Mckenzie Manor Memory Care

Based on observation, interview and record review, conducted during a site visit on 08/28/24, it was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool (ABST). Findings include, but are not limited to:A review of the facility's ABST and resident roster indicated the following:· All 38 residents were listed on the tool (26 MC and 12 SNC).· Resident 3 moved into the MC on 08/22/24 and did not have any care needs entered.· Resident 4 moved into the MC on 08/24/24 and did not have any care needs entered.· Resident 5 moved into the MC on 08/13/24 and did not have all care needs entered.A review of the staffing schedules for 08/13/24-08/27/24 indicated the following:· SNC indicated a one to four staffing ratio needed for day/swing shifts and one to six on Noc shift.· Facility was staffing per the SNC and ABST for the SNC side.· MC ABST indicated 4.14 staff needed for day shift, 3.9 needed for swing shift, and 1.12 for Noc shift.· Facility was not exceeding staffing per the ABST for the MC on dayshift on two separate days.Compliance Specialist observed the MC was staffed with three caregivers and one MT for day shift on 08/28/24. The SNC was staffed with four direct care staff for day shift.In an interview on 08/28/24, Staff 1 (Executive Director) and Staff 2 (Staffing Coordinator) stated the following:· They were not aware of any staffing concerns or needs missed.· They did not know they needed to look at the day with the highest staffing need and round up for the ABST, or that they needed to exceed the ABST to account for unscheduled needs.· If there was a call out in the SNC, we would send staff from the other side, however, would still be staffed at the minimum.On 08/28/24, findings were reviewed with and acknowledged by Staff 1.It was confirmed the facility failed to fully implement and update an ABST.

The findings of the change of ownership survey, conducted 05/02/22 through 05/04/22, 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 livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day
The findings of the re-visit to the initial survey of 05/04/22, conducted 08/15/22, 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. The facility was found to be in substantial compliance with the regulations.

Based on interview and record review, it was determined the facility failed to ensure a move-in evaluation addressed all required elements for 1 of 1 sampled resident (#3) who was recently admitted to the facility. Findings include, but are not limited to:1. Resident 3 was admitted to the facility in 02/2022. Review of the resident's records indicated the move-in evaluation lacked the following elements:* Visits to health practitioner(s), ER, hospital, or nursing facility in the past year;* Personality, including how the person copes with change or challenging situations;* Recent losses; and* Environmental factors that impact the resident's behavior, including noise, lighting, and room temperature.On 05/04/22 the need to ensure move-in evaluations addressed all required elements was discussed with Staff 1 (Administrator), Staff 2 (Regional Director of Operations) and Staff 3 (RN). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that consisted of the resident, the resident's legal representative if applicable, any person of the resident's choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services to the resident, for 3 of 3 sampled residents (#s 1, 2, and 3) whose service plans were reviewed. Findings include, but are not limited to:Resident 1, 2 and 3's most recent service plans lacked documentation a Service Planning Team reviewed and participated in the development of the service plans.The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (Administrator), Staff 2 (Regional Director of Operations) and Staff 3 (RN) on 05/03/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 1 of 1 sampled resident (#1) whose MARs and Controlled Substance Disposition logs were reviewed for accuracy. Findings include, but are not limited to:Resident 1 was admitted to the facility in 10/2021 with a diagnosis of dementia with behaviors. During the acuity interview on 05/02/22, the resident was identified as having recently fracture his/her hip and having it repaired and as being on hospice.The resident had a signed physician order for tramadol (a narcotic pain reliever) 50 mg one tablet every six hours as needed for severe pain.Review of the resident's 04/01/22 through 05/02/22 MARs and the Controlled Substances Log revealed the following:* On 04/09/22 there were two doses of tramadol signed as having been administered on the MAR, but only one dose signed out on the disposition log;* On 04/10/22 there was one dose of tramadol signed as having been given on the MAR, but two doses signed out on the disposition log;* On 04/13/22 there were no doses of tramadol signed as having been administered on the MAR, but one dose was signed out on the disposition log;* On 04/14/22 there was one dose of tramadol signed as having been given on the MAR, but two doses signed out on the disposition log; and* On 04/15/22 there were no doses of tramadol signed as having been administered on the MAR, but there was one dose of tramadol signed out on the disposition log.The number of tablets remaining on the medication card matched the number of tablets indicated in the disposition log.The need to ensure narcotic disposition logs and MARs were accurate and medications were recorded appropriately was discussed with Staff 1 (Administrator), Staff 2 (Regional Director of Operations), Staff 3 (RN), and Staff 7 (Resident Care Manager) on 05/04/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure orders were carried out as prescribed for all medications and treatments the facility was responsible to administer, for 1 of 3 sampled residents (# 2) whose orders were reviewed. Findings include, but are not limited to:Resident 2 was admitted to the facility in 08/2018 with diagnoses including diabetes and received insulin injections multiple times daily.Resident 2's MAR, physician orders, and progress notes, reviewed from 04/01/22 through 05/02/22, revealed the following:* Physician orders instructed staff to check Resident 2's blood glucose levels (CBG) four times daily, before each meal and at bedtime, and record the result. On 04/16/22 Resident 2's CBGs were not checked as ordered. * Insulin Lispro orders instructed staff to inject two units subcutaneously three times a day before meals. There were seven occasions in April when staff documented administration of three units of insulin instead of the two units that were ordered. On 04/16/22 no Insulin Lispro was administered. * Lantus Solostar insulin orders instructed staff to inject 11 units subcutaneous daily at 5 p.m. On 04/16/22 there was no scheduled Lantus Solostar insulin administered as ordered. * Insulin Lispro was ordered to be administered subcutaneously 10 minutes before each meal based on a sliding scale, determined by the resident's CBG. On 04/11/22 at 5:00 p.m. Resident 2's CBG was 238. According to the orders, a CBG of 201 to 300 would require six units of insulin to be administered. No sliding scale insulin was administered at that time. There was no negative outcome identified related to the lack of following physician orders related to insulin administration and CBG monitoring.Resident 2's MARs and orders were reviewed with Staff 1 (Administrator), Staff 2 (Regional Director of Operations), and Staff 3 (RN) on 05/03/22. They acknowledged staff failed to ensure orders were carried out as prescribed.

Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was kept of all medications, including over-the-counter medications that were ordered by a legally recognized prescriber and were administered by the facility for 2 of 3 sampled residents (#s 1 and 3) whose records were reviewed. Findings include, but are not limited to:1. Resident 3 was admitted to the facility in 02/2022 with diagnoses including Alzheimer's, chronic pain, and prostate cancer. Review of Resident 3's MAR, dated 04/01/22 through 05/02/22 identified the following deficiencies:The MAR lacked accurate parameters for use of multiple PRN pain medications. These were acetaminophen (for "mild to moderate" pain), lidocaine patch ("as needed for pain") and hydrocodone (for "moderate to severe" pain). There were no instructions for the sequential order of administration, or for determining Resident 3's pain scale rating.On 05/04/22 the need to keep an accurate MAR of all medications ordered by a legally recognized prescriber and administered by the facility was discussed with Staff 1 (Administrator), Staff 2 (Regional Director of Operations) and Staff 3 (RN). They acknowledged the findings.
2. Resident 1 was admitted to the facility in 10/2021 with a diagnosis of dementia with behaviors.A review of the resident's 04/01/22 through 05/02/22 MARs revealed the following:* The resident had two physician orders for Risperidone (an antipsychotic). One ordered 2 mg every day at 8:00 p.m.; the MAR indicated this was to be administered at 8:00 a.m. The second order was for 1 mg at 8:00 a.m. and 1 mg at 1:00 p.m.; the MAR indicated it was to be administered at 8:00 a.m. and 8:00 p.m.* Administration documentation on the MAR was inaccurate. Staff initialed the MAR multiple times indicating the medication had been administered. Staff 3 (RN) reported the medication was never received from the pharmacy, because the resident's insurance would not cover the cost.The need to ensure the MAR was accurate was discussed with Staff 1 (Administrator), Staff 2 (Regional Director of Operations), Staff 3 (RN) and Staff 7 (Resident Care Manager) on 05/04/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure staff documented non-pharmacological interventions had been tried with ineffective results prior to administering PRN psychotropic medication for 1 of 2 sampled residents (#1) who were prescribed as-needed psychotropic medications. Findings include, but are not limited to:Resident 1 was admitted to the facility in 10/2021 a with diagnosis of dementia with behaviors.A review of the resident's 04/01/22 through 05/02/22 MAR revealed the following:* Resident 1 had physician orders for haloperidol (an antipsychotic) 2mg/ml take 0.5ml by mouth every hour as needed for delirium, nausea, and/or vomiting and lorazepam (for anxiety) 1 mg one tablet by mouth every six hours as needed for anxiety (agitation). The lorazepam order was changed to 0.5mg one tablet by mouth every hour as needed for anxiety or dyspnea on 04/24/22.* Haloperidol was administered on 04/27/22 and 04/29/22. Staff documented non-pharmaceutical interventions were attempted without success prior to administration of the PRN psychotropic medication; they did not, however, document which interventions were attempted.* Lorazepam was administered multiple times between 04/01/22 and 05/02/22. Staff documented non-drug interventions were attempted without success prior to the administration of the lorazepam on eight occasions without noting which interventions were attempted. On the other occasions lorazepam was administered, staff did not documented having attempted any non-pharmaceutical interventions prior to administration of the medication.On 05/04/22 the need to document which non-pharmaceutical interventions were attempted without success prior to administering a PRN psychotropic medication was discussed with Staff 1 (Administrator), Staff 2 (Regional Director of Operations), Staff 3 (RN) and Staff 7 (Resident Care Manager). They acknowledged the findings.

