The findings of the re-licensure survey, conducted  04/03/23 through  04/05/23 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 Home and Community Based Services Regulations OARs 411 Division 004.

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

MCCMemory 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 04/05/23, conducted from 07/05/23 through 07/06/23, 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 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, and that weekly progress on the condition was documented for 2 of 4 sampled residents (#s 1 and 4) who experienced changes of condition.  Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in September 2017 with diagnoses including Parkinson's disease.

The resident's 04/01/23 service plan, 01/03/23 through 04/04/23 progress notes, temporary service plans and physician communications were reviewed. The resident experienced multiple short-term changes without progress at least weekly until resolved and/or lacked resident-specific directions to staff in the following areas:

* Edema;

* Abrasions;

* Buttocks wound: and

* Weakness with increased assistance needs.

The need to ensure short-term changes of condition had documentation of weekly progress until resolution and provided clear, resident-specific directions to staff was discussed with Staff 1 (Administrator) and Staff 2 (RCC/Administrative Staff). They acknowledged the findings.

2. Resident 4 was admitted to the facility in February 2023 with diagnoses including stroke and a recent history of falls.

Observations, interviews and review of Resident 4's clinical records including progress notes, incident reports, service plans, temporary service plans and evaluations revealed the following:

* On 2/26/23, staff documented Resident 4 told staff s/he fell in the bathroom and sustained a skin tear to the right forearm. An alert charting note dated 02/28/23, instructed staff to remind and encourage the resident to call for assistance for all transfers. There was no documented evidence the interventions were communicated to staff on all shifts.

* On 03/06/23, staff documented the resident was found on the floor in the bathroom and noted the resident had a new skin tear on the left elbow and a skin tear on the right arm had re-opened. There was no documented evidence the facility developed resident specific interventions to minimize the resident's fall risk.

* On 03/09/23, staff noted the resident fell and sustained a skin tear to the upper right arm. There was no documented evidence the facility developed resident specific interventions to minimize the resident's fall risk.

During observations on 04/04/23 and 04/05/23, Resident 4 required staffs' assistance to transfer and ambulate.

The need to ensure the facility developed resident specific interventions and communicated the interventions to staff on all shifts when residents experienced changes of condition was discussed with Staff 2 (RCC/Administrative Staff) on 04/05/23. She acknowledged the findings.

1. Facility will develop resident specific interventions for each fall, and communication with ALL staff to minimize or reduce resident fall risks.  TSP's will be used to help follow this correction.

2.  Continual discussion with staff at employee staff meetings, continual communication with direct care staff through quickMAR messaging and clear and consice shift reports.

3.  On a daily basis or as needed after an incident with administrator RCC, and nurse.

4. Administrator

Based on observation, interview, and record review, it was determined the facility failed to ensure an RN assessment was completed timely, documented findings, resident status, and interventions made as a result of the assessment for 1 of 2 sampled residents (#1) who experienced significant changes of condition. Findings include, but are not limited to:

Resident 1 was admitted to the facility in September 2017 with diagnoses including Parkinson's disease.

Weight records, dated 11/01/22 through 04/01/23, and progress notes, dated 01/03/23 through 04/04/23, indicated the resident experienced the following:

* A 10.8 pound weight gain between 02/01/23 and 03/01/23, which constituted an 8.16% severe gain in one month; and

* An 18.6 pound weight loss between 03/01/23 and 04/01/23, which constituted a 13.0% severe loss in one month;

The resident's last weight was noted as 124.4 pounds on 04/01/23. A more current weight was not provided prior to exit.

Progress notes, temporary service plans, and physician communications dated 01/03/23 through 04/04/23 indicated the resident was independent with meals, required some assistance for ADLs which varied related to his/her Parkinson's. The resident was alert and oriented, was at risk for aspiration, received nectar thick liquids and could direct his/her own care. The resident had lower extremity edema, utilized compression stockings and was reminded to elevate his/her legs whenever possible.

Multiple observations of the resident between 04/03/23 and 04/04/23 showed the resident attended only two of the five meal opportunities observed. The resident could ambulate to the dining room and eat independently once served. The resident was observed to eat 100% of the meal and fluid items provided with moderate difficulty due to hand control. A meal tray was delivered to the resident's apartment when s/he did not attend the meal in the dining room. Intake amounts were unknown by staff.

In an interview on 04/03/23, the resident indicated s/he had no concerns about the staff or the care s/he received. The resident indicated sometimes the food was great and other times terrible, but it had started to improve. The resident indicated s/he could get alternate items if needed but sometimes s/he just wasn't hungry.

In an interview on 04/05/23, Staff 1 (Administrator), Staff 2 (RCC/Administrative Staff) and Staff 3 (RN) indicated the resident's intake had not really changed. Staff 3 indicated the resident did have edema which was reported to the physician at the time of the weight gain but the physician did not make any medication changes. Staff 2 and Staff 3 further indicated the resident was now back closer to his/her usual weight. Staff 3 acknowledged she had not documented a complete significant change assessment regarding the weight changes.

