The findings of the Initial Survey, conducted 08/16/22 through 08/18/22, 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, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.

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

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

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 re-visit to the re-licensure survey of 08/18/22, conducted 11/02/22, are documented in this report. It was determined the facility was in compliance with 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.

2. On 08/16/22 at 11:20 am, the surveyor obtained permission and observed Staff 4 (MA) provide incontinent care to Resident 1. During the observation, Staff 4 failed to change gloves after removing the soiled incontinent product and wiping urine from Resident 1's perineum. Additionally, she touched the resident's hands, clothing and clean incontinent brief while wearing the same soiled gloves. After care was completed, Staff 4 removed the gloves and escorted the resident to the dining room for lunch. Although Staff 4 washed her own hands, she failed to assist the resident with hand hygiene.  

The above observation was discussed with Staff 1 (Administrator) on 08/18/22 at 9:00 am. She acknowledged appropriate infection control practices were not implemented.

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:

Observations were made in the MCC during the survey to determine adherence to universal precautions for infection control.

1. On 08/17/22 at 10:30 am, the surveyor obtained permission and observed Staff 4 (MA) provide toileting assistance to Resident 2. During the observation, Staff 4 failed to change gloves after wiping urine from Resident 2's perineum. Staff 4 touched the resident's clothing while wearing the same soiled gloves. Following glove removal, Staff 4 touched the resident's wheelchair handles, robe, dining room chairs and dining room table. Staff 4 was not observed to wash hands after glove removal while in the resident's room or during subsequent tabletop activities in the dining room.

The need to ensure staff exercised universal precautions and infection control standards was discussed with Staff 1 (Administrator) on 8/18/22. She acknowledged the findings.

To correct this action, we have trained all current staff on universal precautions for infection control (from CDC website) during our September 2022 all hands staff meeting.  We have also purchased hand sanitizer stations for several areas around the facility.  To correct this system, all new staff will have more robust training in universal precautions for infection control.  This area will be evaluated and monitored quarterly for quality assurance by the Operations Manager.

Based on observation, interview and record review, it was determined the facility failed to provide a daily activity program of social and recreational activities based on individual and group interests, physical, mental and psychosocial needs, and create opportunities for active participation in the community at large. Findings include, but are not limited to:

During the survey, the MCC was home to nine residents.   

Random resident observations made on 08/16/22 and 08/17/22, review of the activity calendar, and interviews with staff revealed the following:

a. The August 2022 Memory Care Activity Program calendar provided during the entrance conference indicated the following activities would occur on 08/16/22:

* "Walk & Roll;

* Games; and

* Individual Activity."

On 08/16/22, the only activities observed occurred between 2:30 - 3:30 pm, when an activity staff person played cards and music with one resident. Although television movies and music played sporadically, no other activities were observed between 9:30 am and 4:00 pm.

b. On 08/17/22, the activity calendar noted the following activities would occur:

* "Remember When?;

* Exercise; and

* Massage."

The only activities observed between 8:30 am - 3:30 pm were Resident Council at 10:15 am and Bible Study/Hymn Singing with a volunteer at 1:30 pm.

Failure to provide a daily activity program of social and recreational activities based on individual and group interests, physical, mental and psychosocial needs, and that created opportunities for active participation in the community at large was discussed with Staff 1 (Administrator) on 08/18/22 at 9:00 am. Staff 1 stated the facility shared an activity staff person with the sister facility next door. She added that direct care staff were to conduct activities when the activity staff person was not working. She acknowledged the findings and stated she would review the daily activity calendar with direct care staff to ensure activities occurred.

This has been corrected by adding daily activity tasks in the staff electronic charting system.  This would give staff daily directions for activities.  This daily direction will mimic the posted activity calendar.  The facility will also better utilize our activity director to help the staff have accessible activities they can easily do and conveniently access to do with the residents.  Activity bins have been assembled for immediate use by staff/residents.  This will be evaluated quarterly during quality assurance review and the Administrator will be responsible to ensure continued compliance.

Based on interview and record review, it was determined the facility failed to ensure changes of condition were monitored until resolution or consistent with evaluated needs, and interventions were reviewed for effectiveness for 2 of 2 sampled residents (#s 1 and 2) who experienced short-term changes of condition. Findings include, but are not limited to:

1. Resident 1 was admitted in 06/2022.

Resident 1's clinical record and charting notes, reviewed from 06/16/22 through 08/16/22, revealed the following:

a. Resident 1 fell five times between 06/16/22 and 08/06/22. The facility failed to investigate the circumstances for several of the falls to determine if service-planned interventions were implemented, were effective, or if new interventions were needed. Additionally, there was no documented evidence the facility consistently monitored and documented on the progress of the resident's condition at least weekly until resolved.

b. Resident 1 sustained skin injuries on 07/11/22 and 07/16/22. Review of the record revealed no documentation on the progress of the resident's injuries at least weekly until resolved.

