The findings of the re-licensure survey, conducted 8/17/21 through 8/18/21 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Home and Community Based Services Regulations OARs 411 Division 004 and 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 first re-visit to licensure survey of 8/18/21, conducted 11/17/21 through 11/18/21, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 57 for Memory Care Communities.

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 second re-visit to the Change of Ownership survey of 08/18/21, conducted 01/12/22, are documented in this report. It was determined the facility was in compliance with the the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities.

2. Resident 1 was admitted to the facility in May 2021 with diagnoses including dementia.   

The resident's service plan dated 6/11/21 and interviews with care staff between 8/17/21 and 8/18/21 indicated the resident required two staff assistance with ADL care and transfers. The resident was able to make some needs known, was confused with short term memory problems. The resident had a history of attempting self transfers.

Review of incident investigations and progress notes from 5/7/21 through 8/17/21 showed the following:

Investigations were completed for unwitnessed, non-injury falls on 7/18/21, 8/3/21, 8/13/21, 8/14/21 and 8/15/21.

The investigations did not include information on how staff ruled out abuse and neglect. The investigations did not consistently include information regarding staff response at the time of the incident, follow up action taken and administrator review.  

The need to ensure resident incidents were promptly investigated to rule out abuse and neglect was discussed with Staff 1 (RCC), Staff 2 (Previous Administrator) and Staff 3 (RN) on 8/18/21. The staff acknowledged the findings.

3. Resident 4 was admitted to the facility in January 2018 with diagnoses including dementia.   

The resident's service plan dated 6/23/21 and interviews with care staff between 8/17/21 and 8/18/21 indicated the resident was dependent for all ADL care. The resident was able to make minimal needs known and was frequently confused.   

Review of incident investigations and progress notes from 5/16/21 through 8/17/21 showed the following:

a. Investigations were completed of unwitnessed, non-injury falls on 5/16/21, 5/29/21, 5/31/21, 6/5/21 and  6/19/21.

The investigations did not include information on how the staff ruled out abuse and neglect. The investigations did not consistently include information regarding staff response at the time of the incident, follow up action taken and administrator review.  

b. A progress note dated 7/2/21 indicated the resident was found to have a "hematoma/abrasion" to the left shin. The cause of the injury was unknown.  

A progress note dated 7/3/21 indicated the resident was found to have a bruise to the right side of her/his lip. The cause of the injury was unknown.  

A progress note dated 8/15/21 indicated the resident was found to have a skin tear to the arm. No other information was noted on the size, location or side of the body.

There were no investigations completed related to the 7/2/21, 7/3/21 and 8/15/21 incidents to rule out abuse and neglect. The facility was asked to report the injuries of unknown cause to the local SPD office and confirmation was provided prior to survey exit.

The need to ensure resident incidents were promptly investigated to rule out abuse and neglect was discussed with Staff 1 (RCC), Staff 2 (Previous Administrator) and Staff 3 (RN) on 8/18/21. The staff acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure all resident incidents/accidents were thoroughly investigated to rule out abuse and neglect and reported to the local Seniors and People with Disabilities (SPD) office when appropriate for 3 of 4 sampled residents (#s 1, 3 and 4) who had documented incidents/accidents which required investigation and/or reporting. Findings include but are not limited to:

1. Resident 3 was admitted to the facility in 2016 with diagnoses including dementia and osteoarthritis.

Review of Resident 3's clinical records and interviews with staff indicated the following incidents/accidents were not thoroughly investigated and/or reported to the local SPD office:

a. The following was documented in Resident 3's incident reports:

Resident 3 displayed memory, decision making, physical, and hearing impairments.

*6/4/21- Resident 3 was found by staff lying on his/her right side on the floor outside of the resident's bath room. Staff noted a small reddened bump on the right side of the resident's head. The resident was sent to the ER for further evaluation related to complaints of head pain;

*7/27/21- Resident 3 was found by staff on his/her bedroom floor, no injury was noted;

*8/5/21- Resident 3 was found by staff on the floor in front of his/her recliner, no injury was noted;

*8/9/21- Resident 3 was found by staff on the floor laying on his/her right side, no injury was noted; and

*8/13/21 Resident 3 was involved in a physical altercation with another resident. Resident 3 attempted to kiss the other resident on the forehead, the other resident "was not happy about this and put arm out and made contact with [Resident 3] resulting in [Resident 3] having a non injury fall".

The incident reports for the above occurrences stated the facility ruled out abuse, however there was no documented evidence as to how the facility made those determinations and there was no documented evidence the facility reported the incidents to the local SPD office.  

b.  A progress note dated 6/9/21 stated Resident 3's family had transported the resident to a doctors appointment, upon return to the facility staff observed a purple bruise on the left buttocks. There was no documented evidence the facility completed an incident report or investigated the origin of the bruise or reported the incident to local SPD office.

The need to ensure all incidents and/or accidents were thoroughly investigated and/or reported to the local SPD office as needed if abuse was not ruled out, was discussed with Staff 1 (RCC) and Staff 3 (RN) on 8/17/21.

