Print Inspection: XZI0

The findings of the re-licensure survey, conducted 9/14/21 through 9/15/21, 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 for 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 revisit to the re-licensure survey of 09/15/21, conducted 02/28/22 through 03/01/22 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 and Division 57 for Memory Care Communities.

2. Resident 3 was admitted to the facility in April 2020 with diagnoses including dementia.

Review of the resident's service plan, dated 4/25/21, and interviews with care staff on 9/15/21 revealed Resident 3 required full assistance with all ADLs.

On 9/15/21 care staff were observed providing incontinence care for the resident. Care staff removed the resident's wet brief and, without changing gloves, put a clean brief on the resident, adjusted his/her shirt and blanket, moved the bed and placed a fall mat on the floor beside the bed.

The need to ensure proper infection control procedures were followed was discussed with Staff 1 (MC Administrator) on 9/15/21. He acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure appropriate infection control practices were in place related to resident incontinent care and a dressing change. Findings include, but are not limited to:

1. General observations of the dining room on 9/15/21 at approximately 9:15 am showed Resident 2 was seated at a table with other residents. The breakfast meal and dishes had been cleared, only drinks remained on the table. Resident 2 was observed to have a gauze dressing/wrap around the right forearm from the upper wrist to below the elbow. No drainage was visible on the dressing.

Staff 2 (RN) was observed to also be seated at the table next to Resident 2 with a supply box open with treatment and dressing supplies. Staff 2 removed the old dressing, cleaned and re-dressed the wound while he and the resident remained at the table. The soiled items were disposed of into the trash can located at the medication cart. The table was not cleaned after Staff 2 removed the supply box and soiled items.

The surveyor asked a nearby staff to disinfect the table and the area was observed to be cleaned.

In an interview on 9/15/21 Staff 2 (RN) stated the resident had an approximately 8 cm long surgical wound from a cancerous growth removal. The wound had 14 stitches in place. Staff 2 stated he intended to only re-secure the dressing as it was loose but ended up doing a full dressing change. Staff 2 stated he understood he should not have completed the dressing change at the dining room table.

The need to ensure that all staff implemented appropriate infection control practices was discussed with Staff 1 (MC Administrator) and Staff 2 on 9/15/21. The staff acknowledged the findings.

1. Area where wound care occurred was sanitized at time of observation.

2. Care staff to receive training for proper infection control and standard precautions. Care staff to remove gloves when incontinence care has been completed or if they have become visibly soiled or compromised. Routine wound care to occur outside of high use and high touch areas, such as dining room or dining room tables and with standard precautions in place.

3. Monitoring to occur on an ongoing basis as care is observed by MCC and RN.

4. MCC

2. Resident 2 was admitted to the facility in December 2018 with diagnoses including dementia.  

The resident's service plan, dated 6/28/21, and interviews with care staff between 9/14/21 and 9/15/21 indicated the resident required full assistance for all ADL care. The resident was also noted to have memory issues.  

Review of incident investigations and progress notes from 6/12/21 through 8/26/21 showed the following:

* A progress note dated 8/26/21 indicated the resident had sustained an injury of unknown cause in the form of a skin tear to the left forearm.  

An investigation of the 8/26/21 injury of unknown cause was not completed to rule out potential abuse and neglect and was not reported to the local SPD office.  

The need to ensure resident incidents were promptly investigated to rule out abuse and neglect was discussed with Staff 1 (MC Administrator) and Staff 2 (RN) on 9/15/21. The staff acknowledged the findings.

The facility was asked to report the injury of unknown cause to the local SPD office. Confirmation of the report was provided prior to survey exit.

Based on interview and record review, it was determined the facility failed to ensure all instances of suspected abuse, injuries of unknown cause and resident-to-resident altercations were investigated promptly and reported to the local SPD office as needed for 2 of 3 sampled residents (#s 2 and 3) with incidents of suspected abuse. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in April 2020 with diagnoses including dementia.

Review of the resident's clinical records, including progress notes, incident reports, investigations and temporary service plans, dated 6/14/21 through 9/14/21, revealed the resident was involved in a resident-to-resident altercation on 9/8/21. Documentation alleged Resident 3 had hit another resident.

There was no documented evidence the altercation had been investigated in a timely manner. The facility reported the altercation to the local SPD office on 9/14/21, six days after the event.

