The findings of the re-licensure survey, conducted 05/30/23 through 06/01/23, 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 and OARs 411 Division 004 for Home and Community Based Services Regulations.

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 first re-visit to the re-licensure survey on 06/01/23, conducted on 10/18/23, 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.

Based on observation, interview, and record review, it was determined the facility failed to ensure resident service plans were reflective of residents' needs and were readily available to staff, for 1 of 2 sampled residents (#2) whose service plans were reviewed. Findings include, but are not limited to:

Resident 2 moved into the facility in 04/2022 with a diagnosis of Parkinson's disease. S/he was identified during the entrance interview as being on hospice.

The resident's current service plan (dated 04/04/23) was reviewed, and interviews were conducted with care staff.

The resident's service plan was not reflective of the resident's current needs in the following areas:

* Communication;

* Smoking;

* Behaviors;

* Shower schedule;

* Side rail use;

* Sleeping in recliner;

* Eating in room;

* Use of adaptive utensils;

* Frequency of medication refusal;

* Assistance needed with television in room; and

* Assistance needed with beverages in room.

The service plan available to staff was dated 07/18/22.

The need to ensure current service plans were available to staff and provided information regarding resident care needs was discussed with Staff 1 (ED) on 06/01/23. She acknowledged the findings.

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1. A COC on Resident # 2 has been completed by the  facility RN on 6/18/2023. RCC has updated the SP to reflect the resident care needs. SP meeting has been reviewed with staff and family on 6/19/2023

2. RCC and ED to review 24 hour book and chart notes daily for any new changes on residents and update SP as needed.

3. ED, RN and RCC to review all residents for changes weekly at the High Risk meeting and up date Service Plans as needed.

4. RN to provide training with staff on how to write any changes for residents for the SP as residents needs and preferences as they change

5. ED and RCC to monitor.

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 residents choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services, for 2 of 2 sampled residents (#s 2 and 3) whose service plans were reviewed.  Findings include, but are not limited to:

Resident 2 and 3's most recent service plans lacked evidence that a Service Planning Team reviewed and participated in the development of the service plans.

On 06/01/23, the need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (Executive Director). She acknowledged the findings.

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1. Service Plan Meetings have been schedule weekly.

2. RCC will notify all parties ie. Residents, POA, Case Manages and family  friends of residents choice. They  will be notified of the date and time by mail, email and or a phone call.

3. RCC to make monthly schedule of SP meetings that are due.

4. ED to montior weekly.

Based on interview and record review, it was determined the facility failed to notify the physician when a resident refused to consent to orders for 1 of 1 sampled resident (#2) who had documented medication refusals. Findings include, but are not limited to:

Resident 2 moved into the facility in 04/2022 with a diagnosis of Parkinson's disease. During the acuity interview s/he was identified as being on hospice.

Resident 2's 05/01/23 through 05/30/23 MAR was reviewed.

Documentation indicated Resident 2 refused multiple prescribed medications on multiple days on 101 occasions. 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 (ED) and Staff 2 (RCC) on 06/01/23. They acknowledged the findings.

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1. All physician have been notified of what their preferences are and on to be notified on medication refusal.

2. All medication refusal will be notified on stated preferences by fax  

3. RCC to add to the MAR under information orders on the 90 day orders

4. RCC to retrain Med Tech to follow doctors orders on prefences of notifing them of refusals

5. ED and RCC to review chart notes daily.  

Based on interview and record review, it was determined the facility failed to ensure pre-service dementia training was completed prior to beginning work in the facility for 2 of 2 sampled staff (#s 5 and 6) whose training records were reviewed. Findings include, but are not limited to:

Staff training records were reviewed on 05/31/23.

* Staff 5 (MT) hired 04/24/23, and Staff 6 (MT) hired 01/15/23, lacked documented evidence of having completed pre-service dementia training.

On 05/31/23, the need for staff to complete all required pre-service dementia training before working with residents was reviewed with Staff 1 (Executive Director). She acknowledged the findings.