The facility reported the necessary incidents to the local SPD office per the survey team's request and documented confirmation was provided.

C231 Abuse Reporting/ Investigation

1) Facility reported to local SPD office and confirmation was provided to state surveyors before exit for indentified residents 1, 3 and 4. Staff training to policy and OAR requirement with signature of acknowledgement by staff. Instruction by Admin/LN

2) Proper Incident report training during All Staff Mtg by Admin/LN.  

3) Each IR will be audited for compliance to policy and OAR weekly X 30 days, then quarterly thereafter.

4) RCC/LN

Based on observation and interview, it was determined the facility failed to ensure the kitchen was maintained in accordance with OAR 333-150-0000 (Food Sanitation Rules). Findings include, but are not limited to:

Observations of the facility's kitchen on 8/17/21 and 8/18/21 showed the following areas were in need of cleaning and/or repair:

* Flooring throughout the kitchen had large areas of brown discoloration and stains;

* The perimeter of the floor, baseboards, and underneath equipment (dish machines, upright coolers, stove, and shelves) had a buildup of black dirt/dust and food debris;

* Cabinet exteriors throughout the kitchen and walls near the stove and dry food storage had areas of chipped and peeling paint;

* Walls near the dry storage area had a build up of splatters and black smudges; and

* The countertop, near the dish machine, had an area of chipped laminate which exposed the underlying wood material making the surface un-cleanable.

The kitchen was toured with Staff 2 (Previous Administrator) on 8/18/21. She acknowledged the areas in need of cleaning and/or repair.

C240 Kitchen/ Food Sanitation

Kitchen flooring inspected by company that installed the product.  Per their recommendation, floor staining attributed primarily to black floor mats.  Floor inspection reveals all seams are intact, and floor is not in need of replacement.  Floor will be cleaned with manufacturer recommended cleaning product and cleaned with commercial scrubber.  Kitchen cabinets will be repainted, Walls repainted, Kitchen deep cleaned, chipped laminate to be replaced by owner of building on Oct 12, 2021.

1) Kitchen Maintenance Binder created and maintained in kitchen. Kitchen staff to monitor for paint chips, counter damage, or flooring issues.

Administrator to obtain logs monthly and report needed repairs to maintaince on maintenance log.

2) Maintenance to repair as indicated.  

-Kitchen flooring to be inspected by installation company for needed repairs. Repairs will be scheduled as needed.

-Building owner meeting to discuss formica and flooring repairs.  Repairs to be conducted to identified counter and flooring.   

3) Monthly

4) Administrator/owner

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

Resident 1 was admitted to the facility on 5/6/21 with diagnoses including dementia.

Resident 1's new move-in evaluation labeled "Evaluation/Assessment Form," dated 5/3/21 failed to address the following areas:

* Interests, hobbies, social, leisure activities;

* Memory, orientation, confusion and decision making abilities;

* Pain, drug and non-drug interventions;

* Nutrition habits, fluid preferences and weight if indicated;

* Recent losses;

* Unsuccessful prior placements;

* History of dehydration or unexplained weight loss or gain;

* Elopement risk or history; and

* Environmental factors that impact the resident's behavior, including noise, lighting and room temperature.

The need to ensure move-in evaluations included all required elements was discussed on 8/18/21 with Staff 1 (RCC), Staff 2 (Previous Administrator) and Staff 3 (RN). The staff  acknowledged the findings.

C252 Resident Evaluation

Resident 1 evaluation assessment form updated to include missing components

1) All elements of preadmission screenings will be completed on  prior to admission.

2) Nurse or designee to fill out pre-admission form completely prior to admission. Second check will be done by Admin/LN will confirm that all elements of preadmission assessement are completed prior to admission using second check stamp and initial.

3) Admin to audit each admission to facility x 1 quarter for compliance, then quarterly therafter.

4)Administrator.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction to staff and were followed for 3 of 4 sampled residents (#s 1, 3 and 4) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in May 2021 with diagnoses including dementia.

Review of the resident's service plan dated 6/11/21 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:

* Catheter;

* Airbed/air overlay mattress;

* Stage 2 pressure ulcer;

* Weights;

* Behaviors related to calling out; and

* Fluid assistance between meals.

The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (RCC), Staff 2 (Previous Administrator) and Staff 3 (RN) on 8/18/21. The staff acknowledged the findings.

2. Resident 4 was admitted to the facility in January 2018 with diagnoses including dementia.

Review of the resident's service plan dated 6/23/21 showed the service plan was not consistently followed by staff in the following areas:

* Pressure alarm;

* Toileting/incontinent care;

* Behaviors;

* Fall mat; and

* Responding to/operation of a motion alarm.

Observations of the resident on 8/17/21 and 8/18/21 showed a pressure alarm was not consistently in place in the wheelchair or on the resident's bed. A motion alarm located in the resident's room was not functioning properly at the time of observations.

