Print Inspection: KJ3R

The findings of the on-site investigation, conducted on 07/11/23, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

Abbreviations possibly used in this document:

ADL:activities of daily living

CBG:capillary blood glucose or blood sugar

CG:caregiver

CS: Compliance Specialist

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MT:            Medication Tech

MAR:Medication Administration Record

MCC:Memory Care Community

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

RCC:Resident Care Coordinator

RN:Registered Nurse

Based on interview and record review, conducted during a site visit on 07/11/23, it was confirmed the facility failed to ensure service plans were updated quarterly for 2 of 2 sampled residents (#s 4 and 5), whose service plans were reviewed. Findings include, but are not limited to:

Compliance Specialist reviewed Resident 4's most current service plan dated 01/03/23, and Resident 5's service plans dated 10/06/22 and 06/21/23. There was no documented evidence Resident 4's service plan had been updated since 01/03/23, and no documented evidence Resident 5's service plan had been updated between 10/06/22 and 06/21/23.

During an interview, Staff 1 confirmed resident service plans had not been completed on time, however s/he had just started working at the facility on 07/01/23 and had 20 care conferences scheduled for the upcoming week.

The findings were reviewed with and acknowledged by Staff 1 and Staff 2 (Assistant Executive Director) on 07/11/23.

It was confirmed that the facility failed to ensure service plans were updated quarterly.

Verbal plan of correction: New ED started on 07/01/23 and has care conferences already scheduled this week to stay current on care plans. They currently do not have any that are past due. They are using the program Yardi, which alerts them when they have upcoming service plans due.

Based on interview and record review, conducted during a site visit on 07/11/23, it was confirmed the facility failed to ensure service plans were updated quarterly for 1 of 1 sampled resident (#1), whose service plans were reviewed. Findings include, but are not limited to:

Compliance Specialist reviewed Resident 1's service plans dated 12/29/22 and 05/16/23. There was no indication the facility had completed any other service plans between the two dates.

During an interview, Staff 1 (Executive Director) confirmed the facility had been behind on resident service plans, and stated s/he had just started working at the facility on 07/01/23. Staff 1 further stated s/he had 20 care conferences scheduled for the upcoming week. A review of the facility's computer system indicated the facility was currently caught up.

The findings were reviewed with and acknowledged by Staff 1 and Staff 2 (Assistant Executive Director) on 07/11/23.

It was confirmed the facility failed to ensure service plans were updated quarterly.

Verbal plan of correction: New ED started on 07/01/23 and has care conferences already scheduled this week to stay current on care plans. They are using the program Yardi, which alerts them when they have upcoming service plans due.

Based on interview and record review, conducted during a site visit on 07/11/23, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 3 of 3 sampled residents (#'s 3, 4, and 5). Findings include, but not limited to:

Resident 3's signed physicians orders, April 2023 Medication Administration Record (MAR), and facility self-reported fax dated 05/05/23, indicated that on 04/30/23, Resident 3 missed his/her 8:00 pm dose of Diltiazem 120 mg, Flovent 110/mcg/act, Gabapentin 300 mg, Isosorsbide Monomitrate 60 mg, Ipratropium-Albuterol, and Metoprolol 50 mg.

Resident 4's signed physicians orders, April 2023 MAR, and facility self-reported fax dated 05/05/23, indicated that on 04/30/23, Resident 4 missed his/her 8:00 pm dose of Atorvastatin 40 mg, Eliquis 5 mg, Lisinopril 20 mg, and Trazadone 50 mg.

Resident 5's signed physicians orders, April 2023 MAR, and facility self-reported fax dated 05/05/23, indicated that on 04/30/23, Resident 5 missed his/her 8:00 pm dose of carbidopa-levodopa 25-100, cephalexin 500 mg, Docusate 100 mg, Donepezil 5mg, simvastatin 20 mg, and Tamsulosin 0.4 mg.

During an interview, 7/11/23, Staff 1 (Executive Director) stated s/he was not working at the facility during the time of the medication errors, however, the incidents did occur. A staff member walked off their shift and did not pass their scheduled 5:00 pm or 8:00 pm medications. S/he stated during their investigations they did not find any residents who requested or missed any PRN medications. Staff 1 confirmed, all residents who missed their scheduled dose of medication during that time frame had been reported to APS.

The findings were reviewed with and acknowledged by Staff 1 and Staff 2 (Assistant Executive Director) on 07/11/23.

It was confirmed the facility failed to carry out medication and treatment orders as prescribed.

Verbal plan of correction: Facility notified APS of all residents who missed their meds on 4/30/23 during swing shift. Starting in May 2023 the RN did education with staff regarding med passes, orders, PRN follow up, and who to contact when issues arise. They are monitoring the Yardi system daily (clinicians and administration). Continuous med training is ongoing and they will be switching to utilizing a med cart instead of their previous system for passing meds. The previous ED and LPN no longer work at the facility and the new ED Shayna started 7/1/23.

Based on observation and interview, conducted during a site visit on 07/11/23, it was confirmed the facility failed to provide a call system that connects resident units to the care staff center or staff pagers for 1 of 1 sampled resident (#2). Findings include, but are not limited to:

On 07/11/23, at 12:46 pm, Compliance Specialist (CS) observed Resident 2 push his/her call light pendant. After waiting 15 minutes outside of Resident 2's room, CS found Staff 5 (CG) and Staff 6 (CG) in the hallway and asked to see their pagers. Resident 2's call did not register on the pagers until Staff 5 scrolled through his/her pager to review previous calls. After reviewing the previous calls, Resident 2's page came through.  

Staff 5 and 6 both stated sometimes the call lights didn't show up on the pagers at all, they were delayed, or would show up on one pager and not the other. They stated they only had three pagers and one was broken. Resident 2 stated, s/he recently had received a new pendant, and the call light was still not working.

The findings were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 2 (Assistant Executive Director) on 07/11/23.

It was confirmed the facility failed to provide a call system that connected resident units to the care staff center or staff pagers.

Verbal plan of correction:  Administrator did an audit last week. Some areas are not getting the signal right away when pendants are pressed. They are going back to the old walkie talkies that they know worked and ordering new pagers rush order. They will also be monitoring the call lights at the receptionist area. Staff will be re-educated on Thursday 7/13/23 at an in-service and there will be frequent 2-hour checks on residents until the new pagers and walkies arrive. They expect this to be completed by the end of the week.