Print Inspection: 7TUJ

The findings of the re-licensure survey, conducted 05/01/23 through 05/03/23  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 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

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 re-visit to the re-licensure survey of 05/03/23, conducted on 08/10/23, 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 OARs 411 Division 004 Home and Community Based Services Regulations.

3. Resident 2 was admitted to the facility in 2017 with diagnoses including Parkinson's Disease and diabetes (Type 2).

Observations of the resident, interviews with staff and review of the service plan dated 03/21/23, showed it was not reflective of the resident's current care needs and/or did not provide clear direction to staff in the following areas:

* Fall interventions;

* Home health physical therapy; and

* Use of a walker.

On 05/03/23 the need to ensure service plans were reflective of current needs and provided clear direction was discussed with Staff 1 (Executive Director) and Staff 2 (RN). They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current needs and status, provided clear direction to staff, and were implemented for 3 of 4 sampled residents (#s 1, 2 and 4) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 12/2015 with diagnoses including diabetes (Type 2), hypertension, and epilepsy.

In an interview on 05/03/23 Staff 1 (Executive Director) stated Resident 1 was receiving Home Health services, and presented the surveyor with visit notes from Occupational Therapy sessions.

In an interview on 05/02/23 Staff 6 (Life Enrichment Director) stated Resident 1 had exhibited disruptive behaviors during activities.

Resident 1's service plan, dated 03/23/23 was not reflective or lacked clear direction to staff in the following areas:

* Home Health services; and

* Challenging behaviors/interventions.

On 05/03/23 the need to ensure service plans were reflective of current needs, provided clear direction to staff and were implemented was discussed with Staff 1 and Staff 2. They acknowledged the findings.

2. Resident 4 was admitted to the facility in 02/2023 with diagnoses including hypertension, hyperglycemia, and osteoarthritis.

On 05/02/23 a C-PAP machine was observed in Resident 4's room, and the resident stated "I use that at night".

Resident 4's service plan, dated 03/17/23 was not reflective or lacked directions to staff in the following area:

* Use of C-PAP machine.

In an interview on 05/03/23 Staff 2 (RN) acknowledged Resident 4 used the C-PAP, and that it was not included in the resident's service plan.

On 05/03/23 the need to ensure service plans were reflective of current needs, provided clear direction to staff and were implemented was discussed with Staff 1 and Staff 2. They acknowledged the findings.

Resident 1's service plan, dated 03/23/23 was not reflective or lacked clear direction to staff in the following areas:

* Home Health services; and

* Challenging behaviors/interventions.

Provider's Plan of Correction:

1. Service plan was updated to reflect behavior interventions and home health.

2. Service plan meetings will be completed weekly to review upcoming service plan reviews. A final review of the service plan will be completed by Community Nurse/Executive Director before closing and posting the service plan.

3. Quarterly by the Community Nurse/Executive Director unless there is a significant change of condition.

4. The Community Nurse and Executive Director.

Resident 4's service plan, dated 03/17/23 was not reflective or lacked directions to staff in the following area:

* Use of C-PAP machine.  

Provider's Plan of Correction:

1. C-PAP was added to the care plan with the understanding the that resident/family at this time manages all operations, including cleaning and ordering of supplies for C-PAP.

2. Service plan meetings will be completed weekly to review upcoming service plan reviews. A final review of the service plan will be completed by Community Nurse/Executive Director before closing and posting the service plan.

3. Quarterly by the Community Nurse/Executive Director unless there is a significant change of condition.

4. The Community Nurse and Executive Director.

Resident 2 was admitted to the facility in 2017 with diagnoses including Parkinson's Disease and diabetes (Type 2).

Observations of the resident, interviews with staff and review of the service plan dated 03/21/23, showed it was not reflective of the resident's current care needs and/or did not provide clear direction to staff in the following areas:

* Fall interventions;

* Home health physical therapy; and

* Use of a walker.

