The findings of the relicensure survey, conducted 12/06/21 through 12/08/21, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

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  12/08/21 conducted 02/17/22 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 interview and record review, it was determined the facility failed to implement on-site health services recommendations for 1 of 2 sampled residents (#1) who received outside services. Findings include, but are not limited to:

Resident 1 was admitted to the facility in April 2021 with diagnoses including malignancy and atrial fibrillation.

A review of Resident 1's service plan, dated 12/01/21, progress notes and alert charting notes dated 9/02/21 - 11/20/21, identified the following hospice provider recommendations were not communicated to staff to follow:

* Encourage resident to drink fluids and elevate legs; and

* Encourage [resident] to use his/her walker.

Observation of Resident 1 on 12/07/21, revealed s/he had a four wheeled walker and two single point canes in various areas of the room. The resident was seated in his/her recliner with feet on the floor (not elevated) and was not wearing compression stockings. Interview with Resident 1, revealed  s/he wears compression stocking sometimes and will put his/her legs up if needed.  

In an interview on 12/08/21 with Staff 1 (Administrator), she stated outside provider recommendations are usually reviewed and added to the alert charting. T

Resident 1's hospice recommendations were not in progress notes nor added to the current service plan..

The need to ensure the facility coordinated care with outside service providers and communicated recommendations for staff to follow was discussed with Staff 1 on 12/08/21. She acknowledged the findings.  

1. Outside Provider recommendations have been added to resident's service plan.  

2. Medication Aides will review each Outside Provider Note when received to observe for recommendations.  If recommendations are made, these will be added to the resident's Service Plan.

3. Evaluation will occur monthly to ensure Outside Provider recommendations are implemented on the resident Service Plan to show collaboration of care.

4. Admin/RCC/Nurse

Based on interview and record review, it was determined the facility failed to ensure physician's orders were carried out as prescribed for 2 of 3 sampled residents (#s 1 and 2) whose orders were reviewed. Findings include, but are not limited to:

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

Resident 2's physician orders and 11/1/21 through 12/6/21 MARs were reviewed and identified the following:

* Resident 2 had an order on 11/18/21 to discontinue Docusate

Sodium (for constipation) 100 mg two times a day. The 11/18/21 through 12/6/21 MARs identified the Docusate continued to be administered routinely; and

* Physician orders, dated 11/18/21 included to discontinue cyclobenzaprine (for muscle spasms) 5 mg every eight hours as needed for muscle spasms. The 11/18/21 through 12/6/21 MARs included the cyclobenzaprine with a start date of 7/1/21 and no information the medication had been discontinued.

The findings were shared with Staff 1 (Administrator) on 12/8/21. She acknowledged the findings.

2. Resident 1 moved into the facility in 2021 with diagnoses including malignancy and atrial fibrillation and was receiving hospice services.

Signed physician orders from hospice on 11/24/21, and the 11/01/21 to 12/06/21 MARs were reviewed and revealed the following orders were not followed:

* Oxycodone 5 mg PRN pain (was listed on the MAR as discontinued);

* Refresh Tears, one drop into both eyes every hour for dry eyes (was listed on the MAR as PRN); and

* Warfarin 2.5 mg every Wednesday and Friday (the Warfarin orders from 11/19/21 were still listed on the MAR and had not been updated with the 11/24/21 orders from hospice).

In a discussion with Staff 5 (MA), s/he indicated s/he would contacted hospice and have them review and revise the orders.

The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (Administrator) and Staff 2 (RN) on 12/08/21. They acknowledged the findings.

1. The Medication Administration record for both resident's have been updated to reflect the current Physician's orders.

2. Medication Aides have been counseled and re-trained on the facility procedure for processing Physician's Orders once received to ensure accurate medication is being administered.

3. Medication orders will be reviewed by RCC/Nurse weekly to ensure new orders are reflected on the Medication Administation Record.

3. Admin, RCC, Nurse will monitor

Based on interview and record review, it was determined the facility failed to ensure fire and life safety documentation reflected all required fire drill components. Findings include, but are not limited to:

Fire drill records were reviewed from August 2021 to December 2021.

The evacuation/drill documentation did not contain information on the following required areas:

* escape route used;

* problems encountered, comments relating to residents who resisted or failed to participate in the drills;

* evacuation time period needed; and

* the number of occupants evacuated.

The requirements regarding fire drills and fire and life safety instruction for staff were reviewed and a copy of the documentation requirements was provided to Staff 1 (Administrator) and Staff 3 (Maintenance) on 12/08/21. They acknowledged the findings.

1. Educate safety committee and facitlity staff in monthly staff meetings and orientation on proper fire drill protocols to include

potential problems and barriers to overcome, relative escape routes to use based on fire locations, evatuion time tracking, and

occupane avacuee participation

2. Monthly staff meetings will review most recent fire drills to discuss barriers and evaluate effectiveness of drill.

3. Maintenance manager will simulate unannounced fire drill on rotating shifts and document findings as required per regulation.

4. Maintenance manager to reivew monthly.

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements were being met. Findings include, but are not limited to:

Fire and life safety records, reviewed between August 2021 through December 2021, revealed the facility lacked documented evidence of the following:

* Alternate exit routes were used during fire drills;

* Staff interviewed were aware of the designated point of safety; and

* Annual training for residents on fire and life safety content.

The need to ensure all required components of fire and life safety training were provided was discussed with Staff 1 (Administrator) and Staff 3 (Maintenance) on 12/08/21. They acknowledged the findings.

1. Educate safety committee and facitlity staff in monthly staff meetings and orientation on proper fire drill protocols to include potential problems and barriers to overcome, relative escape routes to use based on fire locations, evatuion time tracking, and

occupane avacuee participation

2. Monthly staff meetings will review most recent fire drills utilizing location of fire to educate

on alternate/proper escape route used.

3. Evaluation will occur monthly during each unannouced fire drill on rotating shifts. To be

documented on CPM Fire Drill Form.

4. Maintenance manager to reivew monthly.