The findings of the initial survey, conducted 11/16/2020 through 11/19/2020, 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
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
MCC Memory 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
The findings of the first re-visit to the re-licensure survey of 11/19/20, conducted 2/25/21, 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, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.
2. Resident 1 was admitted to the facility in August 2020 with diagnoses including dementia.
Review of the resident's progress notes, incident investigations and physician communications for 8/25/20 through 11/17/20 showed the following:
* The resident was found undressed and in bed with another resident on 11/2/20. The incident was investigated but not reported to the local SPD office; and
* The resident threw "hot coffee" on another resident on 10/18/20. The incident was investigated but there was no documentation the incident was reported to the local SPD office.
The need to investigate and report incidents to the local SPD office when needed, to rule out abuse and neglect was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 11/17/20 and 11/18/20. The staff acknowledged the findings.
Staff 1 was asked to report the incidents to the local SPD office and provided confirmation of the reports prior to survey exit.
3. Resident 7 was admitted to the facility in February 2020 with diagnoses including dementia.
Review of the resident's progress notes, incident investigations and physician communications for 8/1/20 through 11/17/20 showed the following:
* The resident experienced a non-injury fall from bed on 8/28/20. There was no documented evidence an investigation was completed to rule out abuse and neglect;
* The resident experienced an unwitnessed fall in the bathroom and sustained a skin tear on 9/7/20. There was no documented evidence an investigation was completed to rule out abuse and neglect;
* The progress notes indicated the resident experienced five additional falls and two additional skin tears on 9/7/20. There was no additional information regarding the falls or skin tears, nor was there documented evidence an investigation of any of the falls or skin tears was completed; and
* The resident was found undressed and in bed with another resident on 11/2/20. The incident was investigated, but not reported to the local SPD office.
The need to investigate and report incidents to the local SPD office as appropriate to rule out abuse and neglect was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 11/18/20 and 11/19/20. The staff acknowledged the findings.
Staff 1 was asked to report the incidents to the local SPD office and provided confirmation of the reports prior to survey exit.
Based on interview and record review, it was determined the facility failed to ensure investigations of all incidents were thorough and complete and all incidents of suspected abuse or neglect and injuries of unknown cause were reported to the local SPD office in a timely manner for 3 of 4 sampled residents (#s 1, 6 and 7). Findings include, but are not limited to:
1. Resident 6 was admitted to the facility in September 2020.
a. On 10/5/20 staff found Resident 6 on the floor. An investigation report dated 10/5/20 indicated Resident 6 stated someone pushed him/her. There was no documented evidence the incident had been reported to the local SPD office.
b. An investigation report dated 11/16/20 indicated staff discovered a 1" skin tear on the back of the resident's right arm near the elbow. The resident was not able to say how it happened. There was no documented evidence the injury of unknown cause was reported to the local SPD office.
The need to report incidents of suspected abuse and/or neglect and injuries of unknown cause in a timely manner was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 11/19/20. They acknowledged the findings.
Staff 1 and Staff 2 were requested to report these events to the local SPD office and provided confirmation these reports were made prior to survey exit.
1. All requested Resident incidents have been reported to APS and are presently being reviewed for efficacy and findings.
2. Administrator and RN to take the following classes: Abuse Reporting; Role of the RN in CBC; Elder Abuse Prevention and Reporting (Entire staff of South Beach Manor required to complete). All incidents with unknown cause or injury will be sent to APS via fax
3. This process will be reviewed weekly x 8 weeks then quarterly thereafter
4. Administrator
Based on observation and interview, it was determined the facility failed to ensure the kitchen was kept clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:
Observations of the kitchen on 11/16/20 and 11/17/20 revealed the following:
* Multiple walls and small appliances had splatters, spills and/or drips;
* The stove/oven had a dark accumulation along the front and near the grease trap, long spills down the side of the stove and there was food debris in the oven located on the left;
* The oven located on the right was not operational;
* Food debris and dirt accumulation were located under the shelves in the dry food storage;
* Floors throughout the kitchen had a black haze with some deep crevices where grout had worn away with spills/debris accumulating;
* Refrigerator/freezer units had drips and splatters down the doors, handles and kick plates had food debris on the bottoms of the units;
* Refrigerator shelves in multiple units had spills and/or a white/orange substance accumulated;
* Tile baseboards nearest the stove had black accumulation along the top edges;
* Spills and splatters were on the door and inner walls of the microwave;
* Open storage shelving and shelves in multiple cupboard units had exposed wood with dark stains and debris on multiple shelves;
* Multiple cupboard doors and drawers had spills, drips and/or food debris on the inside and the outside surfaces;
* Metal and plastic shelving racks throughout the kitchen had dust, stains and/or white/gray accumulation;
* Multiple boxes of paper products and juice were stored on the floor in the dry storage area;
* Coffee cupboard in the dry storage had multiple spills, stains and debris inside the cupboard;
* Dust accumulation was noted on the outer vent of the juice machine; and
* Food debris, dead gnats and/or spills were on and around clean dishes, trays and pans on multiple shelves.
The need to ensure the kitchen was kept clean and in good repair was shown to and discussed with Staff 1 (Administrator) and Staff 10 (Dietary Manager) on 11/16/20 and 11/17/20. The staff acknowledged the findings.
