The findings of the change of ownership survey, conducted 04/19/22 through 04/20/22 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 Home and Community Based Services Regulations OARs 411 Division 004.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first re-visit survey to the re-licensure survey of 04/20/22, conducted 06/30/22, 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, interview and record review, it was determined the facility failed to ensure residents who had changes of condition were evaluated, resident-specific instructions or interventions were developed and/or the condition was monitored for 1 of 3 sampled residents (# 5) who experienced changes of condition.  Findings include, but are not limited to:

Resident 5 was admitted to the facility in December 2021 with diagnoses including anxiety, alcohol abuse and a history of falls.

The resident's April 2022 service plan, 12/16/21 through 04/19/22 progress notes, the 12/15/21 initial evaluation and temporary service plans were reviewed. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, and were lacking interventions and resident specific directions to staff in the following areas:

* 12/2021 New admit to facility;

* Pressure ulcer to the sacral region, identified on the admission evaluation dated 12/15/21;

* 01/25/22 Return to facility from a hospitalization; and

* 4/14/22 Fall in the bathroom.

The need to ensure short term changes of condition had documentation to reflect monitoring to resolution at least weekly and provided clear resident specific directions to staff was discussed with Staff 1 (Executive Director), Staff 2 (Med Room Manager) and Staff 3 (Operations Support) on 04/20/22. They acknowledged the findings.

Resident 5 the RN will document a change of condition to include a full fall evaluation,skin assesment as well as an update on the evaluation and service plan. The RN will document weekly on the COC until resolved or new baseline is set.

All resident with frequent falls, skin conerns and/or visits to ER will be evaluated with the fall evaluation QA tool and skin evaluation and all falls going forward will receive an in-depth fall and/or skin evaluation and interventions.

The clinical management team will review all COC each morning at the morning clinical meeting to assure that COC is being monitored until resolved or new base line is set.

The ED will provide oversight.  

Based on interview and record review, it was determined the facility failed to ensure an RN assessment was completed for a significant change of condition, including findings, resident status, and interventions made as a result of the assessment, in a timely manner for 1 of 2 sampled residents (# 1) who experienced significant changes. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 10/2021 with diagnoses including history of stroke and hemiparesis of the left side.

The resident's 03/01/22 through 04/18/22 MAR, current service plan, dated 03/30/22, interim service plans, progress notes, dated 01/13/22 through 04/18/22, weight records from 12/29/21 through 04/18/22 were reviewed, and Staff 2 ( Med Room Manager) was interviewed.

On 01/13/22, the facility RN documented a follow up significant change of condition by video note, regarding an abrupt cognitive decline. The RN reported the resident was able to identify items close to home, location, and self, but not the date or president. There was no further documentation of the incident or instructions.

On 01/20/22, a significant change of condition for cognition and weight loss was documented by the RN. The progress note indicated the resident's weight had previously fluctuated from 132.5 lbs. in October to 127.5 lbs. in December and that the resident now weighed 130 lbs. and reported the resident was easily confused and minimally able to follow directions. "Will continue to monitor."

The above progress note dated 01/20/22 was duplicated and entered again, but dated 01/27/22 and signed on 01/30/22 by the RN.

Weight records identified the resident lost 7 lbs. between 01/20/22 - 02/07/22, or 5.4% of his/her total body weight in one month, which represented a significant change of condition and required a timely facility RN assessment.

Resident 1 experienced significant changes of condition related to an overall mental decline and weight loss. There was no documented RN assessment which included findings, resident status and interventions made based on the condition of the resident until 03/17/22 and 03/30/22.

On 04/20/22, the need to ensure RN assessments were performed in a timely manner for all resident's who had significant changes of condition, and  interventions made as a result of the assessment was discussed with Staff 1 (Executive Director) and Staff 3 (Operations Support). They acknowledged the findings.

Resident 1 the RN will document a change of condition to include a full weight review as well as an update on the evaluation and service plan. The RN will document weekly on the COC until resolved or new baseline is set.

