Print Inspection: KJ3Y

The findings of the re-licensure survey, conducted 12/06/21 through 12/07/21 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, 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 revisit to the re-licensure survey of 12/07/21, conducted on 03/10/22, 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, 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 second re-visit to the re-licensure survey of 12/07/21, conducted 05/12/22 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.

Based on interview and record review, it was determined the facility failed to ensure injuries of unknown cause were promptly and thoroughly investigated to rule out abuse and neglect and reported to the local SPD office as required for 1 of 2 sampled residents (#1) whose incidents were reviewed. Findings include, but are not limited to:

Resident 1 was admitted to the facility in April 2020 with diagnoses including dementia.  

The resident's care plan dated 04/16/21 and interviews with care staff between 12/06/21 and 12/07/21 indicated the resident was dependent for all ADL care and had frequent falls. The resident was unable to direct his/her own care.

Review of incident investigations and progress notes from 08/01/21 through 12/06/21 showed the following:

* A progress note dated 08/04/21 indicated a 3.0 cm bruise was found on the resident's left breast and a 5.0 cm bruise to the right hip. The investigation did not provide information on how the bruise may have occurred, and was not reported to the local SPD.

* A progress note dated 08/17/21 indicated a bruise to the resident's right breast was discovered. There were no additional notes regarding the bruise and no investigation of the injury of unknown cause was completed.

The need to ensure resident incidents, were promptly and thoroughly investigated to rule out abuse and neglect was discussed with Staff 1 (Administrator) on 12/06/21 and 12/07/21. She acknowledged the findings.

The facility was asked to report both injuries of unknown cause to the local SPD office. Confirmation of the reports was provided prior to survey exit.

1. All incident reports will be thoroughly investigated, documented, and followed up on in a timely manner utilizing root, cause, and anaylsis. Facility self-reports will be submitted per regulatory requirements.

2. Staff will be educated on incident and accident investigation as well as self-reporting; and will not assume that certain causes of injury are based on history of falls or bruises. All events will be investgated for every injury of unknown origin regardless of history.

3. Will be reviewed in our stand-up process.  

4.  Administrator

2. Resident 1 was admitted to the facility in April 2020 with diagnoses including dementia.

Observations of the resident, interviews with staff and review of the resident's record were completed on 12/06/21 and 12/07/21.

The resident's last quarterly evaluation was completed on 04/16/21. Additional evaluations were due near 07/16/21 and 10/16/21, but were not completed

The need to ensure resident evaluations were completed at least quarterly was discussed with Staff 1 (Administrator) on 12/07/21. She acknowledged the findings.

3. Resident 3 was admitted to the facility in October 2021.

Observations of the resident, interviews with staff and review of the resident's record were completed on 12/06/21 and 12/07/21.

a. The undated new move-in evaluation and initial service plan dated 10/02/21 did not address the following required elements:

* Visits to health practitioner(s), ER, hospital, or nursing facility in the past year;

* Vital signs if indicated by diagnosis, health problems or medications;

* Personality, including how the person copes with change or challenging situations;

* Unsuccessful prior placements;

* Customary routines: eating, bathing;

* Interests, hobbies, social and leisure activities;

* Ability to manage medications; and

* Environmental factors that impact the resident's behavior, including noise, lighting, and room temperature.

b. The resident's new move in evaluation was not updated within 30 days of admission as required.

The need to ensure move-in evaluations addressed all required elements and were updated as needed within 30 days of admission was discussed with Staff 1 (Administrator) on 12/07/21. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure resident move-in evaluations contained all required elements, updates and changes were made as required within the first 30 days, were reflective of current care needs, ensure quarterly evaluations were completed to correspond with the quarterly service plan updates and that smoking evaluations were completed quarterly for 3 of 3  sampled residents (#s 1, 2 and 3) whose evaluations were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in February 2017 with diagnoses of dementia and history of a stroke with hemiparesis.

During the acuity interview on 12/06/21 Resident 2 was identified as a supervised smoker.

Resident 2's most recent quarterly, full evaluation was completed on 04/27/21. The resident's most recent smoking evaluation was completed on 06/14/21.

The need to ensure evaluations were completed at least quarterly was discussed with Staff 1 (Administrator) on 12/07/21. She acknowledged the findings.  