1. Administrator will re-educate all dietary staff on OAR 411-054-0030 and review findings needing improvement and immediate correction as identified in Statement of Deficiencies C-240.
2. The kitchen/dietary department will be divided into 3 sections with each section assigned to a dietary staff member. The staff member will be given a check sheet identifying all sanitary requirements and operating protocols that they will be held accountable to maintain.
3. The department (and staff assigned to each section) shall be reviewed randomly on a weekly basis to ensure all requirements on checksheets are met, the kitchen is clean and in good repair, and in compliance with all regulatory requirements.
4. The Dietary Director (who will also be assigned a section) will monitor daily. The Administrator (or Senior Manager designated from time to time) shall conduct the audit of the department on a weekly basis for 8 weeks and then monthly thereafter.
Based on interview and record review, it was determined the facility failed to ensure resident move-in evaluations contained all required components prior to the resident moving into the facility for 2 of 2 sampled residents (#s 2 and 6) whose new move-in evaluations were reviewed. Findings include, but are not limited to:
Resident 2 and 6s' move-in evaluations dated 10/13/20 and 9/17/20 failed to address the following areas including, but not limited to:
* Personality, including how a person copes with change or challenging situations;
* Spiritual and cultural preferences;
* Dressing;
* Recent losses;
* Dental status;
* Skin, related to post-op incision site;
* History of dehydration and/or unexplained weight loss;
* Environmental factors that impact the resident's behavior including noise, lighting and room temp; and
* Ability to use the call system.
The need to ensure move-in evaluations included all required components was discussed on 11/18/20 and 11/19/20 with Staff 1 (Administrator) and Staff 2 (RN). The staff acknowledged the findings.
1. The evaluations of Resident #2 and #6 have been updated to reflect a broader inclusion of the social, environmental, medical, behavioral, and mental components as noted in the SOD. Furthermore, the Service Plans have been updated to reflect the same additions and adjustments.
2. Administrator, RCC, and LEC will collaborate to ensure pre-admission evaluation is complete and initial Service Plan reflects an accurate discovery process of prospects condition and needs and review the final plan after reviewed by family to confirm the scope of plan is broad enough to provide for known needs;
3. Evaluated prior to each admission date and during the first 30 days of residency. Further review will be conducted on a quarterly basis.
4. Administrator, RCC, RN and LEC
2. Resident 1 was admitted to the facility in August 2020.
The resident's 9/23/20 service plan was reviewed. The service plan was not reflective of the resident's current status and/or lacked clear direction to staff in the following areas:
* Fall risk;
* Weight loss;
* Elopement;
* Behaviors;
* Relationship with another resident; and
* Teeth brushing and Water Pik use.
The need to ensure service plans were reflective, followed and provided directions to staff was discussed on 11/17/20 with Staff 1 (Administrator) and Staff 2 (RN). The staff acknowledged the findings.
3. Resident 2 was admitted to the facility in November 2020.
The resident's 10/30/20 service plan was reviewed. The service plan was not reflective of the resident's current status, lacked clear direction to staff and/or was not being followed in the following areas:
* Bathing and hygiene;
* Toileting;
* Swelling/Edema;
* Transfers, gait belt use and ambulation;
* Bed mobility; and
* Arm fracture and brace to the right arm.
The need to ensure service plans were reflective, followed and provided directions to staff was discussed on 11/17/20 with Staff 1 (Administrator) and Staff 2 (RN). The staff acknowledged the findings.
4. Resident 7 was admitted to the facility in February 2020.
The resident's 8/31/20 service plan with updates dated 11/2/20 were reviewed. The service plan was not reflective of the resident's current status, lacked clear direction to staff and/or was not being followed in the following areas:
* Relationship w/another resident;
* Fall risk; and
* Hygiene.
The need to ensure service plans were reflective, followed and provided directions to staff was discussed on 11/17/20 with Staff 1 (Administrator) and Staff 2 (RN). The staff acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current needs, provided clear direction to staff, and directions were followed by staff for 6 of 6 sampled residents (#s 1, 2, 3, 5, 6 and 7) whose service plans were reviewed. Findings include, but are not limited to:
1. Resident 3 was admitted to the facility in 2019 with diagnoses including stroke, dementia and major depressive disorder.
Review of Resident 3's records and interviews with staff indicated the 8/19/20 service plan was not reflective of the resident's current needs and/or did not provide clear direction to staff in the following areas:
* History and risk for weight loss;
* Use of specialized plate at meals;
* Nutritional and calorie supplements;
* Inability to swallow medications whole at times;
* Instructions for use of a specialized wheelchair;
* Toileting assistance; and
* Sleep preferences.
The need to ensure service plans were reflective of residents' current needs, provided clear direction to staff and directions were followed by staff was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 11/17/20. They acknowledged the findings.
5. Resident 5 was admitted to the facility in July 2019.
A review of Resident 5's 10/19/20 service plan revealed it did not contain information about his/her current significant weight loss status.
In an interview with Staff 1 (Administrator) and Staff 2 (RN) on 11/19/20, the need for the service plan to reflect the resident's current status in all areas was discussed. Staff acknowledged the findings.
