Print Inspection: X5LI

The findings of the on-site investigation, conducted 12/04/23, 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

Based on interview and record review conducted during a site visit on 12/04/23, it was confirmed the facility failed to ensure if a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, document the change, and update the service plan as needed for 1 of 1 sampled resident (# 6) . Findings include, but are not limited:

A review of Resident 6's service plan, dated 11/12/22, indicated s/he was independent in transfers, ambulation, and toileting tasks.

A review of Resident 6's Temporary Service Plans (TSPs), dated 12/01/22, indicated s/he was placed on alert for skin cancer. On 12/17/22 s/he was admitted to hospice, with "2-hour safety checks and increase toileting care due to pain".

A review of Resident 6's progress notes, dated 10/16/22 through 12/19/22, indicated on 12/13/22 a nurse assessment was completed due to a change in resident's condition.

In an interview on 12/04/23, Staff 1 (Executive Director) stated the 11/12/22 service plan was the last service plan created for Resident 6 and no new evaluation was completed after resident's skin cancer diagnosis or admittance to hospice.

No service plan was available or provided documenting the residents updated care needs due to his/her change of condition.

The facility failed to ensure if a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, document the change, and update the service plan as needed.

The findings were reviewed with and acknowledged by Staff 1 on 12/04/23.

Facility verbal plan of correction:

During weekly clinical meeting nursing staff were to discuss any changes of condition and steps taken. The administrator was to implement monthly quality assurance checks on service plans.

Based on interview and record review, conducted during a site visit on 12/04/2023, it was confirmed the facility administrator failed to ensure adequate professional oversight of the facility's medication and treatment administration system for 1 of 1 sampled resident (# 4). Findings include, but are not limited to the following:

A review of facility self-report, dated 09/24/22, indicated on 09/23/22, Resident 4 moved out of the facility into another community. The secondary community notified Powell Valley Assisted Living that they had received medications for another resident other than Resident 4.

In an interview on 12/04/23, Staff 1 (Executive Director) stated the med techs associated with the mishandling of Resident 4's and the other resident's medications no longer work for the facility.

The facility administrator failed to ensure adequate professional oversight of the facility's medication and treatment administration system.

The findings of the investigation were reviewed with and acknowledged by Staff 1 on 12/04/23.

Facility Verbal Plan of Correction:

A med tech training will be scheduled by the end of the week to occur within the next 60 days. A checklist with sign-off ' s will also be implemented in the next 30 days for resident discharges to ensure a resident has all necessary items upon move-out.

Based on interview and record review, conducted during a site visit on 12/04/23, it was confirmed that the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (# 7). Findings include, but are not limited to the following:

A review of facility Medication Error Incident Report, dated 05/01/23, indicated Staff 4 (Med tech) administered an another resident's medication to Resident 7.

A review of Staff 4's statement, dated 05/01/23, indicated s/he had given Resident 7 another resident's medications, s/he then notified the facility RN, the resident, the resident's  family, and the resident's  PCP. S/he also indicated s/he checked on resident and resident was able to go to the dining room for lunch.

A review of the facility's incident investigation, dated 05/01/23, indicated Staff 4 mixed up the pill cups by putting them in the wrong spot in the pill box.

A review of facility's corrective action form, dated 05/01/23, indicated Staff 4 received re-education on the 5 rights of medication administration and a 60-day written warning.

In an interview on 12/04/23, Staff 1 (Executive Director) stated having the Nurse Crisis team come into the building was helpful to get med techs the necessary training to help prevent these types of medication errors.

The facility failed to carry out medication and treatment orders as prescribed.

The findings were reviewed with and acknowledged by Staff 1 on 12/04/23

Facility verbal plan of correction:

A med tech training will be scheduled by the end of the week to occur within the next 60 days.

Based on interview and record review, conducted during a site visit on 12/04/23, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 17 of 17 sampled residents. Findings include, but are not limited to the following:

A review of self-report, dated 05/15/23, indicated on the morning of 05/13/23 17 residents were invloved in a medication error.  Three of the 17 residents missed all morning AM meds, nine residents missed a single medication, and five residents missed two to three medications. According to self-report all residents involved in the missed medications, their families and physicians were notified.

A review of progress notes and Temporary Service Plans (TSPs) indicated all 17 residents involved were placed on alert charting and TSPs were created to monitor residents.

In an interview on 12/04/23, Staff 1 (Executive Director) stated the nurse crisis team had been working in the facility to allow the med techs employed by the facility to receive training. During the transition from the nurse crisis team back to the facility med techs on 05/13/23 between the NOC shift to the day shift, there was a miscommunication or misunderstanding about who was responsible for passing the early morning medications. Usually the NOC med techs would administer the early AM medications. The nurse crises team did not administer the early AM medications and the facilities day med techs did not realize those medications had not been administered until it was outside of the administration window.

The facility failed to carry out medication and treatment orders as prescribed.

The findings were reviewed with and acknowledged by Staff 1 on 12/04/23.

Facility verbal plan of correction:

A med tech training will be scheduled by the end of the week to occur within the next 60 days. All residents involved in the incident were placed on alert, physicians were followed up with and their orders were followed.

