The findings of the re-licensure survey conducted 08/02/22 through 08/04/22 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 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 re-visit to the re-licensure survey of 08/04/22, conducted on 11/02/22 through 11/03/22, 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 observation and interview it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents. Findings include, but are not limited to:

Resident 3 was admitted to the MCC in 11/2021 with diagnoses including Alzheimer's disease.

Observations and interviews with staff revealed s/he was incontinent of bowel and bladder and relied on staff for all incontinence care needs.

On 08/03/22 at 10:16 a.m., the surveyor obtained permission and observed two CGs provide ADL care for Resident 3. Prior to entering the restroom, one of the CGs was wearing gloves. The second CG put on gloves once in the restroom. The incontinence care was provided and both CGs removed their gloves and left the restroom. A CG then wheeled Resident 3 to the elevator to attend an activity and the other CG took the soiled incontinence products to the garbage. No hand hygiene was observed after the ADL care,  prior to leaving the restroom.

The need to ensure staff consistently used effective universal precautions was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 08/04/22 at 4:20 p.m. They acknowledged appropriate infection control practices were not implemented.

C160:

a.Put all direct care staff through Infection Control Training, highlighting standard precautions and hand hygiene before and after care

b.All direct care staff to go through Infection Control Training prior to service and at least annually

c.All direct care staff to go through Infection Control Training prior to service and at least annually. Each staff member to be signed off

pre-service and at annual training.

d.The Administrator

Based on observation, interview and record review, it was determined the facility failed to ensure resident service plans were updated when a resident experienced a change of condition, were reflective of the residents' current needs and provided clear direction to staff regarding the delivery of services for 2 of 2 sampled residents (#s 2 and 3) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 05/2017 with diagnoses including Alzheimer's disease and anxiety.

Resident 2's 06/2022 service plan and Interim Service Plans (ISPs), dated 05/24/22 through 08/02/22, were reviewed, the resident was observed and staff were interviewed.

The service plan had not been updated when the resident experienced a significant change of condition in 07/2022, nor was it reflective or provided clear caregiving instruction in the following areas:

* Interventions of how to redirect when behaviors occur;

* Interventions of how to provide ADL assistance when care was being refused;

* Vision ability and assistance needed to sit down in common use areas;

* Pain including both non-drug interventions and PRN medications;

* Fall interventions including monitoring the bathroom floor as the resident will attempt to toilet self;

* Interventions of how to redirect when s/he is exhibiting anxiety;

* Showering assistance; and

* What staff should monitor for relating to anxiety triggers.

Resident 2 was observed on 08/03/22 at 9:26 a.m. walking slowly, eyes not fully open, with two staff members standing by. The resident was observed again on 08/04/22 at 3:12 p.m., walking independently at a quicker pace, and much more alert. The amount of assistance needed depending on the day and the resident's ability was not reflected in the service plan.

The need to ensure service plans were updated after a significant change of condition was identified, were reflective of current care needs and provided clear instruction to staff was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 08/04/22. They acknowledged the findings.

2. Resident 3 was admitted to the facility in 11/2021 with diagnoses including Alzheimer's disease.

Resident 3's 06/2022 service plan and Interim Service Plans (ISPs), dated 06/15/22 through 07/31/22, were reviewed, the resident was observed and staff were interviewed.

The service plan was not reflective and/or did not provide clear caregiving instruction in the following areas:

* Hearing aid status;

* Frequency of monitoring vital signs;

* Skin monitoring;

* Pain history, management and how the resident communicates pain;

* Expression of anxiety;

* Fall risk interventions including use of a pool noodle while in bed;

* Toileting assistance;

* Diet texture;

* Use of protective garments during meals;

* Right-sided weakness;

* Assistance and behaviors associated with grooming and hygiene; and

* Walking program.

The need to ensure service plans were reflective of current care needs and provided clear instruction to staff was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 08/04/22. They acknowledged the findings.

C260:

a.Resident 2 and 3's service plan have been updated accordingly

b.The Springs Living Evaluation, which builds the resident's service plan, has prompts for each area listed on the statement of deficiency

c.Service Planning, training provided to Administrator and RN, who will be assisting with RSC tasks until a new one is hired

d.The Administrator

2. Resident 2 was admitted to the facility in 05/2017 with diagnoses including Alzheimer's disease and anxiety.

The resident experienced multiple short-term changes of condition from 04/11/22 through 08/01/22.