6. Resident 6 was admitted to the facility in September 2020 from the hospital, following surgery for a hip fracture.
Resident 6's initial service plan, dated 9/21/20, with handwritten updates from 9/21/20 through 11/16/20, was reviewed. The following areas were not reflected:
* Skin issues;
* Surgery aftercare instructions for managing pain and swelling;
* Range of motion exercises and ambulation for DVT prevention; and
* Interventions developed as a result of multiple falls.
The need for the service plan to accurately reflect the resident's current needs and status and provide direction to staff for providing care was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 11/19/20. They acknowledged the findings.
1. Resident #3: Service Plan has been updated and Staff have been alerted to review the updated additions and clarifications; Resident #1: Service Plan has been updated with cited deficiencies corrected, especially behavioral issues and directions to respond/redirect. Staff have been taught as well as reviewed updated Service Plan. Resident #2, #5, #6, #7: Service Plans have been updated to address the deficiencies noted to make them current. Staff have been put on alert to review the Service Plan binder of noted residents with their updates.
2. A working copy from the current Service Plan binder will be provided to all staff (including Dietary and Life Enrichment Coordinators) for feedback and comment on each resident for the residents 30 day or Quarterly review. Also, scheduled Service Plans for review will be reviewed with residents family (POA) and updated 1 week prior to Plan implementation. Final Service Plan to be sent to family for signature.
3. Evaluation of Service Plan to be on a monthly basis
4. RCC/RN
3. Resident 1 was admitted to the facility in August 2020.
The resident's 8/1/20 through 11/16/20 progress notes and physician faxes were reviewed. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution and/or lacked resident-specific directions to staff in the following areas:
* Suicidal thoughts;
* Exit seeking and behaviors;
* Weight changes;
* Elopement; and
* Hiding medications.
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 on 11/17/20 with Staff 1 (Administrator) and Staff 2 (RN).The staff acknowledged the findings.
4. Resident 2 was admitted to the facility in November 2020.
The resident's 11/6/20 through 11/16/20 progress notes and physician faxes were reviewed. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution and/or lacked resident specific directions to staff in the following areas:
* New admission;
* Edema and swelling to right side of the body;
* Bruises and skin conditions; and
* Wrist fracture and brace use.
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 on 11/17/20 with Staff 1 (Administrator) and Staff 2 (RN). The staff acknowledged the findings.
5. Resident 7 was admitted to the facility in February 2020.
The resident's 8/1/20 through 11/16/20 progress notes and physician faxes were reviewed. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution and/or lacked resident specific directions to staff in the following areas:
* Falls; and
* Skin tears.
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 on 11/17/20 with Staff 1 (Administrator) and Staff 2 (RN).The staff acknowledged the findings.
6. Resident 3 was admitted to the facility in September 2019.
Review of Resident 3's records and interviews with staff indicated the resident experienced multiple changes in condition September - November 2020. The facility failed to ensure the following changes in condition were monitored at least weekly through resolution:
* Significant weight loss;
* Suspected urinary tract infection; and
* A skin tear and bruise to the right arm.
The need to ensure the facility documented weekly monitoring of residents with changes in condition, through condition resolution, was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 11/17/20. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure changes of condition were monitored at least weekly through resolution and determine and document what actions or interventions were needed for changes of condition, including resident-specific instructions communicated to staff on each shift, for 6 of 6 sampled residents (#s 1, 2, 3, 5, 6 and 7) who had changes of condition. Resident 5 experienced severe, ongoing weight loss which posed an immediate threat to the resident's safety and well-being. Findings include, but are not limited to:
1. Resident 5 was admitted to the facility in July 2019 with diagnoses including dementia.
Records dated 6/9/20 through 11/16/20 which included progress notes, alert charting, health assessments, service plan, weight records, physician faxes, and conversation details and the resident's 10/1/20 through 11/16/20 MARs were reviewed.
a. The resident experienced ongoing weight loss as follows:
* A 6.2 pound loss from May 2020 to June 2020 which constituted a severe 5.18% loss in one month;
* An 11.2 pound loss from July 2020 to August 2020 which constituted a severe 10% loss in one month; and
* A 7.2 pound loss from October 2020 to November 2020 which constituted a severe 7.21% loss in one month.
The resident's progress notes and alert charting contained new actions and interventions including offering favorite foods, monitor fit of clothing, nutritional supplement three times a day, and sit with and engage the resident in conversation while eating. There was no documented evidence his/her ongoing weight loss was monitored at least weekly until resolved or that interventions were reviewed and monitored for effectiveness.
The resident's 10/2020 and 11/1-16/20 MARs indicated the resident began receiving a nutritional supplement three times per day on 8/27/20. Interviews with Staff 2 (RN), Staff 3 (Lead CG) and Staff 6 (MA) revealed the resident did not like the supplements and refused them on several occasions. The 10/1 - 11/16/20 MARs indicated the resident refused the supplement on eight occasions in October and on seven occasions in November. In the same interview, Staff 3 stated the facility did not do meal monitoring.
There was no documented evidence previous interventions were reviewed for effectiveness with each successive severe weight loss.
Resident 5 was weighed during the survey and had gained one pound from the last documented weight.