The need to investigate incidents and report abuse or suspected abuse to the local SPD office in a timely manner was discussed with Staff 1 (MC Administrator) on 9/15/21. He acknowledged the findings.

1. Both incidents were reported to local SPD when abuse could not sufficiently be ruled out.

2. MTs and MCC to launch incident report upon any report or observation of an incident. Administrator or RSC to begin investigation and rule out abuse within 24 hours. MCC to report to the local SPD if abuse cannot be ruled out within 24 hours. If MCC is unavailable, designee in charge to ensure that self-reports are completed on time.

3. MCC to review electronic dashboard daily for new incident reports that need investigated. Additionally, incident reports, will be evaluated weekly during weekly chart review.

4. MCC

2. Resident 2 was admitted to the facility in December 2018 with diagnoses including dementia.

Review of the resident's service plan, dated 6/28/21, 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:

* Chronic wounds;

* Transfers, dressing and bathing;

* Edema and weight changes;

* Toileting and incontinence;

* Lift chair use;

* Falls, self transfers and safety interventions;

* Fluid assistance between meals; and

* Wheelchair use, mobility and ambulation.

The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 9/15/21. They acknowledged the findings.

3. Resident 4 was admitted to the facility in December 2018 with diagnoses including dementia.

Review of the resident's service plan, dated 6/14/21, 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:

* Hearing aides;

* Weekly weights;

* Transfers, dressing and bathing;

* Grooming and hygiene;

* Toileting and incontinence;

* Shoulder exercises;

* Falls, self transfers and safety interventions;

* Fluid assistance between meals; and

* Wheelchair use, walker use, mobility and ambulation.

The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (MC Administrator) and Staff 2 (RN) on 9/15/21. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current status and care needs, provided direction to staff for the provision of care and/or were completed quarterly for 3 of 3 sampled residents (#s 2, 3 and 4) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in April 2020 with diagnoses including dementia.

Observations of Resident 3's apartment on 9/15/21 revealed the resident was a two-person transfer with a sit-to-stand assistive device, had half side rails on his/her hospital bed and used a fall mat beside his/her bed.

A review of the resident's most recent service plan, dated 4/25/21, revealed a lack of information about his/her transfer status, use of side rails and fall mat, as well as a lack of instructions to staff about transferring the resident using a sit-to-stand device or the use of and precautions for side rails and the fall mat.

In addition, there was no documented evidence Resident 3's service plan had been completed quarterly.

The need to ensure service plans were reflective of resident needs, provided clear direction to staff regarding the delivery of services and were completed quarterly was discussed with Staff 1 (MC Administrator) and Staff 2 (RN) on 9/15/21. They acknowledged the findings.

1. Care plans have been updated to be refelctive of the sampled residents' current status and care needs. Training has been completed for Caregivers and MTs on Changes Associated with Aging and how to report these changes. Training has been completed with MCC on Individualizing Service Plans.

2. CGs & MTs to complete 24 hour report at shift changes to communicate any changes with residents. Temporary Services Plans (TSP) to be launched immidately by MT to communicate any changes with a resident and clear direction to staff of support needed.

3. 24 hour report to be completed and reviewed daily.

Dashboard to reviewed daily by MCC to identify Service Plans coming due for updates. Service Plan to be reviewed for accuracy weekly by MCC and RN as needed. MCC to evaluate.

4. MCC

Based on interview and record review, it was determined the facility failed to ensure residents who had short term changes of condition were evaluated, resident-specific instructions or interventions were developed and the condition was monitored to resolution at least weekly for 3 of 3 sampled residents (#s 2, 3 and 4) who experienced changes of condition.  Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in December 2018 with diagnoses including dementia.

The resident's 6/28/21 service plan, 6/12/21 through 9/14/21 progress notes, temporary service plans and physician communications were reviewed. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness and/or lacked resident-specific directions to staff in the following areas:

* Repeated falls with and without injury;

* Surgical wounds to the left lower leg and the right forearm;

* Low blood sugars;

* Aggression towards staff;

* New medications and medication changes;

* Skin tears and bruising to the left thigh and a skin tear to the left elbow;

* Edema and weights; and

* Antibiotic use, infection and cellulitis.

