Print Inspection: L6QI

The findings of the re-licensure survey, conducted 05/21/24 through 05/22/24, 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 and OARs 411 Division 004 Home and Community Based Services Regulations.

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 re-visit to the re-licensure survey of 05/22/24, conducted on 11/19/24 through 11/20/24, are documented in this report. It was determined the facility was in compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities 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 resident to resident altercations were immediately reported to the local SPD (Seniors and People with Disabilities) office and promptly investigated for 1 of 1 sampled resident (# 2) who was reviewed for resident to resident altercations. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 12/2023 with diagnoses including dementia.     

Observations of the resident and interviews with the resident's family and staff were conducted. Resident 2's service plan, dated 04/02/24, progress notes, dated 02/15/24 through 05/21/24, and incident investigations, dated 02/19/24 through 03/05/24, were reviewed and revealed the following:

* Staff documented in a progress note dated 05/10/24, "has been relatively agitated toward staff and peers", "[Resident 2] went into peer's rooms", and "Resident also put [his/her] hands on a peer near dinner time."

* There was a handwritten entry on the resident's service plan stating, "has grabbed a housemate's wrist" and "becomes a threat to [him/herself] and others." The entry was not initialed or dated.

There was no documented evidence of investigations or reports to the local SPD office for either occurrence. Staff 2 (Administrator) stated she was unaware the two incidents had happened.

On 05/21/24 at 3:37 pm, Staff 2 provided documentation that both incidents had been reported to the local SPD office.

The need to ensure all resident to resident altercations were immediately reported to the local SPD office and promptly investigated by the facility was discussed with Staff 1 (Chief Operations Manager) and Staff 2 on 05/21/24. They acknowledged the findings.

C231 OAR 411-054-0028 (1-3) REPORTING & INVESTIGATING ABUSE - OTHER ACTION:

1) Update incident report policy and procedures to include APD reporting, investigations as required for altercations and injuries. Inservice staff on reporting and investigating of abuse.                                                                             

2) Policies and procedures will be revised for incident reporting and investigations. All incidents will be investigated and identify: Time, Date, Individuals Present, Reported Description of Event, Response of Staff at time of event, Follow up actions, and Administration Review. Staff will be inserviced on revision of policy and procedures, documentation and reporting requirements.

3)The corrected process will be evaluated quarterly.

4) Review of completion/continued monitoring to be completed by Administration.  

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and preferences, provided clear direction to staff regarding the delivery of services, and dated and initialed when changes were made for 2 of 3 sampled residents (#s 2 and 3) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 12/2023 with diagnoses including dementia.

The resident's service plan, dated 04/02/24, was reviewed. Resident 2 was observed, and staff were interviewed. The service plan was not reflective of the resident's needs and preferences or provided clear caregiving direction in the following areas:

* Person centered interventions for behaviors;

* How the resident acts prior to becoming exit seeking;

* Frequency for staff to check the resident's bathroom;

* Ability to use the call light;

* Direction to staff relating to the use of a bed and recliner sensor alarm;

* Favorite snacks for behavior interventions, where they were stored in the resident's room, and who purchased them;

* Preference of television shows; and

* Emergency evacuation needs.

There was a handwritten update in the Behavior Support section of the service plan that was not dated or initialed.

The need to ensure service plans were reflective of residents' needs and preferences, provided clear direction to staff regarding the delivery of services, and were dated and initialed when changes were made to the service plan was discussed with Staff 2 (Administrator) and Staff 4 (Residential Care Manager) on 05/22/24. They acknowledged the findings.

2. Resident 3 was admitted to the facility in 09/2022 with diagnoses including anxiety and a spinal cord injury.

The resident's 02/27/24 service plan was reviewed. Both Resident 3 and staff were interviewed. The service plan was not reflective of the resident's needs and preferences or provided clear caregiving direction in the following areas:

* Private caregiver's schedule and all duties preformed while at the facility;

* Utensils needed for eating independently;

* Ease of eating independently when in the electric wheelchair;

* Person centered approaches to help with the resident's anxiety and pain with repositioning;

* Conversation topics to help ease anxiety;

* When the resident uses the bilateral hand splints;

* Direction to staff relating to the placement of bilateral foam rolls, the care of the foam rolls, and monitoring for any skin issues;

* Nutritional supplement;

* The resident's ability to advocate for themselves;

* Bathing type, schedule, and direction to staff;

* Assistance needed with a personal cell phone;

* Specific activities the resident participated in; and

* Assistance needed with the television.