The need to respond promptly to significant/severe weight loss with ongoing monitoring, implementation of interventions and evaluation for effectiveness of those interventions was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 11/19/20. They acknowledged the findings.
b. Resident 5 was prescribed a new medication, Risperidone (an anti-psychotic) on 9/16/20. There was no documented evidence the resident was monitored for adverse reactions to the medication after s/he received the first dose.
The need to monitor short-term changes of condition at least weekly through resolution with clear direction to staff was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 11/19/20. They acknowledged the findings.
2. Resident 6 was admitted to the facility in August 2020.
A review of Resident 6's record revealed multiple changes of condition that were not monitored at least weekly through resolution in the following areas:
*Falls;
*Medication changes;
*Return from emergency department visit;
*Skin issues; and
*Catheter removal.
The need to monitor short-term changes of condition at least weekly to resolution with clear direction to staff was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 11/19/20. They acknowledged the findings.
1. Resident #1 had telehealth appointment with psychiatrist/dementia provider, antidepressant added. Resident #2 Skin integrity added to TAR for twice daily. Working with PT after requested. Bruising resolved. Resident #3 UTI was treated imperically with antibiotics. Daughter and MD continue to work on dynamic pan to increase po intake. Requested appetite stimulant. Skin tear and bruising resolved. Resident #5. Admitted to hospice per daughter request. Collaboration with hospice team weekly to improve/maintain po intake. Requesting exemption for daughter to visit as resident eats much better when daughter present. Daughter does not want appetite stimulant nor to prolong her decline. Resident # 6 All outside provider notes (hospital DC, Home health, therapy, etc) faxed to PCP when received. Weekly skin/med monitoring as needed until resolved. No longer has catheter. Resident #7 Reeducation of staff regarding stop and watch and alert monitoring process.
2. Change of Conditions on alert charting until resolved. Weekly weights added to TAR. Interventions/improvements/changes reviewed weekly in Management IDT meeting. Short term monitoring in MAR/TAR for meals, GI/GU or medication ingestion as needed per LN. All outside providers and home health orders faxed to pharmacy and PCP when received. Correction and updates for short term monitoring. Retrained staff on Stop and Watch/Alert charting
3. Monitored daily by Staff and RCC; Review at weekly Resident Review Committee meeting
4. RCC/RN/Admin
Based on interview and record review, it was determined the facility failed to ensure a significant change of condition assessment was completed by the RN, to include findings, resident status and interventions, in a timely manner for 2 of 2 sampled residents (#s 5 and 6) who experienced significant changes of condition. Resident 5 experienced ongoing severe weight loss which posed an immediate threat to the resident's safety and well-being. Findings include, but are not limited to:
1. Resident 5 was admitted to the facility in July 2019.
Records dated 6/9/20 through 11/16/20 which included progress notes, alert charting, health assessments, service plan, weight records, physician faxes, and conversation details and the resident's 10/1/20 through 11/16/20 MARs were reviewed.
a. The resident experienced ongoing weight loss as follows:
* A 6.2 pound loss from May 2020 to June 2020 which constituted a severe 5.18% loss in one month;
* An 11.2 pound loss from July 2020 to August 2020 which constituted a severe 10% loss in one month; and
* A 7.2 pound loss from October 2020 to November 2020 which constituted a severe 7.21% loss in one month.
On 6/9/20 Staff 2 (RN) completed a health assessment form related to weight loss; she indicated in an interview on 11/17/20 this was a significant change of condition assessment. The RN faxed Resident 5's physician and updated his/her service plan to instruct staff to "encourage nutritious snacks between meals and favorite foods." The physician did not respond to the 6/9/20 fax, per the RN.
On 8/10/20 the RN completed a significant change of condition form for continued weight loss. This assessment did not include findings, resident status or interventions. There was no documented follow-up to this significant weight change until 8/26/20 when the RN faxed the resident's physician, who ordered one can of Ensure supplement with meals. The RN also updated the service plan on 8/26/20, including one new intervention related to weight loss: "Monitor fit of clothing, as able. Report to MA or RCC any concerns." There was a "Conversation Details" note dated 8/26/20 with interventions, but there was no documented evidence these had been shared with staff or monitored for effectiveness.
On 9/15/20 the RN faxed Resident 5's physician regarding ongoing weight loss, reporting the resident had not gained any weight since Ensure supplements were started on 8/29/20. The resident's service plan was updated on 9/15/20 with one new weight loss intervention: "Sit with [resident] and engage in conversation while encouraging [resident] to eat/drink." On 9/23/20 the RN again faxed the resident's physician stating the resident continued with decreased oral intake and staff were physically assisting the resident with meals.
On 10/19/20 the RN faxed Resident 5's physician to let them know the resident's weight was up for the month, although s/he continued to pick at their food and would not usually drink an entire Ensure each time it was given.
On 11/9/20 a significant change of condition form was completed by the RN for continued weight loss. This assessment did not include interventions for the resident's weight loss. The same date the RN faxed Resident 5's physician about the continued weight loss, to which the physician responded asking if the resident was interested in hospice and ordering labs. There was no documented evidence of any follow-up to the 11/9/20 significant change of condition assessment with regard to contact with the resident's physician or additional interventions.
