Print Inspection: 9JV6

The findings of the re-licensure survey, conducted 10/27/2021 through 11/1/2021, 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, 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 the re-licensure survey of 11/01/21, conducted 02/09/22, 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, OARs 411 Division 004 Home and Community Based Services Regulations and Division 57 for Memory Care Communities.

Based on observation, interview and record review, it was determined the facility failed to ensure required postings were displayed, in a routinely accessible and conspicuous location to residents and visitors, available for inspection and accurate. Findings include, but are not limited to:

A tour of the facility conducted on 10/28/21 identified the following:

* The most recent survey with plan of correction was not posted and available for view;

* There was no posting of the facility staffing plan; and

* The designee in charge had not been posted to reflect who was in charge.

The need to ensure all required postings were in an accessible and conspicuous location for the public was discussed with Staff 1 (Administrator) and Staff 2 (Operations Specialist) on 10/29/21. They acknowledged the findings.

1.  The most recent survey with plan of correction is available for view and a sign has been posted to guide to the location.  The facility staffing plan has been posted in each house.  The designeee in charge, upon Administrator absence, has been posted.

2.  The Executive Director and Assistant Executive Director received additional training on the Quality Assurance Master Review Schedule; Survey Compliance, that address this rule.  

3.  The Executive Director will review this area monthly per the Quality Assurance Master Review Schedule to ensure correction.

4.  The Executive Director will ensure the corrections are completed and monitored.    

Based on interview and record review, it was determined the facility failed to document evidence of an immediate investigation which reasonably concluded resident incidents were not the result of abuse or neglect and included an administrator's review for 1 of 1 sampled resident (#5) with unwitnessed falls. Findings include, but are not limited to:

Resident 5 was admitted to the memory care unit in 2019 with diagnoses including dementia and had multiple unwitnessed falls.

During an interview with Staff 5 (Wellness Director) s/he stated Resident 5 was dependent on staff for most ADL care and required assistance of at least one person for transfers.

A review of Resident 5's incident reports and progress notes dated 07/28/21 through 10/26/21 revealed s/he had 19 unwitnessed falls. The incident reports did not contain the dates or the names of the person(s) completing the reports, or a way to verify when the investigations had been completed in order to immediately rule out abuse and neglect. The reports also lacked verification the incidents had been reviewed by the Administrator.

During an interview with Staff 1 (Administrator) on 10/28/21, the process for reporting and investigating incidents was discussed. Staff 1 verified the incident reports did not include documentation of the dates and names of persons who completed the investigations as well as the date and review of the Administrator.

The need to ensure investigations contained the required documentation was discussed with Staff 1 and Staff 2 (Operations Specialist) on 10/28/21. They acknowledged the findings and Staff 1 stated the electronic system would be modified to show the dates and signatures of those involved in performing investigations.

1.  The community electronic system has been modified to show dates and signatures of the person involved in completing the investigation and the date, signature and review of the Administrator.

2. The electronic system has been tested to ensure dates and signatures are captured appropriately to address this rule.

3. The Executive Director will review incident reports daily per the Quality Assurance Master Review Schedule; Daily Stand Up to ensure correction.

4.  The Executive Director will ensure the corrections are completed and monitored.     

Based on observation, interview and record review, it was determined the facility failed to ensure resident service plans were reflective of resident needs, provided instructions for staff as to what, when and how services would be provided and were followed for 2 of 6 sampled residents (#s 5 and 7) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 5 was admitted to the memory care in 2019 with diagnoses including normal pressure hydrocephalus and dementia. During observations and interviews on 10/28/21, caregivers reported Resident 5 needed help with most ADL care, experienced multiple falls, had a catheter, was able to feed him/herself and was receiving Hospice support services.

The service plan, dated 10/25/21, and ISP's (Interim Service Plan) were reviewed and were not reflective of the resident's needs in the following areas:

* Level of assistance needed for grooming;

* Ability to manage glasses;

* Recent, gradual weight loss;

* Current activity plan; and

* Attending meals in the dining room versus in bed.

The service plan did not provide clear direction to staff in the following areas:

* Fall interventions to follow to prevent falls;

* Level of transfer assistance needed; and

* Use of side rails and call system.