The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (RCC), Staff 2 (Previous Administrator) and Staff 3 (RN) on 8/18/21. The staff acknowledged the findings.

3. Resident 3 was admitted to the facility in 2018 with a diagnosis including dementia.

Review of Resident 3's service plan dated 8/13/21 indicated the service plan was not reflective of the resident's needs and/or did not provide clear direction to staff in the following areas:

* Fall interventions and the residents ability to use the call light;

* Communication related to the resident's primary language; and

*The resident's tendency to unknowingly invade the personal space of other resident's.

The need to ensure the service plan was reflective of the residents' need and provided clear direction to staff was discussed with Staff 1 (RCC), Staff 2 (Previous Administrator) and Staff 3 (RN) on 8/18/21. They acknowledged the findings.

C 260 Service Plans

Service plan for resident 1, 3, 4 updated to reflect current care needs for each individual resident.

1)Temporary Service Plans will be incorporated into Service plan creation and renewals (30 days, 90 days, and Change of Conditions).

2) All Direct Care Staff is to sign new Service Plan at the start of every shift.

SP binder will be kept in med room to include SP and TSP for each resident. Admin/Resident Care Coordinator will monitor all Temporary Service Plans weekly to ensure all care personnel have read, understood and signed TSP.

All TSPs will remain with SP until quarterly evals are completed and changes identified in TSPs are incorporated into SP.

3)Weekly for TSP by RCC, and with each SP renewal.

4)Administrator

3. Resident 1 was admitted to the facility in May 2021 with diagnoses including dementia.

The resident's June 2021 service plan, 5/19/21 through 8/17/21 progress notes, temporary service plans and physician faxes were reviewed. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness and/or lacked resident specific directions to staff in the following areas:

* Multiple falls;

* Admission to hospice;

* Return from the hospital; and

* Discontinuation of catheter.

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 (RCC), Staff 2 (Previous Administrator) and Staff 3 (RN) on 8/18/21. The staff acknowledged the findings.

4. Resident 4 was admitted to the facility in January 2018 with diagnoses including dementia.

The resident's June 2021 service plan, 5/19/21 through 8/17/21 progress notes, temporary service plans and physician faxes were reviewed. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness and/or lacked resident specific directions to staff in the following areas:

* Multiple falls;

* Emergency room visit;

* Medication changes:

* Neck nodule;

* Behaviors with dressing changes; and

* Laceration with stitches, skin tears and bruise to the lip.

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 (RCC), Staff 2 (Previous Administrator) and Staff 3 (RN) on 8/18/21. The staff acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure residents who experienced changes of condition were evaluated, necessary actions/interventions were determined, documented and communicated to staff and the residents' condition, including effectiveness of interventions, was monitored weekly through resolution for 4 of 4 sampled residents (#s 1, 2, 3 and 4) who had documented changes of condition. Resident 2 experienced severely itchy skin resulting in scratches and sores on her/his back which went untreated. Findings include but are not limited to:

1. Resident 2 was admitted to the facility in 2018 with diagnoses including dementia, Rosacea, and diabetes.

a. Review of the resident's progress notes dated 5/29/21 through 8/16/21, MARs/TARs dated 6/1/21 through 8/16/21, evaluations and service plan dated 6/2/21, temporary service plans and physician's orders and communications revealed the following:

Resident 2's service plan dated 6/2/21 stated the resident had no skin integrity issues.

* An RN progress note dated 6/7/21 stated staff reported the resident had sores on her/his back. The RN documented "red, scabbed areas noted to the back that look to be from scratching. Resident denies pain. Will instruct staff to use lotion on resident's back on shower days in case dry skin is contributing to itching and to keep resident's nails trimmed."

There was no documented evidence a temporary service plan was developed to communicate this intervention to staff on all shifts. There was no documented evidence the resident's skin condition, and the effectiveness of the interventions were monitored weekly.

* On 6/17/21 progress notes stated the facility received faxed orders for two new anti-itch treatments:

Apply moisture cream BID (two times daily) and PRN; and

Apply Hydrocortisone 1/% cream BID and PRN, for no more than two weeks.

The order for the moisture cream was inaccurately transcribed as PRN only and there was no documented evidence the facility applied the cream BID as ordered. There was no documented evidence the facility monitored the status of the resident's skin condition or effectiveness of the treatment orders/interventions.  

* On 7/8/21 an LN progress note stated the Hydrocortisone cream was completed 6/29/21 and noted the resident still had itching on her/his face and back and "has scratched to the point of causing sores" on her/his face. "Will notify PCP and request an order."

* On 7/9/21 the facility received a faxed order from the physician instructing the facility to send the resident to a dermatologist. There was no documented evidence the facility contacted the dermatologist to make an appointment until 7/19/21. The appointment was then scheduled for 8/5/21.

* On 7/24/21 the MT documented staff observed the resident "continuously scratching arms, head, and back" and applied triple antibiotic ointment. Staff noted the sores "seemed to be getting worse" and noted the resident was very confused. There was no documented evidence the resident's worsening skin condition was evaluated or monitored.