The resident's 10/2020 and 11/1-16/20 MARs indicated the resident began receiving a nutritional supplement three times per day on 8/27/20. Interviews with Staff 2 (RN), Staff 3 (Lead CG) and Staff 6 (MA) revealed the resident did not like the supplements and refused them on several occasions. The 10/1-11/16/20 MARs indicated the resident refused the supplement on eight occasions in October and on seven occasions in November. In the same interview, Staff 3 stated the facility did not do meal monitoring.
b. A health assessment form dated 9/21/20 indicated the resident had an "abrupt change of condition" related to increased needs, decreased abilities and increased confusion. There were no interventions included on the assessment.
The need for a thorough RN assessment, including findings, resident status and interventions, to be completed for all significant changes of condition was discussed with Staff 1 (Administrator) and Staff 2 on 11/19/20. They acknowledged the findings.
2. Resident 6 was admitted to the facility in 9/2020.
The resident's weight at admission was 88 lbs. Weight records indicated that in 10/2020 Resident 6 weighed 94 pounds and in 11/2020 89 pounds. From 10/2020 to 11/2020 there was a 5 pound, 5.3% severe weight loss.
A fax was sent to the resident's physician on 11/9/20 by Staff 2 (RN) stating the amount of weight lost and asking if there were any new orders. There was no documented evidence of a response from the physician. There was no documented RN significant change of condition assessment completed for the 11/2020 severe weight loss.
In an interview on 11/19/20, the RN stated she had not been able to complete a significant change of condition assessment due to lack of time. She stated staff had been escorting Resident 6 to meals, talking to her/him during meals to encourage her/him to eat and bribing her/him with ice cream. There was no documented evidence any of these interventions had been added to the resident's record or implemented.
During the survey, 11/19/20, Resident 6's weight had increased by 4.8 pounds from the beginning of November 2020.
The need for a thorough significant change of condition assessment to be completed in a timely manner by the RN for all significant changes was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 11/19/20. They acknowledged the findings.
1. Assessments completed on resident #5 and #6. Service plans updated with chronological interventions, reviews, and weekly monitoring continues.
2. Role of the Nurse in Community Based Care training Course by OHA attended by RN and Administrator; Retrain staff on Alert and Stop and Watch documentation for Service Plan and Change of Condition updates. Weekly review of all residents for change of condition. Service Plan updates to admin until new RCC hired. Office Manager to assist in collecting data r/t changes in needs/abilities for new SP update.
3. RCC review daily; Weekly review of process
4. Administrator and RCC/RN
Based on interview and record review, it was determined the facility failed to ensure recommendations made by outside service providers were included in residents' service plans for 1 of 1 sampled resident (#6) who received on-site services from outside providers. Findings include, but are not limited to:
Resident 6 was admitted to the facility in September 2020 following surgery for a femur fracture. S/he was admitted with a catheter and on Warfarin (an anticoagulant). Hospital discharge orders dated 9/21/20 indicated HH would provide a PT evaluation and catheter monitoring, as well as INR lab draws.
The resident's service plan, dated 9/21/20, and HH notes dated 9/24-11/10/20 were reviewed and revealed HH made the following recommendations:
* 9/28/20: staff should encourage the resident to drink appropriate amounts and notify HH if vitals were out of range or if resident experienced bleeding or bruising;
* 10/6/20: HH requested a higher level of care; and
* 11/6/20: monitor for bowel movements and follow bowel protocols for no BM per physician orders.
There was no documented evidence these recommendations were added to the resident's service plan or followed.
The need to add outside provider recommendations to resident service plans and follow the recommendations was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 11/19/20. They acknowledged the findings.
1. Resident #6: Staff to fax outside provider noted (DC summary, Home Health, and specialists) as soon as received to pharmacy and PCP for prompt advise from PCP. Outside provider notes to be scanned/handed to LN/RCC for review and implementation of her new orders. Retrained staff for short term monitoring of resident (bowel, fluids, food, weights) in QMAR.
2. Retrain staff on processing outside service orders. Retrain to follow current CPM procedures.
3. Med aid to review daily and RCC/RN weekly review.
4. RCC or RN
Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed and/or signed physician orders were documented in the resident's record for 3 of 6 sampled residents (#s 3, 4 and 6). Findings include, but are not limited to:
1. Resident 3's MARs dated 10/1/20 - 11/16/20 , current physicians orders, and current service plan were reviewed and identified the following:
* Resident 3's 8/19/20 service plan revealed s/he required assistance with ADLs. Resident 3 was ordered Clinipro, a medicated toothpaste, to be kept in the resident's bathroom and applied once daily. There was no documented evidence the facility administered the medicated toothpaste daily as prescribed.
The need to ensure physician orders were carried out as prescribed was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 11/17/20. They acknowledged the findings.
2. Review of Resident 4's MARs dated 10/1/20-11/16/20, current physicians orders and staff interviews identified the following:
* On 11/16/20, the facility was unable to locate signed physician orders for numerous medications documented as administered on Resident 4's MARs. Signed physician orders were not obtained from the physician's office until 11/17/20 at the surveyor's request.
The need to ensure current, signed physician orders were maintained in the resident's records was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 11/17/20. They acknowledged the findings.
