Print Inspection: XNXS

The findings of the on-site investigation, conducted 12/18/23 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

bid:twice a day

CBG:capillary blood glucose or

blood sugar

cc:cubic centimeter

CG:caregiver

cm:centimeter

F:Fahrenheit

HH:Home Health

HS or hs:hour of sleep

LPN:Licensed Practical Nurse

MA:Medication Aide

MAR:Medication Administration

Record

MCCMemory Care Community

mg:milligram

ml:milliliter

O2 sats:oxygen saturation in the

blood

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

RN:Registered Nurse

SP:service plan

TAR:Treatment Administration

Record

tid:three times a day

Based on interview and record review, conducted during a site visit on 12/18/23, it was confirmed the facility failed to report a physical injury of unknown cause to the local Department office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse for 1 of 1 sampled resident (#3). Findings include, but are not limited to:

An incident report dated 10/09/23 revealed Resident 3 was found on the floor with a small pool of blood noted that morning. The incident report noted the event was reported to APS on 11/20/23. There was no evidence that the facility ruled out abuse or neglect.

During an interview on 12/18/23, Staff 9 (Consultant) stated the incident was discovered by reviewing incomplete incident reports in their daily clinical meeting in November 2023.

The findings of the investigation were reviewed with and acknowledged by Staff 9 and Staff 10 (Administrator) on 12/18/23.

The facility failed to report a physical injury of unknown cause to the local Department office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse.

Verbal plan of correction: The interdisciplinary team will be going through all incident reports 5 days/week and ensuring completion. They review 24 hour and 72 hour progress notes in clinical meetings. Their consultant had contacted PCC (Electronic Medical Record) to auto-click to include all progress notes on 24 hour report so all charting pops up, but had not yet been resolved. The facility just re-trained staff last week on abuse reporting and investigation guidelines. Training with IDT team on abuse reporting was conducted 12/06/23. Weekend staff should report to Administrator or report to APS. Administrator would come in on the weekend to evaluate the resident and situation if needed on a Saturday. RCC is at the facility on Sundays to assist with APS reporting if needed.

Based on observation, interview and record review, conducted during a site visit on 12/18/23, it was confirmed the facility failed to carry out medication orders as prescribed for 4 of 4 sampled residents (#s 1, 2, 4 and 5). Findings include, but are not limited to:

1. Resident 1's 12/01/23- 12/18/23 MAR noted an order for Tramadol (pain reliever) 50mg Tab take one tablet by mouth every day. On 12/15/23 the medication was noted as given on the MAR. The corresponding narcotic log and the medication card was observed and reviewed and there was no evidence the medication was given on 12/15/23.

During a phone interview on 12/18/23 Staff 14 (MT) became agitated and stated s/he couldn't remember if s/he had given it, but thinks s/he remembered giving it, but then later stated "I guess I forgot to give it." Staff 14 further stated that sometimes s/he initialed and dated next to the narcotics s/he pops on the cards, but sometimes s/he doesn't.

2. A review of Resident 2's chart and 12/01/23 through 12/18/23 MAR identified one occasion when morphine sulfate 20mg/ml was administered per the narcotics log on 12/09/23, and not recorded as administered on the MAR.

The current physician orders in the resident's record, dated 10/18/23, indicated to "notify ElderPlace for change of condition or PRIOR to using."

In an interview on 12/18/23, via phone call with Staff 14 confirmed s/he had administered Resident 2's liquid morphine recently after asking resident if s/he was having hip pain and resident grumbled in response. Staff 14 stated s/he had not contacted ElderPlace and could not remember if s/he charted in the MAR.

3. A review of Resident 4's October and November 2023 MAR noted an order for Lexothyroxine Sodium Oral Tablet 112 MCG 1 Tablet by mouth one time a day every Monday for hypothyroid beginning 06/29/23.  

Resident 4's October 2023 and November 2023 MAR indicated the medication was given as ordered each Monday. Packing slips or proof the medication was received prior to 11/15/23 was requested but was not available.

During an interview on 12/18/23, Staff 1 and Staff 2 (MTs) stated the facility did not have the right dose of Resident 4's Monday dose of levothyroxine for months so the MTs were just giving Resident 4 the regular daily dose and marking it as the higher dose. Staff 1 further stated s/he had notified day shift MTs and management of the issue. Staff 1 and Staff 2 stated the facility received the correct dose for the medication in the last few weeks.

4. A review of Resident 5's chart and 10/01/23 through 12/18/23 MAR's indicated the following:

* 12 instances of Nizoral A-D shampoo not being administer due to "not residents shower day.";

* 2 instances of Trazodone not administered due to medication not available;

* 4 instances of Amiodarone not administered due to medication not available;

* 4 instances of Risperidone not administered due to medication not available;

* 2 instances of Simvastatin not administered due to medication not available;

* 2 instances of Brimonidine Tartrate Ophthalmic Solution not found in cart and 6 instances of medication not administered due to not available;

* 3 instances of Oxycodone not administered due to medication not available; and

* On 10/16/23 all evening medications were missed (13 medications).

The findings of the investigation were reviewed with and acknowledged by Staff 9 (Consultant) and Staff 10 (Administrator) on 12/18/23.

The facility failed to carry out medication orders as prescribed.