All resident with a significant change to their weight  loss or gain will be evaluated with the weight evaluation QA tool and going forward will receive an in-depth weight evaluation and interventions.

The clinical management team will review all COC each morning at the morning clinical meeting to assure that COC is being monitored until resolved or new base line is set.

The ED will provide oversight.

Based on interview and record review, it was determined the facility failed to ensure a safe medication and treatment administration system was in place, that was approved by a pharmacist consultant, registered nurse, or physician. Findings include, but are not limited to:

During the survey, conducted 04/19/22 through 04/20/22, problems were identified in the medication administration system, including several medications for Residents 1, 2 and 5 which lacked reasonable administration time windows on the MAR (multiple medications with times listed as "am" or "pm").

In an interview with Staff 2 (Med Room Manager) was aware of the inaccuracies and was in the process of fixing the facility's medication administration system.  

Administrative oversight of the medication and treatment administration system was also found to be ineffective, based on deficiencies in the following areas:

C 304: Systems: Medication and Treatment Review; and

C 310: Systems: Medication Administration.

The unsafe medication system and lack of adequate professional oversight was discussed with Staff 1 (Executive Director) and Staff 3 (Operations Support) on 04/20/22. They acknowledged the findings.

A complete review of all resident medication administration times were reviewed and updated for accuracy of a safe medicaition administration system

All resident medications will included a parameter of time when each medication is to be administered

Medication reivews will be completed daily, with the clinical team for accuracy of system

The Ed will provide oversight

Based on interview and record review, it was determined the facility failed to ensure a registered pharmacist or registered nurse reviewed all medications and treatments administered to residents by the facility, at least every 90 days. Findings include, but are not limited to:

On 04/20/22, Staff 2 (Med Room Manager) stated the last time residents' medications and treatments were reviewed by a registered pharmacist or registered nurse was on 07/13/21. Staff  2 was currently working with the facility's regional RN to implement a system to review residents' orders quarterly.

The need to ensure a registered pharmacist or RN reviewed medication and treatments administered by the facility at least every 90 days was discussed with Staff 1 (Executive Director) and  Staff 3 (Operations Support) on 04/20/22. They acknowledged the findings.

RN will complete a review of all residents medications and treatments administered by the facility for accuracy and parameters of medication.  

Quarterly for all residents the facility administers medication and treatments for

Quarterly

The ED will provide oversight

Based on interview and record review, it was determined the facility failed to ensure resident's MARs were accurate, included clear instructions and parameters for administration of PRN medication, and documentation of effectiveness for 1 of 3 sampled residents (#1). Findings include, but are not limited to:

Resident 1's 03/01/22 through 04/19/22 MARs were reviewed during the survey. The following inaccuracies were identified:

* Resident 1 had orders for cefdinir (antibiotic) for UTI. Facility staff documented in the MAR they administered the medication on 03/15/22, 03/16/22, and 03/17/22; however, staff reported in the progress notes they were "waiting on antibiotics." Resident 1 received a new order for amoxicillin (antibiotic) for UTI. Facility staff documented in the MAR that the medication was administered from 03/18/22 through 03/23/22. According to the resident's progress notes, the facility was still waiting on the antibiotics. The facility staff failed to accurately document in the resident's progress notes that the medications were administered;

* The resident had PRN pain medications (acetaminophen tablet, acetaminophen suppository, morphine, and oxycodone). The MAR lacked clear direction and instruction to staff regarding the order of administration, and the effectiveness of PRN medications administered was not consistently documented; and

* Resident 1's MAR lacked specific administration times and had duplicate entries of medications.

On 04/20/22, the need for the facility to ensure MARs were accurate and provided clear instruction to unlicensed staff  was discussed with Staff 1 (Executive Director) and Staff 3 (Operations Support ). They acknowledged the findings.

A complete review of medications and and treatments administered by the facility for accuracy of progress note documentation and parameters of medications.

All Resident medications and documentation will be reviewed for accuracy.

Medication and documentation reviews will be completed daily with the clinical team for accuracy of the system.

The ED will provide oversight