The findings of the re-licensure survey conducted 12/06/21 through 12/08/21 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 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 of 12/08/21, conducted 02/22/22 through 02/23/22, 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.

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 second re-visit to the re-licensure survey of 12/08/21, conducted 05/09/22 through 05/13/22 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 interview and record review, it was determined the facility failed to conduct investigations of injuries of unknown cause to rule-out abuse or report the injuries as suspected abuse to the local Seniors and People with Disabilities (SPD) office, for 1 of 1 sampled resident (#4). Findings include, but are not limited to:

Resident 4 was admitted to the facility in 04/2021 and was dependent on staff for transfers and ADL assistance.

On 11/23/21, facility charting notes indicated the resident had an unwitnessed fall resulting in an approximately 9 inch by 12 inch skin abrasion.

There was no documented evidence the facility immediately investigated and documented the injury was not the result of abuse. The facility did not report the injury to the local SPD office as suspected abuse/neglect.

The need to ensure injuries of unknown cause were investigated promptly or reported if necessary was discussed with Staff 1 (ED) and Staff 3 (LPN) on 12/08/21. They acknowledged the facility had not investigated to rule out abuse/neglect.

The surveyor directed Staff 1 to self-report the incident. Verification the facility had reported the incident to the local SPD office was received during the survey.

1.Incident for resident #4 was reported local SPD prior to survey exit. Re-educated IDT team on our 24-hour process including how to review 24/72-hour summary report, which includes every progress note written in the past 24/72 hrs. This allows clinical team to identify any progress notes that require an incident report and ensure timely reporting and follow up.

2.To prevent recurrence, 24-hour summary will be reviewed five days a week as part of our daily standup meeting. On Mondays, the 72-hour summary will be reviewed to include review of all documentation from the weekend. Alert charting audit will be reviewed daily to ensure all steps were completed for any resident change of condition.

3. System will be evaluated five days a week as part of daily standup meeting and education provided to staff as needed if missed components are identified.

4.The Executive Director and facility LN will be responsible for maintaining this system.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (# 1) whose move-in evaluation was reviewed. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 11/2021 with diagnoses including hypertension, pain in ankle and joints of left foot.   

Resident 1's move-in evaluation failed to address the following:

* Customary routines including eating and bathing;  

* List of medications and PRN use;

* Vital signs if indicated by diagnosis, health problems or medications;

* Mental health issues including history of treatment and effective non-drug interventions;

* Pain relating to pharmaceutical and non-pharmaceutical interventions; and

* Complex medication regimen.

The failure to address all required elements in the move-in evaluation was shared with Staff 1 (ED) and Staff 3 (LPN) on 12/08/21. They acknowledged the findings.

1.Resident #1's move-in evaluation has been updated to be reflective of current status in all required areas.

2.To prevent recurrence, IDT team was re-educated on regulations related to evaluations and the importance of them being accurate and reflective of current status and all required components.

3.This system will be reviewed on weekly during our stand-up process and monthly during our CQI meeting. CQI includes rotating audits that include auditing evaluations and service plans to ensure all required components are being maintained and evaluations are reflective.

4.The Executive Director and facility LN will be responsible for maintaining this system.

Based on observation, interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (#7) whose move-in evaluation was reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 7 moved into the facility on 01/2022. The move-in evaluation failed to address the following areas:

* Customary eating and bathing routines;

* Mental health issues including history of treatment and effective non-drug interventions;

* Memory and confusion;

* Dental status;

* Pharmaceutical and non-pharmaceutical pain interventions; and

* Environmental factors that may impact the resident's behavior including, but not limited to: noise, lighting, room temperature.

The need to ensure move-in evaluations included all required elements was discussed on 02/23/22 with Staff 1 (ED) and Staff 3 (LPN). They explained additional evaluation tools and documents were used that were not currently included in the resident record and acknowledged the facility needed to review its move-in process.

1. Implement a new "Pre-Admission Evaluation' form that includes all of the new required elements.

2. A completed 'Pre-Admission Evaluation' form will be required before any move-in is allowed.

3. With each new move in.

4. Director of Sales and Outreach / LPN / RN to ensure all require elements are captured in the completed 'Pre-Admission Evaluation'.

ED to monitor compliance.

2. Resident 1 moved to the facility in 10/2021 with diagnosis including pain in ankle and joints of left foot, and macular degeneration.