The need to ensure service plans were reflective of residents' needs and preferences, and provided clear direction to staff regarding the delivery of services was discussed with Staff 2 (Administrator) and Staff 4 (Residential Care Manager) on 05/22/24. They acknowledged the findings.

C260 OAR411-054-0036 (1-4) SERVICE PLAN: GENERAL

1) All care plans will be reviewed and revised to detailed specific needs of the resident, clear direction to staff regarding the delivery of services and date and ititals of when changes are made.

2) Person-Centered care plans will be updated for each resident, ensuring they are reflective to the care needs and preferences of the resident. Care plans will be informative to staff regarding the delivery of services they provide. All changes/updates will be dated and initialed. Staff will be inserviced on Person-Centered care plans identifing staff instructions within the care plans.

3) Care plans will be evaluated quarterly at care conference.

4) Completion and monitoring will be done by Administration and reviewed by RN.

2. Resident 2 was admitted to the facility in 12/2023 with diagnoses including dementia.  

The resident's progress notes, dated 02/15/24 through 05/21/24, MARs, dated 04/17/24 through 05/21/24, and Change of Condition Monitoring forms, dated 03/02/24 and 03/04/24, were reviewed. The following was identified:

There was no documented evidence the facility determined actions or interventions, provided written communication of the change of condition and any actions or interventions to staff on all shifts, and monitored at least weekly to resolution the following short term changes of condition:

* Multiple dates when medications were refused or missed;

* 02/14/24: Resident 2 was agitated and pushed a staff member into a closet;

* 03/02/24: The resident ran outside, attempting to elope;

* 05/06/24: Resident 2 chased staff with a food cart, entered other residents' rooms, and threw their belongings on the floor; and

* 05/10/24: The resident "Put hands on a peer near dinner time."

The need to ensure the facility determined and documented actions or interventions for short term changes of condition, provided written communication of a resident's change of condition and any required interventions to staff on all shifts, and ensured documentation of staff instructions or interventions were made part of the resident record with weekly progress noted until the condition resolved was discussed with Staff 2 (Administrator) and Staff 4 (Residential Care Manager) on 05/22/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to determine and document actions or interventions for short term changes of condition, provide written communication of a resident's change of condition and any required interventions to staff on all shifts, and ensure documentation of staff instructions or interventions were made part of the resident record with weekly progress noted until the condition resolved for 2 of 3 sampled residents (#s 1 and 2) who experienced short term changes of condition. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 02/2024 with diagnoses including right femoral shaft fracture and dementia.

Resident 1's progress notes, dated 02/21/24 to 05/21/24, current service plan, MAR, dated 05/01/24 to 05/21/24, and Change of Condition Monitoring forms were reviewed. The following was identified:

There was no documented evidence the facility determined actions or interventions, provided written communication of the change of condition and any actions or interventions to staff on all shifts, and monitored at least weekly to resolution the following short term changes of condition:

* 03/20/24: Urinary tract infection, started antibiotics; and

* 05/14/24: Return from hospital after right hip fracture.

The need to ensure the facility determined and documented actions or interventions for short term changes of condition, provided written communication of a resident's change of condition and any required interventions to staff on all shifts, and ensured documentation of staff instructions or interventions were made part of the resident record with weekly progress noted until the condition resolved was discussed with Staff 2 (Administrator) and Staff 4 (Residential Care Manager) on 05/22/24. They acknowledged the findings, and no additional information was provided.

C270 OAR 411-054-0040 (1-2) CHANGE OF CONDITION & MONITORING

1) Revision of our change of condition reporting, documentation, and monitoring process.

2) Revise change of condition documentation form to include what the change of condition is, staff instructions and interventions, and continued monitoring till resolved. Staff will be inserviced on change of condition process.

3) Evaluation of changes of condition will occur at time the change occurred/identified, weekly review/updates, and quarterly at care conference.

