Print Inspection: RWMY

The findings of the re-licensure survey, conducted 01/29/24 through 02/01/24, 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 for 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

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 02/01/24, conducted 07/15/24 to 07/17/24, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for 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 second revisit to the re-licensure survey of 02/01/24, conducted on 10/08/24, 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 a resident-to-resident altercation was immediately reported to to the local Seniors and People with Disability (SPD) office and promptly investigated for 1 of 2 sampled resident (#1) with regular occurrences of resident-to-resident altercations. Findings include, but are not limited to:  

Resident 1 was admitted to the facility in 04/2022 with diagnoses including vascular dementia and coronary artery disease.

Observations of the resident, interviews with staff, and review of the resident's 10/20/23 service plan, 10/27/23 through 01/23/24 temporary service plans, progress notes and incident investigations were completed.

Resident 1 was evaluated to have verbally abusive and aggressive behaviors and a history of repeated incidents of aggression towards Resident 8.

A review of the resident's records showed the following:

* 01/11/24 - Staff documented in a progress note that Resident 8 reported that s/he had come out of her/his room and saw Resident 1 outside her/his door. "[Resident 1] started calling [Resident 8] names and told [her/him] to go back to [his/her] country where [s/he] came from. [Resident 8] mentioned [Resident 1] does it every time [s/he] sees her/him."

There was no documented evidence the facility had immediately reported the incident to the local SPD office nor was there evidence the incident had been promptly investigated.

In an interview on 02/01/24, Staff 3 (Health Services Administrator) indicated she was unaware of the incident and confirmed she had not reported or completed an investigation. Staff 3 was asked to report the incident to the local SPD office. She provided confirmation of the report prior to survey exit.

The need to ensure incidents of abuse or suspected abuse were immediately reported to the local SPD office and promptly investigated was discussed with Staff 2 (Assistant Executive Director), Staff 3, Staff 4 (Director of Health Services, RN), and Staff 6 (Resident Services Coordinator) on 02/01/24. They acknowledged the findings.

1) The verbal altercation incident report for residents 1 and 8 was completed, and APS was promptly notified. The incident reports in PCC automatically trigger an investigation for the RSC and a signature of final approval from the Administrator. The investigation has a prompt for whether abuse can be ruled out or not. In this case, the med tech documented a resident-to-resident altercation in the progress notes, bypassing the incident report, therefore, the investigation did not trigger. Med tech training provided as to why incidents must be documented via the aforementioned process and not solely within a progress note

2) The administrator provided a resource binder for staff in each chart room for abuse reporting, which had the abuse reporting standards, self-report forms, and APS's phone and fax numbers. Moving forward, staff will receive abuse reporting training within 30 days of their new hiring.The administrator will ensure that Health Services employees immediately investigate all reports of abuse and suspected abuse and take the required steps to safeguard residents and prevent future abuse.

3) The administrator will conduct a monthly audit of training records to ensure that all employees have completed their abuse reporting and training.

4)The administrator will see that the corrections are completed and monitored by RSCs and Administrator moving forward.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs and status, and provided clear direction to staff for 3 of 6 sampled residents (#s 3, 4 and 6) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 6 was admitted to the facility in 12/2023 with diagnoses including anxiety, depression, and right knee replacement.

Observations of the resident, interviews with staff and review of the most recent service plan, dated 12/28/23, and temporary service plans, showed the service plan was not reflective of the resident's current care needs and/or did not provide clear direction to staff in the following areas:

* Dementia and associated symptoms;

* Anxiety;

* Depression; and

* Pain issues.

On 02/01/24 the need to ensure service plans were reflective of current needs and provided clear direction to staff was discussed with Staff 2 (Assistant Executive Director) and Staff 3 (Health Services Administrator). They acknowledged the findings.

2. Resident 4 was admitted to the facility in 01/2021 with diagnoses including chronic kidney disease and Alzheimer's disease.

Observations of the resident, interviews with staff and review of the most recent service plan, dated 01/19/24, and temporary service plans, showed the service plan was not reflective of the resident's current care needs and/or did not provide clear direction to staff in the following areas:

* Catheter care including cleaning and positioning of tubing and bag; and

* Outside provider services, including HH PT.

The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 2 (Assistant Executive Director) and Staff 3 (Health Services Administrator) on 02/01/24. The staff acknowledged the findings.

3. Resident 3 moved into the facility in 12/2019 with diagnoses including osteoarthritis of the knee.

The resident's current service plan, dated 01/24/24, and TSPs, dated 11/01/23 to 01/28/24, were reviewed, observations were made, and interviews were conducted. The resident's service plan was not reflective in the following areas:

* Use of anticoagulants;  

* Mobility devices used; and

* Level of evacuation assistance.

The need to ensure service plans were reflective of resident's current needs and preferences was discussed with Staff 2 (Assistant Executive Director), Staff 3 (Health Services Administrator), Staff 4 (Director of Health Services), and Staff 7 (Resident Services Coordinator). They acknowledged the findings.