1. All residents who currently smoke will have their smoking evaluations completed as soon as possible. All residents who have not had their move-in evaluation and service plans that were not updated will be updated as soon as possible with the service plan team.

2. A calender will be+ created to display due dates of each evaluation, in addition to appointments set for service plan updates with service plan team and will be reviewed in daily stand up.

3. Weekly to check calender for appointments and/or due dates of evaluations.

4.  Administrator and/or Resident Care Coodinator

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

1. Resident 1 was admitted to the facility in April 2020 with diagnoses including dementia.

a. Observations of the resident, interviews with staff and review of the care plan dated 04/16/21, showed the care plan was not reflective of the resident's current care needs, was not consistently followed by staff and/or did not provide clear direction to staff in the following areas:

* Hallucinations, combativeness and disrobing;

* Falls and safety interventions;

* Caregiver gender preferences:

* Meal assistance;

* Hospice;

* Toileting; and

* Activity participation.

b. The last update of the service plan occurred on 04/12/21, not quarterly as required.

c. Handwritten updates to the service plan were not dated or initialed.

The need to ensure resident service plans were reflective of current care needs, provided direction to staff, updated at least quarterly and were followed was discussed with Staff 1 (Administrator) on 12/07/21. She acknowledged the findings.

2. Resident 3 was admitted to the facility on 10/03/21 with diagnoses including dementia.

Observations of the resident, interviews with staff and review of the care plan dated 10/02/21, revealed the care plan was not reflective of the resident's current care needs and/or did not provide clear direction to staff in the following areas:

* Hallucinations and refusal of care;

* Bathing, dressing and toileting assistance;

* Knee pain and affect on ADLs;

* Walker use and ambulation; and

* Activity participation and self-isolation.

The need to ensure residents' service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (Administrator) on 12/07/21. She acknowledged the findings.

3. Resident 2 was admitted to the facility in February 2017 with diagnoses including dementia and history of a stroke with hemiparesis.

a. Review of Resident 2's 07/18/21 service plan, progress notes 09/19/21 through 12/06/21, observations of the resident and interviews with staff revealed the service plan was not reflective, was not followed and/or did not include instructions for staff in the following areas:

* Compression stockings;

* Current skin conditions including instructions;

* Use of a scoop plate for meals;

* Toe pain related to hammer toes;

* Hydrocodone for abdominal pain; and

* Monitoring instructions for safety with use of a side rail.

b. The last update of the service plan occurred on 07/18/21, not quarterly as required.

c. Handwritten updates to the service plan were not dated or initialed.

The need to ensure service plan's were reflective of the resident's current status and care needs, provided instruction to staff, were followed, changes and entries to the service plan included a date and initials and updated quarterly was discussed with Staff 1 (Administrator) on 12/07/21. She acknowledged the findings.

1. Will update service plans immediately which will indicate current needs, conditions, changes, preferences, individuality, and choice.            

2. Dates on calender for quarterly updates which will involve service plan team. Any changes made to service plan will be signed and dated by person making the change.

3. Service plan calender will be reviewed weekly for appointmets and due dates. TSPs will be reviewed daily to ensure they are added to the service plan as applicaple.                                                                                                                                    

4. Administrator, Resident Care Coordinator, RN

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that consisted of the resident, the resident's legal representative if applicable, any person of the residents choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services, for 3 of 3 sampled residents (#s 1, 2 and 3) whose service plans were reviewed.  Findings include, but are not limited to:

Resident 1, 2 and 3's most recent service plans lacked documentation a Service Planning Team reviewed and participated in the development of the service plans.

The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (Administrator) on 12/07/21.  She acknowledged the findings.

1. Will coordinate service plan teams for each resident that may include resident, family member, primary care physician, RN, RCC, and Administrator.

2. The facility will designate, coordinate, and confirm service plan teams, date, time, and participation.                                                                                  

3. Weekly checks to enusre appointments aren't missed and that invites/reminders go out in a timely manner.

4. Administrator, RCC

Based on observation, interview and record review, it was determined the facility failed to ensure residents who had short-term changes of condition were evaluated, resident-specific instructions or interventions were developed and reviewed for effectiveness and the condition was monitored to resolution at least weekly for 2 of 4 sampled residents (#s 1 and 3) who experienced changes of condition. Resident 1 experienced repeated falls with head injury without intervention to prevent further injury. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in April 2020 with diagnoses including dementia.