The need for service plans to be reflective of resident's needs and provide clear direction for staff to follow was discussed with Staff 1 (Administrator) and Staff 2 (Operations Specialist) on 10/29/21. They acknowledged the findings.

2. Resident 7 was admitted to the memory care in May 2021 with diagnoses including Alzheimer's disease with late onset and chronic lower back pain.

Observations of the resident, interviews with the resident and staff, review of the service plan, dated 08/30/21, and interim service plans (ISP's) showed the service plan was not reflective of the resident's current care needs, was not consistently followed by staff, did not provide clear direction to staff, and was not accurate in the following areas:

* Daily weights and use of Ted hose were not accurate;

* Weight loss interventions, meal assistance due to weight loss, and chronic pain management, including non-pharmacological interventions for pain lacked clear instructions to staff; and

* Meal monitoring was not consistently followed.

The need to ensure resident service plans were reflective of current care needs, provided clear direction to staff and was followed was discussed with Staff 1 (Administrator) and Staff 2 (Operation Specialist) on 11/01/21. They acknowledged the findings.

1. The Service Plan for resident #5 and #7 have been updated and remaining resident's service plan will be reviewed to ensure each service plan is refective of resident needs and provides clear instruction to staff.   

2.  The Executive Director, Assistant Executive Director  and the Wellness team (Wellness Directors and Wellness LN's), received additional training on the Service Plan policy and procedure and the Service Plan guide that address this rule.

All staff will receive additional training on delivery of service.

3.  The Executive Director and Wellness Team will review this area weekly per their individual Quality Assurance Review Schedules; Service Planning, to ensure correction.

4.  The Executive Director will ensure the corrections are completed and monitored.

2. Resident 5 was admitted to the facility in 2019 with diagnoses including normal pressure hydrocephalus and dementia.

Progress notes, dated 07/27/21 through 10/27/21 noted the resident experienced changes of condition as follows:

Resident 5 experienced 19 falls between 07/28/21 and 10/26/21. Most of the falls were unwitnessed and the resident did not sustain any injuries as a result of the falls. Interim service plans and incident reports for the falls were reviewed along with the service plan completed on 10/25/21. Incident reports identified interventions to be tried, however, these interventions were not consistently added to the service plan or communicated to staff. The records lacked evidence that interventions were monitored for effectiveness to try an reduce the re-occurrence of falls.

The need to monitor changes of condition, identify and communicate interventions and monitor the interventions for effectiveness was discussed with Staff 1 (Administrator) and Staff 2 (Operations Specialist). They acknowledged the findings. Staff 1 modified the service plan form in the electronic system to include current interventions.

Based on observation, interview and record review, it was determined the facility failed to evaluate changes of condition, monitor according to evaluated needs, and identify and implement interventions for 2 of 4 sampled residents (#s 5 and 7) reviewed for changes of condition including weight loss, falls and pain. Resident 7 experienced ongoing pain and severe weight loss. Findings include, but are not limited to:

1. Resident 7 was admitted to the facility in May 2021 with diagnoses including Alzheimer's disease and chronic lower back pain. During the entrance conference, on 10/27/21, staff indicated Resident 7 needed cueing to eat.

a. Observations, interviews with staff, and a review of the service plans and interim service plans were conducted during the survey.

A review of Resident 7's weight records revealed the following:

* Resident's initial weight after move-in, 05/27/21, was 141 lbs;

* On 06/29/21 resident weighed 128.2 pounds, which constituted a severe weight loss of 12.8 lbs. or 9.08 % of his/her total body weight.

The following additional weights were recorded as follows:

* 07/15/21: 126.01 lbs.;

* 07/21/21: 124.8 lbs.;

* 07/28/21: 123.8 lbs.;

* 08/3/21: 122.8 lbs.;

* 08/11/21: 123.6 lbs.;

* 08/18/21: 120.7 lbs.;

* 08/25/21: 121.4 lbs.;

* 09/1/21: 119 lbs.;

* 09/8/21: 117 lbs.;

* 09/15/21: 119 lbs.;

* 09/22/21: 118.2 lbs.;

* 09/28/21: 114.6 lbs.;

* 10/5/21: 120 lbs. (progress note, 10/6/21, documented this was an inaccurate weight);

* 10/13/21: 115.6 lbs.; and

* 10/20/21: 113.8 lbs.