1) The administrator met with RSCs to discuss missing information and details in service plans that needed to be immediately updated, as well as reminding the team (RSCs & RNs) about TSPs that needed to be on the floor for staff to review and sign off on any changes to a resident's service plan. Residents 3, 4, and 6 will receive updated service plans and correct findings.

2)The TSL evaluation in PCC has prompts for all deficient areas identified: dementia, anxiety, depression, pain, outside providers, use of anticoagulants, mobility devices, and level of evacuation assistance. Training will provided to the RSCs, cannot skip any section within the evaluation, which builds the service plan, must stop at each prompt and check for accuracy and personalization to the resident at hand. RSCs will review and personalize service plans after the nurse's initial evaluation in PCC, the first 30 days after move-in, quarterly, and as needed.

RSCs will ensure that service plans reflect residents' current care needs and status, as well as provide clear direction for staff moving forward. RSCS will use the pre-service plan meeting form to ensure that all TSPs have been obtained before updating service plans and interviewing staff about resident's care.

3) RNs, RSCs, and the Administrator will evaluate care plans by reviewing residents' progress reports and TSPS at weekly quality meetings, and service plans will be updated as needed to ensure accuracy.

4) The administrator see that corrections are completed and will monitor this monthly.

2. Resident 4 was admitted to the facility in 01/2021 with diagnoses including chronic kidney disease and Alzheimer's disease.

The resident's current service plan, last modified on 01/19/24, Temporary Service Plans (TSPs) dated 11/06/23 through 01/04/24, and progress notes dated 11/01/23 through 01/27/24 were reviewed.

a. The following short-term changes of condition lacked documentation of actions or interventions needed for the resident and the communication of the determined actions or interventions to staff on all shifts:

* 11/07/23 - Start of lidocaine 5% cream (for ulcerations) and triple antibiotic ointment (for ulcerations);

* 11/08/23 - Return from emergency room (ER) for urinary tract infection (UTI);

* 11/09/23 - Increase in dosage of Eliquis (blood thinner);

* 11/11/23 - Diarrhea;

* 11/28/23 - New onset of "mucousy diarrhea";

* 12/06/23 - Eight missed doses of antibiotic for Clostridium difficile (bacterial infection);

* 01/03/23 - Return from hospital with "urosepsis and/or acute UTI/hematuria";

* 01/09/23 - Blood in urine/blood clots/ER visit; and

* 01/25/24 - HH RN instructions to watch for swelling following catheter change.

b. The following changes of condition lacked documented evidence they were monitored, at least weekly, through resolution:

* 2/18/23 - Redness around neck.

The need to ensure resident-specific actions or interventions for short-term changes of condition were determined, documented, communicated to staff on each shift and the changes of condition were monitored, at least weekly, through resolution was discussed with Staff 2 (Assistant Executive Director) and Staff 3 (Health Services Administrator) on 02/01/24. The staff acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure actions or interventions were determined, documented, and communicated to staff on each shift, and each resident was monitored consistent with his or her evaluated needs and service plan with weekly progress noted until the condition resolved for 2 of 6 sampled residents (#s 3 and 4) who experienced short term changes of condition. Findings include, but are not limited to:

1. Resident 3 moved into the facility in 12/2019 with diagnoses including recurrent cellulitis of the left lower leg, chronic pain, enlarged prostate, and type 2 diabetes.

The resident's current service plan dated 01/24/24, TSPs dated 11/01/23 to 01/28/24, progress notes dated 11/01/23 to 01/28/24, and MARs dated 12/28/23 to 01/28/24 were reviewed, interviews were conducted, and the following was identified:

a. Progress notes indicated the resident experienced the following short term changes of condition:

* 11/03/23: wart on left foot, bruising on right thumb, and dry skin on bilateral heels;

* 12/30/23 - Fall with rug burn to the right elbow; and

* 01/04/24 - Insulin dosage increase (for diabetes).

There was no documented evidence the facility monitored the above changes at least weekly to resolution.

b. On multiple occasions from 12/27/23 to 01/28/24 the resident was not administered the following prescribed medications:

* Clopidogrel 75 mg for stroke prevention on six occasions;

* Montelukast 10 mg for asthma on 30 occasions;

* Sulfamethoxazole-trimethoprim 800-160 mg for infection prevention on 10 occasions;

* Tamsulosin 0.4 mg capsule for enlarged prostate on 10 occasions;

* Multivitamin/Minerals for supplement on 31 occasions; and

* Vitamin D3 1000 unit for supplement on 20 occasions.

There was no documented evidence the facility communicated actions or interventions to staff on all shifts or that the resident was monitored for the missed medications.

c. Progress notes indicated the resident experienced the following short term changes of condition:

* 12/06/23 - Oral surgery;

* 12/27/23 - Urinary tract infection;

* 12/30/23 - Fall with rug burn on right elbow; and

* 01/15/24 - Lower extremity cellulitis.  

There was no documented evidence determined actions or interventions were communicated to staff on each shift.

The need to ensure actions or interventions were determined, documented, and communicated to staff on each shift, and each resident was monitored consistent with his or her evaluated needs and service plan with weekly progress noted until resolution for short term changes of condition was discussed with Staff 2 (Assistant Executive Director), Staff 3 (Health Services Administrator), Staff 4 (Director of Health Services), and Staff 7 (Resident Services Coordinator). They acknowledged the findings.