Interviews with staff and review of the resident's 04/16/21 service plan, 08/01/21 through 12/06/21 progress notes, incident investigations and physician communications were completed.

Observations on 12/06/21 and 12/07/21, revealed the resident had an tab alarm in place while in bed and in the wheelchair. A fall mat was in place when the resident was in bed. The resident had large amounts of bruising to both sides of his/her face, with the largest sections noted to the left side. The resident's arms additionally had multiple bruises. The resident needed frequent repositioning to sit straight up in the wheelchair. The resident was observed multiple times with his/her legs extended straight out with his/her body slid partially down in the wheelchair. The resident appeared very stiff and was not able to reposition him/herself or request assistance.

a. The resident experienced multiple injury and non-injury falls as follows:

* Non-injury falls from the wheelchair or bed occurred on 08/05/21, 08/10/21, 08/18/21 and 09/24/21.

* On 09/17/21 at 7:45 pm, the resident had an unwitnessed fall from bed and was found on the fall mat. Staff heard a loud bang and the resident was observed holding his/her head. The resident was sent to the emergency room for evaluation and returned the same day.

* On 09/21/21 at 8:15 pm, the resident had an unwitnessed fall from bed, hit his/her head and was found bleeding. The resident was transported to the emergency room for evaluation and received staples to a laceration at the back of his/her head.

* On 10/25/21 at 5:15 pm, the resident had a witnessed fall from the wheelchair. The resident stiffened and pushed him/herself to the side falling out of the wheel chair. The resident hit his/her head on the floor. The resident was sent to the emergency room for evaluation.

* On 11/24/21 at 5:30 pm, the resident had a witnessed fall from his/her wheelchair. The resident stiffened and fell out of the chair hitting his/her head on the floor. The resident had a hematoma to the left side of his/her head. The resident was sent to the emergency room for evaluation and returned the same day.

There was no documentation to show ongoing evaluation of existing interventions, determination and implementation of any new interventions and monitoring of those interventions for effectiveness after each of the resident's falls. The facility's investigations of the falls indicated the service plan was not updated and noted the resident had a history of falling out of the wheel chair or bed. The investigations did not indicate what may have contributed to the falls, nor did it address interventions to prevent future occurrences.

Resident 1 had repeated falls with head injury and emergency room trips without sufficient evaluation, monitoring and intervention by the facility to prevent further injuries and falls.

b. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness and/or lacked resident-specific directions to staff in the following areas:

* Bruising to both breasts and the right hip;

* Twitching, yelling and increased pain;

* Behaviors including aggressive, combative with staff:

* Scrapes and scratches to the resident's shin; and

* New medications and medication changes.

The need to ensure short-term changes of condition had documentation to reflect monitoring to resolution at least weekly and provided clear, resident-specific directions to staff was discussed with Staff 1 (Administrator) on 12/07/21. She acknowledged the findings.

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

Observations of the resident, interviews with staff and review of the resident's 10/02/21 service plan, 10/03/21 through 12/06/21 progress notes, incident investigations and physician communications were completed.

The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness and/or lacked resident-specific directions to staff in the following areas:

* Rash;

* Two pressure ulcers to the buttocks;

* Behaviors including refusal of care and severe hallucinations;

* Blood in the urine; and  

* New medications and medication changes.

The need to ensure short-term changes of condition had documentation to reflect monitoring to resolution at least weekly and provided clear, resident-specific directions to staff was discussed with Staff 1 (Administrator) on 12/07/21. She acknowledged the findings.

1.Training for all staff on how to identify short-term and significant change of conditions. Training on process, expectations, and follow-up of how to document and monitor changes of condition will be completed.

2. Post information and lists of what qualifies as short-term and significant change of condition followed by a checklist of required steps to be taken, such as RN assessments, TSPs, prog notes, follow up. In the event of a significant change of condition, a plan on how to care for, monitor, and evaluate will be added to service plan.

3. Daily audits to identify any new change of condition, and audits of TSP binder to follow up or resolve short term change of condition.

4. RN, Administrator, RCC

Based on interview and record review, it was determined the facility failed to coordinate care with outside providers, ensure documentation of visits were maintained in the residents' records, and that recommendations were implemented for 1 of 2 sampled residents (#3) who were receiving home health services from outside providers. Findings include, but are not limited to:

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

During the acuity interview on 12/06/21, Resident 3 was identified as receiving outside provider services related to Physical Therapy (PT).  