The need to ensure short-term changes of condition had documentation to reflect monitoring to resolution at least weekly and provided clear, resident-specific directions to staff was discussed  with Staff 1 (MC Administrator) and Staff 2 (RN) on 9/15/21. The staff acknowledged the findings.

2. Resident 4 was admitted to the facility in December 2018 with diagnoses including dementia.

The resident's 6/14/21 service plan, 6/12/21 through 9/14/21 progress notes, temporary service plans and physician communications were reviewed. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness and/or lacked resident-specific directions to staff in the following areas:

* Numerous falls with and without injury;

* Abrasions and skin tears;

* Medication changes;

* Ongoing weight changes; and

* Decline in condition, increased weakness and drowsiness.

The need to ensure short term changes of condition had documentation to reflect monitoring to resolution at least weekly and provided clear, resident-specific directions to staff was discussed  with Staff 1 (MC Administrator) and Staff 2 (RN) on 9/15/21. The staff acknowledged the findings.

3. Resident 3 was admitted to the facility in April 2020 with diagnoses including dementia.

A review of the resident's clinical record revealed the following:

a. On 6/15/21 Resident 3 was seen in the Emergency Room (ER) and returned with a diagnosis of cellulitis in his/her left hand and a prescription for an antibiotic. The resident was placed on alert charting and monitored through 6/16/21. There was no documented evidence the short-term change of condition was resolved.

b. On 6/21/21 the resident was sent to the ER due to having chest pain. Upon return from the hospital, the resident was placed on alert charting. The resident was monitored through 6/25/21, but there was no documented evidence the short-term change of condition was resolved.

c. Resident 3 received a small cut on his/her face related to a fall on 7/15/21. There was no documented evidence this injury was monitored through resolution.

In an interview on 9/15/21, the need to monitor short-term changes of condition and document progress at least weekly through resolution was discussed with Staff 1 (MC Administrator) and Staff 2 (RN). They acknowledged the findings.

1. Short term changes of condition evaluated for all residents with no intervention needed based on resident condition.

2.  Med-techs are to put out TSPs and initiate alert charting for any short term changes of condition. Nurse will review the alert charting and 24 hour report

daily. Nurse will follow-up to determine if short-term or significant change of condition is present and will monitor, chart and assess accordingly.

Additionally, the MCC and RN will review all residents to evaluate these changes at their weekly chart review meeting. Skin log, bowel log, eMAR Reports, alert charting, care plan updates and vitals are all reviewed. A tracking form is used with specific prompts to question whether there has been a recent change of condition, and whether it is significant or short term change of condition.

Alert charting, 24 hour reports, skin log, and eMAR reports are reviewed daily and at weekly chart review meeting. Care plan updates and vitals are reviewed weekly.

3.  Weekly and evaluated by RN and MCC.

4.  RN  

Based on observation, interview and record review, it was determined the facility failed to ensure the RN performed an assessment, developed interventions based on the condition of the resident, and updated the service plan for 1 of 1 sampled resident (#4 ) who experienced a significant change. Findings include, but are not limited to:

Resident 4 was admitted to the facility in December 2018 with diagnoses including dementia.

Progress notes and physician communications dated 6/14/21 through 9/14/21 and interviews with care staff on 9/14/21 and 9/15/21 indicated the resident had an ongoing decline. The resident was experiencing repeated falls, weakness, drowsiness, decreased meal intake and an increase in care needs. Care staff interviews indicated the resident was more active in the previous 2-3 weeks but was frequently falling and currently the resident needed full assistance with all of her/his ADL care.

The resident was evaluated and placed on hospice on 9/2/21.

The facility failed to ensure an RN assessment was completed for the hospice admission which documented findings, resident status and interventions made as a result of the assessment.

Observations of the resident on 9/14/21 and 9/15/21 showed the resident was unable to independently complete any of her/his daily care but was able to eat independently once items were in reach. The resident was extremely groggy in the morning but once staff got the resident to a more alert status s/he was able to stand for transfers and care.

The need to ensure an RN assessment was completed related to significant changes in condition which documented findings, resident status and interventions made as a result of the assessment was discussed with Staff 1 (MC Administrator) and Staff 2 (RN) on 9/14/21 and 9/15/21. The staff acknowledged the findings.

. Significant changes of condition assesments completed by RN for sampled residents.