The following short term changes of condition lacked documented evidence they were evaluated to determine if any actions or interventions were needed:  

* 05/12/22 - Fall; and

* 07/10/22 - Suicidal ideation.

On 07/15/22, Staff 2 (RN) documented on a change of condition relating to increased behaviors. There was no documented evidence the actions and interventions that resulted from her findings were communicated to staff on each shift.

The following short-term changes of condition lacked documented evidence they were monitored through resolution:

* 04/11/22 - Fall; and

* 07/10/22 - Suicidal ideation.

The need to ensure changes of condition were evaluated to determine if any actions or interventions were needed and, if so, were communicated to staff on each shift and were monitored through resolution was discussed with Staff 1 (Administrator) and Staff 2 on 08/04/22. They acknowledged the findings.

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, the interventions were communicated to the staff, the condition was monitored weekly until resolved and residents were monitored per their evaluated needs for 2 of 2 sampled residents (#s 2 and 3) who experienced changes of condition. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility with diagnoses including Alzheimer's disease.

The resident had multiple documented short-term changes of condition, including two falls, between 05/07/22 and 07/26/22.

The following short-term changes of condition lacked evidence that the resident was evaluated and resident-specific interventions were determined, documented and communicated to staff:

* 06/25/22 - Fall; and

* 07/15/22 - Left shin bruise.

The following short-term changes of condition lacked documented evidence the resident's interventions were monitored through resolution:

* 06/15/22 - Fall;

* 06/25/22 - Fall; and

* 07/15/22 - Left shin bruise.

The need to ensure changes of condition were evaluated to determine if any actions or interventions were needed and, if so, were communicated to staff on each shift and monitored through resolution was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 08/04/22. They acknowledged the findings and no additional information was provided.

C270:

a.Resident 2 and 3's short term changes of condition have been evaluated and reflected in the respective resident's progress notes and service plans

b.Training provided to RN and Administrator, using the ODHS provided "Compliance Guidelines - Change of Condition and Monitoring."

c.Training to Change of Condition to occur at least once a year.

d.The Administrator

Based on observation, interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 1 of 2 sampled residents (# 3) whose orders were reviewed. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 11/2021 with diagnoses including Alzheimer's disease.

Resident 3's MARs, dated 07/01/22 through 08/02/22, corresponding progress notes and current physician's orders were reviewed.

Records revealed the following medications were not given as prescribed on the following dates, with documentation stating the facility was out of the medication:

* Levothyroxine 100 mcg (for thyroid hormone replacement) - 07/16/22;

* Omeprazole 20 mg (to treat heartburn) - 07/31/22;

* Prednisone (to treat inflammation) - 07/08/22 and 07/24/22;

* Silvasorb (for wound care) - 07/10/22;

* Micanazole 2% powder (for skin integrity) - 07/27/22; and

* Probiotic (for GI health) - 07/26/22.

During a meal observation on 08/03/22 at 9:06 a.m., Resident 3 had just finished his/her breakfast when Staff 3 (MT) brought multiple crushed medications to take. In an interview with Staff 3, she reported she administered the following time sensitive medications:

* Omeprazole 20 mg - take 1 capsule by mouth every day take 30 minutes before meals; and

* Glipizide 5 mg (to treat diabetes)  - take 1 tablet every morning 30 minutes before meals.

The need to ensure physician orders are carried out as prescribed was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 08/04/22. They acknowledged the findings.

C303:

a.Resident 3's medications are all ordered and present for administration

b.RN trained on how to run report on PCC to inform her of what medications have been documented as "unavailable." Med Tech training provided as to proper follow-up when out of medication. eMAR prompts Med Tech to administer time-sensitive medications, med tech training provided on proper response when unable to administer medications on- time.

c.Training to be provided at least once a year.

d.The RN

Based on interview and record review, it was determined the facility failed to ensure residents' MARs were accurate, documented reasons for use and provided clear instruction and parameters for administration of PRN medications for 2 of 2 sampled residents (#s 2 and 3) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 05/2017 with diagnoses including Alzheimer's disease.