Observations of the resident, interviews with staff and review of outside provider notes and progress notes from 10/02/21 through 12/06/21 were completed.

The resident was admitted to PT services on 11/03/21 for strengthening and ambulation. PT visits were to occur twice a week for six weeks.

PT visit notes were not consistently documented and/or recommendations were not implemented as follows:

*There were only three visit notes documented between 11/03/21 and 12/6/21.  

*PT recommendations on 11/03/21 instructed staff to encourage short walks in the resident's room using the front wheeled walker; and

*PT recommendations on 12/02/21 instructed staff to walk in the hallway with the resident twice a day, wrap the left knee with an ace bandage or brace once obtained and supervise closely.

There was no evidence the recommendations were implemented and/or communicated to staff.

The need to ensure on-going coordination of care was maintained, documented and recommendations were implemented was discussed with Staff 1 (Administrator) on 12/06/21. She acknowledged the findings.

1. Will create a binder with blank forms and instructions for all on and off site health services to be filled out at the end of each visit and then reviewed with med tech, RCC, or Admin to ensure recommendations are documented and implemented as applicaple.

2. A binder for outside services with instructions to be filled out at the end of each session for each resident on services will be placed at the entrance of the facility. Training with med tech and RCC regarding protocol and steps for documenting and implementing any new changes.

3. Weekly audits of outside service binder to ensure visits have been documented and implemented accordingly.

4. Administrator, RCC

Based on observation, interview and record review, it was determined the facility failed to ensure signed physician orders were documented in the resident's record for 1 of 3 sampled residents (# 2) related to wound care. Findings include, but are not limited to:

Resident 2 was admitted to the facility in February 2017 with diagnoses including dementia and history of a stroke with hemiparesis.

The resident's MARs/TARs dated 11/01/21 through 12/06/21, current physicians orders, progress notes from 09/19/21 through 12/06/21 and service plans were reviewed and identified the following:

The resident's clinical records revealed the following:

*On 10/31/21, the resident had a rash to the top of the left hand with self inflicted scratches.

*On 11/8/21, the resident had a new diagnoses of  impetigo.

*On 11/12/21,  the resident had impetigo with cellulitis. Limited duration treatments were prescribed.

The progress notes, dated 11/23/21 through 12/06/21 revealed the facility was completing daily dressing changes to the scratches on the top of the left hand to include cleaning, intermittent antibiotic ointment application, and covering the scratches with a non-stick dressing. The dressing was secured with an ace or dressing wrap.

On 12/6/21, observation of the dressing change revealed the left hand and lower arm was red and there were scratches to the top of the hand. The treatment observed included cleaning of the scratches, covering the scratches with a non-stick dressing and wrapping the hand and arm to approximately two inches below the elbow.

There was no signed order for the treatment being provided to Resident 2's left hand and arm.

The need to ensure current, signed physician orders were maintained in the resident's records for all treatments provided was discussed with Staff 1 (Administrator) and Staff 3 (RN) on 12/07/21. They acknowledged the findings.

1. An audit of medications and treatments will be completed to ensure that there is a valid primary care physician order in place for each medication and treatment listed on the medication and treatment administration record.

2. Education and training will be completed with staff to ensure that they provide medications and treatments only as ordered by the primary care physician.

Weekly audits of medication and treatment administration records.

3. A monthly recapitulation of primary care physician orders will be completed to ensure that the medication and treatments are matching the medication and treatment administration records. This will be done monthly for three months to ensure compliance and then quarterly thereafter.

4. Administrator, RCC, RN

Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was maintained for all facility administered medications and orders for 2 of 3 sampled residents (#1 and 3) whose medication records were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in April 2020 with diagnoses including dementia.

Review of the resident's 08/01/21 through 12/06/21 progress notes, physician communications, and the 11/01/21 through 12/06/21 MARs showed the following:

* Blanks were noted on the MAR for multiple medications and monitoring orders on 11/15/21 and 11/16/21; and

* Meal monitoring was noted on the MAR with instructions to staff to provide the resident a health shake or alternative if they ate less than 50%. The resident declined the meal or ate less than 50% on 34 occasions with no documentation an alternate or health shake were provided.

