The findings of the re-licensure survey, conducted 11/27/23 through 12/01/23, 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, Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.

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

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 revisit to the re-licensure survey of 12/01/23, conducted 05/13/24 through 05/15/24, 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 Home and Community Based Services Regulations OARs 411 Division 004.

Based on interview and record review, it was determined the facility failed to ensure the move-in evaluation contained all required elements and addressed sufficient information to develop an initial service plan to meet the resident's needs for 1 of 1 sampled resident (# 2) who was recently admitted to the facility, and the most recent quarterly evaluation was reflective of the resident's current needs for 1 of 2 sampled residents (# 3) whose records were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 08/2023 with diagnoses including asthma, hypertension, neurofibromatosis, cataract, and depressive disorder.

Review of the move-in evaluation identified the following required elements were not documented as being addressed:

* Customary routines related to sleeping and bathing;

* Interests, hobbies, social, leisure activities;

* Spiritual, cultural preferences and traditions;

* Personality: including how the person copes with change or challenging situations;

* Pharmaceutical and non-pharmaceutical interventions for pain, including how a person expresses pain or discomfort;

* Nutritional habits, fluid preferences and weight if indicated;

* Complex medication regimen;

* History of dehydration or unexplained weigh loss or gain;

* Elopement risk or history;

* Recent losses; and

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

2. Resident 3 was admitted to the facility in 12/2021 with diagnoses including anemia, polyneuropathy, paroxysmal atrial fibrillation, combined systolic (congestive) and diastolic (congestive) heart failure, and edema.

Review of the quarterly evaluation revealed the quarterly evaluation was not reflective of the resident's current needs in the following areas:

* History of dehydration or unexplained weight loss or gain;

* Recent losses; and

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

The need to ensure the initial move-in contained all required elements and the quarterly evaluations were reflective or the resident's current needs was reviewed with Staff 1 (Administrator), Staff 3 (Resident Care Manager), and Staff 16 (LPN) on 11/29/23. They acknowledged the findings. No further information was provided.

1. Additional training on the completion of initial evaluations to be done with the LPN. LPN has been instructed to ensure all boxes are checked and a narrative for each portion of the evaluation/service plan to ensure step by step instructions for staff to care for resident.

2.RN and ED will review eval prior to move in to ensure all areas have been completed.

3. Evaluations will be reviewed prior to each move in. Then every 30, 60, and 90 days.

4. Clinical Team (ED, RCC, RN, LPN)

2. Resident 1 was admitted to the MCC in 08/2022, with diagnoses including Parkinson's Disease, anxiety, and dementia.

Resident 1's service plan, dated 11/26/23, was not reflective of the resident's current status or did not provide clear instructions to staff in the following areas:

* use of wheel chair;

* activity participation/involvement; and

* challenging behaviors.

Observations on 11/28/23, noted Resident 1 sitting in a wheel chair for both meals and activities.

In an interview on 11/28/23, Staff 10 (Caregiver) stated Resident 1 used a wheel chair "when needed, depending on how [he/she] is doing that day".

On 11/30/23 the need to ensure service plans were reflective of residents current needs and provided clear directions to staff was discussed with Staff 1 (Administrator) and Staff 3 (Resident Care Manager). 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' current care needs and provided clear directions to staff regarding the delivery of services for 2 of 4 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 08/2023 with diagnoses including asthma, hypertension, neurofibromatosis, cataract, and depressive disorder.

Interviews with the resident and staff, and review of the current service plan revealed Resident 2's service plan was not reflective of the resident's current needs or lacked clear instructions to staff in the following areas:

* Dental status and use of assistive devices;

* Dietary and nutrition management including current allergies;

* Instructions on non-pharmaceutical interventions for pain, including how a person expresses pain or discomfort;

* Instructions for whom skin impairments should be reported to;

* Instructions for whom weight gain or loss, and changes in appetite should be reported to;

* Instructions on signs and symptoms of depression to report while on anti-depressant therapy; and

* Instructions on signs and symptoms of infection to report while monitoring incision site with sutures.

The need to ensure the service plan reflected residents' current needs and provided clear instructions to staff regarding delivery of services was reviewed with Staff 1 (Administrator), Staff 3 (Resident Care Manager), and Staff 16 (LPN) on 11/29/23. They acknowledged the findings. No further information was provided.