The need to ensure the facility monitored short term changes of condition with weekly progress noted until resolution, and fall interventions were reviewed to determine if they were effective and appropriate was shared with Staff 1 (Administrator) on 08/18/22 at 9:00 am. She acknowledged the findings. No new information was provided.

2. Resident 2 was admitted to the facility in 07/2022 with diagnoses including Alzheimer's disease and pulmonary fibrosis.

A review of the resident's clinical records indicated the following changes of condition had not been monitored at least weekly to resolution or consistent with his/her evaluated needs:  

a. An Incident Report dated 07/11/22 stated, "At lunch noticed [his/her] right knee is a big bruise." A progress note dated 07/24/22 stated, "[S/he] does have a bruise on [his/her] right knee from a prior fall."

b. Resident 2 was hospitalized from 07/28/22 to 08/05/22 for a urinary tract infection and possible upper respiratory infection.

The need to ensure changes of condition were monitored at least weekly until resolution or consistent with evaluated needs was discussed with Staff 1 (Administrator) on 08/18/22. She acknowledged the findings.

To correct this violation, the RN did late charting on the short-term changes of condition that had been monitored through completion but not properly documented in the progress notes.  Facility RN was new to the RCF rules and regulations this year.  Training was conducted with the RN and Administration team to review requirements on monitoring through condition resolution for all short-term changes of condition.  This will be evaluated quarterly during quality assurance review and the RN will be responsible to ensure continued compliance.

Based on interview and record review, it was determined the facility failed to ensure an RN assessment was completed in accordance with the resident's condition for 1 of 1 sampled resident (#2) who experienced changes of condition which required an RN assessment. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 07/2022 with diagnoses including Alzheimer's disease and pulmonary fibrosis.

Review of the resident's clinical records from 07/01/22 through 08/16/22 indicated the resident was hospitalized 07/28/22 - 08/05/22 with a urinary tract infection and possible upper respiratory infection. The resident was admitted to hospice on 08/05/22.

Hospitalization and admission to hospice represented a significant change of condition for Resident 2 for which an RN assessment was required.

There was no documented evidence the RN had assessed the status of the resident, documented findings as a result of the assessment, or developed interventions related to the resident's significant change of condition.

On 08/18/22 Staff 1 (Administrator) said she had just spoken on the phone with the facility RN who stated she had not completed an assessment.

The need to ensure an RN completed an assessment based on the resident's condition was discussed with Staff 1 on 07/18/22. She acknowledged the findings.

To correct this violation, RN completed CoC assessment on resident #2.  Facility RN was new to RCF rules and regulations this year.  To correct this system, training was conducted with RN to review requirements on need and timing of completion of RN assessment on change of conditions.  This will be evaluated quarterly during quality assurance review and the RN will be responsible to ensure continued compliance.

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

1. Resident 1 was admitted in 06/2022 with diagnoses which included Alzheimer's, hypertension and anxiety.

Review of the resident's clinical record revealed the following:

a. Resident 1 had an order for Quetiapine Fumarate 25 mg 1.5 tablets twice a day for anxiety.

The MAR, reviewed from 08/01/22 through 08/16/22, revealed staff were administering the Quetiapine once a day, not twice a day as ordered.

The discrepancy was discussed with Staff 1 (Administrator) on 08/16/22. She stated she would clarify the order with the physician.

In an interview on 08/16/22 at 4:00 pm, Staff 1 stated the order was clarified and staff were not administering the correct dose of Quetiapine. She stated the physician had been notified of the error and staff informed of the correct dose of medication.

b. The resident had an order for Carvedilol 3.125 mgs one tablet twice a day for hypertension.

According to the MAR, staff were instructed to hold the medication if the "heart rate is under 60 and if BP [blood pressure] is under 120/80 ..." However, there was no order authorizing staff to hold the medication.

From 08/01/22 through 08/16/22, staff held the medication on five occasions.

During a telephone interview on 08/17/22 at 2:55 pm, Staff 2 (RN) stated she wrote the parameters/instructed staff to hold the medication and failed to obtain a physician order authorizing the change.