2. Resident 6 was admitted to the facility on 9/21/20.
A review of Resident 6's hospital discharge orders and 9/1 - 11/16/20 MARs revealed there was no documented evidence that wound care orders dated 9/21/20 were carried out as prescribed. Orders included the following:
* Keep dressings clean/dry/intact;
* Remove all dressings and shower the morning after your discharge;
* The large absorbent dressing is covering 3 small dressings and they may all be removed;
* Leave the Steri-strips open to air if no drainage from the wound; and
* Keep incisions clean/dry, apply clean dry dressings as needed for any drainage.
The need to follow all physician orders as prescribed was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 11/19/20. They acknowledged the findings.
1. Resident #3, toothpaste added to QMAR for documentation of use. Resident #4 Current physican order set was received from PCP. Review of all charts for current physician order sets. Resident #6 retrained staff to add wound care orders to TAR for daily monitoring. Located assessment from admission and request for updated orders, now in chart.
2. Retrain staff on effective processing of treatment orders and follow-up on pending. Retrain staff on entering and tracking treatment orders in TARS
3. Med-Aids to track daily; RCC's on weekly basis.
4. RCC or Licensed
4. Resident 1 was admitted in August 2020 with diagnoses including dementia.
Review of the resident's 10/1/20 through 11/16/20 MARs showed multiple medication refusals. There was no evidence the resident's physician was notified of the refusals.
The need to ensure resident refusals of medications and/or treatments were reported to the physician was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 11/17/20 and 11/18/20. The staff acknowledged the findings.
3. Resident 4 was admitted to the facility in July 2020 with diagnoses including senile dementia and diabetes type 2.
Review of Resident 4's MARs dated 10/1/20 - 11/16/20 and physician's fax communications identified the following:
* On the October 2020 MAR, staff documented the resident refused a treatment order for topical application of Nystatin powder for a rash on two occasions. There was no documented evidence the physician was notified of the refusals.
The need to ensure the facility notified the physician/practitioner when a resident refused to consent to orders was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 11/17/20. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused to consent to orders for 4 of 5 sampled residents (#s 1, 4, 5 and 6) who had documented medication and treatment refusals. Findings include, but are not limited to:
1. Resident 5 was admitted to the facility in July 2019.
A review of Resident 5's 10/1 - 11/16/20 MARs revealed the resident refused medications on 16 occasions in October and 11 occasions in November. There was no documented evidence the physician had been notified of the refusals.
The need to notify the physician of resident medication refusals was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 11/19/20. They acknowledged the findings.
2. Resident 6 was admitted to the facility in September 2020.
A review of Resident 6's 10/1 - 11/6/20 MARs/TARs indicated the resident refused medications and/or treatments on 12 occasions in October and one time in November. There was no documented evidence the physician was notified of the refusals.
The need to notify the physician of resident medication and/or treatment refusals was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 11/19/20. They acknowledged the findings.
1. Residents #1, #4, #5, and #6: The designated PCP's for the foregoing residents were notified by fax of both past and present refusals/missed meds to bring the providers up to date and to receive any further orders if applicable;
2. Retrain all MA's on Medication and Order refusals by residents, and the proper PCP notification and QMAR documentation of refusal event. All refusals or denials to be faxed immediately to PCP. Until response is received, MA shall fax every 3 days.
3. Regional oversight RN to provide Administrator with daily audit report; Administrator to verify notification has been sent via fax and the recording thereof in QMAR; Monitored daily
4. Administrator/RCC
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 2 of 2 sampled residents (#s 1 and 6) who were prescribed a PRN medication to address behaviors. Findings include, but are not limited to:
Review of Resident 1's and Resident 6's 10/1/20 through 11/16/20 MARs and progress notes showed the following:
a. Resident 1 was prescribed Quetiapine (antipsychotic medication) 25 mg twice a day as needed for "extreme agitation or psychosis not responsive to non-pharmacological techniques."
The resident was administered the Quetiapine once between 10/1/20 and 11/16/20. There was no documentation of non-drug interventions that were attempted or the specific reasons the medication was given.
b. Resident 6 was prescribed Lorazepam 1 mg tab, ½ tab every 6 hrs as needed for "anxiety (agitation)."
The facility administered the Lorazepam to the Resident four times between 10/1/20 and 11/16/20.
There were no non-pharmaceutical interventions on the MAR for staff to attempt prior to administering the medication, no documentation regarding the effectiveness of the medication administered and no information for the staff related to how the resident's anxiety/agitation was displayed.
The need to ensure staff documented non-drug interventions had been attempted with ineffective results prior to administering a PRN psychoactive medication, effectiveness of the medication was documented and staff were aware of the signs of residents' agitation and anxiety was discussed on 11/17/20 and 11/19/20 with Staff 1 (Administrator) and Staff 2 (RN). They acknowledged the findings.
1. Resident #1 and #6: Conducted QMAR audit for interventions, area to document interventions, and area to document effectivness of medication. Reviewed and retrained staff to correct current process for PRN administration beginning with Resident #1 and #6.