Resident 7's initial service plan, dated 05/21/21, noted the resident had a history of weight loss which included a 14-pound loss within two months prior to admission. The initial service plan lacked weight loss interventions.

Resident 7's current service plan dated 8/30/21 and interim service plans included the following instructions and/or information for staff:

* 07/15/21 offer to reheat food, remake the meal or offer an alternative;

* 07/19/21 document weight and meal monitoring on MAR;

* 07/19/21 encourage resident to come out of room, utilize weight day during the week to do this, offer nutritional supplements, offer alternatives or have family bring in food;

* 07/21/21 offer pudding, peanut butter and jelly sandwich, Jello, chicken or veggie soup;

* 07/28/21 continue to offer meals and snacks, monitor intake;

* 08/4/21 encourage resident to eat meals or snacks;

* 09/8/21 offer food of interest and encourage her to come out for two meals; and

* 10/12/21 Puree diet and thin liquids.

On 07/15/21 Staff 8 (Wellness Nurse) documented the following:

* "ability to eat: independent";

* "hydration concerns: yes"; and

* "Poor appetite and weight loss, offer alternatives and snacks, PCP prescribed Mirtazapine 7.5 mg in hopes of stimulating appetite. This does not appear to be effective, family brings in nutritional supplements, PCP appointment to discuss poor meal intake and weight loss, resident is on weekly weights, meal monitoring."

Staff 8 noted previous interventions related to the residents weight loss, however, failed to evaluate the effectiveness of the interventions or develop new interventions when the resident experienced continued weight loss.

On 10/25/21 staff documented in a progress note the resident "doesn't want to eat the puree food, [s/he] said that it is a baby food and [s/he] is not going to eat that".

Review of the MAR dated 10/1/21 through 10/26/21 identified meal monitoring percentages were not documented on 32 occasions and nutritional supplements were not documented as given on four occasions.

In interviews conducted on 10/28/21, Staff 21 (MT) and Staff 13 (MT) stated the following:

* "I don't force [him/her] to eat anything, I approach three times, if [s/he] doesn't want to eat then [s/he] doesn't." "No, we have not tried to cue or sit with [him/her], I think [s/he] wouldn't like that and besides, I feel like I would be overstepping. [S/he] is independent and can physically eat, [s/he] just doesn't want to."

* "I just ask [him/her] why [s/he] isn't eating and I ask if [s/he] wants something else. I don't know, what else is there to do?"

Resident 7 experienced a severe weight loss from 05/27/21 to 06/29/21, when s/he lost 9.07% of total body weight within 30 days. The resident continued to lose weight from 06/29/21 to 8/25/21 for a total of 13.90 %, or 12.8 lbs. within three months.

On 10/29/21 at 9:45 am, Surveyor observed Staff 9 (Wellness Nurse) weigh the resident and recorded the weight at 113.0 lbs. This constituted an additional severe weight loss of 19.86% of  his/her total body weight within six months.

There was no documented evidence the residents continued weight loss had been evaluated, weight loss interventions were monitored or reviewed for effectiveness, new interventions attempted and documented and resident-specific instructions communicated to staff when the resident continued to lose weight. This put the resident at risk for continued weight loss.

b. Observations, interviews with the resident and staff, review of the service plan and interim service plans (ISP's) and review of the progress notes were conducted during the survey.

A review of the initial service plan dated 05/21/21 noted "pain is rare for [resident]. Team will follow most current orders on the MAR and notify wellness team of any changes."  

A review of the current service plan dated, 08/30/21, failed to address pain issues.  

Resident 7's clinical records indicated the Resident had been prescribed PRN Oxycodone on 06/4/21. Between 08/6/21-10/7/21 the resident was administered PRN Oxycodone on 34 occasions. The resident ran out of the pain medication on 10/7/21. At the time of the survey the facility had not refilled the order; and

* Resident 7 was prescribed a Capsaicin Patch for pain, three times per day. The MAR dated 10/1/21- 10/26/21 identified 30 incidents where the pain patch had not been initialed as administered. The facility was unable to verify the resident received the medication.