* On 8/5/21 progress notes stated the resident returned from an appointment with new orders to apply Sarna HC lotion several times a day, PRN whenever patient was scratching.

* On 8/6/21 a progress note indicated the resident stated her/his back was very itchy and the MT applied triple antibiotic ointment.

* On 8/12 a progress note stated the facility spoke with the resident's family to inform them the Sarna HC was an over-the-counter treatment and would not be covered by insurance, the family agreed for the pharmacy to bill them for the treatment.

b. Interviews conducted with staff during the survey indicated the following:

* On 8/17/21 the surveyor requested any notes or documentation related to the resident's skin condition. The RN provided a skin note dated 8/16/21 which stated the resident had a 1.0 cm by 1.0 cm sore on the upper left back.

* On 8/18/21 Staff 9 (CG) stated the caregiving staff observed the residents' skin during showers and stated Resident 2 had sores all over her/his back, arms and chest, some were open but no bleeding or oozing that staff were aware of. Staff 9 stated the resident was frequently seen scratching at arms, back and chest and all treatments were applied by the treatment aides not the caregiving staff.

* During an interview on 8/18/21 with Staff 4 (MT) and Staff 5 (Treatment Aide) they reported the Sarana HC lotion was just recently delivered to the facility and Staff 5 provided a treatment record which indicated the Sarna HC was administered on 8/16/21 and 8/17/21.

c. Observation made during the survey indicated the following:

The surveyor requested the facility RN and an RN surveyor complete an observation of Resident 2's skin. During the observation the RN surveyor noted the following:

* Multiple open and scabbed areas were noted on the resident's arms. The lower left arm had three open areas. The upper right arm had five open and scabbed sores.

* Multiple open sores were noted on the residents back, from the neck to the shoulder and down to the mid back, no drainage from the sores was noted; and

* A red, swollen pustule area approximately 2.0 cm by 3.0 cm was noted on the right side of the resident's head.

The RN surveyor instructed the facility RN to complete a thorough assessment of the resident's skin and report to the resident's physician.

Resident 2 experienced severely itchy skin resulting in scratches and sores on her/his back which went untreated and were not monitored by the facility resulting in worsening of Resident 2's skin condition. At the time of survey the resident had developed numerous sores and wounds on his/her back, arms, and chest as well as a potentially infected wound on his/her head.

The need to ensure residents who experienced changes of condition were evaluated and necessary actions/interventions were determined, documented, and communicated to staff and the residents' condition, including effectiveness of interventions, was monitored weekly through resolution was discussed with Staff 1 (RCC), Staff 2 (Previous Administrator) and Staff 3 (RN) on 8/18/21. The staff acknowledged the findings.

2.  Resident 3 was admitted to the facility in 2016 with diagnoses including dementia and osteoarthritis.

Review of Resident 3's clinical records indicated the facility failed to determine necessary actions/interventions and communicate those interventions to staff on all shifts and the facility failed to provide weekly monitoring of the resident's condition including the effectiveness of interventions when Resident 3 experienced the following short term changes of condition:

* 5/19/21- Staff documented the resident had a lump on the abdomen;

* 6/4/21- The resident had a fall and hit his/her head;

* 6/9/21- Staff discovered a bruise to the resident's left buttocks;

* 7/4/21- Staff documented the resident lost a front tooth during the dinner meal;

* 7/10/21- Staff documented signs and symptoms of a urinary tract infection and obtained an urine analysis;

* 7/27/21- The resident had an unwitnessed non- injury fall. Staff found the resident on his/her bedroom floor;

* 8/5/21- The resident had an unwitnessed non-injury fall. Staff found the resident on the floor in front of his/her recliner chair; and

* 8/10/21- The resident had an unwitnessed non-injury fall in the hallway.

The need to ensure,  when residents experienced changes of condition, the facility determined necessary actions/interventions and communicated the interventions to staff on all shifts and ensure weekly monitoring of the resident's condition including the effectiveness of intervention was provided and documented in the residents record was discussed with Staff 1 (RCC), Staff 2 (Previous Administrator) and Staff 3 (RN) on 8/18/21. The staff acknowledged the findings.

Orders, treatments identified for residents 1,2,3,4 completed and followed through to completion.

1) Significant Change of Condition Log added to 24hr book will be monitored weekly until resolved by RN.  

2) Admininstrator an LPN will audit weekly to make sure signifcant change of condition is being monitored until resolution.

3)  Evaluate Quarterly Team Meeting at time of Service Plan review to Audit Changes are Effective - Administrator, RN, LPN, and RCC responsible.

4) Administrator.

Based on interview and record review, it was determined the facility failed to ensure physicians orders were available in the residents' records and were carried out as prescribed for 2 of 4 sampled residents (#s 1 and 2) whose orders were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in May 2021 with diagnoses including dementia.  

The resident's 7/23/21 signed physician orders and 8/1/21 to 8/17/21 MARs showed the following:

* An order for Morphine Sulfate 20 mg/1.0 ml, give 0.25 ml by mouth twice daily at 8:00 am and 5:00 pm for pain.