1. Additional training on the completion of person centered service plans to be done with the LPN and RCC. LPN and RCC  has been instructed to ensure all boxes are checked and a narrative for each portion of the evaluation/service plan to include resident prefrences and needs.

2.RCC, LPN, and ED to ensure adequate details are added to each service plan as well as step by step instructions for staff to follow.  

3. Evals will be reviewed prior to each move in. Then every 30, 60, and 90 days.

4. Clinical Team (ED, RCC, RN, LPN)

Based on observation, interview, and record review, it was determined the facility failed to determine and document what action or intervention was needed for the resident with a short-term change of condition, communicate actions or interventions to staff on each shift, and/or to document weekly progress until the condition resolved for 2 of 4 sampled residents (#s 2 and 3) reviewed with changes of condition. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 08/2023 with diagnoses including asthma, hypertension, neurofibromatosis, cataract, and depressive disorder.

Clinical records, including the current service plan, observation notes from 08/27/23 through 11/27/23 were reviewed, and interviews with facility staff and the resident were conducted.

The following short-term change of conditions lacked documentation the facility determined what resident-specific action or intervention was needed for the resident, communicated the determined action or intervention to staff, and documented weekly progress until the condition resolved:

* 09/23/23: Redness in right eye;

* 10/20/23: Witnessed fall with no injury reported;

* 10/29/23: "Resident has had diarrhea stool for the past 36 hours ....";

* 10/31/23: Dark urine;

* 11/01/23: Emergency Room visit related to surgical removal of neurofibroma;

* 11/02/23: Discontinued medications: Naproxen 500mg (for pain), Atenolol 50mg (for blood pressure), and Benazepril 10mg (for blood pressure);

* 11/02/23: New medication order: Senna 8.6mg (for bowel care);

* 11/03/23: New medication order: Clindamycin 300mg (antibiotic);

* 11/15/23: Abdominal pain and diarrhea;

* 11/16/23: Abdominal pain and diarrhea;

* 11/19/23: Diarrhea;

* 11/23/23: Rash under right breast and on the back;

* 11/24/23: Emergency Room visit related to nausea/vomiting and skin infection; and

* 11/26/23: Emergency Room visit related to back skin cellulitis, skin maceration and bleeding from neurofibroma.

2. Resident 3 was admitted to the facility in 12/2021 with diagnoses including anemia, polyneuropathy, paroxysmal atrial fibrillation, combined systolic (congestive) and diastolic (congestive) heart failure, and edema.

Clinical records, including the current service plan, observation notes from 08/27/23 through 11/27/23 were reviewed, and interviews with facility staff and the resident were conducted.

The following short-term change of conditions lacked documentation the facility determined what resident-specific action or intervention was needed for the resident, communicated the determined action or intervention to staff, and documented weekly progress until the condition resolved:

* 09/04/23: " ...leg's toes were weeping a yellow color resident stated that s/he saw blood in the shower ...";

* 09/07/23: Shortness of breath;

* 09/08/23: Shortness of breath;

* 09/10/23: " ...right leg is very infected ...";

* 09/23/23: "Wounds on the bottom of residents L foot are very tender and beginning to swell ...";

* 11/09/23: Discontinued medications: Aquaphor ointment (for skin care), Ferrous Sulfate 325mg (supplement), and Probiotic (for digestive health);

* 11/09/23: "It appears resident is struggling with bouts of depression ...." and

* 11/24/23: Unwitnessed fall with no injuries reported.

The need to ensure the facility evaluated the resident's short-term changes of condition and determined what resident-specific action or intervention was needed for the resident following a short-term change of condition, communicated the determined action or intervention to staff, and documented progress until the condition resolved was reviewed with Staff 1 (Administrator), Staff 3 (Resident Care Manager), and Staff 16 (LPN) on 11/29/23. They acknowledged the findings. No further information was provided.

1. Adequate documentation and resolution to be added to the short term changes.

2. All potential short term or significant change in conditions will be reviewed by reading the observation notes daily. Any changes or concerns will be sent to the RN and LPN to review.

3. Daily by the administrator reading all of the observation notes. This will also be added to daily/weekly checklist to ensure ISP and Alert Charting are completed as well as weekly monitoring and resultions by the nursing team.