The need to ensure MARs had complete documentation for all orders was discussed with Staff 1 (Administrator) on 12/07/21. She acknowledged the findings.

2. Resident 3 was admitted to the facility in October 2021 with diagnoses including dementia and congestive heart failure.

Review of the resident's 10/03/21 through 12/06/21 progress notes, physician communications, and the 11/01/21 through 12/06/21 MARs showed the following:

* Blanks were noted on the MAR for multiple medications and monitoring orders on 11/8/21, 11/15/21, 11/16/21 and 11/19/21; and

* Staff were to record daily weights for the resident. The order contained no direction to staff on what to do with the weights they recorded and what parameters to follow for reporting changes.

The need to ensure MARs had complete documentation for all orders was discussed with Staff 1 (Administrator) on 12/07/21. She acknowledged the findings.

1.Staff will be educated of the importance of following primary care physician orders regarding health shakes, meals, weights, and how to document, provide alternatives, and follow-up with results. Resident physician orders will be audited for parameters with instructions on when to notify primary care physician of changes/ reporting which includes weight parameters and missed medications.

2. The facility will post a checklist and instructions on how to monitor, proceed, document, and follow-up with recording information pertaining to primary care physician orders including parameters and instructions on notifying primary care physician.

3. Weekly audits to ensure alternatives and follow-up have been properly documented and that the primary care physician has been notified.

4. Adminstrator, RCC, RN

Based on interview and record review, it was determined the facility failed to ensure PRN medications used to treat a resident's behavior had written, resident-specific parameters and non-drug interventions for staff to attempt prior to administering a PRN psychoactive medication, for 1 of 1 sampled resident (#1) who were prescribed a PRN medication to address behaviors. Findings include, but are not limited to:

Resident 1 was admitted to the facility in April 2020 with diagnoses including dementia.

Review of the resident's 11/01/21 through 12/06/21 MARs and progress notes and 08/12/21 physician orders showed the following:

* Lorazepam 0.5 mg (anti-anxiety medication), one tablet every two hours PRN for anxiety, restlessness or agitation.

The Lorazepam was administered seven times between 11/01/21 and 12/06/21.  

The MARs did not contain resident-specific parameters for staff describing how the resident expressed anxiety, restlessness or agitation. Additionally, there was no documentation of what non-drug interventions were to be attempted prior to administration of the medications.

The need to ensure resident-specific information on how the resident expressed anxiety/agitation and that non-drug interventions were attempted and documented prior to administration of the medication was discussed with Staff 1 (Administrator) on 12/07/21. She acknowledged the findings.

1. Obtain orders from primary care physician that specifies parameters that describe behaviors and non-pharmalogical interventions to be attempted before administering PRN medication.

2. Staff training about how to identify reasons for behaviors using root-cause-analysis and how to implement non-pharmalogical interventions before administering PRNs.

3. Weekly audits to ensure non-pharmalogical interventions have been attempted before administering PRN medication and that proper documentation and follow-up notes have been completed.

4. Administrator, RCC, RN

Based on interview and record review, it was determined the facility failed to ensure PRN psychotropic medications used to treat a resident's behavior had resident-specific parameters, non-pharmacological interventions were reflected on the MAR, direct care staff administering the medication had knowledge of common side effects and when to contact a health professional regarding side effects, and all direct care staff had knowledge of non-pharmacological interventions for 2 of 2 sampled residents (#s 1 and 4) who were prescribed PRN psychotropic medication. This is a repeat citation. Findings include, but are not limited to:

1. Resident 1 moved into the facility in 2020 and had diagnoses which included Alzheimer's dementia.

Review of the resident's service plan, physician orders, and 03/01/22 through 03/10/22 MAR revealed the following:  

Resident 1 was prescribed lorazepam 0.5 mg (anti-anxiety medication) one tablet every two hours PRN for anxiety, restlessness or agitation.

The facility failed to ensure the MAR included the following required information:

* Resident-specific parameters regarding how Resident 1 expressed anxiety, restlessness or agitation;

* Non-pharmacological interventions to be attempted prior to considering the administration of the medication;

* Common side effects; and

* When to contact a health professional regarding side effects.

Additionally, the record lacked documentation that all direct care staff had been informed of non-pharmacological interventions for Resident 1.