The MAR indicated the medication was to be given at 8:00 am and 8:00 pm and was signed as given. There was no additional orders located regarding a change in the medication administration time.

* An order for Quetiapine 25 mg, give half a tablet by mouth daily at bedtime, 8:00 pm to help with sleep.

The MAR showed the medication was given at 8:00 am and 8:00 pm each day. There was no additional orders located regarding a change in the medication administration times.

The need to ensure orders were available in the resident's record for all prescribed medications and were administered as ordered by the prescriber was discussed with Staff 1 (RCC), Staff 2 (Previous Administrator) and Staff 3 (RN) on 8/18/21. The staff acknowledged the findings.

2. Resident 2 was admitted to the facility in 2018 with diagnosis including Rosacea and dementia.

Review of Resident 3's current physician orders and MARs dated 6/1/21 through 8/16/21 showed the following:

* An order dated 6/16/21, instructed staff to apply Aveeno moisturizing lotion twice daily and as needed (PRN) for dry skin.  The order was inaccurately transcribed to the MAR as PRN only. There was no documented evidence the facility administered the treatment twice daily as ordered;

* On 7/9/21, the facility received a faxed order from the physician instructing the facility to send Resident 2 to a dermatologist. There was no documented evidence the facility contacted the dermatologist to schedule an appointment until 7/19/21; and

* On 8/5/21 the facility received an order instructing staff to apply Sarna HC (an over the counter treatment for itching) "several times a day, PRN when patient is scratching." There was no documented evidence the facility administered the treatment from 8/5/21 through 8/16/21.

The need to ensure physician's orders were carried out as prescribed was discussed with Staff 1 (RCC), Staff 2 (Previous Administrator) and Staff 3 (RN) on 8/18/21. They acknowledged the findings.

C 303- Systems- Treatment Orders

1) Resident 1's MAR for Morphine has been clarified for 8am- 8pm. New Seroquel order has been received and updated on MAR. Resident 3 Aveeno Moisturizing cream order clarification has been received and incorporated into MAR.

2) QMAR update to alert Med Tech's earlier of pending need for controlled substance reorders to give more time for PCP response - Adminstrator, LPN, Pharmacy

3) Noc shift tasked with DAILY re- ordering of ALL medications with 10 doses or less left. Re-order tracking log added to 24hr book. Checked daily by LPN, RCC, and Admin to assure progress is being made in attaining the medication and it is documented. Will be utilizing triple check system for new orders including proper parameters for PRN medications to including sequence of med admin- 1st check Med Tech, 2nd check RCC/Admin, 3rd check LN

4) Daily Clinical Meeting to review any medication exceptions on the dashboard - Admin, Nurses, RCC

5 ) Quarterly QA meeting to assure changes are effective - Admin, Nurses, RCC

2. Resident 1 was admitted to the facility in May 2021 with diagnoses including dementia.

Review of the resident's 5/17/21 through 8/19/21 progress notes, 7/23/21 physician orders and the 8/1/21 through 8/17/21 MARs/TARs showed the following:

* Bisacodyl suppository PRN for constipation.

The MAR gave no direction to staff on when to start the medication.

* Morphine Sulfate 20 mg/1.0 ml, give 0.25 ml every hour as needed for pain or shortness of breath and Tylenol 650 mg suppository every six hours as needed for mild pain or fever.

The MAR gave no direction to staff on which medication to use first for the resident's pain.

The need to ensure MARs were complete and included clear direction to staff for PRN medication administration was discussed with Staff 1 (RCC), Staff 2 (Previous Administrator) and Staff 3 (RN) on 8/18/21. The staff acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure an accurate MAR/TAR was maintained for all facility administered medications and treatments, including resident specific parameters for PRN administration for 2 of 4 sampled residents (#s 1 and 2) whose orders were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 2018 with diagnosis including hypertension and dementia.

Review of Resident 3's current physician orders and MARs dated 6/1/21 through 8/16/21 showed the following:

* The MARs instructed staff not to administer Atenolol (a medication for hypertension) if the resident's systolic blood pressure (SBP) was under 110 and diastolic blood pressure (DBP) was under 60 and pulse was under 65. The MAR lacked documented evidence the resident's blood pressure was taken prior to the administration of the medication from 6/1/21 through 8/16/21; and

*The MARs instructed staff not to administer Lisinopril (a medication for hypertension) if the resident's systolic/diastolic blood pressure was less than 120/60. The MAR lacked documented evidence the resident's blood pressure was taken prior to the administration of the medication from 6/1/21 through 7/22/21.

The need to ensure an accurate MAR was maintained, was discussed with Staff 1 (RCC), Staff 2 (Previous Administrator) and Staff 3 (RN) on 8/18/21. They acknowledged the findings.

C 310 Medication Administration

Orders received for residents 1, 2 to clarify order of administration of prn medications. Orders clarified for hold parameters.

1) MAR updated with blood pressure parameters for indentified resident.

