Print Inspection: BF0N

The findings of the initial survey conducted 07/18/22 through 07/20/22 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 Home and Community Based Services Regulations.

Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living 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 07/20/22, conducted 12/12/22, 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 Home and Community Based Services Regulations.

Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living 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

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 second revisit, to the initial licensure survey of 07/20/22, conducted on 02/16/23, 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, 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 ensure MARs included resident-specific parameters for PRN medications for 1 of 2 sampled residents (# 1) whose medications were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 05/2022 with a diagnosis of guillain-berre syndrome.

Resident 1's 07/01/22 through 07/17/22 MARs were reviewed during the survey. The following PRN medications lacked clear parameters for administration:

* PRN oxycodone, naproxen, Tylenol and diclofenac all prescribed to treat pain, lacked clear parameters for the sequence of administration.

* PRN senna, magnesium citrate, polyethylene glycol and bisacodyl suppository all ordered for bowel care lacked clear parameters which medication was to be administered first.

* PRN hydrocortisone cream and diphenhydramine both for itching did not have clear parameters to guide staff which to utilize first.

The need to ensure MARs included clear parameters for multiple PRN medications that were prescribed to treat the same condition was discussed with Staff 1 (Administrator) and Staff 2 (Administrator in training) on 07/20/22. They acknowledged the findings.

1.The resident was assessed and is capable of making medication decisions, the PCP has agreed as well they are capable of deciding. The resident's MAR has been updated to reflect this.

2. The RCC and RN will review all incoming orders to ensure that correct parameters are set for different PRN medications that can be used for the same issue.

3. The area will constantly be addressed as medication changes happen.

4. RCC and RN.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate for 3 of 3 sampled residents (#s 2, 3 and 4). This is a repeat citation. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 3/2022.

Residents 2's MARs were reviewed from 12/01/22 through 12/12/22 and the following was noted:

* Reasons for use was not indicated for all medications.

The need for the facility to ensure MARs were accurate was discussed with Staff 2 (Administrator) on 12/12/22 at 12:45 pm. She acknowledged the findings. No further information was provided.

2. Resident 3 was admitted to the MCC in 07/2022 with diagnoses which included dementia.

Residents 3's MARs, reviewed from 12/01/22 through 12/12/22 revealed the following:

* S/he had an order for lidocaine cream to be applied to "affected areas four times a day as needed." The MAR lacked resident-specific instructions for the application of the cream;

* Reasons for use was not indicated for all medications; and

* The MAR directed staff to administer Seroquel (antipsychotic) 25 mg 1/2 tablet two times a day PRN agitation and anxiety. However, the MAR lacked resident specific instructions for how s/he expressed agitation and anxiety.

On 12/12/22, the need for the facility to ensure MARs were accurate and provided clear instruction to unlicensed staff was discussed with Staff 2 (Administrator). She acknowledged the findings. No further information was provided.

3. Resident 4 was admitted to the MCC in 09/2022 with diagnoses which included Alzheimer's dementia.

Residents 4's MARs were reviewed from 12/01/22 through 12/12/22 and the following was noted:

* Lack of resident-specific instructions for multiple PRN bowel medications, including sequence of administration;

* Reasons for use was not indicated for all medications; and

* The MAR directed staff to administer PRN Lorazepam for anxiety, PRN Haldol for agitation, and PRN Morphine for pain. However, the MAR lacked resident specific instructions for how s/he expressed anxiety, agitation, and pain.

In an interview on 12/12/22 at 12:45 pm, Staff 2 (Administrator) reviewed the resident's MAR. She confirmed several medications lacked reasons for use, and the multiple PRN bowel medications, PRN Lorazepam, PRN Haldol, and PRN morphine lacked specific instructions for staff. No further information was provided.

C 310

1.) Resident 2,3, and 4 MAR's were reviewed. The medication record of each redsident lacked the minimum medication record for each resident. PCP has been advised that all medications require at minimum current month day and year. Name of medications, reason for use of the drug, dosage, route. It must also list the medication specific instruction. If applicable side effects time sensitive doses. Resident specific parameters and instrucions for PRN's. The MAR lacked individual instructions per resident centered care. OAR has been reviewed with RCC and Medication Technicians. To ensure that if a medication order does not include medication record minimum clarification will be sought in a timely manner from PCP.

2.) The RCC and facility nurse will review all incoming orders to ensure that all correct parameters are included in the orders of regulation OAR 411-054-0055 Systems medication administration.

3.) The areas of this regulation will constantly be addressed as medication changes happen.