4. Clinical Team (ED, RCC, LPN, RN)

Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed for 2 of 4 sampled residents (#s 2 and 4) whose orders were reviewed. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 2022 with diagnoses including mild cognitive impairment and muscle weakness.

Resident 4's current physician orders, dated 11/06/23, and MARs from 11/06/23 through 11/27/23 were reviewed and included the following:

* MD order dated 11/07/23 was in place for daily weights to monitor for swelling after a brain injury. Weights were not taken on 11/08/23, 11/11/23, 11/18/23, 11/23/23, and 11/25/23; and

* The following medications were not administered on the following dates:

- 11/08/23 and 11/10/23 - docusate sodium 250 mg (stool softener);

- 11/08/23 Lamotrigine 20 mg (antacid), multi vitamin, Vitamin C and Vitamin D (supplements); and

- 11/10/23 bumetanide 1 mg (diuretic).

The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (Administrator), Staff 3 (Resident Care Coordinator), and Staff 16 (LPN) on 11/30/23. They acknowledged the findings.

2. Resident 2 was admitted to the facility in 08/2023 with diagnoses including asthma, hypertension, neurofibromatosis, cataract, and depressive disorder.

Review of Resident 2's current physician orders and MARs from 11/01/23 through 11/27/23 revealed the following:

* Atenolol 50mg (for blood pressure) two tabs orally twice daily was discontinued on 11/02/23 per legally recognized practitioner order. However, according to the MAR, the medication was administered on 11/03/23 and morning pass 11/04/23;

* Atenolol 50mg was ordered to be administered one tab orally daily on 11/02/23 per legally recognized practitioner order. According to the MAR, the medication administration started on 11/07/23;

* Senna 8.6mg (for bowel care) was ordered to be administered one tablet orally daily and held for loose stool. According to Observation notes, Resident 2 had diarrhea 11/15/23 and 11/16/23, and Senna 8.6mg was administered on 11/15;

* Loperamide 2mg (for diarrhea) was ordered to be administered one tab orally after each subsequent loose stools and if loose stools accompanied by abdominal pain, fever, or blood in stools, alert RN and PCP immediately. According to Observation note on 11/16/23, Resident 2 "stated she still has stomach pain and diarrhea." There was no documented evidence RN and PCP were notified immediately as ordered; and

* Resident 2 had two contradicting medications orders: Senna 8.6mg (for bowel care) and Loperamide 2mg (for diarrhea as needed). According to the MAR, both medications were administered on 11/11/23, 11/15/23, and 11/27/23.

The need to ensure physician or other legally recognized practitioner orders were carried out as prescribed was reviewed with Staff 1 (Administrator), Staff 3 (Resident Care Manager), and Staff 16 (LPN) on 11/29/23. They acknowledged the findings. No further information was provided.

1. In depth MT training to ensure all MT's are completing medication and treatment orders. Complete MAR audit to be completed.

2. Staff are instructed and trained to notify the clinical team of any medication / treatment orders. Staff continue to follow 3 Step medication approval.

3. Monthly MAR audits to be completed as well as any medication/treatment orders to be addressed when sending the 90 day orders.

4. MT's, and Clinical Team (ED, RCC, LPN, RN)

3. Resident 4 was admitted to the facility in 2022 with diagnoses including mild cognitive impairment and muscle weakness.

Resident 4's current physician orders, dated 11/06/23, and MARs from 11/06/23 through 11/27/23 revealed on 11/08/23 Resident 4 refused docusate sodium (stool softener).

There was no documented evidence the facility notified the physician or other legally recognized practitioner each time the resident refused to consent to the orders.  

The need to ensure the facility notified the physician or other legally recognized practitioner of medication and treatment refusals was reviewed with Staff 1 (Administrator), Staff 3 (Resident Care Manager), and Staff 16 (LPN) on 11/29/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to notify the physician/practitioner if a resident refused consent to an order for 3 of 3 sampled residents (#s 1, 2 and 4) who had documented refusals. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 08/2022, with diagnoses including Parkinson's Disease, anxiety, and dementia.

Review of Resident 1's MAR, dated 11/01/23 through 11/27/23, revealed the resident refused prescribed doses of medication on five occasions. These included three doses of Sinemet (for Parkinson's symptoms) and two doses of Seroquel (mood stabilizer).