Provider's Plan of Correction:

1. Fall interventions, home health physical therapy, and the use of a walker have been added to the service plan.

2. Service plan meetings will be completed weekly to review upcoming service plan reviews. A final review of the service plan will be completed by Community Nurse/Executive Director before closing and posting the service plan.

3. Quarterly by the Community Nurse/Executive Director unless there is a significant change of condition.

4. The Community Nurse and Executive Director.

Based on interview and record review, it was determined the facility failed to determine and document what action was needed for a resident and ensure staff instructions were made part of the record for 2 of 3 sampled residents (#s 1 and 2) with a change of condition. Findings include, but are not limited to:

Resident 1 and 2's current service plans and last 90 days of charting notes were reviewed during the survey. The following deficiencies were identified:

1. Resident 2 was admitted to the facility in 2017 with diagnoses including Parkinson's Disease and Diabetes Type 2.

a. An incident report dated 04/19/23 documented "found resident on the floor in room barely responsive" and documented low blood pressure of 80/50 and low blood sugar of 75.

Resident 2 was admitted to the hospital, was diagnosed with adult failure to thrive, and had medication changes including an oral diabetes medication instead of insulin.

Resident 2 returned to the facility on 04/23/23 and was monitored for "changes in behaviors or appetite." However, there was no evidence interventions or instructions for staff were determined and documented and made part of the resident record after the change of condition.

b. The record documented multiple non-injury falls by Resident 1, with the following intervention developed: "remind to call for assistance".

There was no documented evidence the intervention was evaluated for effectiveness following repeated falls.

On 05/03/23 the need to ensure interventions or instructions for staff were determined, documented, and made part of the resident record was discussed with Staff 1 (Executive Director) and Staff 2 (RN). They acknowledged the findings.

2. Resident 1 was admitted to the facility in 12/2015.

The resident's service plan, dated 03/23/23, progress notes, dated 02/01/23 through 05/01/23, temporary service plans, and incident reports were reviewed. The resident experienced multiple short-term changes without documentation of needed interventions or monitoring of existing interventions for the following areas:

* Falls; and

* Behaviors.

a. The records documented three falls by Resident 1, with the following interventions developed:

* Keep pathways clear;

* Non-slip shoes;

* Grab bars in bathroom;

* Call for assistance when toileting; and

* Limit items on walker.

There was no documented evidence these interventions were evaluated for effectiveness, following repeated falls.

b. Resident 1's service plan documented the resident "would have loud outbursts and shake his/her fist at you". Progress notes stated the resident had become "so disruptive at times, that [he/she] had been asked to leave the activity room".

There was no documented evidence interventions had been developed for these behaviors.

On 05/03/23 the need to ensure development of needed interventions, and monitoring of those interventions for effectiveness was discussed with Staff 1 (Executive Director) and Staff 2 (RN). They acknowledged the findings.

Resident 2 was admitted to the facility in 2017 with diagnoses including Parkinson's Disease and Diabetes Type 2.

a. An incident report dated 04/19/23 documented "found resident on the floor in room barely responsive" and documented low blood pressure of 80/50 and low blood sugar of 75.

b. The record documented multiple non-injury falls by Resident 1, with the following intervention developed: "remind to call for assistance".

There was no documented evidence the intervention was evaluated for effectiveness following repeated falls.

Provider's Plan of Correction:

1. Change of condition service plan completed including documentation of interventions and/or instructions for staff regarding recent change of condition and repeated falls.

2. Incident follow-up will be completed within one week, checking with staff for the effectiveness of fall prevention and/or instructions. RCM will review any further incidents and possible changes in conditions with the Community Nurse and Executive Director at weekly service plan meetings. A final review will be completed by Community Nurse/Executive Director before closing and posting of the service plan.

3. Quarterly by the Community Nurse/Executive Directoor/RCM unless there is a significant change of conditon or further falls.

