Print Inspection: 9IT3

The findings of the change of ownership survey, conducted 8/17/21 through 8/19/21, 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, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.

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, conducted 11/9/21, for the re-licensure survey of 8/19/21, 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, OARs 411 Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004.

Based on interview and record review, it was determined the facility failed to monitor short-term changes of condition through resolution for 2 of 3 sampled residents (#s 1 and 3) who experienced changes of condition. Findings include, but are not limited to:

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

A review Resident 1's clinical record revealed the following:

* Resident 1 was receiving treatment for a rash in the groin area. On 5/19/21 staff identified an open area in the fold between the resident's left thigh and stomach.

* On 7/31/21 medication doses were adjusted for two medications.

There was no documented evidence these changes of condition were monitored through resolution.

The need to monitor short-term changes of condition until they resolve was discussed with Staff 2 (Administrator), Staff 3 (RCC) and Staff 4 (LPN) on 8/18/21. They acknowledged the findings.

2. Resident 3 was admitted to the facility in March 2021 with diagnoses including dementia.

A review of the resident's clinical record revealed the following:

* On 6/13/21 the resident returned to the facility from the ER; and

* On 6/15/21 Resident 3 was diagnosed with a urinary tract infection and prescribed antibiotics.

There was no documented evidence the facility monitored these changes of condition, at least weekly, until resolved.

On 8/18/21 the need to monitor short-term changes of condition through resolution was discussed with Staff 2 (Administrator), Staff 3 (RCC) and Staff 4 (LPN). They acknowledged the findings.

C270 - Change of Condition - Plan of Correction

1) Change of Condition Log Added to 24hr Book - Administrator

2) Daily Clinical Meeting Binder to go over documentation to assure progress notes, timely treatment, and follow up until resolved/DC'd - Administrator, RN, LPN, and RCC.

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

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

1. Resident 2 was admitted to the facility in July 2021 with diagnoses including dementia and anxiety.  

Review of the current physician orders and 8/1/21 through 8/17/21 MAR revealed the following:

* Clonazepam (prescribed for anxiety) twice daily was not administered from 12:00 pm 8/3/21 through 8/9/21 as the medication was not available.

The need to ensure physician orders were followed was reviewed with Staff 2 (Administrator), Staff 3 (RCC), Staff 4 (LPN), Staff 5 (RN) and Staff 6 (Former Administrator). They acknowledged the findings.

2. Resident 3 was admitted to the facility in March 2021 with diagnoses including dementia.

A review of the resident's August 1 through August 17, 2021 MAR identified

11 occasions when the following medications were not administered as prescribed because the medication was not available:

* Fluoxetine (for bipolar disorder);

* Furosemide (for heart failure);

* Sulfamethoxazole (an antibiotic); and

* Haloperidol (an antipsychotic).

On 8/18/21 the need to follow physician orders was discussed with Staff 2 (Administrator), Staff 3 (RCC) and Staff 4 (LPN). They acknowledged the findings.

C303 - Systems - Treatment Orders

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

2) NOC shift tasked with DAILY re-ordering of ALL medications with 10 doses or less left.  Re-order tracking log added to 24 hr book.  Checked daily by LPN, RCC, and Admin to assure progress is being made in attaining the medication and it is documented.

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

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

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/or treatment refusals. Findings include, but are not limited to:

Resident 1 and 2's 8/1/21 through 8/17/21 MARs were reviewed. The residents' records showed multiple medication and/or treatment refusals.

There was no documented evidence the facility notified the physician each time the resident refused to consent to the orders.  

On 8/18/21, the need to ensure the facility notified physicians of medication and/or treatment refusals was discussed with Staff 2 (Administrator), Staff 3 (RCC), Staff 4 (LPN), Staff 5 (RN) and Staff 6 (Former Administrator). The staff acknowledged the findings.

C305 - Systems: Resident Right to Refuse

1) Standard Fax form formatted for Med Techs to notify PCP each time a medication is refused. - Admin

2) Training for Med Techs held for new process. - RCC, LN, Admin.

3) Daily Clinical Meeting to review dashboard and "exceptions" tab for refused or missed medication and assure plan is in place to address issues with PCP. - Admin

4) Weekly review of refusals by LPN to determine compliance as well as need to ask PCP for DC of meds or alternate treament to be considered.  

5) Quarterly QA Meeting to assure changes made are effective and continuing.

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 8/18/21. 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 2 (Administrator) and Staff 6 (Former 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 a functioning 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 showed that all exit doors did not have an operational alarm or other acceptable system to alert staff when residents exited the building.

The need to ensure exit doors were equipped with an alarming device or other acceptable system was discussed with Staff 2 (Administrator) and Staff 6 (Former Administrator). They acknowledged the findings.

C555 - Call Sys, Exit Dr Alarm, Phones, TV, or Cable

1) Door alarms have been installed for all exit doors and are in good working order. Maintenance - 8/19/2021

2) Maintence 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 Maintence Binder) - Admin

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

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

Based on 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 530 and C 555.

Z 142 - Admin Compliance - Refer to C530 and C 555

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 270, C 303 and C 305.

Z 162 Compliance with Rules Health Care - Refer to C 270, C303, and C 305

Based on interview and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan for each resident was developed and included in the service plan for 1 of 2 sampled residents (#3) whose service plans were reviewed. Findings include, but are not limited to:

Resident 3's current service plan was reviewed during survey. The service plan lacked information and staff instructions related to individualized nutrition and hydration status and needs.  

The need to develop individualized service plans addressing residents' nutrition and hydration needs was discussed with Staff 2 (Administrator), Staff 3 (RCC) and Staff 4 (LPN). They acknowledged the findings.

Z 163 - Nutrition and Hydration

1) Nutrition and Hydration form created and added to Admission paperwork - Admin

2) Activity Director tasked with follow up with families to assure completion - Activity Director, Admin

3) Admission Audit paperwork completed by Admin to assure Nutrition and Hydration plan is added to all New Service Plans

4) Individual Nutrition and Hydration plans for each resident added to all existing Service Plans. - Admin

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

Based on interview and record review, it was determined the facility failed to ensure an individualized activity plan was developed for each resident based on their activity evaluation for 3 of 3 sampled residents (#s 1, 3 and 4) whose records were reviewed. Findings include, but are not limited to:

Although Resident 1, 3 and 4's service plans offered some information about the resident's interests, the facility had not fully evaluated the residents':

* 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 residents with more individualized activities.

The need to ensure each resident was evaluated and an individualized activity plan was developed was reviewed with Staff 2 (Administrator), Staff 3 (RCC), Staff 4 (LPN) and Staff 5 (RN) on 8/18/21 and 8/19/21. They acknowledged the findings.

Z 164 - Activities

1) Activity 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 Adminsitrator at time of Service Plan creation and renewals ( 30 days, 90 days, Change of Conditions)

4) Activity Plan will be apart 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 upons 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.