Print Inspection: UAN1

The findings of the relicensure survey, conducted 02/06/24 through 02/09/24, 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, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 Home and Community Based Services Regulations.

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

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 first re-visit to the re-licensure survey of 02/09/24, conducted 05/13/24, 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, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.

Based on interview and record review, it was determined the facility failed to ensure all incidents of abuse and/or neglect were reported to the local SPD office for 1 of 1 sampled residents (# 2) with incidents of resident-to-resident altercations. Findings include, but are not limited to:

Resident 2 moved into the memory care facility in 11/2022 with diagnoses including dementia with behavioral disturbance.

Review of the resident's progress notes and incident reports documented the following resident-to-resident incidents:

* 11/21/23: Resident 2 repeatedly struck another resident on the upper arm;

* 11/21/23: Resident 2 threw a plate of food at another resident; and

* 01/06/24: Resident 2 was involved in a verbal altercation with another resident and threw a fork, hitting the other resident's arm.

Investigations were completed at the time of the incidents; however, the incidents were not reported to the local SPD office.

On 02/07/24, survey requested the facility report the incidents to the local SPD office. Confirmation the incidents were reported was provided on 02/08/24.

On 02/09/24, the need to ensure all incidents of abuse and/or neglect were reported to the local SPD office was discussed with Staff 1 (Administrator) and Staff 2 (RN). They acknowledged the findings.

1. The administrator sent copies of the incident reports with self report sheet for the two physical alteraction incidents involving resident 2 on 11/21 and the verbal alteraction involving resident 2 on 1/6 to APS.

2. The administrator provided a resource binder for staff in the chart room for abuse reporting, which includes the Abuse Reporting Standards, self-report forms, and APS's phone and fax numbers. Staff will receive abuse reporting training within 30 days of their new hire. Direct care staff will be required to take the same class no later than 4/9/24. The administrator or designee will ensure that Health Services employees immediately investigate all reports of abuse and suspected abuse to take the required steps to safegaurd residents and prevent future abuse.

3. The Business Office Manager or designee will conduct a monthly audit of training records to ensure that all employees have completed their abuse reporting and training.

4. The administrator or designee will see that the trainings are completed and monitored moving forward.  

Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused to consent to orders for 1 of 1 sampled resident (# 2) who had documented medication refusals. Findings include, but are not limited to:

Resident 2 moved into the facility in 11/2022 with diagnoses including dementia with behavioral disturbance. The resident had a history of difficulty sleeping.

The clinical record included directions for staff to notify the physician "after three consecutive refusals or missed doses" of medications.

A review of the 01/01/24 through 02/06/24 MARs identified the resident refused multiple medications three consecutive times, including:

* Melatonin (for sleep);

* Acetaminophen (for pain); and

* Gabapentin (for pain).

There was no documented evidence the physician had been notified of the refusals.

The need to notify the practitioner of resident medication refusals was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 02/08/24. They acknowledged the findings.

1. Resident 2's PCP has been notified of the refusals. RN or designee will place an order in the MAR for reminders of resident's medication refusals notification order for med techs.

2. RNs are updating orders in the MAR to show medication technicians when to notify doctor of refusals. Medication Technicians will receive training by 4/9/24 on how and when to notify doctor of missed or refused medications.

3. This will be monitored and reviewed by the Registered Nurses or designee during the weekly quality meeting.

4. The DHS or designee 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 residents' MARs were accurate and included specific parameters for use of PRN medications for 2 of 2 sampled residents (#s 1 and 2) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the MCC in 11/2023, with diagnoses of atrial fibrillation, Parkinson's disease, and Alzheimer's disease.

Review of Resident 1's MAR, dated 01/01/24 through 02/06/24, identified the following deficiencies:

a. The MAR lacked reasons for use for the following medications:

* Cerave lotion (moisturizer);

* Fluconazole 200 mg (antifungal); and

* Quetiapine 25 mg (antipsychotic).

b. The MAR included the following PRN medications for constipation:

* Bisacodyl 10 mg Suppository; and

* Senna 8.6 mg.

The MAR lacked parameters to direct staff on the sequential order of use for these PRN medications.

On 02/09/24, the need to ensure complete and accurate MARs were kept for all medications, including reasons for use and clear PRN parameters, was discussed with Staff 1 (Administrator) and Staff 2 (RN). They acknowledged the findings.

2. Resident 2 moved into the facility in 11/2022 with diagnoses including spinal stenosis and dementia with behavioral disturbance.

Review of the resident's 01/01/24 through 02/06/24 MARs and physician orders, dated 12/03/23, revealed the following:

a. Physician's order for Lorazepam Intensol 0.5mg by mouth every 6 hours as needed for anxiety or sleep was listed twice on both the January 2024 and February 2024 MARs.

In an interview with Staff 2 (RN) on 02/08/24, it was determined this was a duplicate order.

b. The resident had orders for Milk of Magnesia (MOM) for constipation as needed and Bisacodyl for constipation as needed. The MAR instructed staff to give the MOM first for constipation, but lacked clear instructions for staff regarding when, specifically, to administer the MOM.

c. On 02/01/24, the MAR was left blank for the 1900 administration of Resident 2's Gabapentin, Rampiril, and acetaminophen.

The need to ensure the MAR was accurate and contained resident-specific instructions was discussed with Staff 1 (Administrator) and Staff 2 on 02/08/24. They acknowledged the findings.

1) MARs were reviewed for Residents 1 and 2. Resident 1 had indications for use and parameters added. Resident 2 had duplicate order removed and added clarification on when to give specific medications.

2) RNs or designee will run a weekly report on residents who are missing parameters. Medication Technicians will receive training as needed, based on that report. RN or designee will ensure parameters are added once discovered missing.