The resident's 07/01/22 through 08/02/22 MARs and progress notes dated 04/12/22 through 08/02/22 were reviewed.

On 07/25/22 at 6:33 p.m., a progress note indicated the resident was going to go to the Emergency Department to be evaluated. A progress note on 07/26/22 at 9:42 p.m. confirmed the resident had returned to the facility.

The following medications were documented as administered at 5:00 p.m. on 07/26/22:

* Gabapentin (prescribed for Alzheimer's disease); and

* Memantine (used to slow the progression of dementia).  

An interview on 08/03/22 at 11:24 a.m. with Staff 3 (MT) revealed that the computer program was confusing when it pertained to missed medications due to the resident being out of the facility. A follow-up interview with Staff 1 (Administrator) on 08/04/22 confirmed the two medications were not administered.

The need to ensure accurate documentation on residents' MARs was discussed with Staff 1 and Staff 2 (RN), who acknowledged the findings.

2. Resident 3 was admitted to the facility in 11/2021 with diagnoses including Alzheimer's disease.

Resident 3's MARs, dated 07/01/22 through 08/02/22, were reviewed.

a. Silvasorb gel, used for skin integrity, lacked a documented reason for use on the MARs.

b. The following scheduled medications lacked specific instructions to staff:

* Prednisone 5 mg (to treat inflammation) - take one tablet by mouth every day for management of rheumatoid arthritis, may increase to five tablets for flares; and

* Metformin 500 mg (to treat diabetes) - take one tablet by mouth twice daily, "Notify pharmacy if tolerated."

c. The following PRN medications lacked specific parameters and/or instructions to staff:

* Morphine sulfate 20 mg/ml solution (to treat pain) - take 0.25mL by mouth every 15 minutes as needed for pain and/or shortness of breath;

* Tramadol 50 mg tablet (to treat pain) - take one tablet by mouth three times daily as needed for pain;

* Flonase Suspension 50 mcg/act (to treat allergies) - one spray in each nostril every 24 hours as needed for allergies; and

* Lorazepam Intensol 2 mg/ml (to treat anxiety) - take 0.25mL by mouth every four hours as needed for agitation, anxiety and nausea.

The need to ensure medications on the MARs included reason for use, resident-specific instructions to staff for scheduled and PRN medications and resident-specific parameters for PRN medications was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 08/04/22. They acknowledged the findings.

C310:

a.A late entry has been made in Resident 2's eMAR to reflect the two medications were not administered, because the resident was out of the facility. The Med Techs have been trained as to how to document "resident unavailable" on the software program used to document against the MAR. Resident 2's MAR was reviewed and both reason for use and specific instructions added to all medications pointed out in the statement of deficiency.

b.All residents MARs have been audited for reason for use and need for specific instructions to staff.

c.Training provided to RN, as part of final orders check, ensure reason for use and specific instructions for staff are added to the order, during the multi-check order approval process. Training also provided to RN on how to run reports to help identify orders that require the above.

d.Training to be provided at least once a year.

Based on interview and record review, it was determined the facility failed to ensure all required fire drill components were documented and failed to provide fire life safety instruction to staff on alternating months. Findings include, but are not limited to:

On 08/02/22, fire drill and fire and life safety training records for the previous six months were requested.

Review of the documentation provided identified the following:

* Fire drill records lacked consistent documentation of the following components:

- Escape routes used; and

- Number of occupants evacuated.

* Fire and life safety instruction was not consistently provided to staff on alternate months.

The requirements regarding fire drills and fire and life safety instruction for staff were reviewed with Staff 1 (Administrator) on 08/04/22. She acknowledged the findings.