1) RNs, RSCs, and the Administrator met to discuss resident changes in condition, which will be addressed through the following actions: Resident 3 and Resident 4 were added to the RN's skin log, progress notes will be entered, and TSPs distributed to staff for review and signature.

2) The med tech will place the resident on alert (thereby charting daily) and put out a TSP for changes to medications, falls, skin issues, infections, and surgery. The nurse follows up on each resident on alert charting to ensure interventions are working and whether additional TSPs need to be put out . Med Techs, RSCs and RNs will be coached on the significance of distributing TSPs to staff so that resident-specific actions or interventions for short-term changes in condition are determined, documented, and communicated to staff on each shift. Med Techs will be trained at the monthly Health Services meeting on receiving, confirming orders, triple checking, and changing the start and end dates in PCC when confirming a prescription for antibiotics or medicine.

3)Change of Condition monitoring will be reviewed during weekly quality meetings with RNs, RSCs, and the Administrator to ensure that no information is missing and that all steps have been carried out and documented appropriately.

4) The DHS will be in charge of ensuring that the necessary modifications are implemented and monitored moving forward.

Based on interview and record review, it was determined the facility failed to ensure a safe medication system and failed to ensure adequate professional oversight. Findings include, but are not limited to:

During the relicensure survey, conducted 01/29/24 through 02/01/24, the facility failed to ensure a safe medication and treatment system, and administrative oversight was found to be ineffective based on deficiencies in the following areas:

C 303: Systems: Medication and Treatment Orders;

C 305: Systems: Resident Right to Refuse;

C 310: Systems: Medication Administration; and

C 325: Systems: Medication and Treatment-General.

Failure to ensure a safe medication system and to ensure adequate professional oversight based on deficiencies related to medication administration was discussed during the exit meeting on 02/01/24.

1)Please see the Plan of Corrections for C 303, C 305, C 310, and C 325.

DHS and the Administrator are reviewing facility medication systems and plan to make adjustments in the following areas:

a)  physician Orders in place for future oversight by our DHS nurse and Administrator to ensure that Med Techs are educated and instructed on system and treatment orders, as well as physician and follow-up orders. DHS will provide an Antibiotic Order Protocol that includes guidance for Med Techs on when to alert the RN and PCP, confirming orders in a timely manner, and ensuring that physician orders are carried out exactly as prescribed.

b) The TSL move-in orders provides boxes for the PCP in terms of how often he or she wishes to be notified of medication refusals. Medications refused: The RN will fax the PCP and ask how frequently they want to be notified about medication refusals. When a medication refusal occurs, the Medication Technician or RN will enter an order into MAR to notify the PCP.

c) MAR Accuracy: Registered nurses or designee in RN's absence will run a daily report on residents who are missing indications for the use of medication, as well as educate Medication Technicians on how to mark the correct code for medications that are missed, unavailable, or not administered.

d) Self-Administration of Medication-After completing a self-administration of Medication assessment, the registered nurse will ensure that all residents' PCPs are faxed and that a written order of approval for self-administration of prescription medications. The registered nurse will check on current residents who are self-medicating to ensure they have a valid order from their primary care physician.

2) The facility will complete a Medication Administration audit for the community, including: implementing the scanners for PCC when Med Technicians are administering meds, running a daily report for missed meds, meds unavailable or meds not given for all residents and follow up with Medication Technicians, NARC book audit to be done monthly by RNs, RNs will run a report for missing indications for use of medications for all residents, implement specific instructions in the 24 hour book for medication technicians on confirming orders, and the new process for antibiotic orders.

3) The medication systems will be reviewed monthly by DHS, RNs and the administrator.

4) The DHS will be responsible for ensuring that corrections are made and monitored by both the DHS and the Administrator moving forward.

2. Resident 5 moved into the facility in 04/2022 with diagnoses including Parkinson's disease and Type 2 diabetes.

Resident 5's 01/01/24 through 01/29/24 MAR, corresponding progress notes, and current physician orders were reviewed.

The resident had a physician's order dated 01/02/24 to take carbidopa-levodopa 25-250 mg, 1.5 tablets at 7:00 am, 10:00 am, 1:00 pm, 4:00 pm, and 1 tablet at 7:00 pm and bedtime for Parkinson's disease. The bedtime dose was scheduled at 10:00 pm on the MAR. Records revealed the medication was not administered at 10:00 pm on the following dates due to the resident sleeping:

* 01/02/24;

* 01/03/24;

* 01/05/24; and

* 01/06/24.

The need to ensure physician orders were carried out as prescribed was discussed with Staff 2 (Assistant Executive Director), Staff 3 (Health Services Administrator), Staff 4 (Director of Health Services, RN), and Staff 6 (Resident Services Coordinator) on 02/01/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 3 of 7 sampled residents (#s 3, 4 and 5) whose orders were reviewed. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 01/2021 with diagnoses including chronic kidney disease and Alzheimer's disease.