3) This will be evaluated and tracked by the facility RN or designee and reported on at the weekly quality meeting.

4) Moving forward, monitoring will be the responsibility of DHS or designee.

Based on interview and record review, it was determined the facility failed to ensure PRN medications used to treat residents' behaviors had written, resident-specific parameters and non-pharmacological interventions had been tried with ineffective results prior to administering PRN psychotropic medications for 2 of 2 sampled residents (#s 1 and 2) who were prescribed PRN psychotropics.  Findings include, but are not limited to:

1. Resident 1 was admitted to the MCC in 11/2023, with diagnoses including Parkinson's disease, hypertension, and Alzheimer's disease.

Review of Resident 1's MAR, dated 01/01/24 through 2/06/24, indicated the resident was prescribed the following PRN psychotropic medications:

* Lorazepam 0.5 mg, "every 4 hours as needed for anxiety"; and

* Quetiapine 25 mg, "every 4 hours as needed for agitation."

The record lacked resident-specific parameters to direct staff on how the resident displayed agitation vs. anxiety.

On 02/09/24, the need to ensure PRN medications to treat behaviors had written, resident-specific parameters was discussed with Staff 1 (Administrator) and Staff 2 (RN). They acknowledged the findings.

2. Resident 2 moved into the facility in 11/2022, with diagnoses including dementia with behavioral disturbance.

Review of Resident 2's MARs, dated 01/01/24 through 02/06/24, indicated the resident was prescribed PRN psychotropic medications including:

* Haloperidol 0.5 mg, "every hour as needed for agitation"; and

* Lorazepam 0.5 mg every 6 hours "for anxiety."

a. The record lacked resident-specific parameters to direct staff on how the resident displayed agitation vs. anxiety.

In an interview with Staff 2 (RN) on 02/08/24, it was determined the resident-specific instructions had been added to the MAR on 02/07/24 and changes to the instructions were in process.

b. There was no documented evidence non-pharmacological interventions were tried and ineffective prior to administration of the PRN lorazepam on six occasions between 01/01/24 and 01/21/24.

The need to ensure PRN medications given to treat a resident's behaviors had written, resident-specific parameters and there was documentation that non-pharmacological interventions had been tried with ineffective results prior to administration was discussed with Staff 1 (Administrator) and Staff 2 on 02/08/24. They acknowledged the findings.

1. MARs are being updated to include a list of interventions for residents 1 and 2. This will allow the Med Tech to document accurate information on attempted non-pharmacological interventions, prior to administering PRN psychotropic medications.

2.Staff training to be provided on new protocols for psychotropic interventions. This training will be completed no later than 4/9/24. This will include agitation vs anxiety training, and the importance of non-pharmacological interventions prior to administering PRN psychotropic medications.

3. RN or designee to audit for parameters during the triple checks and report all corrections needed at weekly at quality meeting. Trends will be assessed and specific Med Tech training will be required as needed based on results.

4. RN or designee to confirm parameters at triple check and MCA to check quarterly.

Based on observation, interview, and record review, it was determined the facility failed to update an acuity-based staffing tool (ABST) to accurately reflect all tasks for each resident, including the amount of staff time needed to provide care, for 2 of 2 sampled residents (#s 1 and 2). Findings include, but not limited to:

The facility's ABST was reviewed with Staff 1 (Administrator) on 02/07/24, and the individual ABST records for Residents 1 and 2 were reviewed.

During interviews with staff and observations of resident care, the current ADL needs and other tasks required for sampled residents were not reflected in the ABST, including an accurate amount of staff time needed to provide care.

The need to ensure all time needed for providing care to residents was accurate in the ABST was reviewed with Staff 1 on 02/07/24. She acknowledged the findings.

1. ABST for impacted residents has been updated with individualized times.

2. On 3/6/24, Administrator received training from the State on ABST usage, accuracy and regulations.

3. Checklist will be updated to include reminders to update ABST tool upon move in, quarterly and as needed. ABST will be updated and checked for accuracy around the time of the quarterly care conference and upon sig change of condition.

4. The administrator will track completion, and the Assistant Executive Director or designee will conduct a monthly audit.  

Based on observation, interview, and record review, it was determined the facility failed to ensure compliance with non-healthcare related Residential Care and Assisted Living regulations. Findings include, but are not limited to:

Refer to C231 and C361.

Refer to above C231 and C361

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 C305, C310, and C330.

Refer to above C305, C310 and C330

Based on interview and record review, it was determined the facility failed to ensure an individualized activity plan was developed for each resident, based on an activity evaluation, for 2 of 2 sampled residents (#s 1 and 2) whose records were reviewed. Findings include, but are not limited to:

Resident 1 and 2's service plans and evaluations were reviewed. There was no documented evidence the facility had fully evaluated the residents':

* Current abilities and skills;

* Emotional and social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for the resident to participate; and

* Activities that could be used as behavioral interventions, if necessary.

There was no documented evidence of specific activity plans which detailed what, when, how, and how often staff should offer and assist the residents with more individualized activities.

On 02/09/24, the failure to ensure all residents had individualized activity plans developed and implemented, based on their activity evaluations, was discussed with Staff 1 (Administrator) and Staff 2 (RN). They acknowledged the findings.

1. Individualized Activity Plan has been updated with details on activities of interest as per the regulations - The residents now have a current individualized activity plan that includes: Current abilities and skills; Emotional and social needs and patterns; physical abilities and limitations; adaptations necessary for the resident to participate; and activties that could be used as behavioral interventions, if necessary.

2. Incorporation of new forms for resident activities are being completed with the help of Life Enrichment and entered as a tool to assist with person centered care planning for activities.

3. RSC or designee will review activities form and update service plan and ensure required information is covered.

4. Administrator or designee will audit each service plan around the time of care plan meeting to ensure proper information is included.