Verbal Plan of Correction: Staff 9 and Staff 10 will audit the narcotics which will be completed by 12/19/23. Staff 9 is working with MAR service provider to put in time parameters for medication administration. There will be an in-service for all med techs on the rights of medication administration. The consulting RN is beginning the process of reviewing all physician orders and ensuring appropriate medication in stock and ordered. Administrator to audit competencies for all MTs by 12/12/23. Competencies for individuals will be verified on the staff member's next scheduled day. Staff 14 will be removed from the medication cart and counseling provided to determine employment status moving forward.

Based on observation, interview and record review it, conducted during a site visit on 12/18/23, it was determined 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. Findings include, but are not limited to:

The facility's posted staffing plan was observed and reviewed on 12/18/23 which included the need for the following staff:

Day shift: 2 MTs, 6 CGs

Evening shift: 2 MTs, 6 CGs

During interview, Staff 10 (Administrator) stated their posted staffing plan had not increased since she started in October 2023 as the facility had a condition imposed prohibiting new move-ins.

A review of time cards for 11/20/23 noted a total of six care staff (MTs and CGs) worked on day and evening shift.

During interview, Staff 10 stated the facility must have had call outs on 11/20/23 that led to being short-staffed.

The findings of the investigation were reviewed with and acknowledged by Staff 9 (Consultant) and Staff 10 on 12/18/23.

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.

Verbal plan of correction: The facility was utilizing agency staff and will complete a head count of staff available each shift. They are actively hiring for all shifts and offering referral bonuses.

Based on observation, interview and record review, conducted during a site visit on 12/18/23, it was determined 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. Findings include, but are not limited to:

The facility's posted staffing plan was observed and reviewed on 12/18/23 which included the need for the following staff on night shift: 2 MTs and 4 CGs.

During interview, Staff 10 (Administrator) stated their posted staffing plan had not increased since she started in October 2023 as the facility had a condition imposed prohibiting new move-ins.

A review of time cards for night shift on 10/21/23 as identified in the complaint revealed only three care staff (MTs and CGs) worked on the shift.

During interview, Staff 10 (Administrator) stated the facility must have had call outs on 10/21/23 that led to being short-staffed.

The findings of the investigation were reviewed with and acknowledged by Staff 9 (Consultant) and Staff 10 on 12/18/23.

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.

Verbal plan of correction: The facility is utilizing agency staff and will complete a head count of staff available each shift. They are actively hiring for all shifts and offering referral bonuses.

Based on interview and record review, conducted during a site visit on 12/18/23, it was confirmed the facility failed to documents that they have observed and evaluated the individual's ability to perform safe medication and treatment administration unsupervised for 1 of 3 sampled MTs (#14). Findings include, but are not limited to:

Staff 14's (MT) training records were reviewed. Staff 14 was hired on 10/24/23 and medication pass competencies checklist were signed by Staff 14 and his/her trainer on 11/21/23 indicating Staff 14 had received instruction on the competencies. There was no signature indicating the competencies were observed at a minimum of one medication pass or that Staff 14 had given medications under direct supervision of the trainer.

A review of resident records revealed Staff 14 began documenting in narcotic logs and MARs as a MT as early as 11/09/23.

The findings of the investigation were reviewed with and acknowledged by Staff 9 (Consultant) and Staff 10 (Administrator) on 12/18/23.

The facility failed to document that they have observed and evaluated the individual's ability to perform safe medication and treatment administration unsupervised.

Verbal plan of correction: Administrator to audit competencies for all MTs by 12/12/23. Competencies for individuals will be verified on the staff member's next scheduled day. Staff 14 will be removed from the medication cart and counseling provided to determine employment status moving forward.

Based on interview and record review, conducted during a site visit on 12/18/23, it was confirmed the facility failed to provide records upon request to the department. Findings include, but are not limited to:

In an email dated 11/27/23, Witness 1 (Department staff) stated s/he had requested documents in person on 11/20/23, sent a second request by email on 11/21/23, followed up by phone on 11/22/23 and received requested records on 11/27/23.

Records submitted by Witness 1 confirmed an email was sent on 11/21/23 and records were not received until 11/27/23.

During an interview on 12/18/23 Staff 10 (Administrator) stated moving forward they would ensure that any documents requested by department staff are provided prior to them leaving the facility.

The findings of the investigation were reviewed with and acknowledged by Staff 9 (Consultant) and Staff 10 on 12/18/23.

The facility failed to provide records available upon request.

Verbal plan of correction: Facility to provide requested documents to department prior to exit.

Based on observation and record review, conducted during a site visit on 12/18/23, it was confirmed the facility failed to keep the inside of the facility free from unpleasant odors. Findings include, but are not limited to the following:

During a walkthrough of the facility a strong, pervasive urine like odor was observed in the 300's hall of the facility near the entrance door and strongest near the kitchenette.

A review of daily communication logs dated 12/14/23 indicated a resident near the location of the odor had been urinating on his/her bedroom floor and refused to wear a brief.

The findings of the investigation were reviewed with and acknowledged by Staff 9 (Consultant) and Staff 10 (Administrator).

The facility failed to keep the interior of the facility free from unpleasant odors.

Verbal Plan of Correction: Maintenance will locate the source of the urine odor and steam clean the floors, which will be completed by 12/22/23.