Print Inspection: RL07

The findings of the on-site investigation, conducted on 10/31/23, 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

Notes on Abbreviations:

"The abbreviations listed above can be used in the report without identifying the abbreviation within the report itself.

"Residents will be identified by "Resident 1", "Resident 2" etc, do not abbreviate.

"Staff will be identified by "Staff 1", "Staff 2" etc. do not abbreviate.

"If you introduce an abbreviation in the report, make sure it is a word that has a standard abbreviation associated with it and that it needs to be abbreviated. You don't need to abbreviate a word that you only use once in a report.

Based on observation and interview, during a site visit conducted on 10/31/23, it was confirmed the facility failed to post the name of the administrator or designee in charge in a routinely accessible and conspicuous location to residents and visitors. Findings include, but are not limited to:

During a site visit on 10/31/23, CS observed no posted sign naming the administrator or designee in charge.

In an interview on 10/31/23, Staff 1 (ED) confirmed, there was no sign to indicate who the manager on duty was.

It was confirmed the facility failed to post the name of the administrator or designee in charge.  

On 10/31/23, the findings were reviewed with and acknowledged by Staff 1.

Verbal plan of correction: Staff 1 will post a manager on duty on the board by the med room along with the other staff posted working for that shift starting immediately.

Based on interview and record review, during a site visit conducted on 10/31/23, it was confirmed the facility failed to carry out medication orders as prescribed, for 3 of 3 sampled residents (#s 1, 2, and 3). Findings include, but not limited to:

A review of Resident 1, 2, and 3's 10/01/23 through 10/30/23 MARs, indicated the following routine medications had not been reordered, were on backorder, or were "unavailable":

·Resident 1:

oMetoprolol hypertension was to be administered one time daily, had not been administered between 10/18/23 to 10/26/23.

oAmlodipine for high blood pressure was to be administered one time daily, had not been administered between 10/17/23 to 10/19/23.

oMelatonin for sleep was to be administered one time daily, had not been administered between 10/27/23 to 10/30/23.

oSenna for constipation was to be administered one time daily, had not been administered between 10/04/23 to 10/12/23.

oVitamin D3 to be administered one time daily, had not been administered between 10/15/23-10/17/23.

·Resident 2:

oKetoconazole cream was prescribed and ordered on 10/18/23 and had not been administered until 10/23/23 and 10/25/23.

oNitrofurantoin Macro for urinary tract infections was to be administered one time daily, had not been administered between 10/10/23 to 10/13/23.

·Resident 3:

oKetoconazole cream was prescribed on 10/16/23 and arrived at the facility on 10/17/23. The cream was not administered until the evening of 10/24/23 at 7:00 pm.

oMelatonin for sleep was to be administered two tablets one time daily, had not been administered between 10/02/23 to 10/09/23.

oOxycodone for pain was to be administered three times daily, had not been administered between 10/20/23 to 10/24/23.

During an interview on 10/31/23, Staff 2 (AED/BOM) stated, "There have been several medication errors, and we are still in the process of turning them into APS. On 10/19/23 we had a MT meeting telling them to call myself, the ED, or the Nurse if an order needed to be imputed into the system. The staff during the following weekend did not do this resulting in many medications having been missed. We had another meeting with the staff on 10/25/23."   

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

On 10/31/23, the findings were reviewed with and acknowledged by Staff 1.

Verbal plan of correction: The facility self-reported medication error to APS, completed an Incident Report, ISP's, placed resident on Alert Charting. Staff 1 has been working with all MT's and has a MT meeting weekly.

Based on observation, interview, and record review, during a site visit conducted on 10/31/23, it was confirmed the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident, for 1 of 1 sampled resident (#3) and an unsampled resident. Findings include, but are not limited to:

In an interview on 10/31/23, Staff 3 (CG) stated the following:

• "There have been no showers completed yet today."  
• "Last Tuesday, on 10/24/23, I worked as the only CG for a 12-hour shift and was so busy I was unable to take a lunch break."  
• "The ED works on NOC shift as a MT at least one to two times a week."  
• "There are no activities personal or housekeeper working today, CG's are expected to absorb those job duties. On days like this, housekeeping often does not get completed."  
• "The facility schedules two 12-hour shifts with two CG's and one MT for days and one CG and one MT for nights."  

On 10/31/23, Staff 1 (ED) confirmed, s/he had been working as a MT on noc shift "typically one to two times a week for months." Staff 1 also stated, the facility no longer had any two- person transfers.  

On 10/31/23, CS observed the following:

• Two CG's and one MT working.
• Resident 3 and an unsampled had hair that was greasy, nails unclipped and dirty with particles under the nails.
• CS did not observe a housekeeper or activities staff working.

A review the posted staffing plan indicated the staffing for the facility was two 12-hour shifts, day shift needed two CG ' s and one MT and night shift needed one CG and one MT. A review of the staff timecards for 08/28/23 to 10/01/23 indicated the facility was consistently short staffed often scheduling one CG for day shift. The timecards, dated 10/24/23, indicated for day shift one CG and one MT worked and for night shift two CG worked and Staff 1 (ED) worked as the MT.

It was confirmed the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident.

On 10/31/23, the findings were reviewed with and acknowledged by Staff 1.

Verbal plan of correction: The facility has been and continues to work on hiring more staff. Staff 1 stated s/he will ensure all showers are completed.

Based on observation and interview, conducted during a site visit on 10/31/23, it was confirmed the facility failed to ensure directions were posted on the outside of the entry door to allow access to the building. Findings include, but not limited to:

On 10/31/23, CS observed a door with a sign stating, "welcome, main entrance visitors enter here." CS did not observe a doorbell at the main entrance or a sign instructing visitors to go to a different door. CS went to the old entrance door, and observed a sign that stated, "ring doorbell and use other door."  

During an interview on 10/31/23, Staff 2 (AED/BOM) stated, "We have changed the location of our front entrance door permanently. You must go to the old entrance to ring the doorbell to let staff know you are wanting to be let in and then walk to the new entrance door."  

It was confirmed the facility failed to ensure directions were posted on the outside of the entry door to allow access to the building.

On 10/31/23, the findings were reviewed with and acknowledged by Staff 1.

Verbal plan of correction: Staff 1 put a sign on the new door explaining clearer direction as CS left the building.