Print Inspection: ZONM

The findings of the Change of Ownership survey, conducted 06/26/24 through 06/27/24, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 Home and Community Based Services Regulations.

Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living 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

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 revisit to the re-licensure survey of 06/27/24, conducted on 09/20/24, are documented in this report. It was determined the facility was in compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004.

Based on interview and record review, it was determined the facility failed to monitor residents conditions based on their evaluated needs and document on the progress of short term changes of condition at least weekly until resolved, for 1 of 2 sampled residents (#2) who experienced changes of condition. Findings include, but are not limited to:

Resident 2 was admitted to the facility in November 2023 with diagnoses including dementia.

The resident's 06/10/24 service plan, 03/26/24-06/24/24 progress notes, and temporary service plans were reviewed. Resident 2 was evaluated to be at risk for falls. The resident experienced multiple short term changes without evaluation of interventions and documented monitoring until resolution in the following areas:

* Falls;

* Wound; and

* Multiple emergency department visits for hip dislocation.

The need to monitor residents per their evaluated condition and monitor short term changes to resolution was discussed with Staff 1 (Regional Director of Operations) and Staff 2 (ED) on 06/26/24 and 06/27/24. They acknowledged the findings.

1. All residents will be placed on alert charting for any changes in condition, medications or incidents. Monitoring will continue each shift until resolved and closed by the Executive Director or Nurse. Any change of condition needed and observed will be reported and put on the nursing communication board in Point click care and communicated with the nurse.

2. Executive Director will check alert charting for correct opening documentation on incidents and change of conditions and monitoring. The Executive Director and Nurse will close alerts when resolved.

3. The Executive Director and will check at least 3 times a week that staff are completing alert charting each shift.

4. The Executive Director and Nurse will be responsible to see that corrections are complete and monitored  

Based on interview and record review, it was determined the facility failed to ensure MARs included resident-specific parameters for PRN medications and medication specific instruction to direct non-licensed staff for 2 of 2 sampled residents (#s 1 and 2) whose medications were reviewed. Findings include, but are not limited to:  

Resident 1 and 2's 06/01/24 through 6/26/24 MARs and current medication orders were reviewed.

1. Resident 2's was admitted to the facility in 11/2023 with diagnoses including dementia.

Resident 2 had orders for:

*Lidocaine 4% patch every 12 hours as needed for pain;

*Acetaminophen 325 mg two tablets as needed for pain; and

*Oxycodone 5 mg every six hours as needed for severe pain.

All three medications had been administered.

The MAR lacked clear instructions to staff which medication to attempt first, how pain may be expressed, and where pain was located.

2. Resident 1's was admitted to the facility in 05/2023 with diagnoses including dementia.

Resident 1 had orders for:

*Ibuprofen 400 mg every six hours as needed for pain; and

*Acetaminophen 325 mg two tablets as needed for pain - Moderate; Pain mild; pain Severe

Neither medication had been administered.

The MAR lacked clear instructions to staff which medication to attempt first, how pain may be expressed, and where pain was located.

The need to provide clear parameters and instructions to guide non-licensed staff in the administration of PRN medications was reviewed with Staff 1 (Regional Director of Operations). She acknowledged the findings.

1. Each Residents PRN medications have been reviewed and updated to reflect clear instructions and sequencing.

2. All PRN orders will be reviewed by Facility Nurse before adding to the Electronic Medication Administration Record

3. Upon admit, quarterly and as needed

4. Executive Director and Nurse

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 C0270 and C 310.

Refer to C270 and C310