2. Med-techs are to put out TSPs and initiate alert charting for any change in condition. Nurse will review the alert charting and 24 hour report daily. Nurse will follow-up to determine if short-term or significant change of condition is present and will monitor, chart and assess accordingly.

Residents to be monitored for Significant changes of condition by RN and RSC's.  This monitoring will take place during daily dashboard reviews of EHR (includes alert charting, 24 hour reports, vital monitoring, eMAR reports, skin monitoring) and weekly chart reviews.

3. Systems to be reviewed weekly by RN and MCC.

4.  RN

Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules, for 1 of 1 sampled residents (# 2) who received insulin injections by unlicensed facility staff.  Findings include, but are not limited to:

During the acuity interview on 9/14/21, Resident 2 was identified to be administered insulin injections by non-licensed staff.

Review of Resident 2's delegation documentation during the survey revealed the following:

Staff 7 (MT) and Staff 15 (MT) were initially delegated to perform insulin injections on Resident 2 on 7/7/21 and 7/8/21. Re-evaluation of Staff 7 and 15's delegation duties was not completed within 60 days of initial delegation.

The need to ensure delegation and supervision of special tasks of nursing care were completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules was discussed with Staff 3 (Executive Director). She acknowledged the findings.

1.  Delegation duties reviewed in detail for all delegated Med-Techs.

2.  Monthly reviews to ensure accuracy by RN.

Additionally, a delegation tracker is kept to record dates of delegation and track when coming due. In addition to the RN reviewing delegation dates, MTs should check the tracker weekly and communicate with the RN if they are nearing their due date.

3.  Monthly reviews to ensure accuracy by RN.

4. RN

Based on interview and record review, it was determined the facility failed to coordinate care with outside providers, ensure documentation of visits was maintained in the residents' records and that recommendations were implemented for 3 of 3 sampled residents (#s 2, 3 and 4) who were receiving home health services from outside providers. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in December 2018 with diagnoses including dementia.  

During the acuity interview on 9/14/21, Resident 2 was identified as receiving outside provider services related to wound care.  

Review of the resident's record showed skilled nursing for wound care began most recently on 7/11/21. The resident had a chronic leg wound which was previously treated outside the facility and was transitioned to home health visits in the facility. Wound care visit notes were not consistently documented and/or recommendations were not implemented as follows:

* Nursing visits for wound care were to occur twice weekly. Wound care visits were documented on eight occasions between 7/11/21 and 9/14/21;

* Nursing recommendations on 7/11/21 and 7/26/21 noted staff were to encourage the resident to elevate her/his legs to reduce edema and limit salt intake;

* Nursing recommendations on 8/26/21 noted staff were to notify home health if the dressing came off or was soiled;

* Nursing recommendations on 9/7/21 noted a podiatry appointment was recommended for nail care, a cloth barrier be placed between skin and Circaid wrap to right lower extremity to avoid new wounds and skin breakdown and apply A + D ointment or lotion to arms and legs daily; and

* Nursing recommendations on 9/2/21 noted apply A + D ointment to arms and right lower leg daily, apply Circaid wrap to right lower leg daily, off at night ensuring tubigrip or stockinet was on leg under Circaid wrap to prevent wounds, ensure nylon on left lower extremity to prevent two layer wraps from rolling down with pants and please call home health for any questions or concerns.

There was no evidence the recommendations were implemented or communicated to staff.

The need to ensure on-going coordination of care was maintained, documented and recommendations were implemented was discussed with Staff 1 (MC Administrator) and Staff 2 (RN) on 9/15/21. The staff acknowledged the findings.

2. Resident 4 was admitted to the facility in December 2018 with diagnoses including dementia.  

During the acuity interview on 9/14/21, Resident 4 was identified as receiving outside provider services related to hospice care.  

Review of the resident's record showed hospice services began on 9/2/21. Hospice care visit notes were not consistently documented as follows:

* Hospice visit notes were documented on 9/2/21 and 9/3/21. There were no other documented visits. Visits were to occur twice weekly.

The need to ensure on-going coordination of care was maintained and documented was discussed with Staff 1 (MC Administrator) and Staff 2 (RN) on 9/15/21. The staff acknowledged the findings.