4) RN weekly review, Administration quarterly review.  

Based on interview and record review, it was determined the facility failed to notify the physician or other practitioner when a resident refused to consent to an order, for 2 of 2 sampled residents (#s 2 and 3) with documented medication refusals. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 12/2023 with diagnoses including dementia.

The resident's MARs, dated 04/17/24 through 05/21/24, physician's orders, and progress notes, dated 02/15/24 through 05/21/24, were reviewed and revealed the following refusals:

* 03/07/24: "[Refused] medications to help with [his/her] behaviors";

* 03/25/24: "Refused all night time medications";

* 05/11/24: Refused levothyroxine (for hypothyroidism), allopurinol (for gout), hydrochlorothiazide (for hypertension), losartan (for hypertension), pravastatin (for cholesterol); and

* 05/02/24: Quetipine (for agitation), donepezil (for dementia), and Vitamin D3 (for a supplement).

There was no documented evidence staff notified the prescriber of the above refusals.

The need to ensure the physician or other practitioner was notified if a resident refused consent to an order was discussed with Staff 2 (Administrator) and Staff 4 (Residential Care Manager) on 05/22/24. They acknowledged the findings.  

2. Resident 3 was admitted to the facility in 09/2022 with diagnoses including anxiety and a spinal cord injury.

The resident's 04/17/24 through 05/21/24 MARs, physician's orders, and progress notes, dated 05/09/24 through 05/21/24, were reviewed and revealed the following refusals:

* Enemeez plus (for constipation) on 10 occasions;

* Polyethylene (for constipation) on 13 occasions;

* Lactulose (for constipation) on 10 occasions;

* Docusate (for constipation) on four occasions; and

* Bisacodyl (for constipation) on six occasions.  

On 05/22/24 at 9:22 am, Staff 12 (Personal Care Assistant) stated she would notify the physician of the refusals for "important medications, like for blood pressure." For any other medications, she verified that she would document the refusal on the resident's MAR.

There was no documented evidence staff notified the prescriber of the above refusals.

The need to ensure the physician or other practitioner was notified if a resident refused consent to an order was discussed with Staff 2 (Administrator) and Staff 4 (Residential Care Manager) on 05/22/24. They acknowledged the findings.  

C305 411-054-0055 (1)(J-K) SYSTEMS; RESIDENT RIGHT TO REFUSE.

1) All primary care providers will need to be contacted for their preference to refusal notifications. MARs will need to indicate the PCPs preferences. Refusal notification form to be developed and implementated. Staff education and inservice for resident refusals.

2) Contacted all PCPs and currently updating their preference of notifications to refusals. PCP preference of notification will be added to MAR for information, all refusals will be documented in MAR and on refusal form, documented in chart and filed in their personal health record. New residents, PCP preference will be obtained as part of the admissions process. Staff to have inservice on resident's right to refuse and process to follow.

3) At each new admission and monthly

4) Resident Care Manager will monitor refusals and notify PCPs when required.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate, included reasons for use, and resident specific parameters and instructions for PRN medications for 1 of 3 sampled residents (# 3) whose MARs were reviewed. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 09/2022 with diagnoses including anxiety and a spinal cord injury.

The resident's 04/17/24 through 05/21/24 MARs and physician's orders were reviewed and revealed the following inaccuracies:

* Resident 3 had an order for tizanidine (for muscle spasms) to administer four times daily and as needed. The scheduled doses were reflected on the MAR, but the PRN doses were not.

* There was no reason for use listed for Ocusoft lid scrub pad.

* There was a duplicate entry for acetaminophen (for minor aches and temperature greater than 101), one tablet by mouth every four hours as needed.

* The physician's order for PRN oxycodone specified for pain "level [five] or above." This was not transcribed on the MAR.

* There was no direction to staff on the sequential order for the PRN administration of acetaminophen or oxycodone, or if the resident was able to self-direct.

The need to ensure MARs were accurate, included reasons for use, and resident specific parameters and instructions for PRN medications was discussed with Staff 2 (Administrator) and Staff 4 (Residential Care Manager) on 05/22/24. They acknowledged the findings.   