During interviews with Resident 7 on 10/28/21 and 10/29/21, s/he stated:

"I'm not feeling well, my back hurts real bad, and "It hurts, hurts, hurts, that's why I'm laying down, it's the only thing that helps."

In an interview Staff 13 (MT) stated "I don't think [s/he] has a PRN for Oxycodone." Surveyor and Staff 13 reviewed the med cart and the eMAR record on 10/28/21 and discovered the Resident was still prescribed Oxycodone however, there medication had not been received by the facility and was not available.

There was no documented evidence the facility evaluated the residents pain, consistently monitored the resident's pain level, failed to implement non-pharmacological interventions for pain and document resident-specific instructions to staff, or updated the service plan with interventions related to chronic pain. The failure of the facility to evaluate or monitor Resident 7's pain resulted in unreasonable discomfort to the resident.

The need to ensure pain and weight loss interventions were monitored or reviewed for effectiveness, new interventions attempted and documented and resident-specific instructions communicated to staff, or the service plan updated with interventions when the resident continued to have severe weight loss was discussed with Staff 1 (Administrator), Staff 2 (Operation Specialist), Staff 4 (Assistant Administrator) and Staff 8 (Wellness Nurse) on 10/28/21. They acknowledged the findings.

1.  Resident #5 and #7:  A change of condition evaluation was completed, monitoring implemented or updated, and the service plan updated with identified needs including clear instruction to staff.  Remaining resident records will be reviewed to ensure change of condition has been identified, evaluated, appropriate interventions and monitoring , including effictiveness of interventions, until resolved and until resolution is documented.     

2.  The Executive Director, Assistant Executive Director, and the Wellness team received additional training on the Change of Condition policy and procedure that address this rule.    

3.  The Executive Director and Wellness Team will review this area daily per their individual Quality Assurance Review Schedules; 24 hour book Change of Condition, to ensure correction.

4.  The Executive Director will ensure the corrections are completed and monitored.

Based on observation, interview and record review, it was determined the facility failed to ensure an RN assessment was completed for 1 of 1 sampled resident (#7) who experienced significant changes of condition related to weight loss and chronic pain. Resident 7 continued to experience significant weight loss and pain. Findings include, but are not limited to:

Resident 7 was admitted to the facility in May 2021 with diagnoses including Alzheimer's disease and chronic lower back pain.

a. Observations, interviews with staff, and a review of the service plan and interim service plans were conducted during the survey, and revealed the following:

Resident 7 experienced a severe weight loss of 12.8 lbs. or 9.08 % of his/her total body weight from 5/27/21 to 6/29/21. This constituted a significant change of condition related to severe weight loss.

An RN assessment was completed two weeks later, on 7/15/21 for the severe weight loss identified on 6/29/21. The RN completed an interim service plan for the change of condition on 7/19/21.

Resident 7 experienced an additional weight loss of 6.8 pounds between 5/27/21- 8/25/21, which constituted a severe weight loss of 13.90 % in a three-month period.

There was no documented evidence the facility RN completed an assessment for the severe weight loss identified on 8/25/21, documented findings, resident status, and interventions made as a result of the assessment and communicated clear instructions for staff or updated the service plan when the resident continued to lose weight.

On 10/29/21 at 9:45 am, Surveyor observed Staff  9 (Wellness Nurse) weigh the resident and recorded the weight at 113.0 lbs. This constituted an additional significant weight loss of 5.95% for a total of 19.86% total weight loss within six months.

b. Resident 7 had chronic lower back pain that was identified in June when s/he was prescribed PRN Oxycodone. On 7/23/21, Resident 7 was prescribed Capsacian pain patch for chronic lower back pain.

* Between 8/6/21-10/7/21 the resident was administered PRN Oxycodone on 34 occasions. The resident ran out of the pain medication on 10/7/21. The facility had a current prescription for the medication, however failed to follow up to ensure the medication was received and available for administration;  and

* Resident 7 was prescribed a Capsaicin Patch for pain, three times per day. The MAR dated 10/1/21- 10/26/21 identified 42 incidents where the pain patch had not been initialed as administered. The facility was unable to verify the resident received the medication.