3. Resident 3 was admitted to the facility in April 2020 with diagnoses including dementia.

A review of Resident 3's clinical record revealed there was one visit note from an outside provider dated 6/29/21.

In an interview with Staff 2 (RN) on 9/15/21, he indicated he had seen the resident's  PT three times in the previous five weeks. Staff 2 stated he had worked closely with the PT to obtain a hospital bed with side rails, a sit-to-stand mechanical lift and a fall mat for the resident.

There was no documented evidence Staff 2 had any communication with a PT regarding the resident at any time in the previous five weeks, nor was the resident's service plan updated to include the equipment obtained.

The lack of documentation of coordination of care with outside providers was discussed with Staff 1 (MC Administrator) and Staff 2 (RN) on 9/15/21. They acknowledged the findings.

1. Outside provider notes for each resident were reviewed and care planned accordingly.

2. Outside provider notes to be reviewed daily by Med-Tech and TSPs, alert charting or incident reports launched for any changes identified. MCC to do a second check for review of details and if accurate documentation and communication has been started. Final review to be done by RN.

Additionally, all Outside provider notes to be reviewed weekly during each resident chart review.

3.  System to be reviewed weekly during chart review by MCC and RN.

4. MCC

2. Resident 4 was admitted to the facility in December 2018 with diagnoses including dementia.

Review of the resident's 6/14/21 through 9/14/21 progress notes, physician communications, the 8/1/21 through 9/14/21 MARs and 3/1/21 through 9/14/21 weight records showed the following:

* An order to check vital signs including blood pressure, pulse, temperature, oxygen saturation and weight monthly.

No weights had been recorded since March 2021. Additionally, other vital signs were inconsistently recorded since May 2021.

* An order to check blood sugar three times a day and report to RN if below 70 or above 350.

There were 11 occasions between 8/1/21 and 9/14/21 when the resident's blood sugar was recorded as below 70 with the lowest blood sugars in the mid 40s. There was no documentation the RN was notified.

The need to ensure MARs were complete and included clear direction to staff for PRN medication administration was discussed with Staff 1 (MC Administrator) and Staff 2 (RN) on 9/15/21. The staff acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed and that all medication and treatment orders were documented in the resident's facility record for 2 of 3 sampled residents (#s 2 and 3) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in April 2020 with diagnoses including dementia.

Review of Resident 3's 8/1/21 through 9/14/21 MARs and physician orders revealed the following:

* There was no physician order for PRN Hydrocodone/APAP (a narcotic pain reliever);

* There was no signed order for oxygen;

* Current signed physician orders for multiple standing PRN orders were missing; and

* An order for zinc oxide ointment (for skin care), signed 7/8/21, had not been transcribed to the MAR.

The need to follow physician orders as written and to have physician orders for all medications and treatments administered was discussed with Staff 1 (MC Administrator) and Staff 2 (RN) on 9/14/21 and 9/15/21. They acknowledged the findings. No further documentation was provided.

1.  Listed discrepencies have been reconciled with appropriate physician. Med techs have been trained on following physician orders.

2. Upon receiving any new order, after-visit summary, or med list from a doctor a three-check system will take place. First, Med-Tech will reconcile against eMAR, MCC will double check and RN will triple check. We will fax doctor to clarify if any discrepencies are identified.

Additionally, medication reviews to occur on a quarterly basis for all residents.

Through monthly audits we will initiate pulling random sampling of residents of which will be the responsibility of the MCC and Administrator.

When notification to a provider is required per the orders, Med-Tech to be trained on and utilize charting prompt in MAR to document if notification took place.

3. Upon receipt of any medication order or list. Monthly checks through random audits. Quarterly medication reviews for all residents.

4.  MCC

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

1. Resident 2 was admitted to the facility in December 2018 with diagnoses including dementia.

Review of the resident's 6/14/21 through 9/14/21 progress notes, physician communications and the 8/1/21 through 9/14/21 MARs showed the following:

* Treatment orders for a skin tear to the "R Elbow x 2" indicated wash with saline, pat dry with gauze pad, approximate edges with moist cotton swab, apply steri strips, leave in place until they fall off, cover with non-stick Telfa pad and tubular med webbing to hold in place every other day.

The 8/1/21-9/14/21 MAR reflected 16 of the 22 opportunities were coded as "9/other see progress notes" without any other information to indicate what had occurred.