2) Med aids to review medication administration policy- Admin, LN

3) Medication pass audit -

4) LN  

2. Resident 1 was admitted to the facility in May 2021 with diagnoses including dementia.

Review of the resident's physician orders and the 11/1/21 through 11/17/21 MARs/TARs revealed the following:

a. The portion of the hospice orders to notify hospice prior to administering PRN Bisacodyl suppository (for constipation) and PRN Acetaminophen suppository (for pain) were not fully transcribed, staff were unaware to contact hospice prior to administering.

b. Quetiapine PRN for agitation lacked clear resident specific parameters directing staff when to administer.

The need to ensure MARs were complete and included clear direction to staff for PRN medication administration was discussed with Staff 16 (Administrator), Staff 1 (RCC), and Staff 17 (LPN) on 11/18/21. The staff acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure an accurate MAR/TAR was maintained for administration of medications, including resident specific administration instructions, parameters and reasons for use for PRN medications for 2 of 3 sampled residents (#s 1 and 5) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 5 was admitted to the facility in 10/2020 with diagnoses including bipolar mood disorder and dementia.

Review of Resident 5's current physician orders and MARs dated 11/01/21 through 11/17/21 revealed the following:

a. Acetaminophen 325 mg tablet every six hours as needed for pain;

* Acetaminophen 650 mg suppository every six hours as needed for pain or temperature greater than 100 degrees F; and

* Hydromorphone 1 mg every 15 minutes as needed for pain or shortness of breath.

The MAR lacked specific administration instructions for pain medications.

b. Alum & Magnesium Hydrox-Simethicone 30 ml every four hours as needed for upset stomach or heartburn; and

* Antacid-Antigas liquid 30 ml every four hours as needed for upset stomach or heartburn.

The MAR lacked specific administration instructions for the gastrointestinal medications.

c. Haloperidol 2 mg every two hours as needed for anxiety/agitation;

* Lorazepam 0.5 mg every four hours as needed for anxiety or shortness of breath; and

* Z ABH cream 1 ml to be applied topically to the inner wrist every six hours as needed for anxiety/agitation.

The MARs did not contain resident specific parameters for staff describing how the resident expressed anxiety and agitation and lacked specific administration instructions for the psychotropic medications.

d. Hyoscyamine every four hours as needed for terminal secretions did not contain resident specific parameters for staff describing the symptoms of terminal secretions, or additional instructions as indicated.

e. Iprat-Albut nebulizer treatment every six hours as needed lacked the reason for use on the MAR.

f. Senna liquid 10 ml ordered twice daily as needed for constipation lacked specific administration instructions in relation to three other PRN bowel care medications on the MAR (1. Milk of Magnesia, 2. Bisacodyl suppository and 3. Enema).

The need to ensure that PRN medications on the MAR/TAR's included resident specific administration instructions, parameters and reasons for use for administration of PRN medications was discussed with Staff 16 (Administrator), Staff 17 (LPN) and Staff 1 (RCC) on 11/18/21.  They acknowledged the findings.

C 310 Systems - Medication Administration

Orders received for residents 1 and 5 to clarify order of administration of PRN medications. Instructions describing resident specific symptoms added to applicable PRN medicatons.

1) MAR updated with PRN medication peramters for identified residents

2) 3 check system completed in 24 hours to ensure timely manner of corrections to orders

3) MAR Audit once monthly and at each new admission

4) LN  

Based on interview and record review, it was determined the facility failed to ensure PRN psychotropic medications used to treat a resident's behaviors and anxiety had written, resident-specific parameters and non-drug interventions for staff to attempt prior to administering the medication for 1 of 2 sampled residents (#1) who were prescribed PRN medication to address behaviors. Findings include, but are not limited to:

Resident 1 was admitted to the facility in May 2021 with diagnoses including dementia.

Review of the resident's 8/1/21 through 8/17/21 MAR and 7/23/21 physician orders showed the following psychotropic medications:

* Lorazepam 0.5 mg (a psychotropic medication) one tablet every two hours as needed for anxiety, restlessness or insomnia.

The facility administered the Lorazepam to the resident on six occasions in August 2021.

* Haloperidol 1 mg (a psychotropic medication) give a half tablet every two hours as needed for nausea, vomiting, hallucinations, agitation or delirium: and

* Quetiapine 25 mg (a psychotropic medication) give a half tab one hour after scheduled dose as needed for agitation.

The facility did not administer either medication during August 2021.

The MARs did not contain resident specific parameters for staff describing how the resident expressed anxiety, restlessness and agitation. Additionally, there was no documentation of what non-drug interventions were attempted prior to administration of the medications.

The need to ensure there were resident-specific descriptions of how the resident expressed anxiety, restlessness and agitation and that non drug interventions were attempted and documented prior to administration of the medication was discussed with Staff 1 (RCC), Staff 2 (Previous Administrator) and Staff 3 (RN) on 8/18/2021. The staff acknowledged the findings.