The need to ensure the required information for PRN psychotropic medications was documented in the MAR and clinical record was discussed with Staff 1 (Administrator) and Staff 3 (RN) on 03/10/22. The staff acknowledged the findings.

2. Resident 4 moved into the facility in 2022 with diagnoses which included dementia and Diabetes Type II.

Review of the resident's service plan, physician orders and 03/01/22 through 03/10/22 MAR revealed the following:  

Resident 4 was prescribed Remeron (anti-depressant medication) PRN one 15 mg tablet daily at bedtime as needed for sleep.

The facility failed to ensure the MAR included the following required information:

* Resident-specific parameters regarding what would trigger the medication to be given;

* Non-pharmacological interventions to be attempted prior to considering the administration of the medication;

* Common side effects; and

* When to contact a health professional regarding side effects.

Additionally, the record lacked documentation that all direct care staff had been informed of non-pharmacological interventions for Resident 4.

The need to ensure the required information for PRN psychotropic medications was documented in the MAR and clinical record was discussed with Staff 1 (Administrator) and Staff 3 (RN) on 03/10/22. The staff acknowledged the findings.

1. The RN will add to the Medication administration record information for interventions to be attempted prior to administration of PRN medications for resident behaviors

2. Staff will be properly educated and trained how to identify and determine causes for behaviors using root-cause-analysis and attempt non-pharmacological interventions before administering a psycotropic PRN.

3. Staff will be trained how to document specific behaviors, non-pharmacological interventions, result of attempts made, PRN given, side effects, and result of PRN. Staff will be trained on when and how to notify primary care physician .

4. Weekly audits to ensure non-pharmacological interventions have been attempted before administering PRN medication and that proper documentation and follow-up notes have been completed.

Administrator, RCC, RN

Based on interview and record review, it was determined the facility failed to ensure fire and life safety documentation reflected all required fire drill components. Findings include, but are not limited to:

Fire drill records were reviewed from July 2021 to December 2021.

The following deficiencies were identified:

* There was no documented evidence the facility was conducting fire drills every other month on alternating shifts for the memory care community;

* There was no documented evidence the facility was conducting fire and life safety training on alternating months to fire drills; and

* The evacuation/drill documentation did not contain information on the escape routes used, problems encountered, evacuation time period needed, staff members on duty and participating in the memory care and the number of occupants evacuated.

The requirements regarding fire drills and fire and life safety instruction for staff were reviewed with Staff 1 (Administrator) on 12/06/21. She acknowledged the findings.

1. The facility will create and coordinate a safety team, including a calender for fire drills and fire safety meetings to be completed.

2. Designate staff member (kitchen manager) to the safety team lead to conduct fire drills and safety meetings monthly.

3. Monthly

4. Administrator, Safety Team Manager

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

Refer to C 303 and Z 162.

1. Facility will succeed in implementing plan of correction for C330 and maintain compliance thereafter.

2. C330 Please refer to plan of correction for this specific tag.

3. C330 Please refer to plan of correction for this specific tag.

4. C330 Please refer to plan of correction for  this specific tag.

Based on observation and interview, it was determined the facility failed to ensure metal gardening tools were secured to prevent unsupervised resident use. Findings include, but are not limited to:

Observations of the secure outdoor area on 12/06/21 and 12/07/21 showed multiple metal garden tools, of varying sizes, were in an open storage unit. The tools observed  included shovels and a pitch fork. A gate to the area had a lock in place which was not secured. The area remained unsecured during subsequent observations until the morning of 12/07/21 after additional requests to secure the yard tools.

The need to ensure the residents' outdoor area did not have potential safety hazards was discussed with Staff 1 (Administrator) on 12/06/21 and 12/07/21. She acknowledged the findings.

1. Garden tools will be locked and secured in a non-resident area. Keyless locks willl be placed on gate, daily rounds will be completed to ensure environment is secure and safe. The staff will be trained and educated to not leave items that may be dangerous to residents unattended. For example garden tools, and will be secured in a non-resident area when not in use.

2. Staff will be educated of the importance of being mindful of residents and environmental surroundings by keeping hazardous items locked and secured at all times and by ensuring the gate is locked. Staff will complete daily safety rounds of environment.