* Ensure chocolate liquid, drink 1 bottle twice a day as needed.

There were no parameters to direct staff when to give the resident the Ensure and no documentation to reflect the drink had been given at all between 8/1/21 and 9/14/21. The resident's intake varied during this time period and s/he experienced small decreases in weight.

* Tylenol 325 mg take two tablets every six hours as needed for mild to moderate headache, joint or musculoskeletal pain and Morphine Sulfate 20 mg/ml give 0.25 mls every hour as needed for moderate to severe pain.

The MAR gave no direction to staff on which medication to use first for the resident's pain.

The need to ensure MARs were complete and included clear direction to staff for PRN medication administration was discussed with Staff 1 (MC Administrator) and Staff 2 (RN) on 9/15/21. The staff acknowledged the findings.

2. Resident 4 was admitted to the facility in December 2018 with diagnoses including dementia.

Review of the resident's 6/14/21 through 9/14/21 progress notes, physician communications, the 8/1/21 through 9/14/21 MARs and 3/1/21 through 9/14/21 weight records showed the following:

* Treatment orders for skin tear to the "Inner Left Thigh" and "Left Forearm" indicated wash with saline, pat dry with gauze pad, approximate edges with moist cotton swab, apply steri strips, leave in place until they fall off, cover with non-stick Telfa pad and tubular med webbing to hold in place every other day.

The 8/1/21 through 9/14/21 MAR reflected 41 of the 44 opportunities for the thigh treatment were coded as "9/other see progress notes" without any other information to indicate what had occurred.   

The 8/1/21 through 9/14/21 MAR reflected 9 of the 22 opportunities for the left forearm treatment were coded as "9/other see progress notes" and two additional opportunities were recorded as sleeping or refused, without any other information on what had occurred.  

* Aspercreme with Lidocaine 4% cream to wound bed as needed for pain with debridement, Lidocaine 4% topical solution 40 mg/ml apply 2.0 ml to wound as needed for pain with wound care and "Lidocaine 4% Anecream 15 GM" apply 2.5 grams topically as needed for pain with wound care.  

The MAR gave no direction to staff on which medication to use first for the resident's wound pain, nor did it indicate what wound to treat.  

The need to ensure MARs were complete and included clear direction to staff for PRN medication administration was discussed with Staff 1 (MC Administrator) and Staff 2 (RN) on 9/15/21. The staff acknowledged the findings.

3. Resident 3 was admitted to the facility in April 2020 with diagnoses including dementia.

Review of the resident's 8/1/21 through 9/14/21 MARs revealed the following:

* Four medications (Atorvastatin, Olanzapine, Albuterol and "fiber therapy") lacked reasons for use;

* Three PRN pain medications (Tylenol, Celecoxib and Norco) were lacking parameters;

* There were blanks where staff had not initialed for administration of medication; and

* Instructions for four medications (Asmanex, Metoprolol, Preservision and Celecoxib) were incorrectly transcribed to the MAR from the physician orders.

The need to have an accurate MAR was discussed with Staff 1 (MC Administrator) and Staff 2 (RN) on 9/14/21 and 9/15/21. They acknowledged the findings.

1. PRN medications for sampled residents now have clear instructions. The medications without reasons for use now have reasons for use. Incorrectly transcribed medications have been rectified. Staff education for notifying RN if parameters are missing on a PRN.

2. Upon receiving a PRN order, staff will follow multi-check process: a Med-Tech wil complete first check and if no parameters are in place, will chart "do not give, must notify RN first." Then RN will do final check and place parameters. RN will also follow-up to place PRN paramaters upon any notification from MT that parameters are not in place.

PRN and indications for use would be captured during the weekly chart review. Additionally, RN to pull weekly PRN report to identify if parameters are missing.  

3. Weekly by the MCC and RN

4. RN  

Based on interview and record review, it was determined the facility failed to ensure PRN medications used to treat a resident's behavior had written, resident-specific parameters and non-drug interventions for staff to attempt prior to administering a PRN psychoactive medication, for 1 of 1 sampled resident (#4) who was prescribed a PRN medication to address behaviors. Findings include, but are not limited to:

Resident 4 was admitted to the facility in December 2018 with diagnoses including dementia.