2. Train MA's on Non-pharmaceutical intervention options available; Create and provide for staff a list of interventions possible with residents that take PRN psychotropics. Train MA's on QMAR intervention recording
3. RCC to evaluate weekly
4. RCC or Licensed LPN
Based on interview and record review, it was determined the facility failed to provide documented evidence fire drills included all required components. Findings include, but are not limited to:
Fire and life safety records dated April-October 2020 were reviewed and lacked the following required components:
* Escape routes used;
* Problems encountered, comments related to residents who resisted or failed to participate in the drills;
* Evacuation time-period needed; and
* Number of occupants evacuated.
The need to ensure the facility was in compliance with all required fire drill components was discussed with Staff 1 (Administrator) and Staff 3 (Maintenance Supervisor) on 11/18/20. They acknowledged the findings.
1. Educate safety committee and facility staff in monthly staff meetings and orientation of new employees as to proper fire drill protocols to include potential problems and barriers to overcome, relative escape routes to use based on fire locations, evacuation time tracking, and occupant evacuee participation;
2. In each monthly staff meeting (as well as direct feedback to staff upon conclusion of each fire drill), review the most recent fire drills discussing timely responses by staff, problems and barriers observed, escape route utilization; time management to successful evacuation and occupant participation;
3. In each unannounced fire drill on rotating shifts, the maintence director will monitor the drill at the site of designated fire to evaluate and then document findings of drill;
4. The safety Committee will review the evaluation for improvements; the Administrator shall ensure effectivness of drills.
Based on interview and record review, it was determined the facility failed to provide documented evidence alternating evacuation routes were used during fire drills and failed to ensure resident evacuation levels were determined and met. Findings include, but are not limited to:
Fire and life safety records for April- October 2020 were reviewed and lacked the following components:
* Alternating evacuation routes used during fire drills; and
* Documentation resident evacuation levels were determined and met.
The need to ensure fire and life safety training included all required components was discussed with Staff 1 (Administrator) and Staff 3 (Maintenance Supervisor). They acknowledged the findings.
1. Educate safety committee and facility staff in monthly staff meetings and orientation of new employees as to proper escape routes to use based on fire locations, and what would consitutue the necessity of utilizing one route versus another based on fire location and safe exit.
2. In each monthly staff meeting (as well as direct feedback to staff upon conclusion of each fire drill), review the most recent fire drills discussing route utilization and resident evacuation level success or improvement required.
3. Evaluation will take place every other month in each unannounced fire drill on rotating shifts. This will be documented in CPM Fire Drill Evaluation Document.
4. The Maintence Director will monitor the drill at the site of designated fire to evaluate protocol compliance. Another safety committee staff member will be assigned to assess for proper resident evacuation levels. Findings of the drill will be documented and reviewed by Safety Committee and approved by Administrator
Based on observation and interview, it was determined the facility failed to ensure courtyard pathway edges did not contain drop-offs and that tools were not left unsecured in the resident outdoor area. Findings include, but are not limited to:
Observations of the interior courtyard of the facility on 11/16/20 showed drop-offs at the pathway edges in excess of four inches in multiple areas.
Additionally, there were multiple metal yard tools left unsecured in the courtyard seating area nearest the dining room. The tools were secured at the surveyor's request.
The need to ensure pathways in the resident courtyard did not have potential tripping hazards and that all tools were not left unsecured was discussed with Staff 1 (Administrator) and Staff 3 (Maintenance Supervisor) on 11/16/20. The staff acknowledged the findings.
1. Gardening tools have been removed and will be removed from courtyard area when not in use; Tools will be stored in a locked or secured location where access is limited to staff only; Pathway edge drop-off's have been filled with dirt and decorative river rock;
2. Staff will be trained by Maintenance Director about proper allocation of gardening tool utilization for residents and the accountable return and safe storage of each tool;
3. Maintence Director will walk the courtyard daily to ensure no tools have been left out;
4. Aministrator will ensure compliance to this protocol is effective through communication with Maint. Dir. and courtyard walk-thru's as well.
Based on observation and interview, it was determined the facility failed to ensure the environment was maintained in good repair. Findings include, but are not limited to:
Observations of the facility on 11/16/20 showed:
* The interior courtyard doors had multiple broken and missing pieces of the lattice from the center glass portions of the doors;
* The double doors were difficult to latch when shutting; and
* The double doors located furthest from the dining room had a large and deep hole, approximately 3.0 inches by 4.0 inches, at the bottom of the door with multiple layers of missing and chipped paint around the hole.
The need to ensure the exterior of the facility was in good repair was discussed with Staff 1 (Administrator) and Staff 3 (Maintenance Supervisor). The staff acknowledged the findings.
1.- 2.
Facility shall bid, contract and replace both sets of doors. Order confirmation to be in place prior to January 18, 2021;
3. New doors will be checked quarterly by Maintenance Director to ensure they remain in good working order
4. Administrator shall ensure project completion will be in compliance with date stated herein.
C 160: OAR 411-54-0025 (4) Reasonable Precautions. (4) Reasonable precautions must be exercised against any condition that could threaten the health, safety, or welfare of residents.
Z 155: 411-057-0155 Staff Training Requirements. (2) ALL STAFF TRAINING REQUIREMENTS. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5).* (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person's hire. All completed trainings must be documented by the facility.