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1.All staff will complete Pre-Service dementia training before they are allowed to work.

2.ED and the Business Office Manager to monitor that all staff has completed training before they are released to work and or added to a work schedule

3.ED and BOM are to both sign off on the new hire check list

4.All new hire employee files are not to be filed away until it is completed and sign off by ED

5.BOM to do weekly audits on all new employee files hired in the last 30 days

6.BOM to audit weekly employee files for annual training.

7.ED to monitor

Based on interview and record review, it was determined the facility failed to ensure 1 of 2 newly hired direct care staff (#6) demonstrated competency of skills in all assigned job duties within 30 days of hire. Findings include, but are not limited to:

Facility training records reviewed on 05/31/23 identified the following:

There was no documented evidence Staff 6 (MT), hired on 01/15/23, had demonstrated competency in all required areas within 30 days of hire including:

* The role of service plans in providing individualized resident care;

* Providing assistance with the activities of daily living;

* Changes associated with normal aging;

* Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition;

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

* Other duties as applicable.

On 05/31/23, the need to ensure newly hired direct care staff demonstrated competency of skills in all assigned job duties within 30 days of hire was discussed with Staff 1 (Executive Director). She acknowledged the findings.

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1. ED and BOM are to montior / audit  and that all all new staff have completed all their training within 30 days of their hire date.

2. ED and BOM to sign off on any the new hire check list that it is completed.

3. BOM and ED to montior weekly

4. BOM to montior  that all new employees has demonstrated competency check list with in 30 day of hire.

5. BOM to montior all new staff files weekly.

6. New hire folders are not to ne filed away until all training is complete and BOM has done a complete audit.

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

The exterior of the facility was toured on 05/30/23 and 05/31/23. The following deficiencies were identified:

* Exterior pathways in the front of the building contained drop-offs up to approximately 2 inches, measured from the edge of a concrete sidewalk to the edge of the next concrete sidewalk.  These drop-offs created potential fall hazards for residents.

On 05/31/23, the building's exterior was toured with Staff 1 (Executive Director). She acknowledged the findings.

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1. Bark has been ordered and will fill in the area that drop off around the concrete sidewalks.

2. The sidewalks with the 2 inch drop offs will be repaired.

ESD will contact appropriate contractors to repair the area of concern.

3. ESD and ED will continue to monitor and walk the outside of the community monthly.

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

Observations of the facility interior and exterior on 05/30/23 and 05/31/23 identified the following areas in need of cleaning and repair:

A. Interior:

* Multiple areas of the carpet in the corridors throughout the facility had stains and black spots;

* Multiple apartment doors, door frames, and walls had significant dings and paint scrapes;

* Multiple ceiling tiles had holes and cracks; and

* Multiple wood dining room chairs were worn down to bare wood.

B. Exterior:

* Multiple Benches in the front court yard were worn and had exposed rusted metal; and

* The building siding had dirt and green matter build up.

On 05/31/23, the need to ensure the environment was kept clean and in good repair was discussed with Staff 1 (Executive Director). She acknowledged the findings.

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1. Carpet has been professionaly cleaned by Stanley Cleaners on 6/2/23

2. Carpet will be inspectedby ESD and housekeeping weekly and spot cleaned as needed

3. Carpets to be done professionaly once a year or as needed.

4. ESD and ED to montior carpets monthly.

5. Ceiling tiltes to be replaced by ESD.

6. ED and ESD to monitor monthly and and replace ceiling tiles as needed

7. Dining Room Chairs will be sanded and restained to make surface cleanable.

8. ED and DSM to montior chairs weekly make sure they are cleanable.

9. Wood benches have been removed by ESD and new ones have been orderer.  Metal benches will be sanded and painted by ESD

10  Out side of the community will be powerwashed to remove dirt and green matter and cleaned as needed.

11 ED and ESD to montior and walk around and outside the community monthy.

12. Door handles to be replaced and rekeyed

13. Residents door will be repaired and repainted

14. ESD and ED to montior all doors.