Review of the resident's 11/01/23 to 01/30/24 MARs, physician orders dated 08/10/23, 11/24/23 and 01/03/24, and progress notes dated 11/01/23 through 01/27/24 revealed the following:

a. On 11/24/23 vancomycin (antibiotic) 125 mg was ordered four times a day for Clostridium difficile (bacterial infection of colon) for 10 days. The MAR indicated a start date of 11/24/23.

* The MAR for vancomycin on 11/24/23 revealed four blanks at 8:00 am, 12:00 pm, 4:00 pm and 8:00 pm, and on 11/25/23 two blanks at 8:00 am and 12:00 pm. The 4:00 pm dose on 11/25/23 indicated the medication was not available and the 8:00 pm dose referred to the progress notes. The progress notes from 11/25/23 stated  "we did not have an order for the medication" and a separate entry one minute later noted "Medication was not confirmed in computer yet." On 11/26/23 at 8:00 am the MAR revealed Resident 4 received vancomycin four times a day with the last dose given at 8:00 pm on 12/03/23.  

* On 12/04/23 progress notes indicated Resident 4's vancomycin was, "found in med-cart still had 8 doses left but order says complete in MAR following up with RN/PCP."

* On 12/14/23 a fax was sent to the physician reporting the reason for the missed doses was the "order dates never adjusted" for the two day delay in getting the antibiotic started.

* On 12/17/23 the physician responded "Please make sure further med tech training is completed To avoid future med errors. We were lucky this time [s/he] had cleared the virus without the full dosing."

* On 12/28/23 Resident 4 was admitted to the hospital and returned to the facility on 01/03/24. The orders upon discharge indicated the resident was diagnosed with severe sepsis with acute organ dysfunction.

During an interview on 01/31/24 at 2:10 pm, Staff 5 (Assistant Director of Health Services/RN) and Staff 7 (Resident Services Coordinator) confirmed Resident 4 did not get the full ten days of vancomycin for the bacterial infection.

b. There was no documentation on the resident's MAR for the following ordered medications:

* Olmesartan 20 mg daily; and

* Polyethylene glycol powder daily.

During an interview on 01/31/24 at 10:10 am, Staff 5 acknowledged Resident 4 had not received the above medications. She clarified with his/her physician and received a verbal order to discontinue the olmesartan and the daily polyethylene glycol.  

The need to ensure physician orders were carried out as prescribed was discussed with Staff 2 (Assistant Executive Director), Staff 3 (Health Services Administrator) and Staff 7 (Resident Services Coordinator) on 02/01/24. The staff acknowledged the findings.

3. Resident 3 moved into the facility in 12/2019 with diagnoses including edema, chronic pain, and diabetes.

Review of the resident's 12/01/23 to 01/30/24 MARs and physician orders dated 12/12/23 and 01/19/24 revealed the following:

a. Resident 3 had physician orders for the following medications, and staff marked "med not available" on the MAR on the following occasions from 12/27/23 to 01/28/24:

* Clopidogrel 75 mg for stroke prevention on six occasions;

* Montelukast 10 mg for asthma on 30 occasions;

* Sulfamethoxazole-trimethoprim 800-160 mg for infection prevention on 10 occasions;

* Tamsulosin 0.4 mg capsule for enlarged prostate on 10 occasions;

* Multivitamin/Minerals for supplement on 31 occasions; and

* Vitamin D3 1000 unit for supplement on 20 occasions.

During an interview at 4:00 pm on 01/29/24, Staff 5 (Assistant Director of Health Services) confirmed the above medications were not in the facility and had not been administered. She stated the facility had recently taken over managing the resident's medications but the resident and family did not want to use the facility pharmacy. Survey requested a plan to ensure the resident's medications were administered as prescribed and received confirmation the above medications were ordered on 02/01/24.

b. Resident 3 had physician orders for the following medications, and staff marked "sleeping" on the MAR on 01/13/24:

* Atorvastatin 40 mg for cholesterol;

* Mirtazapine 30 mg for difficulty sleeping;

* Montelukast 10 mg for asthma;

* Metformin 1000 mg for diabetes;

* Preservision Areds for supplement;

* Acetaminophen 500 mg for pain; and

* Gabapentin 800 mg for pain.

During an interview at 1:30 pm on 01/30/24, Staff 5 confirmed the medications had not been administered.

The need to ensure medication orders were carried out as prescribed was discussed with Staff 2 (Assistant Executive Director), Staff 3 (Health Services Administrator), Staff 4 (Director of Health Services), and Staff 7 (Resident Services Coordinator). They acknowledged the findings.

1)The physician orders for Residents 3, 4, and 5 will be reviewed by RNs and the Administrator, and TSPs will be created for each problematic area, and Med Techs will be instructed on system and treatment orders, as well as physician and follow-up orders.

2) DHS will implement an Antibiotic Order Protocol and train Med Techs to flag orders and bring them to the nurse's attention as soon as possible for RN review. MedTechs are going to be educated on how to confirm orders on time, place a STAT order for medications that need to start right away, change the start time to when the medication is available in the facility, and follow up with the RN and pharmacy. Medical technicians will be trained to ensure that physician orders are carried out exactly as prescribed. Triple checks will be changed from the binder to the wall folders for an easier process.