4.  Community Nurse, RCM and Executive Director.

Resident 1 was admitted to the facility in 12/2015.  The resident's service plan, dated 03/23/23, progress notes, dated 02/01/23 through 05/01/23, temporary service plans, and incident reports were reviewed. The resident experienced multiple short-term changes without documentation of needed interventions or monitoring of existing interventions for the following areas:

* Falls; and

* Behaviors.

a. The records documented three falls by Resident 1, with the following interventions developed:

* Keep pathways clear;

* Non-slip shoes;

* Grab bars in bathroom;

* Call for assistance when toileting; and

* Limit items on walker.

There was no documented evidence these interventions were evaluated for effectiveness, following repeated falls.

b. Resident 1's service plan documented the resident "would have loud outbursts and shake his/her fist at you". Progress notes stated the resident had become "so disruptive at times, that [he/she] had been asked to leave the activity room".

There was no documented evidence interventions had been developed for these behaviors.

Provider's Plan of Correction:

1. Service plan was updated to reflect interventions for falls, and behaviors. The service plan also includes behavioralist interventions and suggestions per their report.

2. Incident follow-up will be completed within one week, checking with staff for the effectiveness of fall prevention and/or instructions. RCM will review any further incidents and possible changes in condition with the Community Nurse and Executive Director at weekly service plan meetings. A final review will be completed by Community Nurse/Executive Director before closing and posting the service plan.

3. Quarterly by the Community Nurse/Executive Director/RCM unless there is a significant change of condition or further falls.

4. Community Nurse, RCM, and Executive Director.

3.  Resident 3 was admitted to the facility in 06/2022 with diagnoses including diabetes (Type 2) and chronic kidney disease (Stage 3).

Review of Resident 3's MAR, dated 04/01/23 through 04/30/23 identified the following deficiencies:

* On 04/02/23 the MAR lacked documentation of whether the medications vitamin D 50 MCG, Pantoprazole Sodium 1 tab, adult multivitamin 1 tab, metroprolol succinate ER 50 mg, Saccharomyces boulardii 250 mg, and gabapentin 100 mg were administered; and

* The MAR lacked accurate parameters for use of two PRN pain medications. These were acetaminophen and tramadol. There were no instructions for the sequential order of administration.

In interview on 05/03/23 Staff 2 (RN) stated she was aware of a computer issue on that day, the medications had been given as ordered, and should have been entered into the electronic MAR when the issue was resolved.

On 05/03/23 the need to keep an accurate MAR of all medications that were ordered by a legally recognized practitioner and were administered by the facility was discussed with Staff 1 (Executive Director) and Staff 2 (RN). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was kept of all medications that were ordered by a legally recognized practitioner and were administered by the facility for 3 of 4 sampled residents (#s 1, 3 and 4) whose records were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 12/2015.

Review of Resident 1's MAR, dated 04/01/23 through 04/30/23, identified the following deficiencies:

The MAR lacked accurate parameters for use of two PRN pain medications. These were acetaminophen 500 mg and tramadol 50mg. There were no instructions for the sequential order of administration.

On 05/03/23 the need to keep an accurate MAR of all medications that were ordered by a legally recognized practitioner and were administered by the facility was discussed with Staff 1 (Executive Director) and Staff 2 (RN). They acknowledged the findings.

2. Resident 4 was admitted to the facility in 02/2023. Review of Resident 4's MAR, dated 04/01/23 through 04/30/23, identified the following deficiencies:

The MAR lacked accurate parameters for use of two PRN pain medications. These were acetaminophen 325 mg and tramadol 50 mg. There were no instructions for the sequential order of administration.

On 05/03/23 the need to keep an accurate MAR of all medications that were ordered by a legally recognized practitioner and were administered by the facility was discussed with Staff 1 (Executive Director) and Staff 2 (RN). They acknowledged the findings.

Resident 1 was admitted to the facility in 12/2015.