Review of Resident 4's 8/1/21 through 9/15/21 MARs and progress notes and 9/2/21 hospice orders showed the following:

* Quetiapine (antipsychotic medication) 25 mg as needed for agitation;

* Haloperidol (antipsychotic medication) 1.0 mg every hour as needed for delirium; and

* Lorazepam (anti-anxiety medication) 0.5 mg every hour as needed for anxiety.  

The Lorazepam and Haloperidol were not administered to the resident as of 9/15/21. The Quetiapine was discontinued as of 9/2/21.  

The MARs did not contain resident-specific parameters for staff describing how the resident expressed anxiety and delirium. Additionally, there was no documentation of what non-drug interventions were to be attempted prior to administration of the medications.

The need to ensure there were resident-specific descriptions of how the resident expressed anxiety and delirium and that non-drug interventions were attempted and documented prior to administration of the medication was discussed with Staff 1 (MC Administrator) and Staff 2 (RN). The staff acknowledged the findings.

1. Psychotropic medications have been updated with non-pharmalogical interventions to follow and how anxiety/agitation presents.

2. During weekly chart reviews, psychotropic medications will be reviewed to ensure they have non-pharmalogical interventions and signs and symptoms related to indicated use.

3. This area will be evaluated at the same time of the weekly chart reviews by RN and MCC.

4. RN

Based on observation, interview and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities was assessed including a thorough review by an RN, PT or OT prior to use for 1 of 1 sampled residents (#3) who had side rails. Findings include, but are not limited to:

Resident 3 was admitted to the facility in April 2020.

During the acuity interview on 9/14/21, the resident was identified as having side rails on his/her bed.

On 9/14/21 at 12:02 pm the resident's bed was observed to have two half length side rails in the up position.

There was no documented evidence the device with potentially restraining qualities had been assessed by an RN, PT or OT, staff had been instructed on the use of and precautions for the side rails, the service plan had identified the use of the device or it had been evaluated quarterly.

The lack of a side rail assessment, instruction to staff, inclusion in the service plan and quarterly evaluations was discussed with Staff 1 (MC Administrator) and Staff 2 (RN) on 9/15/21. They acknowledged the findings.

1. RN has assessed residents side rails. Training completed by all staff on side rail use, safety, checking against the service plan and notifying management of any unauthorized side rail.

2. All supportive devices with restraining qualities that are recommended will be reviewed during our weekly chart reviews.

Upon entering side rail use for a resident in their Evaluation, an assessment will be prompted for RN to complete.

Re-train staff quarterly on side rail safety, use, service planning and reporting to management.

3.  To be reviewed weekly by RN.

Training to occur quarterly.

4. RN  

Based on interview and record review, it was determined the facility failed to ensure fire and life safety instruction to staff was provided on alternate months and that documentation reflected all required fire drill components. Findings include, but are not limited to:

Fire drill and fire and life safety records were reviewed from March 2021 to August 2021. The following deficiencies were identified:

* There was no documented evidence the facility was conducting fire drills every other month on alternating shifts for the memory care community;

* There was no documented evidence the facility was providing fire and life safety training on alternating months for staff; and

* The evacuation/drill documentation did not contain information on the escape route used, problems encountered, evacuation time period needed, staff members on duty and participating in the memory care and the number of occupants evacuated.

The requirements regarding fire drills and fire and life safety instruction for staff were reviewed with Staff 1 (MC Administrator) on 9/14/21 and with Staff 6 (Maintenance Assistant) on 9/15/21. The staff acknowledged the findings.

1. Fire drill forms have been updated to include the missing components that must be documented.

2. Fire drill form has been updated to be used going forward. Staff education to occur according to fire and life safety training calendar. Monthly calendar of fire and life safety trainings and drills has been updated and will be followed.

3. To be evaluated on a monthly basis by Director of Plant Operations and MCC.

4. Director of Plant Operations

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements were being met. Findings include, but are not limited to:

Fire and life safety records, reviewed between March 2021 through August 2021, revealed the facility lacked documented evidence of the following:

* Alternate exit routes were used during fire drills; and

* Staff interviewed were not aware of the designated point of safety.

The need to ensure alternate exit routes were used during fire drills and all staff were aware of the designated point of safety was discussed with Staff 1 (MC Administrator) on 9/14/21 and Staff 6 (Maintenance Assistant) on 9/15/21. The staff acknowledged the findings.