*OAR 411-054-0070(5) Training within 30 Days: Direct Care Staff. (8) ADDITIONAL REQUIREMENTS. (b) Must be trained in the use of the abdominal thrust and First Aid.
Based on observation, interview and record review, it was determined the facility failed to ensure compliance with non-healthcare related Residential Care and Assisted Living regulations. Findings include, but are not limited to:
Refer to C 231, C 240, C 420, C 422, C 510 and C 513.
Refer to C231, C240, C420, C422, C510, C513 per survey notation
Based on observation, interview and record review, it was determined the facility failed to provide healthcare services in accordance with OARs 411 Division 54 for Assisted Living and Residential Care Facilities. Findings include, but are not limited to:
Refer to C 252, C 260, C 270, C 280, C 290, C 303, C 305 and C 330.
Refer to C252, C260, C270, C280, C290, C303, C305, C330 per survey notation
Based on interview and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan for each resident was developed and included in residents' service plans, for 5 of 7 sampled residents (#s 2, 3, 5, 6 and 7) whose records were reviewed. Findings include, but are not limited to:
Residents 2, 3, 5, 6 and 7s' current service plans were reviewed during survey. Each of the service plans lacked information and staff instructions related to individualized nutrition and hydration status and needs.
On 11/18/20 and 11/19/20, the need to develop individualized service plans addressing residents' nutrition and hydration needs was discussed with Staff 1 (Administrator) and Staff 2 (RN). They acknowledged the findings.
1. Residents #2, #3, #5, #6, and #7: Each Resident has been reviewed in the Resident Review Committee to discuss eating and drinking utinsels and opportunities and preferences for consumption to optimize nutrition and hydration intake. Monitoring of these residents were all discussed and planned. Service Plans were updated accordingly.
2. Train and educate all staff on the identification, response, and treatment of Nutrition and Hydration needs of residents; Retrained staff for Stop and Watch program for notifiying MA/RCC and LN for changes in eating/drinking patterns. Retrained staff for short term monitoring (food, fluids, GI/GU output, behaviors, weight) to be added to MAR/TAR as needed and when requested by RCC/LN. All staff have been assigned to an OHA training class.
3. Report to RCC/Licensed nurse any changes to baseline eating or drinking patterns via Stop and Watch or other direct communication; Weekly review in Resident Review Committee
4. RCC or Licensed Nurse
Based on interview and record review, it was determined the facility failed to evaluate and develop individualized activity plans for 5 of 6 sampled residents (#s 2, 3, 5, 6 and 7) whose activity plans were reviewed. Findings include, but are not limited to:
Residents 2, 3, 5, 6 and 7s' records were reviewed during the survey. There was no documented evidence an activity evaluation had been completed and the service plans individualized to reflect the residents' current preferences; abilities and skills; emotional/social needs and patterns. There was no specific activity plan which detailed what, when, how and how often staff should offer and assist each resident with individualized activities.
On 11/18/20 and 11/19/20, the lack of an activity evaluation and individualized activity plan was discussed with Staff 1 (Administrator), Staff 2 (RN) and Staff 8 (Life Enrichment Coordinator). The staff acknowledged the findings.
1.Residents #2, #3, #5, #6, and #7: LEC has reviewed, assessed, developed, and updated each residents Service Plan with a personalized activity plan on an individual and group basis.
2. LEC will create activity plans based on the Service Plan (to be found in Life Enrichment binder reviewed and signed off by each Staff member) for each resident. LEC will ensure accessibility to all staff and ensure staff utilize the identified activities to engage residents on an individual basis or group basis depending on the individualized plan. Plans will include structured or non-structured activities.
3. Life Enrichment Plans will be written by LEC at resident move-in and reviewed quarterly or at resident change of condition.
4. Administrator will review initial plans and again on a quarterly basis (resident change of condition) to ensure plans are complete and updated effectively.
Based on interview and record review, it was determined the facility failed to provide an individualized service plan for behavioral symptoms that negatively impacted the resident or others in the community for 1 of 4 sampled residents (#1) with documented behaviors. Findings include, but are not limited to:
Resident 1 was admitted to the facility in August 2020 with diagnoses including dementia.
Resident 1's record documented behaviors including exit seeking, pounding on windows and/or doors, actual elopement from the facility, attempting to remove safety blocks from windows to fully open to leave, throwing items at other residents and yelling at others.
The resident's service plan, dated 9/23/20, did not address the behaviors and/or lacked individualized interventions to assist staff in minimizing the negative impact of the behaviors.
On 11/18/20 the need to develop individualized behavior plans for residents with behavioral symptoms was discussed with Staff 1 (Administrator) and Staff 2 (RN). They acknowledged the findings.
1. Resident #1: The Service Plan has been updated to include a thorough individualized plan, identifying the specific behaviors for staff to be aware of and the alternative interventions and directions related thereunto in response.
2. Educate staff on the identification of negative behaviors of residents that impact staff and other residents and on intervention options for those negative behaviors; Update Service Plans and create alerts when resident negative behaviors are discovered. Also include specific intervention and redirection options available to staff to help in addressing those behaviors.
3. Weekly Resident Review Committee and Quarterly Service Plan reviews
4. RCC or Licensed Nurse