3) DHS will assess orders, missed medications, and medications that are not available on a weekly basis.

4) DHS will see to that the corrections are made and monitored moving forward.

Based on interview and record review, it was determined the facility failed to notify the physician or other practitioner if a resident refused to consent to an order for 1 of 2 sampled residents (#3) who had medication refusals. Findings include, but are not limited to:

Resident 3 moved into the facility in 12/2019 with diagnoses including edema, chronic pain, and diabetes.

Review of the resident's 12/01/23 to 01/30/24 MARs and physician orders dated 12/12/23 and 01/19/24 revealed the following:

Staff documented on 01/05/24 the resident refused the following medications:

* Easy iron 28 mg capsule (no reason for use);

* Sulfamethoxazole-trimethoprim 800-160 mg for infection prevention;

* Tamsulosin 0.4 mg capsule for enlarged prostate;

* Primidone 50 mg tablet (no reason for use);

* Famotidine 20 mg tablet for acid reflux;

* Metformin 1000 mg tablet for Type 2 diabetes;

* Preservision capsule for supplement;

* Acetaminophen 500 mg caplets for pain;

* Gabapentin 800 mg tablet for pain;

* Duloxetine 60 mg capsule for depression/nerve pain; and

* Lantus 100 unit/ml subcutaneous solution for type 2 diabetes.

There was no documented evidence the physician was notified of the above medication refusals.

The need to ensure the physician or other practitioner was notified if a resident refused to consent to an order was discussed with Staff 2 (Assistant Executive Director), Staff 3 (Health Services Administrator), Staff 4 (Director of Health Services), and Staff 7 (Resident Services Coordinator).

1) Resident 3's MAR will specify how often the PCP wants to be notified of medication refusals. The RN will fax the PCP and ask how often they want to be notified about medication refusals. RN will place an order in MAR when to notify PCP of Medication refusals.

2) RNs will check resident charts to ensure that we have an order for notifying the PCP of medication refusals and that it is documented in the MAR, including when to notify the PCP.

3) This will be reviewed and monitored by registered nurses during weekly qulaity meetings.

4) DHS will be responsible for ensuring that corrections are completed and monitored moving forward.

Based on interview and record review, it was determined the facility failed to ensure the physician or other practitioner was notified when a resident refused to consent to a medication or treatment order for 1 of 1 resident (#9) who had medication and treatment refusals. This is a repeat citation. Findings include, but are not limited to:

Resident 9 moved into the facility in 12/2022 with diagnoses including hypertension and congestive heart failure (CHF). The resident's current prescriber orders, 07/01/24 to 07/15/24 MAR, and progress notes were reviewed. The following was identified:

Staff documented the resident refused the following medications and treatments:

* Amlodipine (for hypertension) on five occasions;

* Doxazosin (for hypertension) on five occasions;

* Furosemide (for CHF) on five occasions;

* Polyethylene glycol (for constipation) on five occasions;

* Potassium chloride (a diuretic) on five occasions;

* Senna (for constipation) on five occasions;

* Calmoseptine ointment (for Stage 2 pressure ulcer) on six occasions;

* Omeprazole (for indigestion) on eight occasions;

* Sodium chloride (for low sodium levels) on eight occasions;

* Hydralazine (for hypertension) on fourteen occasions;

* Prednisilone ophthalamic solution (eye drops) on eight occasions; and

* "Check weight every month" on one occasion.

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

The need to ensure the physician or other practitioner was notified when a resident refused to consent to a medication or treatment order was discussed with Staff 3 (Health Services Administrator) and Staff 22 (Director of Health Services/RN) on 07/16/24. They acknowledged the findings.

1) Director of Health Services faxed 9's PCP requesting how often they want to be notified of medication refusals and put out

a TSP for staff of when to notify 9's PCP of medication refusals. 9's PCP was faxed of recent medication refusals. Director of Health Services & Administrator discussed the state's findings with Med Techs about medication refusals and the requirement

of notifying the PCP and if the see that we are missing an order for medication refusals that they are to notify the PCP and let Director of Health Services know. Director of Health Services ran the med refusal report for all assisted living residents and followed up with the med techs.

2) The Director of Health Services, delegated RN or designee will run the refused medication report on PCC daily and follow up with med techs about faxing the PCP. Director of health services will follow up to ensure PCP was notified. Director of health services went over this information at the med tech meeting on 7/24/24. Director of health services added a tab divider into the pending fax binders so when they complete an audit, they will have a certain area these faxed notifications will be kept which will be easier for follow up. Director of health services, RN, Admin, RSCs or designee are completing an audit for residents who have been refusing meds and ensuring they have an order of how often the PCP wants to be notified & faxing the resident's PCP.

3) The Director of health services, RN or designee will run the refused medication report daily.

4) The Director of health services, Administrator or designee will be responsible for seeing that the corrections are completed and Director of health services or designee will be responsible for monitoring weekly.

3. Resident 6 was admitted to the facility in 12/2023 with diagnoses including anxiety, depression, and right knee replacement.