C310 OAR 411-054-0055 (2) SYSTEMS: MEDICATION ADMINISTRATION

1) MARs will need to be reviewed and verified with valid orders; update as needed ensuring the following: Current Month,day and year. Medication name, reason for use, dose, route with date and time given. Any specific instructions/parameters, allergies/sensitivitites, initials of individual administering meds, ensuring no duplicatons of orders, and instruction for 2 medication for the same treatment; sequential order of what medication to use first.  Staff review on medication administration.

2) Verify all orders with MAR ensuring all above elements are present. Education staff though inservice on medication administration.

3) MARs will be reviewed at least monthly

4) RCM and/or Administration and/or RN.  

Based on interview and record review, it was determined the facility failed to ensure order changes obtained by the telephone were documented in the resident's record, and the telephone order was followed-up with written, signed orders for 1 of 1 sampled resident (# 2) whose MAR was reviewed. Finding include, but are not limited to:

Resident 2 was admitted to the facility in 12/2023 with diagnoses including dementia.

The resident's MARs, dated 04/17/24 through 05/21/24, physician's orders, and progress notes, dated 02/15/24 through 05/21/24, were reviewed.

There was an entry on Resident 2's MAR directing the facility to administer one "CBD/THC [cannabidiol/tetrahydrocannabinoid] gummy"  by mouth daily at bedtime for sleep, and an additional CBD/THC gummy as needed once daily for restlessness and agitation.

There was no documented evidence of a physician's order for the facility to administer the scheduled or PRN CBD/THC gummy.  

On 05/22/24 at approximately 11:00 am, Staff 4 (Residential Care Manager) stated that she called the resident's physician for the order and he approved it over the telephone. When the physician faxed the order to the facility, it referred to a "supplement" with no name of the medication indicated and no direction to staff for administration.

The need to ensure order changes obtained by the telephone were documented in the resident's record, and the telephone order was followed-up with written, signed orders from the physician was discussed with Staff 2 (Administrator) and Staff 4 on 05/22/24. They acknowledged the findings.  

C320 OAR 411-054-0055 (4) SYSTEMS: MEDICATION & TREATMENT - GENERAL

1) Phone order process will need to be updated with follow up procedures to ensure hard copies are received from PCP with clear identification of medication/treatment, clear instructions/parameters and signed by PCP. Staff to be educated on phone order processes.

2) Phone order form implementated with follow up till order is recieved to ensure order is on file in a timely manner. When order is received it will be review for accuracy and signature of PCP.  Received order from PCP to be found acceptable or return to query PCP for clear identification and/or instructions/parameters. Staff to be educated through inservice on phone order processes.  

3) All phone orders will be reviewed weekly

4) RN will be responsible to review that all phone orders are signed, accurate and with approprate instructions for reason being prescribed.  

Based on interview and record review, it was determined the facility failed to update an acuity-based staffing tool (ABST) before a resident moved in to the facility, when there was a significant change of condition, and no less than quarterly. Findings include, but are not limited to:

The ABST was reviewed on 05/22/24 and the following was identified:

a. The ABST was not updated to include data for an unsampled resident in Building One.

b. The ABST was not updated to include data related to a significant change of condition Resident 1 experienced.

c. The ABST for multiple unsampled residents had not been reviewed or updated quarterly.

During an interview on 05/22/24 at 8:20 am, Staff 2 (Administrator) confirmed the unsampled resident had not been entered into the ABST, and the ABST was not updated with Resident 1's significant change of condition.

The need to ensure the ABST was updated before a resident moved in to the facility, when there was a significant change of condition, and no less than quarterly was discussed with Staff 2 on 05/22/24. She acknowledged the findings.

C361 OAR 411-054-0037 (1-8) ACUITY-BASED STAFFING TOOL

1)ABST will need to be updated with all resident to determine appropriate staffing levels for the facility. Staffing updates will need to be done; before any move-in, as needed the first 30 days, anytime there is a significant change of condition, and quarterly.

2) ABST updated with all residents care needs. All new admissions will be entered into ABST prior to move in, as needed within the first 30 days, for any significant change of condition and quarterly at the time of care conference.

3) At every resident's care conference, new admission,   change of condition and as needed.

4) Administration