4.) RCC, facility nurse and designees.

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 1 of 1 sampled resident (#3) who was prescribed PRN medications for behaviors. Findings include, but are not limited to:

Resident 3 was admitted to the MCC in 07/2022 with diagnoses including dementia.

Resident 3 had a physician's order for Seroquel 25 mg ½ tablet twice a day for agitation or anxiety.

Review of MARs from 12/01/12 - 12/12/22, revealed staff administered PRN Seroquel on 11 occasions. There was no documented evidence staff consistently attempted non-drug interventions with ineffective results prior to administering the psychotropic medication.

In an interview on 12/12/22 at 12:00 pm, Staff 18 (MT) reviewed the MAR and progress notes and acknowledged staff were not consistently documenting non-drug interventions attempted prior to administering the PRN Seroquel.

The need to ensure staff documented non-pharmacological interventions had been tried with ineffective results prior to administering PRN psychotropic medications was reviewed with Staff 2 (Administrator) on 12/12/22 at 12:45 pm. She acknowledged the findings.

CC 330

1.)  Resident 3's MAR was reviewed. Individualized non pharmalogical interventions have been identified and are in place. Medication Technicians have been educated that they may only use PRN psyscotropic medications after documented non-pharmalogical interventions have been tried with ineffective results.

2.) The RCC, facility nurse or designee will ensure that individualized non pharmalogical interventions have been identified and are in place.

3.) The RCC, facility nurse or designee will audit documentation of medication of PRN psyscotropic medications documented non-pharmalogical interventions have been tried with ineffective results. On going to ensure proper use of psyscotropic medication.

Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) that met the regulation. Findings include, but are not limited to:

There was no documented evidence the facility was using an ABST which would determine a staffing plan reflective to meet the 24-hour scheduled and unscheduled needs of residents.

On 07/18/22, Staff 1 (Administrator) reported the facility had not implemented an ABST. Staff 1 stated he would follow up to ensure the ABST was implemented as required.

1.The DHS provided ABST was put into place immediatley. The ABST is now being used and all resident information has been entered.

2. All new resident or residents have a COC will have there information updated in the ABST.

3. Whenever a new resident moves in or a resident has a change of condition.

4. The administrator or RCC will enter in the ongoing ABST information.

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 sampled newly-hired direct care staff (#s 9 and 11) completed abdominal thrust and First Aid training. Findings include, but are not limited to:

Training records were reviewed on 06/19/22 and revealed the following:

Training records for Staff 9 (CG) hired 06/15/22, and Staff 11 (MT/CG) hired 06/11/22, were reviewed on 07/19/22 with Staff 4 (RCC). She confirmed the above mentioned staff did not have abdominal thrust or First Aid training.

The need to ensure newly-hired direct care staff completed abdominal thrust and First aid training was reviewed with Staff 1 (Administrator) and Staff 2 (Administrator in Training) on 07/20/22. They acknowledged the findings.

1. Staff received training for abdominal thrust and first aid.

2. All staff before going on to the floor will need to ensure the check list of all items are submitted to the RCC, including abdoominal thrust and first aid training.

3. Every Year RN to teach abdominnal thrust class, and all new hires as they are onboarded.

4. RCC and RN.

Based on interview and record review, it was determined the facility failed to ensure 1 of 3 direct care staff (#13) had documented evidence of completion of First Aid training within 30 days of hire. This is a repeat citation. Findings include, but are not limited to:

Staff training records were reviewed on 12/12/22 and revealed Staff 13 (CG), hired 09/14/22, lacked documented evidence they had completed First Aid training within 30 days of hire.

The need for staff to complete all required training in the specified time frames was discussed with Staff 2 (Administrator) on 12/12/22 at 1:25 pm. She acknowledged the findings.

C 372

1.) Staff member 13 and 14 have finished all required orientation and competency paperwork and training.

2.) All staff will complete all required CBC pre-sevice dimentia training and complete all other training requirements within 30 days of hire for direct care staff. Staff will be required to go through a check off list of all education and will not be alloweed to work on the floor until all items are completed and submitted per the OAR.

3.) Staffing/Education Coordinator will complete the on boarding process and ensure all paperwork and orientation is completed with OAR compliance.

4.) Staffing/Education Coordinator, RCC, Administrator and designee.

Based on interview and record review, it was determined the facility failed to ensure their survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:

Refer to Z155, C310 and C372.

C455

1.) The survey plan of correction previously documented on 7/20/2022 has been updated to better assist the community to comply with a sucessful plan of correction.