Review of Resident 1's MAR, dated 04/01/23 through 04/30/23, identified the following deficiencies:

The MAR lacked accurate parameters for use of two PRN pain medications. These were acetaminophen 500 mg and tramadol 50mg. There were no instructions for the sequential order of administration.  

Provider's Plan of Correction:

1. Parameters have been entered for PRN pain medications for all necessary MARs.

2. During our three-check medication order process the Community Nurse and RCM will review any PRN medication orders to make sure parameters are requested and put in place.

3. Quarterly by the Community Nurse, RCM, and/or Executive Director.

4. The Community Nurse, RCM, and Executive Director.

Resident 4 was admitted to the facility in 02/2023. Review of Resident 4's MAR, dated 04/01/23 through 04/30/23, identified the following deficiencies:

The MAR lacked accurate parameters for use of two PRN pain medications. These were acetaminophen 325 mg and tramadol 50 mg. There were no instructions for the sequential order of administration.

Provider's Plan of Correction:

1.  Parameters have been entered for PRN pain medications for all necessary MARs.

2. During our three-check medication order process the Community Nurse and RCM will review any PRN medication orders to make sure parameters are requested and put in place.

3. Quarterly by the Community Nurse, RCM, and/or Executive Director.

4. The Community Nurse, RCM, and Executive Director

Resident 3 was admitted to the facility in 06/2022 with diagnoses including diabetes (Type 2) and chronic kidney disease (Stage 3).

Review of Resident 3's MAR, dated 04/01/23 through 04/30/23 identified the following deficiencies:

* On 04/02/23 the MAR lacked documentation of whether the medications vitamin D 50 MCG, Pantoprazole Sodium 1 tab, adult multivitamin 1 tab, metoprolol succinate ER 50 mg, Saccharomyces boulardii 250 mg, and gabapentin 100 mg were administered; and

* The MAR lacked accurate parameters for use of two PRN pain medications. These were acetaminophen and tramadol. There were no instructions for the sequential order of administration.

In interview on 05/03/23 Staff 2 (RN) stated she was aware of a computer issue on that day, the medications had been given as ordered, and should have been entered into the electronic MAR when the issue was resolved.

Provider's Plan of Correction:

1. Parameters have been entered for PRN pain medications for all necessary MARs. Daily audits (M-F) will now be completed to review accuarcy of the MAR.

2. During our three-check medication order process the Community Nurse and RCM will review any PRN medication orders to make sure parameters are requested and put in place. RCM will audit to make sure the daily MAR audits are being completed.

3. RCM Audit log will be turned in weekly to the Community Nurse.

4. The Community Nurse, RCM and Executive Director.  

Based on observation and interview, it was determined the facility failed to ensure all interior and exterior surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the residents were kept clean and in good repair. Findings include, but are not limited to:

The facility grounds were toured with Staff 5 (Maintenance Director) on 05/02/23. The following items were in need of cleaning or repair:

* Wood railing of outdoor deck near kitchen was warped, with cracked and peeling paint;

* Dark stains were present on multiple carpet areas throughout the building.

On 05/02/23 the areas needing cleaning and repair were shown to and reviewed with Staff 1 (Executive Director) and Staff 5. They acknowledged the findings.

The facility grounds were toured with Staff 5 (Maintenance Director) on 05/02/23. The following items were in need of cleaning or repair:

* Wood railing of outdoor deck near kitchen was warped, with cracked and peeling paint;

* Dark stains were present on multiple carpet areas throughout the building.

Provider's Plan of Correction:

1. Wood railing will be replaced and painted. The carpet will be replaced in some areas and cleaned professionally in other areas per our professional carpet cleaning company's recommendations.

2. Our maintenance team will complete a yearly stain protective/re-painting to the back deck including an inspection. Professional carpet cleaning is now scheduled quarterly.

3. Quarterly with our Quality Assurance Meeting.

4. Maintenance Director and Executive Director.