The facility failed to ensure an RN assessment was completed for the weight losses and gains from February 2023 to March 2023 which documented findings, resident status, and interventions made as a result of the assessment.

The need to ensure an RN assessment was completed which documented findings, resident status, and interventions made was discussed with Staff 1, Staff 2 and Staff 3 on 04/05/23. They acknowledged the findings.  

1. There was not a clear understanding of the rule, and what surveryors had mentioned was new to us.  We understand the rule now and what is expected, regarding weight loss/gain and percentages.  Careful attention was paid to this residents weight as it was noted in the findings.  Better documentation, and oversight will be implemented regarding weights.

2. Better documentation and oversight of weights and communication with PCP.

3. Monthly and as needed regarding changes of condition

4. Administrator

Based on interview and record review, it was determined the facility failed to develop a staffing plan to meet the scheduled and unscheduled needs of the residents based on care minutes calculated by their ABST tool. Findings include, but are not limited to:

The facility's ABST tool calculations, resident ABST data entries and the facility's staffing plan were reviewed on 04/03/23 and 04/04/23 and showed the following:

* The facility was using an ABST tool that generated daily staff hours but was not consistently staffing to the levels identified. The ABST staffing calculations noted 2.5 to 3.5 staff were needed on day shift and swing shift depending on the day of the week.

* The ABST staffing calculations noted 1.5 staff were needed on the overnight shift.

* The facility's posted staffing plan indicated two staff were assigned to day shift and evening shift and one staff was assigned to the overnight shift.

Staff 1 (Administrator) and Staff 2 (RCC/Administrative Staff) confirmed two staff, which consisted of one caregiver and one MT, were assigned to the day shift and evening shift. One staff, which consisted of a medication technician, was assigned to the overnight shift.

Observations of the facility from 04/03/23 through 04/05/23 during day shift and swing shift showed two staff assigned to the floor, one caregiver and one medication technician.

The need to ensure ABST staffing calculations were used to develop a staffing plan to meet resident needs was discussed with Staff 1 and Staff 2. They acknowledged the findings.

1. ABST will be updated to reflect accurate time appropriated to each resident, to include only direct care staff.  Administrator will discuss with care staff and med techs, to get an accurate depiction of time spend providing direct care only.  Also discuss with ODHS ABST staff get a better understanding of how to input correct information.

2.  Monitoring on every change of condition, and quarterly with care plans as needed for each resident.

3.  Every change of condition, quarterly, and as needed.

4. Administrator

Based on observation and interview, it was determined the facility failed to ensure all exterior pathways were made of hard and smooth material, were accessible and free from tripping hazards, and were maintained in good repair. Findings include, but are not limited to:

Observations of the facility's exterior environment, conducted 04/03/23 through 04/05/23, showed pathways located in the facility's courtyard and pathways leading to the facility's entrance and parking lot had multiple drop offs, in excess of two inches, along the pathway edges. The drop offs created a potential tripping hazard for residents.

Additionally, the pathways leading to the facility's entrance and parking lot had areas of cracked and degraded concrete which created a potential tripping hazard for residents.

During a walk through of the facility's exterior environment on 04/04/23, the need to ensure exterior pathways were made of hard and smooth material, were accessible and free from tripping hazards and were maintained in good repair was discussed with Staff 1 (Administrator) and Staff 2 (RCC/Administrative Staff). They acknowledged the findings.

1.  All exterior areas will be evaluated and repaired.  Either with concrete filler, asphalt, or replacement as is appropriate for the repair to meet specified requriement.  New bark dust has been ordered, will be delivered and installed on June 12, 2023.  Contractor has been notified, and will be come by for an assessment of the needed repairs on concrete.

2.  Quarterly inspections of exteriors will be performed, to ensure there are no drops offs and the concrete is in good repair void of tripping hazards.

3.  Quarterly inspections.

4. Administrator

Based on observation and interview, it was determined the facility failed to ensure all exit doors were equipped with operational alarming devices or other acceptable systems to alert staff when residents exited into the courtyard. Findings include, but are not limited to:

Observations of the facility's interior and exterior environment, conducted 04/03/23 through 04/05/23, revealed the following:

Multiple doors which exited to the facility's courtyard were not equipped with operational alarming devices or other acceptable systems to alert staff when residents exited into the courtyard.

During a walk through of the facility's environment on 04/04/23, Staff 1 (Administrator) and Staff 2 (RCC/Administrative Staff) verified the exit doors were not equipped with alarming devices or other acceptable systems to alert staff when residents exited into the courtyard.

1.  NorthEast door will be equiped with an alarming device to ensure that staff are notified when residents are exiting into the courtyard.

2. Alarm will be installed.

3. After installation to ensure proper performance and function.

4. Administrator