C 330 Psychotropic Medication

1) Create alternative measure list for Med Tech built into QMAR for psychotropic PRN's.

2) Weekly audits of psychotropic medication administration and interventions - LN

3) Med aids to review and re-sign company policy and procedure for psychotropic medications

4) LN/Admin weekly X4 weeks, then monthly X3 months, then quartly review via exteneral pharmacy review

Based on interview and record review, it was determined the facility failed to ensure their relicensure survey plan of correction was implemented and satisfied the Division.

Refer to C 310 and Z 162.

C 455 Inspections and Investigations: Insp Interval

Refer to C310

1) Corrections of MAR completed

2) Completion of C310 SOC tag by compliance date

Based on observation and interview, it was determined the facility failed to ensure courtyard surfaces were maintained in good repair and that the facility grounds were orderly and free of litter. Findings include, but are not limited to:

Observations of the courtyard on 8/17/21 showed the following:

* Concrete that had cracked, separated and was pushing up creating an uneven surface;

* Multiple drop offs of 2-3 inches along pathway edges;

* Numerous large black garbage bags both intact and shredded, behind and next to the storage shed in the resident courtyard. The bags appeared to be full of pop cans with used plastic silverware, socks, soiled/discolored paper products and other debris inside and on top of the bags.

The need to ensure pathways in the resident courtyard did not have potential tripping hazards and that the facility grounds were kept free of trash and debris was discussed with Staff 2 (Previous Administrator) on 8/17/21. The trash bags were removed after the environment tour with Staff 2. She acknowledged the findings.

C 510 General Building Exterior

1) Identified uneven concrete surface to be repaired by maintance. Monthly walk through for edges and ground sweeps. Maintance will assure exterior furinture is properly secured and to report it to Admininstrator.

2) Maintance request forms available for all staff - Admin

3) Staff training on when to fill out a form and what to do with it (put in Maintance Binder) - Admin

4) Maintance Binder created and maintained in Admin office.

5) Quarterly QA meeting to assure that changes are effective and being followed- Admin

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

Observations of the facility on 8/17/21 and 8/18/21 showed the following areas in need of cleaning or repair:

* Multiple walls and door frames in the dining room and TV area had black streaks, scrapes, drips and dings;

* Multiple chairs in the dining room had food stains and debris on the backs or arms;

* Gaps between the floor and wall in the dining room had debris and dark accumulation. The dining room floor had multiple boards pulling apart, had large cracks and/or pieces missing;

* A leather recliner and an upholstered sitting chair had large rips to the fabric on the foot rest and seat. Two upholstered sitting chairs had large white crusty stains to the seat and dark gray/black stains to the arm rests;

* Window sills in the dining room had debris, dead insects and bubbled laminate surfaces;

* Carpet in the TV area and long hall near the nursing office had multiple black stains of varying sizes; and

* Counter edges in the dining room and laundry room had large chips and pieces of missing laminate.

The areas in need of cleaning and/or repair were shown to and discussed with Staff 2 (Previous Administrator) on 8/17/21. She acknowledged the findings.

C 513 Doors, Walls, Elevators, Odors

1) Flooring will be repaired by external flooring company. Listed furniture has been removed 8/18/21. Identified areas have been repainted and cleaned including window sills and carpet. Kitchen services will be repaired by 10/17/21.

2) Housekeeping/Maintance Log has been created for needed repairs for facility. Housekeeping/Maintance will sign off items when completed.

3) Adminstrator to obtain logs monthly.

4) Quarterly QA meeting to assure that changes are effective and being followed - Administrator.

Based on observation and interview, it was determined the facility failed to ensure washing machines had a minimum rinse temperature of 140 degrees Fahrenheit or used a chemical disinfectant when washing soiled linens and soiled clothing. Findings include, but are not limited to:

The facility laundry room was observed on 8/17/21 and 8/18/21. The washing machines were a residential type with no indicator for the water temperature. The detergent the facility used did not include a disinfecting agent.

The need to ensure soiled laundry was properly disinfected was discussed with Staff 1 (RCC) and Staff 2 (Previous Administrator) on 8/18/21. They acknowledged the findings.

C 530 - Housekeeping and Laundry

1) Oxiclean Sanitizer implemented. Added to list of supplies to re-order. Admin

2) Laundry Policy Updated- Owner

3) Staff training at All Staff Mtg to go over new procedure - Admin

4) Quarterly QA Review that systems are being used and effective. Admin, LPN, RCC, RN

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

Observations on 8/17/21 and 8/18/21 showed exit doors to the resident courtyard did not have an operational alarm or other acceptable system to alert staff when residents exited the building. Motion alarm sensors were observed above the doors but were turned off and/or pointed towards the ceiling.

The need to ensure exit doors were equipped with a functional alarming device or other acceptable system was discussed with Staff 1 (RCC) and Staff 2 (Previous Administrator) on 8/17/21 and 8/18/21. The staff acknowledged the findings.