Review of Resident 6's MAR, dated 01/01/24 through 01/29/24, and physician orders, dated 12/27/23, revealed the following deficiencies:

The MAR lacked reasons for use for the following medications:

* Acyclovir 400 mg;

* Coenzyme Q10 100 mg;

* Donepezil 5 mg;

* Esomeprazole 40 mg;

* Gemfibrozil 600 mg;

* Latanoprost .005% soln;

* Loratadine 10 mg;

* Quetiapine 25 mg;

* Rosuvastatin 10 mg;

* Timolol Maleate 0.5% soln;

* Trazodone 100 mg;

* Venlafaxine 75 mg;

* Donepezil 5 mg (PRN);

* Meclizine 25 mg (PRN); and

* Quetiapine 25 mg (PRN).

On 02/01/24, the need to ensure an accurate MAR was kept for all medications administered by the facility was discussed with Staff 2 (Assistant Executive Director) and Staff 3 (Resident Services Coordinator). They acknowledged the findings.

4. Resident 2 was admitted to the facility in 01/2023, with diagnoses including anxiety, depression, and gastroesophageal reflux disease.

Review of Resident 2's MAR, dated 01/01/24 through 01/29/24, and physician orders, dated 11/27/23, revealed the following deficiencies:

The MAR lacked reasons for use for the following medications:

* Pantoprazole 40 mg;

* Sertraline 100 mg;

* Tramadol 50 mg;

* Ofloxacin 0.3 % soln; and

* Ondansetron 4 mg (PRN).

On 02/01/24, the need to ensure an accurate MAR was kept for all medications administered by the facility was discussed with Staff 2 (Assistant Executive Director) and Staff 3 (Resident Services Coordinator). They acknowledged the findings.

2. Resident 4 was admitted to the facility in 01/2021 with diagnoses including chronic kidney disease and Alzheimer's disease.

Review of the resident's 01/01/24 to 01/30/24 MARs and physician orders dated 01/03/24 revealed the following:

The following medications lacked a reason for use on the MAR:

* Colchicine 0.6 mg tablet;

* Furosemide 20 mg tablet;

* Jardiance 10 mg tablet;

* Metoprolol Succinate 50 mg tablet;

* Potassium Chloride 20 mEq;

* Culturelle 15 billion cell capsule;

* Eliquis 5 mg;

* Cephalexin 500 mg capsule; and

* Lidocaine 5% ointment.

The need to ensure the MAR was accurate and included reasons for use was discussed with Staff 2 (Assistant Executive Director), Staff 3 (Health Services Administrator) and Staff 7 (Resident Services Coordinator) on 02/01/24. The staff acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was kept, including resident-specific parameters and instructions for PRN medications for 4 of 7 sampled residents (#s 2, 3, 4, and 6) whose records were reviewed. Findings include, but are not limited to:

1. Resident 3 moved into the facility in 12/2019 with diagnoses including edema, chronic pain and diabetes.

Review of the resident's 12/01/23 to 01/30/24 MARs and physician orders dated 12/12/23 and 01/19/24 revealed the following:

a. The following two medications were on the resident's MAR starting 12/28/23:

* Sulfamethoxazole-trimethoprim 800-160 mg for infection prevention; and

* Tamsulosin 0.4 mg for enlarged prostate.

The resident's orders dated 12/12/23 indicated sulfamethoxazole-trimethoprim had been discontinued, and there were no orders in the facility for the tamsulosin until 01/19/24. During an interview at 4:00 pm on 01/29/24, Staff 5 (Assistant Director of Health Services, RN) stated the medications were not in the facility and had not been administered to the resident.

b. Resident 3's MARs included the following medications that were marked as administered:

* Sulfamethoxazole-trimethoprim 800-160 mg for infection prevention on 12/30/23, 12/31/23, 01/12/24, and 01/13/24;

* Tamsulosin 0.4 mg for enlarged prostate on 12/30/23, 12/31/23, 01/12/24, 01/13/24, and 01/24/24; and

* Multivitamin for supplement on 01/22/24.

During an interview at 4:00 pm on 01/29/24, Staff 5 confirmed the medications were not in the facility on the above dates and had not been administered.

c. The resident had orders for ibuprofen 400 mg tablet PRN for pain and oxycodone 10 mg tablet PRN for pain. The MAR lacked parameters to instruct unlicensed staff which medication to administer first.

d. The resident had orders for staff to collect CBGs and the MAR lacked resident-specific parameters including when staff should contact the RN or prescriber.

e. The following medications lacked a reason for use on the MAR:

* Primidone 50 mg tablet;

* Budesonide formoterol 80-4.5 mcg inhaler;

* Cefadroxil 500 mg capsule;

* Easy iron 28 mg capsule; and

* Therapeutic M tablets.

The need to ensure the MAR was accurate and contained resident-specific parameters and instructions was discussed with Staff 2 (Assistant Executive Director), Staff 3 (Health Services Administrator), Staff 4 (Director of Health Services), and Staff 7 (Resident Services Coordinator). They acknowledged the findings.