Review of the resident's service plan, dated 10/28/21, interviews with staff and Resident 1, revealed the service plan was not reflective of the resident's current health status and lacked clear direction to staff in the following areas:

* Pain;

* Dietary and nutrition relating to a self reported diverticulitis diagnosis; and

* Use of hearing aids.

The need to ensure resident service plans were reflective and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 3 (LPN) on 12/08/21. They acknowledged the findings.

3. Resident 5 moved into the facility in 02/2018 with diagnosis including atrial fibrillation and chronic obstructive pulmonary disease.

Review of the resident's service plan, dated 11/01/21 and interviews with staff, indicated the service plan was not reflective of the resident's current health status, was not being followed or lacked clear direction to staff in the following areas:

* Bed making;

* Who checks the resident's weight each morning;

* Assistance with clothing selection;

* Unwillingness to ambulate;

* The oxygen tanks and equipment delivery times; and

* Resident 5 arranges his/her own transportation.  

The need to ensure resident service plans were reflective and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 3 (LPN) on 12/08/21. They acknowledged the findings.

4. Resident 4 was admitted to the facility in 04/2018 and was dependent on staff for transfer and ADL assistance.

Review of the resident's service plan, dated 10/24/21 and interviews with staff, indicated the service plan was not reflective of the resident's current health status, was not being followed or lacked clear direction to staff in the following areas:

* Incontinence, bowel and bladder care; and

* Pain management.

The need to ensure service plans were reflective and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 3 (LPN) on 12/08/21. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' status and needs, were being followed, and provided clear direction for staff regarding the delivery of services for 5 of 5 sampled residents (#s 1, 2, 3, 4 and 5) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 2016.

Interviews with care staff and review of the resident's clinical records revealed s/he had recently undergone treatments related to difficulty swallowing and throat pain.

The resident's service plan, dated 09/27/21, was not reflective of the resident's status and needs in the following areas:

* Weight loss due to difficulty swallowing and decrease in food intake and nutritional supplement use; and

* Meals, including decrease in food intake, and the need for soft textured foods when requested.  

The need to ensure service plans were reflective and provided clear direction to staff was discussed with Staff 1(ED) and Staff 3 (LPN) on 12/09/21. They acknowledged the findings.

5. Resident 3 was admitted to the facility in 12/2020.

Review of the resident's service plan, dated 09/27/21, interviews with staff and Resident 3, indicated the service plan was not reflective of the resident's current health status and lacked clear direction to staff in the following areas:

* Emergency evacuation;

* Current skin issues;

* Diet; and

* Home health status.

The need to ensure service plans were reflective and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 3 (LPN) on 12/08/21. They acknowledged the findings.

1.Resident #1, #2, #3, #4 and #5's service plans have been updated to include all required components and to accurately reflect their current status, needs and preferences. Updated service plans were printed and put in service plan binder for staff to review and sign. A form was implemented for care staff to document any discrepancies between service plan and actual care needs or preferences. Form is to be turned into RCC or LN so that service plans can be updated timely.

2.To prevent recurrence, all staff will be re-educated regarding the importance of reporting any inaccuracies on service plans to RCC or LN. Service plan correction form will continue to be utilized. Rotating service plan audits will be conducted as part of monthly CQI process.

3.This system will be reviewed five days a week as part of our daily standup process. ISPs (Interim Service Plan) prog notes will be reviewed daily as part of the 24hr/72hr summary review and service plans will be updated as needed. Additionally, this system will be reviewed monthly as part of our CQI process. Service plans will be reviewed and signed off by each dept. upon admission, at 30 days and quarterly thereafter or with significant change of condition. Each dept. head is responsible for reviewing the accuracy of the service plan as it relates to their dept.

4.The Executive Director, LN and RCC will be responsible for maintaining this system.

2. Resident 1 was admitted to the facility in 10/2021 and was put on a 14 day quarantine due to a COVID-19 protocol. Progress notes, dated 10/29/21 through 11/26/21 were reviewed.

The following was noted:

* 10/30/21 - the resident expressed wanting to meet everyone;

* 11/02/21 - the resident reported feeling lonely; and

* 11/04/21 - the resident "can't wait to get out and meet more people."

There was no documented evidence the status of Resident 1's new admission and the 14 day quarantine were monitored at least weekly through resolution.

The need to ensure the facility had a system documenting changes of conditions at least weekly until resolved was reviewed with Staff 1 (ED) and Staff 3 (LPN) on 12/08/21. They acknowledged the findings.