On 8/23/21, Staff 8 (Wellness Nurse) documented in a progress note the resident wasn't feeling well due to back pain and felt better if s/he were laying down.

There was no documented evidence Staff 8 assessed the residents pain to include documented findings, resident status, and interventions made as a result of the assessment or update the service plan.  

During interviews with Resident 7 on 10/28/21 and 10/29/21, s/he stated:

"I'm not feeling well, my back hurts real bad, and "It hurts, hurts, hurts, that's why I'm laying down, it's the only thing that helps."

The facilities failure to assess the residents pain resulted in ongoing untreated pain and discomfort.

The need to ensure the facility RN completed an assessment for significant weight loss and pain, documented findings, resident status, and interventions made as a result of the assessment and communicated clear instructions for staff or updated the service plan was discussed with Staff 1 (Administrator), Staff 2 (Operation Specialist), Staff 4 (Assistant Administrator) and Staff 8 (Wellness Nurse) on 10/28/21. They acknowledged the findings.

Refer to C 270, example 1 a and 1b.

1.  Resident #7:  The community RN completed a change of condition nursing assessment.  Remaining resident records will be reviewed to ensure identified change of condition has been assessed by the community RN.

2.  The Executive Director, Assistant Executive Director, and the Wellness team received additional training on the Change of Condition policy and procedure that address this rule.    

3.  The Executive Director and Wellness Team will review this area daily per their individual Quality Assurance Review Schedule; 24 hour book Change of Condition, to ensure correction.

4.  The Executive Director will ensure the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 1 of 5 sampled residents (#7) whose orders were reviewed. Findings include, but are not limited to:

Resident 7's current physician orders dated 7/29/21 and 10/1/21 through 10/26/21 MAR identified the following deficiencies:

* Resident 7 had a  physician order for a Capsaicin patch for pain to be administered three times daily. The October MAR identified 42 occasions the pain patch was not documented as administered to the resident as ordered; and

* Nutritional Supplement was not documented as administered on four occasions.

Facility staff were unable to verify the medication and nutritional supplement were given as ordered.

The need to ensure physician orders were carried out as prescribed was discussed with Staff 1 (Administrator) and Staff 2 (Operation Specialist) on 11/1/21. They acknowledged the findings.

1.  All Medication Administration Records (MAR) will be reviewed to ensure medication or treatment orders are carried out as prescribed.      

2.  The Executive Director, Assistant Executive Director, Wellness Team and all Med Tech's received additional training on the Medication Administration policy and procedure, including documenting when a medication or treatment is delivered, that address this rule.

3.  The Executive Director and Wellness Team will review this area daily per the Quality Assurance Master Review Schedule; Daily Stand Up Clinical Review, to ensure correction.  The Med Tech's will review this area each shift per the 24 HR Resident Report MAR review, to ensure correction.

4.  The Executive Director will ensure the corrections are completed and monitored.

2. Resident 7's 10/1/21 through 10/26/21 MAR was reviewed, and the following inaccuracies were identified:

* PRN Tylenol exceeded the daily dose parameter;

* On 10/9/21, Isosobride (blood pressure medication) hold parameter was not followed;

* There were multiple blanks on the MAR for the following medications or treatments:

- Tylenol;

- Capsaicin Patch (for pain);

- Eliquis;

- Fluticasone nasal spray;

- Isosobride (blood pressure medication);

- Levothyroxine (thyroid medication);

- Memantine (dementia medication);

- Vitamin D3;

- Nutritional Supplement;

- Weekly weights;

- Covid-19 monitoring;

- Meal monitoring and meal percentages;

- Monthly weights and vitals;

- Blood pressure vital;

- Oxygen saturation levels; and

- Temperature.

The need to ensure MAR's included clear parameters for unlicensed staff, parameters were being followed and included documentation that all medications and treatments were initialed as administered during the medication pass was reviewed with Staff 1 (Administrator) and Staff 2 (Operation Specialist) on 11/1/21. They acknowledged the inaccuracies.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate, included medication-specific instructions and had specific parameters for PRN medications for 3 of 5 sampled residents (#s 2, 5 and 7). Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in October 2021 with diagnoses including diabetes.