1. Fire drill form updated to include the alternate exit route used during fire drill, as well as prompting for questioning about designated point of safety.

2.Fire drill form has been updated to be used going forward. Staff education to occur according to fire and life safety training calendar. Monthly calendar of fire and life safety trainings and drills has been updated and will be followed.

3. To be evaluated on a monthly basis by Director of Plant Operations and MCC.

4. Director of Plant Operations

Based on observation and interview, it was determined the facility failed to ensure courtyard surfaces were maintained in good repair. Findings include, but are not limited to:

Observations of the courtyard near the fountain on 9/14/21, showed there were multiple drop-offs of 2-4 inches along pathway edges and sitting areas in the courtyard.

The need to ensure pathways in the resident courtyard did not have potential safety hazards was discussed with Staff 1 (MC Administrator) on 9/14/21. He acknowledged the findings.

1. Drop offs along walking paths have been filled in to eliminate the potential hazards.

2. Plant operations to perform environmental audits of paths to ensure they are free of potential hazards on a monthly basis and as identified.

3. MCC and Director of Plant Operations to evaluate this area at least quarterly.

4. Director of Plant Operations, MCC

Based on observation and interview, it was determined the facility failed to ensure the environment was maintained in clean and good repair. Findings include, but are not limited to:

Observations of the facility on 9/14/21 and 9/15/21 showed the following areas in need of cleaning or repair:

* Multiple walls had scrapes, splatters/drips or gouges;

* Multiple black/dark gray stains of varying sizes were noted to carpets in common areas;

* Black stains on the carpet, of varying sizes in resident room #s 13, 18 and 24, large carpet stains outside room doors for room #s 19 and 32;

* Multiple chairs in the theater area and sitting area nearest the fireplace, had debris and dark gray/brown/orange stains to the sides of the chairs, foot rests and seats;

* A large piece of missing/chipped wood was noted to the top of the table under the TV in the theater area and missing/chipped laminate on the side wall under the large horseshoe counter were observed;

The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (MC Administrator) on 9/14/21. He acknowledged the findings.

1. Noted areas needing cleaning or repair have been addressed or repaired. Carpet in theater to be replaced in the next 60 days, lead time for materials and installation at this time varies.

2. Environmental audit of resident apartments and common areas to occur at least monthly and follow up to be performed by our maintenance team or outside contractors.

3. Environmental audits to be evaluated monthly by MCC.

4. MCC

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to C160, C231, C420, C422, C510 and C513.  

Refer to plans of correction for C160, C231, C420, C422, C510, and C513.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 11, 12 and 13) completed all required 30-day competency demonstration and 1 of 1 veteran staff (#7) completed a total of 16 hours of annual training. Findings include, but are not limited to:

A review of staff training records revealed the following:

1. Staff 11 (CG), Staff 12 (CG) and Staff 13 (MT) were hired 6/16/21, 7/4/21 and 8/8/21, respectively. There was no documented evidence they had demonstrated competency in their job duties within 30 days of hire in the following areas:

* The role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Changes associated with normal aging;

* Identification, documentation and reporting of changes of condition;

* Conditions that require assessment, treatment, observation and reporting; and

* General food safety, serving and sanitation.

2. There was no documented evidence Staff 7 (CG), hired 10/30/17, completed the required 16 hours of annual training.

The facility's failure to ensure staff completed all required training in a timely manner was discussed with Staff 1 (MC Administrator) and Staff 2 (RN) on 9/15/21. They acknowledged the findings.

1. By 11/14/21, all employees have completed preservice and 30-day training requirements.

Additionally, new staff members will not start training on the floor until these trainings are completed. Also, by 11/14/21, employees who are lacking their 16 hours of annual inservice training related to the provision of care will be assigned additional trainings to meet the hours requirement. A training report can be ran to help audit training records.

2. Business Office Manager and Administrator will audit training records at least every two weeks for trainings that are not complete.

3. This will be evaluated by the Business Office Manager and Administrator at least monthly.

4. MCC

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 C260, C270, C280, C282, C290, C303, C310, C330 and C340.

Refer to plans of correction for C260, C270, C280, C282, C290, C303, C310, C330, and C340.