3. Resident 4 was admitted to the facility in 04/2018 with a unilateral leg amputation and was dependent on staff for transfer and ADL assistance.

A review of Resident 4's clinical records, 09/08/21 through 12/07/21, revealed the resident had ten falls. The resident sustained a skin tear with the fall on 11/23/21.

There was no documented evidence the facility had monitored the falls for latent injury and weekly through resolution.  

In interview on 12/07/21 with Staff 3 (LPN), she acknowledged that alert charting was not completed for the falls, and the resident was no longer being monitored for the skin tear.

The need to ensure all changes of conditions were monitored to resolution was discussed with Staff 1 (ED) and Staff 3 on 12/08/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure short-term changes were monitored for effectiveness, and/or failed to consistently monitor changes through to resolution for 3 of 4 sampled residents (#s 1, 3 and 4) who had changes of condition. Findings include, but are not limited to:

1. Resident 3's progress notes, dated 09/08/21 through 12/06/21 revealed the resident experienced the following changes of condition:

* Missed medications; and

* Multiple medication changes.

There was no documented evidence the missed medications or multiple medication changes were monitored until resolution.

The need to ensure the facility had a system documenting changes of conditions at least weekly until resolved was reviewed with Staff 1 (ED) and Staff 3 (LPN) on 12/08/21. They acknowledged the findings.

1.IDT team has been educated on regulations and policy related to the monitoring of short-term change of condition and the need to monitor and evaluate interventions for efficacy and provide documentation until resolution.

2.To prevent recurrence, we will educate HCCs on change of condition process including when to place residents on alert for LN to assess and implement interventions. Alert charting audit and 24hr/72hr summary will be reviewed at standup as well as alert charting audit to ensure timely interventions are implemented. If a change of condition is identified as a significant change, resident will be placed on weekly RN assessments for additional oversight until resolution or a new baseline is established.

3.This system will be reviewed five days a week as part of our standup process and monthly during our CQI process, which includes an audit of all significant changes of condition.

4.The Executive Director, LN and RCC will be responsible for maintaining this system.

Based on interview and record review, it was determined the facility failed to ensure pre-service dementia care training had been completed, with certification, prior to staff providing direct care to residents, for 2 of 3 newly hired staff (#s 11 and 17). Findings include, but are not limited to:

The facility's training records reviewed on 12/07/21 revealed:

Staff 11 (CG) hired 07/23/21, and Staff 17 (MT) hired 11/23/21, lacked documented evidence they had completed the required pre-service dementia training prior to providing direct care to residents.

The training program and requirements were discussed with Staff 1 (ED), Staff 3 (LPN) and Staff 5 (Business Office Manager) on 12/08/21. They acknowledged the required training had not been completed.

1.New hire staff identified (#11 and #17) have completed dementia care training.

2.To prevent recurrence, education has been provided to BOM and RCC regarding the State regulation that specify staff providing direct care to residents are to receive dementia care training with certification prior to staff providing direct care to residents. New hire employees will be also educated of this regulation. Employee training grid will be maintained by the BOM.

3.Employee training grid will be reviewed weekly as a part of our standup process and monthly during our CQI process to ensure compliance.

4.The Executive Director, BOM, RCC and Administrative Assistant will be responsible for maintaining this system

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 newly hired staff (#s 11 and 18) had demonstrated competency in all required areas within 30 days of hire. Findings include, but are not limited to:

Review of the facility's training records on 12/07/21 revealed the following:

Staff 11 (CG), hired on 07/23/21, and Staff 18 (MT), hired on 07/19/21, did not have documented evidence of demonstration of competency in assigned duties, including medication and treatment administration training, completed within 30 days of hire date.

Staff 11 did not have documented evidence of completion of First Aid certification and abdominal thrust training within 30 days of hire.

The need to ensure staff had documented evidence of competency demonstration in all assigned duties, within 30 days of their hire date, was discussed with Staff 1 (ED), Staff 3 (LPN) and Staff 5 (Business Office Manager) on 12/08/21. They acknowledged the required training had not been completed.

1.New hire staff identified (#11 and #18) have demonstrated competency in all required areas indicated.

2.To prevent recurrence, education has been provided to BOM and LN regarding the State regulation that specify all new hire staff must demonstrate competency in all required areas within 30 days of hire. Employee training grid will be maintained by the BOM with each respective department head providing evidence of training to the BOM.

3.Employee training grid will be reviewed weekly as a part of our standup process and monthly during our CQI process to ensure compliance.