Failure to ensure physician orders were carried out as prescribed was discussed with Staff 1 (Administrator) on 08/18/22. She acknowledged the findings. No further information was provided.

2. Resident 2 was admitted to the facility in 07/2022 with diagnoses including Alzheimer's disease and pulmonary fibrosis.

Resident 2's signed physician orders and 07/1/22 through 08/15/22 clinical records were reviewed.  

Resident 2 had physician orders dated 08/05/22 for "Dietary nutrition supplements two times daily [BID]."

There was no documented evidence the facility was providing dietary nutrition supplements to Resident 2. In an interview with Staff 1 (Administrator) on 08/18/22 she stated that "hospice doesn't usually like to use nutritional supplements."

The need to follow physician orders as written was discussed with Staff 1 on 08/18/22. She acknowledged the findings.

This violation was fixed by correcting the med order in the eMAR and notifying the primary care physician for resident #2.  It was also fixed by optaining clarification on the order for dietary supplements for resident #1 and discontinuing this order as instructed.  This system will be corrected by requiring all orders to be reviewed by the facility RN prior to filing.  Medication will not be accepted into our eMAR without verification of written order (unless done by the RN).  Medication orders will be reviewed monthly by the Administration team and reviewed, reconciled, and signed by the primary care physician quarterly.  The RN will be responsible for monitoring to ensure continued compliance.

2. Resident 1 was admitted in 06/2022 with diagnoses which included Alzheimer's, hypertension and anxiety.

Resident 1's MARs were reviewed for the time period of 08/01/22 through 08/16/22.

Staff documented Resident 1 refused:

* Amlodipine (for hypertension) on two occasions;

* Calcium supplement on three occasions;

* Alprazolam (for anxiety) on two occasions;

* Tylenol on two occasions;

* Levetiracetam (for seizures) on one occasion;

* Melatonin (for insomnia) on two occasions;  

* Stimulant laxative plus (for constipation) on two occasions; and

* Polyethylene glycol (for constipation) on two occasions.

There was no documented evidence the facility notified Resident 1's physician/practitioner of the refusals.

In an interview on 08/17/22, Staff 1 (Administrator) reviewed the record and acknowledged there was no documented evidence the facility had notified the physician/practitioner of the refusals.

Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused to consent to orders for 2 of 2 sampled residents (#s 1 and 2) who had documented medication and treatment refusals. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 07/2022 with diagnoses including Alzheimer's disease and pulmonary fibrosis.

Resident 2's MAR was reviewed for the time period of 08/01/22 through 08/16/22.

Staff documented Resident 2 refused:

* Aspirin (for heart health) on one occasion;

* Sertraline (for depression) on one occasion;

* Atorvastatin calcium (for cholesterol) on one occasion;

* Famotidine (for GERD) on one occasion;

* Vitamin D3 on one occasion; and

* Nystatin (for perineal rash) on one occasion.  

There was no documented evidence the facility notified Resident 2's physician/practitioner of the refusals.

The need to notify the physician of resident medication and treatment refusals was discussed with Staff 1 (Administrator) on 08/18/22. She acknowledged the findings.

This violation was corrected by sending communications to each primary care physician to notify them of the past refusals.  This communication will ask each provider how and when they would want to be notified of future refusals.  We have created a standard form to communicate refusals.  Quality assurance will be completed monthly by the RN and Administrator to make sure all refusals have been reported as the primary care physician desired.

Based on observation and interview, 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 C160.

Refer to C160

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 C242, C270, C280, C303 and C305.

Refer to C242, C270, C280, C303, and C305

Based on interview and record review, it was determined the facility failed to evaluate and develop individualized activity plans for 2 of 2 sampled residents (#s 1 and 2) whose records were reviewed. Findings include, but are not limited to:

There was no documented evidence an activity evaluation had been completed or individualized activity plan developed for Residents 1 and 2 to reflect the following:

* Current abilities and skills;

* Emotional/social needs and patterns;

* Physical abilities and limitations;

* Adaptations needed to participate; and

* Identification of activities for behavioral interventions.

There was no activity information included in Resident 1 and 2's service plans.

The requirements regarding activity evaluations and developing individualized activity plans was reviewed with Staff 1 (Administrator) on 08/18/22. She acknowledged the findings.

This violation was corrected by creating an individual activity plan for each resident.  The activity plans will be available for all staff to access and utilize for personalized activities.  To correct this system, an activity profile will be submitted to families of new residents prior to move in and a robust activity plan will be created upon admission.  This area will be evaluated and monitored quarterly for quality assurance by the Administrator.