C 555 - Call Sys, Exit Dr Alarm, Phones, TV, or Cable

1) Door alarms have been installed for all exit doors 8/19/2021

2) Maintenance Request Forms Available for all staff- Admin

3) Staff training on when to fill out a form and what to do with it (put in Maintenance Binder)- Admin

4) Maintenance Binder created and maintained in Admin office. Maintenance emailed weekly any door alarm replacement - Admin

5) Quarterly QA Meeting to assure that changes are effective and being followed. Admin

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 C 231, C 240, C 510, C 513, C 530 and C 555.

Z 142 - Admin Compliance - Refer to C530 and C555

Based on interview and record review, it was determined the facility failed to ensure all newly hired direct care staff completed all required training within 30 days of hire for 1 of 4 newly hired direct care staff (#15), whose training records were reviewed. Findings include but are not limited to:

Training records were reviewed on 8/18/21 and the following was identified:

Staff 15 (MT) was hired on 5/24/21. There was no documented evidence Staff 15 completed the required demonstration of skill competency within 30 days of hire.

The need to ensure all newly hired direct care staff completed all required training was discussed with Staff 1 (RCC) on 8/18/21, she stated Staff 15 would be removed from the schedule until all training was completed.

Z155 Staff Training

1) Audit tool attached to all employee charts - RCC to ensure staff returns training packet at the end of shift. All training records to stay on site of facility.

2) Quarterly audits for accuracy - Administrator, RCC

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 C 252, C 260, C270, C 303, C 310 and C 330.

Z162 Compliance with Rules Health Care-See Plan of correction for C270, C303

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 310.

Compliance with Rules of Health Care - See Plan of correction for C310.

Based on observation, interview and record review, it was determined the facility failed to consistently provide meaningful activities for all residents that promoted or helped sustain the physical and emotional well-being of the resident and failed to ensure an individualized activity plan was developed for each resident based on their activity evaluation, for 3 of 4 sampled residents (#s 1, 2 and 3) whose service plans were reviewed. Findings include, but are not limited to:

Resident 1, 2 and 3's service plans offered some information about the resident's interests, but the facility had not fully evaluated the resident's:

* Current abilities and skills;

* Emotional and social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for the resident to participate; and

* Activities that could be used as behavioral interventions, if necessary.

There was no specific activity plan which detailed what, when, how and how often staff should offer and assist the resident with more individualized activities.

Observations on 8/17/21 and 8/18/21 showed multiple small group activities being led by facility staff. Residents 1, 2 and 3 were not invited to activities, assisted with mobility to the activity or provided adaptations to participate in the activity.

The need to ensure all residents had individualized activity plans developed and implemented to engage them in meaningful activities was discussed with Staff 1 (RCC), Staff 2 (Previous Administrator) and Staff 3 (RN). The staff acknowledged the findings.

Z 164 - Activities

1) Acitivity and Social history form created and will be added to Admissions paperwork- Admin

2)Activity Director will be responsible for following up with families to assure these are turned in as well as interviewing new residents to develop Activity Plan

3) Activity Director will turn in plan to Administrator at time of Service Plan creation and renewals (30 days, 90 days, Change of Conditions)

4) Acitivity Plan will be a part of the Service Plan

5) Activity Director will maintain Activity Service plan book and add/ change as needed in between Service plan review dates

6) Any changes will be added to Service Plan upon Service Plan review by Admin/ RCC

7) Admissions paperwork Audit form completed by Admin and maintained in Resident Chart

8) Quarterly QA meeting to assure changes made are effective and being followed.

Based on observation and interview, it was determined the facility failed to ensure furniture in the outdoor recreation areas was of sufficient weight and design to not aid in elopement and that fencing was no less than six feet in height. Findings include, but are not limited to:

On 8/17/21 and 8/18/21 tour of the facility courtyard showed the following:

* Five tall, metal patio chairs which were easily moveable and not of sufficient weight or design to prevent potential elopement.

The facility was asked on 8/17/21 to remove the chairs or secure them to prevent elopement. The chairs were again observed on the patio on 8/18/21 at which time two female residents were observed to move the chairs they were sitting in around the patio without difficulty. The residents stated they were looking for a sunny spot to sit and did not approach the fence or attempt to leave the courtyard.

The facility was again asked to remove or secure the chairs. The chairs were immediately removed from the patio area.

* Four large sections of fencing were less than six feet in height, sections varied from approximately 67 inches to 71 inches tall.

The fencing sections that were less than six feet in height were shown to and discussed with Staff 2 (Previous Administrator) and Staff 13 (Maintenance) on 8/17/21. The staff acknowledged the findings.

Z 173 Secure Outdoor Recreation Area

1) Furniture has been secured and bolted down by maintance 8/19/2. See POC for C513, C510

2) Maintance Request Forms available for all staff- Admin

3) Staff training on when to fill out a form and what to do with it (put in Maintenance Binder) - Admin

4) Maintenance Binder created and maintained in Admin office. Maintenance emailed weekly any outdoor furniture needs fixing or replacement - Admin

5) Quarterly QA Meeting to assure that changes are effective and being followed - Admin