1) Residents 2, 3, 4, and 6 had their MARs reviewed. Resident 3's medications are now being ordered through our facility's pharmacy. Medication Technicians who use incorrect documentation will be immediately addressed by RN. Residents who use an outside pharmacy or whose families supply medications will be contacted when their medications are running low, and if family fails to respond or bring in medications, the facility will order or STAT through our in-house pharmacy to ensure the resident does not go without medication. The RN will enter the resident 3's missing parameters to guide unlicensed personnel on which medication to give initially. The RN will change the specific parameters for Resident 3's CBGs. RN will update residents 2, 3, 4, and 6's meds in MAR with missing indications for use and missing parameters.

2) The TSL self-administration assessment includes a prompt for the nurse to reconcile the resident's medication list which will be done by RNs moving forward. RNs will run a weekly report on residents who are missing indications for medication use and parameters, as well as education for Medication Technicians on how to mark the correct code for drugs that are missed, unavailable, or not given.

3) This will be evaluated and tracked weekly as part of the missing medication and meds unavailable report by the facility RNS.

4) Moving forward, monitoring will be the responsibility of DHS and RNs.

Based on interview and record review, it was determined the facility failed to ensure a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications for 1 of 1 sampled resident (#3) who self-administered medications. Findings include, but are not limited to:

Resident 3 moved into the facility in 12/2019 with diagnoses including asthma.

Review of the resident's 12/01/23 to 01/30/24 MARs and physician orders dated 12/12/23 and 01/19/24 revealed the following:

The resident had orders for budesonide formoterol 80-4.5 mcg inhaler (no reason for use) and an updated RN assessment to self-administer. However there was no documented evidence the resident had a written physician order to self-administer the medication.

The need to ensure a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications was discussed with Staff 2 (Assistant Executive Director), Staff 3 (Health Services Administrator), Staff 4 (Director of Health Services), and Staff 7 (Resident Services Coordinator). They acknowledged the findings.

1) The RN faxed resident 3's PCP requesting self-administration of medication and received a response.

2) The TSL self-med assessment includes a prompt for the nurse to check to see if we have an order for the resident to self-administer. Once we get that order, it will be added to the orders tab of the resident's chart, therefore, we will have a "refreshed" order with every 90 day P.O.'s. The registered nurse will verify that all residents' PCPs are faxed after completing a self-administration of medications assessment and that there is a written order of approval for self-administration of prescription medications. The registered nurse will audit current residents who are self-medicating to ensure that they have a current valid order from their primary care physician.

3) This will be evaluated by the RN's during move-in,  quarterly and as needed.

4) The RN will be responsible for making sure that the corrections are completed and also monitored by the DHS.

Based on interview and record review, it was determined the facility failed to document non-pharmacological interventions had been tried with ineffective results prior to administering PRN psychotropic medications for 1 of 1 sampled residents (#10) who used a PRN psychotropic medication. Findings include, but are not limited to:

Resident 10 was admitted to the facility in 07/2023 with diagnoses including Parkinson's disease and major depressive disorder.

Review of Resident 10's MAR dated 07/01/24 to 07/15/24 listed PRN mirtazapine (an antidepressant) to be administered "7.5 mg 0.5 tablet (3.75 mg) to 1 tablet (7.5 mg) by mouth nightly as needed for sleep and mood", and indicated staff had administered the medication PRN three times.

The MAR did not list resident specific parameters for when to administer the PRN, and there was no documented evidence staff attempted non-drug interventions with ineffective results before giving the medication.

The need to develop non-pharmacological interventions and document the attempted interventions were ineffective prior to administering Resident 10's PRN psychotropic medication was reviewed with Staff 3 (Health Services Administrator), Staff 2 (Director of Health Services), and Staff 5 (Assistant Director of Health Services, RN) on 07/17/24. They acknowledged the findings.

1) Faxed PCP about specifying parameters for when to administer PRN medication. Updated order received and RN updated MAR. MAR & TSP updated for staff regarding non-pharmacological interventions to try prior to administering PRN medication for resident 10.

2) DHS, RNs, RSCs and the Administrator are completing a full audit of all assisted living residents who have PRN psychotropic medications, for missing indication for use, parameters on what dose to give and ensuring non-pharmacological interventions are in place and being used prior to giving PRN medication. DHS educated Med Techs about The Springs Living PRN decision Tree at the Med Tech Meeting on 7/24/24 and posted the print out in the Med Tech's chart room.

DHS, RNs, RSCs and designee will review residents with new orders during daily dashboard meeting, new orders will be checked for missing parameters, interventions and a TSP will be made during the meeting and put in place.

3) The PRN psychotropic medication report will be reviewed during weekly quality meetings by Director of health services, RNs, RSC, Administrator and/or designee and missing interventions will be followed up by the DHS or RN/designee. RN will check the orders daily via the triple check box and review for PRN medications with missing parameters and interventions.

4) Director of health services, Administrator or designee will be responsible for ensuring that the corrections are completed and Director of health services will be responsible for monitoring this moving forward.