2.) The management team will continue to review the areas of deficiency until all regulatory requirements are met.

3.) the plan of correction will be satisfied within the aloted time frame.

4.) Administrator, RCC, Facility Nurse, Staffing/Education Coordinator and other management designee

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 alert staff when residents exited the building. Findings include, but are not limited to:

Observations during the survey revealed exit doors, including the doors to the enclosed courtyard, had no alarm or other acceptable system to alert staff when residents exited the building.

The failure to ensure doors were equipped with an alarming device or other acceptable system was discussed with Staff 1 (Administrator) and Staff 2 (Assistant Administrator) on 07/20/22. They acknowledged the findings.

1. Door alarm notification equipment has been ordered and will be installed that will notify staff when a resident has exited to a courtyard.

2. All exterior doors will have notification equipment installed on them going forward.

3. Only when batteries need replacing, device will notify staff if low battery or no power.

4. Maintnance to ensure all equipment is installed and batteries are replaced.  

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 361, C 372 and C 555.

See C361, C372, and C555.

Based on interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:

Refer to C372.

Z142

1.) Refer to plan of correction for C 327.

2.) Refer to plan of correction C 327.

3.) Refer to plan of correction C 327.

4.) Refer to plan of correction C 327.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 7, 9 and 11) had completed all required orientation, pre-service training prior to beginning their job duties and/or had documented evidence of competency demonstrated within 30-days of hire. Findings include, but are not limited to:

Review of training records for newly hired Staff 7 (CG) hired 06/08/22, Staff 9 (CG) hired 06/15/22 and Staff 11 (MT/CG) hired 06/11/22 identified the following deficiencies:

*Staff 9 failed to have documented evidence of completing all orientation, pre-service training and demonstrated competency in all areas prior to beginning their job duties; and

*Staff 7 and 11 failed to have documented evidence of completing all pre-service training prior to beginning their job duties and documented competency demonstrated within 30-days of hire.

On 07/20/22, the need to ensure all orientation, pre-service training and competency demonstrated was completed prior to starting job duties was discussed with Staff 1 (Administrator) and Staff 2 (Assistant Administrator). They acknowledged the findings.

1. Staff 7, 9, and 11 have finished all required orientation and competency paperwork.

2. All staff will be required to go through the check off list and will not be allowed to work on the floor until all items are completed and submitted.

3. As staff are onboarded RCC to ensure all paperwork and orientation work is completed and submitted.

4. RCC and Administrator.

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 sampled newly hired staff (#s 13 and 14) completed all required pre-service training, and 3 of 3 newly hired staff (#s 13, 14 and 15) completed competency training within 30 days of hire and prior to independently providing personal care to residents. This is a repeat citation. Findings include, but are not limited to:

Staff training records were reviewed on 12/12/22 at 1:25 pm. The following were identified:

a. Staff 13 (CG) was hired 09/14/22.

* There was no documented evidence she completed fire safety and emergency procedure pre-service training prior to performing any job duties.

* There was no documented evidence Staff 13 demonstrated competency in assigned job duties within 30 days of hire and prior to working independently in the following areas:

- Changes associated with normal aging;

- Identification, documentation, and reporting of changes of condition; and

- Conditions that require assessment, treatment, observation, and reporting.

b. Staff 14 (CG) was hired 10/28/22. There was no documented evidence she had completed the following required training:

* Abuse reporting pre-service training; and

* There was no documented evidence Staff 14 demonstrated competency in assigned job duties within 30 days of hire and prior to working independently in the following areas:

- Changes associated with normal aging;

- Identification, documentation, and reporting of changes of condition; and

- Conditions that require assessment, treatment, observation, and reporting.

c. Staff 15 (CG) was hired 10/26/22. There was no documented evidence Staff 15 demonstrated competency in assigned job duties within 30 days of hire and prior to working independently in the following areas:

- Changes associated with normal aging;

- Identification, documentation, and reporting of changes of condition; and

- Conditions that require assessment, treatment, observation, and reporting.

The facility's failure to ensure staff completed all required training in a timely manner and prior to working independently was discussed with Staff 2 (Administrator) on 12/12/22. She acknowledged the findings.

Z 155

1.) Refer to plan of correction C 372.

2.) Refer to plan of correction C 372

3.) Refer to plan of correction C 372

4.) Refer to plan of correction C 372

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 310.

See C310.

Based on 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 C310 and C330.

Z 162

1.) Refer to C 310 and C330.

2.) Refer to C 310 and C330.

3.) Refer to C 310 and C330.

4.) Refer to C310 and C330.