3. Daily

4. Administrator, all staff

Based on observation and interview, it was determined the facility failed to ensure the environment was maintained in clean and good repair. Findings include, but are not limited to:

Observations of the facility on 12/06/21 showed the following areas in need of cleaning or repair:

* Chipped and peeling cabinets in the kitchen; and

* Numerous dining room chairs had tares of varying sizes, along the armrests, with exposed fabric and/or stuffing.

The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (Administrator) on 12/06/21 and 12/07/21. She acknowledged the findings.

1.Facility will replace chairs/furniture that is noted to have wear and tear and that can be potentially harmful to residents. Facility will replace or repair identified kitchen cabinets.

2. Weekly audits will be competed to ensure all furniture, shelves, handrails, and other environmental items are in safe working order.

3.Weekly envirinmental rounds.

4.Administrator, Maintenance

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 231, C 420, C 510 and C 513.

C231, C420, C510, C513: Please refer to plan of corrections for each specific tag

C231, C420, C510, C513: Please refer to plan of corrections for each specific tag

C231, C420, C510, C513: Please refer to plan of corrections for each specific tag

C231, C420, C510, C513: Please refer to plan of corrections for each specific tag

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 newly hired staff (#s 11 and 12) demonstrated competency in all required areas within 30 days of hire. Findings include, but are not limited to:

Review of the facility's training records on 12/07/21 revealed the following:

The facility lacked documented evidence Staff 11 (MT), hired 07/23/21 and Staff 12 (CG), hired 08/01/21 demonstrated competency within 30 days of hire related to the following required training topics:

* Role of the service plans in providing individualized care;

* Providing assistance with ADLs;

* Changes associated with normal aging;

* Identification, documentation and reporting of changes of condition;

* Conditions that require assessment, treatment, observation and reporting; and

* General food safety, serving and sanitation.

Additionally, Staff 11 lacked documentation of training on medication pass and treatments.

The need to ensure newly hired staff demonstrated competency in all required areas within 30 days of hire was discussed with Staff 1 (Administrator) on 12/07/21. She acknowledged the findings.

1.Completed staff training and checklists so they are all up to date on pre-service and training.

2. Create system to keep track of training and CEU's

3. Monthly

4.Administrator, RCC

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 252, C 260, C 262, C270, C 290, C 303, C 310 and C 330.

C252, C260, C262, C270, C290, C303, C310, C330: Please refer to plan of correction for each specific tag

C252, C260, C262, C270, C290, C303, C310, C330: Please refer to plan of correction for each specific tag

C252, C260, C262, C270, C290, C303, C310, C330: Please refer to plan of correction for each specific tag

C252, C260, C262, C270, C290, C303, C310, C330: Please refer to plan of correction for each specific tag

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 330.

1. C330 Please refer to plan of correction for this specific tag.

2. C330 Please refer to plan of correction for this specific tag.

3.  C330 Please refer to plan of correction for this specific tag.

4. C330 Please refer to plan of correction for this specific tag.

Based on observation and interview, it was determined the facility failed to ensure that fencing was no less than six feet in height. Findings include, but are not limited to:

A tour of the facility courtyard on 12/06/21 showed multiple sections of fencing around the perimeter of the secured outdoor area were less than six feet in height. The shortest sections were approximately 68 inches.

The fencing sections that were less than six feet in height were discussed with Staff 1 (Administrator) on 12/06/21. She acknowledged the findings.

1. Replace or repair part of fencing that does not comply with regulations.

2. Monthly rounds of outside perimeter

3. Monthly

4. Administrator, Maintenance

Based on observation and interview, it was determined the facility failed to ensure outside perimeter fencing allowed for egress in the event of an emergency. Findings include, but are not limited to:

The facility's outdoor areas were toured on 12/06/21 and 12/07/21. A perimeter fence between the outer patio's and surrounding properties at the back of the building, were observed to have two gates. Both gates were secured with keyed locks.  

In an interview on 12/07/21 Staff 1 (Administrator) confirmed the patio gates could only be unlocked with a key. Staff 1 stated the two observed gates were the only two secured with a keyed lock, the remaining gate was secured with a keypad. Staff 1 acknowledged the need to ensure all the gates provided a quick release option that did not require a key.

1. Replace existing key locks on gates with keyless locks.

2. Monthly checks on locks to ensure they are proper working order

3. Monthly

4. Administrator, Maintenance