The resident's 10/13/21 through 10/27/21 MARs and TARs and 10/13/21 physician orders were reviewed. The MARs/TARs contained blank spots in the documentation for the following treatments and medications:

* Humalog kwikpen (for diabetes);

* Latanaprost (eye drops);

* Lotrisone (antifungal cream); and

* Cranberry capsules (supplement).

The need for accurate records was discussed with Staff 1 (Administrator) and Staff 2 (Operations Specialist) on 10/29/21 and 11/1/21. The staff acknowledged the findings.

3. Resident 5 was admitted to the facility in October 2019 with diagnoses including dementia.  Review of the MAR, dated 10/1/21 to 10/27/21, indicated the following deficiencies:

* The MAR lacked parameters for PRN pain medications acetaminophen and hydrocodone and morphine, regarding which to administer first;

* The MAR lacked parameters for PRN bowel medications Senna, Bisacodyl and Milk of Magnesia regarding the sequential order of use; and

* Multiple blank spaces on the MAR for medications including acetic acid, Quetiapine and daily blood pressure readings.

On 10/29/21 the need to maintain an accurate MAR for all medications/treatments ordered by a legally recognized prescriber and administered by the facility was discussed with Staff 1 (Administrator). She acknowledged the findings.

1.  The Medication Administration Record for resident #2, #5 and #7 were updated and remaining resident MAR's reviewed, to ensure accurate medication records including medication specific instructions and specific parameters for PRN medications.  

2.  The Executive Director, Assistant Executive Director, and Wellness team received additional training on the Medication Administration policy and procedure; processing orders and all Med Techs received additional training on the Medication Administration policy and procedure; following orders and documenting when a medication or treatment is delivered, that address this rule.

3.  The Executive Director and Wellness Team will review this area daily per the Quality Assurance Master Review Schedule; Daily Stand Up Clinical Review, to ensure correction.  The Med Tech's will review this area each shift per the 24 HR Resident Report MAR review, to ensure correction.

4.  The Executive Director will ensure the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure staff documented non-pharmacological interventions had been tried with ineffective results prior to administering PRN psychotropic medications for 2 of 2 sampled residents (#s 4 and 5) who were prescribed PRN medications to treat the residents' behaviors. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in November 2020 with diagnoses including bipolar disorder and anxiety. Resident 4 was prescribed PRN lorazepam to treat symptoms of bipolar disorder. The 10/2021 MAR indicated the resident was administered the medication on 4 occasions.

The facility failed to document what non-pharmacological interventions were attempted and ineffective prior to administering the psychotropic medication on 4 of the 4 occasions.

The need to ensure staff attempted and documented non-pharmacological interventions were ineffective prior to administering PRN psychotropic medications to treat a resident's behavior was discussed with Staff 1 (Administrator) and Staff 2 (Operations Specialist) on 11/1/21. They acknowledged the findings.

2. Resident 5 was admitted to the facility in October 2019 with diagnoses including dementia. Resident 5 was prescribed PRN lorazepam for anxiety. The 10/2021 MAR indicated the resident was administered the medication on 10/26/21.

The facility failed to document what non-pharmacological interventions were attempted and ineffective prior to administering the psychotropic medication.

In an interview on 10/29/21, Staff 1 (Administrator) stated the non-pharmacological interventions were added to the electronic MAR, and staff training was needed to ensure Med Tech's documented the attempts prior to administering the PRN medication.

The need to ensure staff attempted and documented non-pharmacological interventions were ineffective prior to administering PRN psychotropic medications to treat a resident's behavior was discussed with Staff 1 (Administrator) and Staff 2 (Operations Specialist) on 10/29/21. They acknowledged the findings and stated the staff training on the electronic system would occur.

1.  The community electronic system has been modified to improve the process of documenting non-pharmacological interventions attempted and ineffective prior to administering pshychotropic medication.

2.  The Executive Director, Assistant Executive Director and Wellness team received additional training on the Medication Administration policy and procedure; monitoring documentation and all Med Techs received additional training on the Medication Administration policy and procedure; documentation, that address this rule.