There was no documented evidence the facility notified the physician/practitioner when the resident refused consent to the orders.

In an interview on 11/29/23, Staff 3 (Resident Care Coordinator) presented the surveyor with a written policy for informing physicians about refusals, and a fax form used to do so. However, Staff 3 stated there was no evidence of notification for any of the refusals for Resident 1.

On 11/30/23 the need to ensure residents' physicians were notified of all refusals, unless otherwise directed, was discussed with Staff 1 (Administrator) and Staff 3. They acknowledged the findings.

2. Resident 2 was admitted to the facility in 08/2023 with diagnoses including asthma, hypertension, neurofibromatosis, cataract, and depressive disorder.

Resident 2's MARs from 11/01/23 through 11/27/23 and corresponding Observation notes were reviewed. The resident's records showed the Silvadene 1% cream (for skin care) was refused on 12 occasions.

There was no documented evidence the facility notified the physician or other legally recognized practitioner each time the resident refused to consent to the orders.  

The need to ensure the facility notified the physician or other legally recognized practitioner of medication and treatment refusals was reviewed with Staff 1 (Administrator), Staff 3 (Resident Care Manager), and Staff 16 (LPN) on 11/29/23. They acknowledged the findings. No further information was provided.

1. PCP will be faxed regarding all missed medications

2. New forms to be faxed to pcp for notification of missed medications to determine when the pcp would like to be faxed. Once fax is returned, RN will add when to notify to the MAR. Form to be utilized for all residents. Missed medication form to be pulled weekly to assure compliance with any missed medications for the week and to assure notifications were completed.

3. PCP notification form to be reviewed or sent upon move in, frequent missed medications, or during 90 day eval.

4. MT,  and Clinical Team (ED, RCC, LPN, RN)

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 sampled newly hired staff (#s 7, 8, and 9) completed pre-service and 30 day competency training as required. Findings include, but are not limited to:

Training records for Staff 7 (CG), hired 7/20/2023,  Staff 8 (CG), hired 06/15/23, and Staff 9 (MT), hired 03/20/23, were reviewed with Staff 4 (Business Office Manager) on 11/29/23.

There was no documented evidence Staff 7, 8, and 9 had completed the following required Memory Care Community pre-service training:

*  Pre-service Infectious Disease Prevention for community based care;

*  Environmental factors for a resident's well being;

*  Family support and role of the family;

*  Behaviors that require evaluation and assessment;

*  Use of supportive devices with restraining qualities, and

*  Changes associated with normal aging.

The need to ensure staff completed all required pre-service training before working independently was discussed with Staff 1 (Administrator) on 11/30/23. She acknowledged the findings.

1. Currently working on receiving an updated training plan and add to Relias.

2. We will have an updated training list to follow that is reflective of state requirements.

3. Training plans and updates checked weekly, added to BOM weekly checklist.

4. To be completed by BOM and ED to ensure completed.

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 C252,  C260, C270, C303, and C305.

Refer to C252, C260

Based on interview and record review, it was determined the facility failed to fully evaluate each resident for activities and develop an individualized activity plan based on their activity evaluation, for 1 of 1 sampled resident (#1) whose records were reviewed.

Resident 1 was admitted to the MCC in 08/2022, with diagnoses including Parkinson's Disease, anxiety, and dementia.

Resident 1's service plan, dated 11/26/23, included information about past and current hobbies and interests. However, the facility had not fully evaluated the resident regarding:

* Current abilities and skills;

* Emotional and social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for the resident to participate; and

* Activities that could be used as behavioral interventions, if necessary.

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, based on information gathered from the evaluation.

On 11/30/23, the need to ensure the facility completed a thorough activity evaluation, developed an individualized activity plan, and provided meaningful daily activities for each resident was discussed with Staff 1 (Administrator) and Staff 3 (Resident Care Coordinator). They acknowledged the findings.

1. Service Plan and Care Plan to be updated to include an individualized acitivity plan for each resident.

2. Service/Care Plan to address history, likes & dislikes, etc. Life enrichment manager or Clinical team will update life stories and current care plans to be reflective of activity needs, likes, and dislikes.

3. Initally, then 30, 60, and 90 days and every 90 dyas thereafter.

4. Clinical Team (ED, RCC, RN, LPN)