C420:

a.Please Attachment for documentation of the last Months six months of fire drills.

b.The documents will show the fire drill was completed in both Assisted Living and Memory care.

c.The documents are dated:

-2/23/2022

-3/20/2022

-4/26/2022

-5/31/2022

-6/8/2022

-7/29/2022

d.Escape routes listed and acknowledge in all fire drill documentation See Document name " Fire and safety-Training/Drill Documentation". Page 2 question #9.

e.New Documentation was created to add the question "Number of Occupants evacuated". Please attached document " Post Fire Drill Evaluation Form".

f.Escape routes listed and acknowledge in all fire drill documentation See Document name " Fire and safety-Training/Drill Documentation". Page 2 question #9.

g.New Documentation was created to add the question "Number of Occupants evacuated". Please attached document " Post Fire Drill Evaluation Form".

Based on observation and interview, it was determined the facility failed to keep all interior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows and furniture) and all equipment necessary for the health, safety and comfort of the resident clean and in good repair. Findings include, but are not limited to:

The interior of the building was toured on 08/02/22 at 10:27 a.m. The following areas needed cleaning or repair:

* Doors for resident rooms 104, 105 and 111 had staining, drips, gouges in the wood and/or scratches in the paint;

* Door frames for resident rooms 107, 108, 110 and 111 had brownish drips;

* Door frames throughout the community were gouged and chipped with bare wood exposed;

* Window screen for room 105 was torn;

* Handrails across from the medication room and across from resident room 110 were raised at joints, increasing risk for skin tears;

* Lighting fixtures and windows throughout the community had spider webs;

* Walls throughout the community had white drips;

* Chair rail in the TV room was gouged with bare wood exposed;

* Piano laminate was not attached at the corner;

* Lounge chair in TV room near the TV had staining on the seat;

* Fireplace had brown/pink residue near the mantle;

* Floor of the dining room had food debris;

* Bench near resident room 106 and 111 had staining on the seat;

* Washers and dryers were surrounded by dust and debris; and

* Laundry room floors were scuffed with black and brown marks.

The need to keep interior materials and surfaces and all equipment necessary for the health, safety and comfort of the resident clean and in good repair was discussed with Staff 1 (Administrator) on 08/04/22 at 3:45 p.m. She acknowledged the findings.

C513

a.Work Order for All Trim and Doors in Memory care to be painted. See attachment.

b.Work order placed. Window screen for room 105 has been replaced. See attachment.

c.Work order for handrail has been put in. Handrails will be fixed. See attachment.

d.All housekeeping staff have been provided updated checklist, see attachment "Housekeeping cleaning schedule "

e.All walls wiped and disinfected to remove white drip marks and smudges.

f.    All Light fixtures and windows have been dusted and cleared of cob webs and dust.

g.Work order placed Chair rail will be painted and exposed wood will be covered. See attachment for work order. Work order placed for Piano laminate. It will be re-glued to close any gaps. See attachment for work order.

h.Fire place area has been cleaned, there is no residue. Training provided to staff to ensure area maintains cleanliness. See attachment "Housekeeping cleaning schedule ".

i.Dining room floor will commonly have debris due to Memory cares motor control and cognitive impairments. These are situational occurrence and the area is cleaned after all residents have finished, their meals and snacks. Staff have been provided

j.training to emphasize the need for timeliness in the cleanup process.

k.Washer and dryers have been dusted and cleared of any Debris; Training provided to ensure all cleaning task completed. See attachment "Housekeeping cleaning schedule ".

l.Director Of Plant Operations

Based on observation, interview and record review, it was determined the facility failed to provide a call system that connected resident units to the care staff center or staff pagers. Findings include, but are not limited to:

During observations in the MCC on 08/02/22 at 11:20 a.m., it was noted that resident bedrooms did not have a pull cord or other call system which allowed residents to alert staff in the event of an emergency. However, all restrooms within the MCC did have functioning pull cords.

In an interview with Staff 12 (MT) on 08/02/22 at 12:59 p.m., she confirmed there were only two residents in the MCC who had pendant alarms. She went on to confirm the evening shift frequently monitored all residents and encouraged residents to stay in common areas during the day for safety.

Service plans confirmed that Residents 1, 2 and 3 were evaluated for their ability to use a call light. In Resident 1's record it stated that s/he "rarely used" his/her call light and was observed to request assistance verbally. Residents 2 and 3 were evaluated to be unable to use their call lights, which was confirmed through observation and interview.