Based on interview and record review, conducted during a site visit on 12/04/23, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (# 8). Findings include, but are not limited to the following:

A review of Resident 8's June 2023 MAR indicated on 06/02/23 his/her Quetiapine for severe anxiety was to be taken by mouth three times daily at breakfast, around 4:00 pm, and at bedtime; and discontinued on 06/13/23. The MAR indicated between 06/03/23 and 06/13/23 there were four administration times at 8 am, 12 pm, 5 pm and 8 pm. For the dates between 06/04/23 and  06/12/23, Resident 8 received four doses of Quetiapine each day.

A review of Resident 8's physician orders, dated 06/02/23, indicated a change in his/her Quetiapine order. Resident was to take "Quetiapine three times a day: with breakfast; around 1600, and at bedtime. May take an additional 1 tablet by mouth a day as needed for persistent insomnia/ anxiety/ hallucinations."

In an interview on 12/04/23, Staff 3 (Care Coordinator) stated Resident 8 had a lot of changes to his/her Quetiapine order in June 2023.

The facility failed to carry out medication and treatment orders as prescribed.

The findings were reviewed with and acknowledged by Staff 1 (Executive Director) on 12/04/23.

Facility verbal plan of correction:

A med tech training will be scheduled by the end of the week to occur within the next 60 days. The 3rd med tech scheduled on days will allow time for RCC staff and med techs to ensure all paperwork is being input correctly and timely.

Based on interview and record review, conducted during a site visit on 12/04/23, it was confirmed the facility failed to provide direct care staff sufficient in number to meet the scheduled and unscheduled needs of the residents for 2 of 2 sampled residents (#s 2 and 3). Findings include, but are not limited to:

During an interview on 12/04/23, Staff 1 (Executive Director) stated the facility expected call lights to be answered within 10-15 minutes.

During an interview on 12/04/23, Residents 1 and 2 stated they sometimes had to wait half an hour or more to get a response to their call lights.

Call light logs, dated 11/26/23 through 12/02/23, indicated the following:

a. Resident 2 waited 27 minutes for his/her call light to be answered on 11/26/23;

Resident 2 waited 33 minutes for his/her call light to be answered on 11/29/23;

Resident 2 waited 25 minutes for his/her call light to be answered  on 11/30/23; and

Resident 2 waited 33 minutes for his/her call light to be answered  on 11/29/23.

b. Resident 3 waited 59 minutes for his/her call light to be answered  on 11/26/23; and

Resident 3 waited 27 minutes for his/her call light to be answered  on 11/30/23.

The findings were reviewed with and acknowledged by Staff 1 on 12/04/23.

The facility failed to provide direct care staff sufficient in number to meet the scheduled and unscheduled needs of the residents

Verbal plan of correction: The administrator will be auditing the call light logs weekly to identify any trends or staff members and taking action to ensure call lights are answered timely. Currently in the process of hiring staff in order to schedule a 3rd med tech on day shift to assist during peak hours.

Based on interview and record review, conducted during a site visit on 12/04/23, it was confirmed the facility failed to provide direct care staff sufficient in number to meet the scheduled and unscheduled needs of the residents for 2 of 2 sampled residents (#s 2 and 3). Findings include, but are not limited to:

During an interview on 12/04/23, Staff 1 (Executive Director) stated the facility expected call lights to be answered within 10-15minutes.

During an interview and observation on 12/04/23, Resident 1 and Resident 2 stated they sometimes had to wait half an hour or more to get a response to their call lights.

Call light logs, dated 11/26/23 through 12/02/23, were reviewed and indicated:

* Resident 3 waited 59 minutes for his/her call light to be answered on 11/26/23;

* Resident 2 waited 27 minutes for his/her call light to be answered on 11/26/23;

* Resident 2 waited 33 minutes for his/her call light to be answered on 11/29/23;

* Resident 2 waited 25 minutes for his/her call light to be answered on 11/30/23;

* Resident 2 waited 33 minutes for his/her call light to be answered on 11/29/23; and

* Resident 3 waited 27 minutes for his/her call light to be answered on 11/30/23.

The facility failed to provide direct care staff sufficient in number to meet the scheduled and unscheduled needs of the residents.

The findings were reviewed with and acknowledged by Staff 1 on 12/04/23.

Facility verbal plan of correction:

The administrator will be auditing the call light logs weekly to identify any trends or staff members and taking action to ensure call lights are answered timely. The facility was in the process of hiring staff in order to schedule a 3rd med tech on day shift to assist during peak hours.

Based on interview and record review, conducted during a site visit on 12/04/2023, it was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool (ABST). Findings include, but are not limited to the following:

In an interview on 12/04/23, Staff 1 (Executive Director) stated the facility currently uses an excel spreadsheet that s/he manually copies the information from the resident service plans into the spreadsheet and then s/he generate a 24-hour staffing plan based on the data input for all of the residents.

A review of the facility's ABST excel spreadsheet and the resident roster indicated there were two residents that were listed on the resident roster that were showing as blank rooms on the ABST.

A review of Resident 2 and Resident 3s' service plans indicated the service plans did not address the following required ABST ADLs:

·Repositioning in chair or bed,

·Assisting with leisure activities, and

· Responding to call lights.

The facility failed to fully implement and update an ABST.

The findings of the investigation were reviewed with and acknowledged by Staff 1 on 12/04/23.