s/he would benefit from.
On 01/04/24 the need to ensure the facility evaluated each resident and provided an individualized activity plan for each resident was discussed with Staff 1 (Executive Director)and Staff 3 (Lead Med Tech). Staff 1 acknowledged the findings.
2. Resident 9's service plan offered some information about the resident's interests however, the facility had not completed an evaluation that addressed the following:
* Physical abilities and limitations;
* Adaptations necessary for the resident to participate; and
* Identification of activities for behavioral interaction.
There was no specific activity plan that detailed what, when, how and how often staff should offer and assist the resident with individualized activities s/he would benefit from.
The need to ensure the facility evaluated all residents for activities was discussed with Staff 1 (Executive Director) and Staff 3 (Lead Med Tech) on 01/04/24. Staff 1 acknowledged the findings.
Resident's surveyed service plans were immediately updated with new individualized activity plans utilizing a form that meets all required information. All remaining resident's service plans will be updated with the new individualized activity plans as well.
SP for all residents will be reflective of the individualized activity plans to ensure that all the residents current abilities and activity needs are met. These will be completed and updated quarterly and as needed to ensure Service Plan is accurate and correct information is being provided to care staff.
This will be audited weekly and as needed by Life Enrichment Director (Activities) and Executive Director until all existing service plans have been audited. This will then be audited quarterly and updated with the SP.
Executive Director will be responsible for ensuring this is completed/monitored.
There are no detail notes for this visit.
Based on observation, interview, and record review, it was determined the facility failed to ensure the door to the secured outdoor courtyard was accessible to residents except during nighttime hours or during severe weather and to have a policy for when the doors to the outdoor areas would be locked. Findings include, but are not limited to:
On 08/16/23 and 08/17/23 between 9:00 AM and 12:00 PM the weather was clear and dry with a moderate temperature. The door to a secured outdoor courtyard remained locked during that time. In an interview on 08/17/23, Staff 6 (MT) stated the door was locked because it was "too warm" for residents to go outside. Staff 6 stated she did not know the current temperature but guessed "85-90 degrees would be too warm".
The policy provided by Staff 1 (ED) regarding resident access to the outdoor courtyard stated, "All care staff are to thoroughly check the courtyards multiple times a shift, at least every 1-2 hours. You are to report to the Med Tech on duty when you have checked the courtyards." Staff 1 stated the facility did not restrict resident access to the courtyard based on time of day but did restrict access based on extreme weather conditions. She acknowledged the current written policy did not clearly define these weather conditions for staff.
On 08/17/23 the need to provide access to secured outdoor courtyard areas, except during nighttime hours or during severe weather was discussed with Staff 1. She acknowledged the findings.
A policy has been created stating when courtyard doors are to be opened and locked during extreme weather conditions. Specifics have been added to help guide the staff for consistency and safety. Signs have been placed on both courtyards stating when the doors will be locked.
Carestaff will continue to utilize the alarm system and check the courtyards when alerted to residents outside at all times.
Documentation of locking and unlocking courtyard doors will be kept and completed by Med Tech.
Lead Med Tech will be responsible for auditing this weekly and Executive Director will audit monthly.
There are no detail notes for this visit.
Based on observation and interview, it was determined the facility failed to ensure residents were not locked outside of their rooms and failed to have individual identifiers to assist residents in recognizing their rooms. Findings include, but are not limited to:
The MCC was toured on 08/14/23. Resident rooms 103, 111, 113, and 115 were occupied and lacked any individualized identification to assist residents in recognizing their room.
During observations on 08/14/23 through 08/17/23, doors to resident rooms on the MCC unit were observed closed. Further observations revealed many of the closed doors were locked. Multiple residents were observed being unable to go into their rooms without locating staff and asking to be let in.
In an interview on 08/15/23 Staff 11 (CG) stated resident's doors were locked to prevent wandering residents going into other's rooms. If residents wanted access to their rooms, they could let staff (who had keys) know and they would let them in.
The need to ensure residents were not locked out of their rooms and that rooms had individualized identifiers to assist residents in recognizing their rooms was discussed on 08/17/23 with Staff 1 (ED). She acknowledged the findings.
Executive Director has retrained all staff on leaving doors unlocked unless otherwise stated in the service plan. Service plans have been updated to ensure that ability to use key or alternatives are listed in their service plan.
Lifestyle Enrichment Director has replaced all identification boxes to ensure they are on the correct room for the correct resident. She will be responsible for updating these with new residents and when residents change rooms.
Med Tech, Lead Med Tech, Resident Services Coordinator and Executive Director will be responsible for doing walk-throughs daily and ensuring doors are unlocked unless otherwise stated in service plan. They will be responsible for ensuring the proper identification boxes are outside of the correct room.
Executive Director and/or Resident Services Coordinator will be responsible for auditing walk-through's monthly.
There are no detail notes for this visit.