Based on interview and record review, it was determined the facility failed to review the Acuity Based Staffing Tool (ABST) for each resident no less than quarterly and to use the results to develop and routinely update the facility's staffing plan. Findings include, but are not limited to:

Review of the facility's online ABST indicated several sampled and unsampled residents' ABST data had not been updated quarterly.

On 02/01/24, the need to ensure residents' ABST was reviewed no less than quarterly and the tool was used to develop and update the facility's staffing plan was discussed with Staff 1 (Executive Director), Staff 2 (Assistant Executive Director), Staff 3 (Health Services Administrator), Staff 4 (Director of Health Services, RN), Staff 6 (Resident Services Coordinator), and Staff 7 (Resident Services Coordinator), They acknowledged the findings.

1. ABST for impacted residents will be updated to reflect more accurate times.

2. The administrator will provide additional education to RSCs on how to update the ABST tool and to do so in a timely manner.

3. The RSC's checklist for pre-service planning will be revised to include a reminder to update the ABST at move-in, 30-days after move-in, quarterly, and as needed. ABST will be updated and verified for correctness around the time of the quarterly care conference and during any significant change in condition.RSCs will open and close the resident's ABST even if no changes have occurred, to create the time stamp for evaluating the need to add any changes.

4. The administrator will track completion, and the assistant executive director or designee will conduct monthly audits.   

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired direct-care staff (#s 16, 18 and 19) demonstrated satisfactory performance in all assigned duties within 30 days of hire. Findings include, but are not limited to:

On 01/31/24 and 02/01/24 review of staff training records and interviews with Staff 2 (Assistant Executive Director) indicated the following:

a. There was no documented evidence Staff 16 (MT), Staff 18 (CG), and Staff 19 (CG), hired on 11/06/23 and 10/03/23, respectively, demonstrated competency in their job duties within 30 days of hire in the following areaa:

* Changes associated with normal aging;

The need to ensure staff had demonstrated competency in all job duties within 30 days of hire was reviewed with Staff 2 (Assistant Executive Director) and Staff 3 (Health Services Administrator) on 02/01/24. They acknowledged the findings.

1) Training documentation will be reviewed to verify that the 30-day competency checklist for all care staff includes the necessary demonstrated competency for changes associated with natural aging as well as conditions that require assessment, treatment, observation, and reporting.

2) The facility contacted the Home Office to request a training document that outlines what is taught in staff training courses to ensure all is covered.

3) The Administrator or designee will review this every 30 days, and prior to the employee being on the floor.

4) The Administrator, Assistant Executive Director, or Designee will be responsible for completing and monitoring the corrections moving forward.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 long term staff (#s 20 and 21) had completed annual training on infectious disease outbreak and infection control. Findings include, but are not limited to:

On 01/31/24 and 02/01/24 review of staff training records and interviews with Staff 2 (Assistant Executive Director) indicated the following:

Staff 20 (Housekeeper) hired 02/23/22, and Staff 21 (Dining Room Server) hired 07/08/22 lacked evidence of completing annual Infectious Disease Prevention training.

The need to ensure administrators and employees completed annual infectious disease outbreak and infection control training was discussed with Staff 2 (Assistant Executive Director) and Staff 3 (Health Services Administrator) on 02/01/24. The staff acknowledged the findings.

1) Staff 20 and 21 are completing their infection-control training.

2) The facility will ensure that all employees complete their infection control course before working on the floor, and will check all staff training records to verify that those who have not completed their annual infection training do so in order to be in compliance. The facility will develop a tracking tool for all departments on TEAMs to make it easier to track where employees are in their trainings, and all department heads will update their departments under the Administrator's supervision.

3) The facility administrator or designee will evaluate and update training records on an ongoing basis, within 30 days of each hire and annually.

4) The Administrator and Assistant Executive Director will ensure that the corrections are performed and monitored going forward.

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

Refer to C305.

1) Refer to tag 305. 1) Director of Health Services faxed 9's PCP requesting how often they want to be notified of medication refusals and put out

a TSP for staff of when to notify 9's PCP of medication refusals. 9's PCP was faxed of recent medication refusals. Director of Health Services & Administrator discussed the state's findings with Med Techs about medication refusals and the requirement

of notifying the PCP and if the see that we are missing an order for medication refusals that they are to notify the PCP and let Director of Health Services know. Director of Health Services ran the med refusal report for all assisted living residents and followed up with the med techs.

2) The Director of Health Services, delegated RN or designee will run the refused medication report on PCC daily and follow up with med techs about faxing the PCP. Director of health services will follow up to ensure PCP was notified. Director of health services went over this information at the med tech meeting on 7/24/24. Director of health services added a tab divider into the pending fax binders so when they complete an audit, they will have a certain area these faxed notifications will be kept which will be easier for follow up. Director of health services, RN, Admin, RSCs or designee are completing an audit for residents who have been refusing meds and ensuring they have an order of how often the PCP wants to be notified & faxing the resident's PCP.

3) The Director of health services, RN or designee will run the refused medication report daily.

4) Director of health services, Administrator or designee will be responsible for ensuring that the corrections are completed and Director of health services will be responsible for monitoring this moving forward.