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 C252 and C262.

Based on interview and record review, it was determined the facility failed to ensure 1 of 3 newly hired staff (#9) completed all required pre-service orientation, 2 of 3 staff (#s 9 and 11) demonstrated competency in their assigned job duties within 30 days of hire, and 1 of 1 long-term staff completed the required number of annual in-service training hours. Findings include, but are not limited to:Staff training records were reviewed on 05/04/22.1. There was no documented evidence Staff 9 (MA), hired 12/19/21, completed pre-service orientation prior to performing any job duties.2. There was no documented evidence Staff 9 (MA) or Staff 11 (MA), hired 12/19/21 and 06/21/21, respectively, demonstrated competency in their caregiver job duties within 30 days of hire.3. There was no documented evidence Staff 8 (MA), hired 11/15/19, completed the required number of annual in-service training hours.The facility's failure to ensure staff completed all required trainings within the allotted time was discussed with Staff 1 (Administrator) and Staff 2 (Regional Director of Operations) on 05/04/22. They acknowledged the findings.

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 C302, C303, C310 and C330.

Based on interview and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan was developed for each resident and included in the service plan for 2 of 3 sampled residents (#s 1 and 3) whose service plans were reviewed. Findings include, but are not limited to:Current service plans for Residents 1 and 3 were reviewed during the survey. The service plans lacked information and staff instructions related to individualized nutrition and hydration status and needs. On 05/04/22 the need to develop individualized service plans which addressed each resident's nutrition and hydration needs was discussed with Staff 1 (Administrator), Staff 2 (Regional Director of Operations), and Staff 3 (RN). They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to evaluate all required elements for activities and to develop an individualized activity plan from the evaluation for 2 of 3 sampled residents (#s 1 and 3) whose service plans were reviewed. Findings include, but are not limited to:A review of the activity evaluation and service plan for Residents 1 and 3 revealed the following:1. The activity evaluation did not adequately address the following required elements:* Past and current interests;* Current abilities and skills;* Physical abilities; and* Adaptations necessary for the resident to participate.2. Individualized activity plans, which addressed what, when, how, and how often staff should offer and assist the resident with activities, were not developed from the activity evaluation and documented.The need to ensure the facility completed a thorough activity evaluation and developed an individualized activity plan based on the evaluation for each resident was discussed with Staff 1 (Administrator), Staff 2 (Regional Director of Operations), Staff 3 (RN) and Staff 7 (Resident Care Manager) on 05/04/22. They acknowledged the findings.