3.  The Executive Director and Wellness Team will review this area daily per the Quality Assurance Master Review Schedule; Daily Stand Up Clinical Review, to ensure correction.  The Med Tech's will review this area each shift per the 24 HR Resident Report MAR review, to ensure correction.

4.  The Executive Director will ensure the corrections are completed and monitored.

Based on observation and interview, it was determined the facility failed to ensure courtyard pathway edges did not contain drop-offs to prevent a tripping hazard for residents. Findings include, but are not limited to:

The facility consisted of five houses. The outdoor courtyard/patio areas were toured on 10/28/21 and 10/29/21. Drop-offs were observed along the sidewalks in each of the courtyard and patio areas of all houses.

The need to ensure all exterior pathways were maintained free of drop-offs was discussed with Staff 1 (Administrator) and Staff  2 (Operations Specialist) on 10/29/21. They acknowledged the findings.

1.  The sidewalk to yard edges have been filled in, where needed, in all outdoor courtyard and patio areas.

2.  The Executive Director, Assistant Executive Director and Maintenance Director received additional training on the Safe Walk Survey that address this rule.

3.  The Executive Director and Maintenance Director will review this area quarterly per the Maintenance Quality Assurance Review Schedule; Safety, to ensure correction.   

4.  The Executive Director will ensure the corrections are completed and monitored.  

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 152, C 231 and C 510.

Refer to C 152, C 231 and C 510

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 260, C 270, C 280, C 303, C 310 and C 330.

Refer to C 260, C 270, C 280, C 303, C 310 and C 330

Based on observation, interview and record review, it was determined the facility failed to ensure an individualized nutrition plan was developed and included in the service plan for 2 of 2 sampled residents (#s 5 and 7) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 5's current service plan was reviewed during the survey. The service plan stated the resident required food be cut up into small pieces, was independent with eating and was able to make dining needs and preferences known.

Observations of meals on 10/28/21 and 10/29/21 showed Resident 5 ate meals in bed, was able to feed him/herself once set up by staff and required reminders and assistance from staff to receive any snacks or fluids. Weight records reviewed from 4/1/21 through 10/1/21 showed slow, gradual weight loss over 6 months. The service plan lacked information and instructions for staff to follow related to the slow weight loss, when and how to provide snacks and ensure individualized nutrition needs and preferences were being met.  

The need to provide a daily meal program for nutrition and hydration based upon the resident's preferences and needs, available throughout each resident's waking hours and documented in the resident's service plan was discussed with Staff 1 (Administrator) and Staff 2 (Operations Specialist) on 10/29/21. They acknowledged the findings.

2. Resident 7 was admitted to memory care in May 2021 with diagnoses including Alzheimer's disease with late onset.

Observations, interviews with staff, review of the service plan and interim service plans were conducted during the survey.

A review of Resident 7's clinical records revealed the following:

* Resident 7's service plan, dated 5/21/21, noted the resident was independent with eating, was a light eater, needed strong encouragement to eat, and had experienced a 14-pound weight loss prior to move in. Although the recent history of weight loss was identified, the initial service plan lacked a resident specific nutrition and hydration plan to address the weight loss; and

* Resident 7 continued to experience severe weight loss after move in. The service plan dated 8/30/21 noted resident was independent with eating, was a light eater, needed strong encouragement to eat and was at risk of dehydration. The service plan continued to lack information and staff instruction related to individualized nutrition and hydration needs to address the weight loss and dehydration risk.

On 11/1/21, the need to develop individualized service plans addressing residents' nutrition and hydration needs was discussed with Staff 1 (Administrator) and Staff 2 (Operation Specialist). They acknowledged the findings.

1.  The Service Plan for resident #5 and #7 have been updated with an individualized nutrition plan.  Remaining resident Service Plans will be reviewed to ensure an individualized nutrition plan.  

2.  The Executive Director, Assistant Executive Director  and the Wellness team, received additional training on the Service Plan policy and procedure and the Service Plan guide that address this rule.

3.  The Executive Director and Wellness Team will review this area weekly per their individual Quality Assurance Review Schedules; Service Planning, to ensure correction.

4.  The Executive Director will ensure the corrections are completed and monitored.