4.The Executive Director, BOM, and LN will be responsible for maintaining this system.

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 veteran staff (#s 10, 12, 13 and 15) completed the minimum required 16 hours of annual in-service training. Findings include, but are not limited to:

Facility training records were reviewed on 12/07/21 and revealed the following:

Staff 10 (CG) hired on 09/18/20, Staff 12 (CG) hired on 02/10/20, Staff 13 (CG) hired on 09/21/20  and Staff 15 (MT) hired on 04/10/18 did not have documented evidence of completing the required 16 hours of annual in-service training.

The need to ensure all required in-service training hours and requirements were completed annually was reviewed with Staff 1 (ED), Staff 3 (LPN) and Staff 5 (Business Office Manager) on 12/08/21. They acknowledged the findings.

1.Veteran staff identified (#10, #12, #13, and #15) will receive the required 16 hours of annual in-service training.

2.To prevent recurrence, education on the regulation and policy regarding the minimum required 16 hours of annual in-service training will be provided to veteran staff, BOM and other applicable staff.

3.Employee training grid will be reviewed weekly as a part of our standup process and monthly during our CQI process to ensure compliance.

4.The Executive Director, BOM, and LN will be responsible for maintaining this system.

Based on interview and record review, it was determined the facility failed to conduct unannounced fire drills every other month at different times of the day, evening and night shifts, failed to include required components on fire drill records, and failed ensure fire and life safety instruction was provided to staff on alternate months. Findings include, but are not limited to:

Fire and life safety records, reviewed between 05/2021 - 10/2021, revealed the following:

* Fire drill records lacked documentation of the following components:

- Problems encountered, including comments relating to residents who resisted or failed to participate in drills;

- Staff members on duty and participating;  

- Number of occupants evacuated; and

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

The requirements regarding fire drills and fire/life safety instruction for staff was reviewed with Staff 7 (Environmental Services) on 12/07/21 and with Staff 1 (ED) and Staff 3 (LPN) on 12/08/21. They acknowledged the findings.  

1.Environmental Services educated on the regulation and policy regarding unannounced fire drills and required components and providing instruction to staff on alternant months.

2.To prevent recurrence fire drill records will include documentation of the following components: - Problems encountered, including comments relating to residents who resisted or failed to participate in drills; - Staff members on duty and participating; - Number of occupants evacuated; and Fire and life safety instruction will be consistently provided to staff on alternate months.

3.Environmental Services will review documentation weekly as a part of our standup process and monthly during our CQI process to ensure compliance.

4.The Executive Director and Environmental Services Director will be responsible for maintaining this system.

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements were being met. Findings include, but are not limited to:

Fire and life safety records were requested during the survey. The following deficiencies were identified:

* Documentation that fire and life safety training was provided to residents within 24 hours of move-in; and

* Documentation that annual fire and life safety training was provided to residents, including all required training topics.

Additionally, staff interviewed during the survey were not aware of the designated point of safety.

The need to ensure residents received fire and life safety training within 24 hours of admission, were re-instructed at least annually, and all staff were aware of the designated point of safety was discussed with Staff 7 (Environmental Services) on 12/07/21 and with Staff 1 (ED) and Staff 3 (LPN) on 12/08/21. They acknowledged the findings.  

1.Education provided to Environmental Services and DSO regarding regulation and policy that fire and life safety training must be provided to residents within 24 hours of move-in; and that annual fire and life safety training must be provided to residents to include all required training topics. Additionally, all staff must receive training and be aware of the designated point of safety.

2.To prevent recurrence: The DSO will play an active role in providing fire and life safety training to residents within 24 hours of move-in. The Environmental Services Director will ensure the annual training is provided to residents to include all required training topics. The Environmental Services Director will also ensure all staff have received training and are aware of the designated point of safety.

3.Environmental Services and the DSO will review documentation weekly as a part of our standup process and monthly during our CQI process to ensure compliance.

4.The Executive Director, Environmental Services and DSO will be responsible for maintaining this system.

Based on observation, interview and record review, it was determined the facility failed to ensure its relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:

Refer to C 252.

1. Hiring new DSO.

2. Provide training to new DSO on Tag C252 requirements and new 'Pre-Admission Evaluation' form.

3. With each new move in.

4. Director of Sales and Outreach / Nurse to ensure all required elements are captured in the completed 'Pre Admission Evaluation'.

ED to monitor compliance.