The need to provide a call system that connected resident units to the care staff was discussed with Staff 1 (Administrator) on 08/04/22 at 3:45 p.m. She confirmed the findings.

A.All memory care residents are assessed at initial move in for the use of a pendant.

B.Please see the example attached, The springs Living Move in evaluation.

C.All memory care resident have a call system in their apartment.

Based on 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 C 160, C 231, C 420, C 513 and C 555.

Z142, refer to plan of correction for C160, C231, C513, and C555.

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 C 260, C 270, C 300, C 303 and C 310.

Z162, refer to plan of correction for C260, C270, C300, and C310.

Based on interview and record review, it was determined the facility failed to evaluate and develop individualized activity plans for 1 of 2 sampled residents (# 2) whose service plans were reviewed. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 05/2017 with diagnoses including Alzheimer's disease and anxiety.  

Although there was some information related to the resident's past interests, the documentation lacked the following components:

* Current interests;

* Current abilities and skills;

* Emotional and social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for the resident to participate; and

* Identification of activities for behavioral interventions.

There was no specific activity plan which detailed what, when, how and how often staff should offer and assist the resident with more individualized activities.

The lack of an activity evaluation and individualized activity plan was discussed with Staff 1 (Administrator) on 08/04/22. She acknowledged the findings.

Z164:

a.Resident 2's service plan was updated in each area identified as lacking in the statement of deficiency

b.The Springs Living Evaluation, which builds the resident's service plan, has prompts for each area listed on the statement of deficiency.

c.All initial evaluations , completed by RN, and following 30 day, quarterly, anal and significant change assessments, completed by RSC, include service planning for residents

( please see attachment for copy of Evaluation). Evaluation includes past biographies, family, culture, religion, hobbies, interest, psychical, emotional and cognitive strengths an limitation that staff and life enrichment might need to support.

d.Move in meeting with family will now include the life enrichment team to meet with Memory care residents family to ensure that the care plane completely represents the resident needs and preferences. Administrator held in service with life enrichment and initiated new standards as of 8/12/22

e.At 30 day, quarterly and annual, RSC will meet with Life enrichment and they will provide updates and in all areas on the assessment to ensure the latest service plan reflects the resident current interest.

f.Monthly activities calendar will be reviewed when a new Memory care residents has moved in to ensure that interest are represented in the programing.

g.Please see Life Enrichments packets provided to residents family at move in meeting attached.

h.All 16 Memory care residents care plans will be reviewed by RSC to ensure all the components of Activities is acknowledged.

i.Service Planning, training provided to Administrator, RN, and RSC.

j.The Administrator will be responsible to competing all training.

Based on observation and interview, it was determined the facility failed to ensure residents were not locked out of their rooms. Findings include, but are not limited to:

During the survey, observations of resident rooms revealed multiple rooms were locked from the outside, preventing residents from entering their rooms without assistance from staff. Caregiving staff each carried a key which could open residents' rooms, and caregivers provided prompt assistance when residents requested to go to their rooms.

On 08/02/22, Staff 6 (CG) was observed to go to resident room 101 and to unlock the door prior to entry. When questioned about why doors were being locked, Staff 6 stated the facility was locking doors to keep residents from entering.

In an interview with Staff 2 (RN) on 08/03/22 at 11:12 a.m., she confirmed that the doors were locked from the outside, so residents don't wander into rooms. She went on to state that the residents could leave their room without assistance and were able to enter their rooms with an escort. She demonstrated the doors were not locked from the inside.

The need to ensure residents were not locked outside their rooms, and to include the preference for a locked door in the service plan if the resident requested a locked door, was discussed with Staff 1 (Administrator) on 08/04/22 at 3:45 p.m. She acknowledged the findings.

Z176:

a.All doors have been unlocked and service plans updated for resident preference if the resident prefers his or her door to be locked

b.After The Springs acquired this building, the Memory Care was remodeled to include Dutch Doors, so that the bottom half could be shut, but the top half open. Thereby, discouraging residents from wandering into other residents room. Education provided to Administrator and RN about alternative interventions to attempt if the Dutch Doors are not working such as, STOP signs or large, flat black doormat in front of doors

c.Training on wandering interventions to be provided at least once a year.

d.The Administrator.