The findings of the re-licensure survey, conducted  08/01/22 through 08/03/22 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 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 revisit to the re-licensure survey of 08/03/22, conducted 05/02/23 through 05/04/23, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Based on interview and record review, it was determined the facility failed to ensure new move-in evaluations addressed all required elements for 2 of 2 sampled residents (#s 1 and 4) whose new move in evaluations were reviewed.  Findings include, but are not limited to:

Review of the new move-in evaluations for Resident 1, admitted 05/2022, and Resident 4, admitted 08/2022, revealed that all required elements had not been addressed.

The need to ensure new move-in evaluations contained all required elements was discussed with Staff 1 (Executive Director), Staff 2 (Assisted Living Director), Staff 3 (RN), and Staff 5 (Regional Director of Operations) on 08/03/22. They acknowledged the findings.

Pre Move in eval form was updated to reflect all required elements.  Updated form has been distributed to ALD/MCD and RN for use.  

ED, ALD/MCD and RN have reviewed the required elements for the pre move in eval and the updated form to assure understanding.  ALD/MCD and RN will review for completion of the updated version of the form for each future move in.

Review of completed premove in eval will be conducted within 48 following admission to verify completion.  

ALD/MCD RN and ED

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction to staff regarding care and services, and were followed by staff 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 March 2021 with diagnoses including diabetes and hypertension.

Observations of the resident, interviews with staff, and review of the service plan dated 06/26/22 showed the service plan was not reflective of the resident's current care needs, did not provide clear direction to staff, and/or was not followed by staff in the following areas:

* Dressing, toileting, and ambulation;

* Transfers and gait belt use;

* Electric wheelchair care and use;

* Catheter care and stoma care;

* Skin risk, pressure reduction, and repositioning;

* Resident non compliance with care and approaches to utilize;

* Private caregiver hours and facility responsibilities; and

* Falls and safety interventions.

The need to ensure resident service plans were reflective of current care needs, provided direction to staff, and were followed was discussed with Staff 1 (Executive Director), Staff 2 (Assisted Living Director), Staff 3 (RN), and Staff 5 (Regional Director of Operations). The staff acknowledged the findings.

2. Resident 1 was admitted to the facility in 05/2022 with diagnoses including mild cognitive impairment.

Review of the resident's facility record and interviews with staff revealed the 06/25/22 service plan was not reflective of the resident's current status and care needs in the following areas:

* Continence and toilet use;

* Discontinuation of compression socks;

* Two-person transfers versus mechanical lift;

* Strategies for addressing behaviors: and

* Resident's habit of picking at his/her skin.

The need to ensure service plans were reflective of the resident's status and care needs was discussed with Staff 1 (Executive Director), Staff 2 (Assisted Living Director), Staff 3 (RN), and Staff 5 (Regional Director of Operations) on 08/03/22. They acknowledged the findings.

Care needs for sampled residents #1 & #2 have been reviewed and service plans updated for any noted missing information.  A review of the remaining residents service plans will be completed to verify accuracy.

Training on the service planning process and use of Temporary Care Plans has been provided to the new Assisted Living Director to assure understanding of purpose and process for use.  Development if the initial and ongoing service plans will include a review of resident current care needs as well as any behavior patterns such as refusals of care to assure information is present for staff reference. ALD will conduct reviews daily on days worked of progress notes and occurrence related documents to identify for needed TCP's or service plan updates.

Daily review of progress notes & SP routine of initial, 30 day and 90 day or with a significant change of condition

Assisted Living Director with oversight from Executive Director

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 the condition was monitored at least weekly to resolution for 3 of 4 sampled residents (#s 1, 2 and 3) who experienced changes of condition.  Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in March 2021 with diagnoses including diabetes and hypertension.

Observations of the resident, interviews with staff, review of the service plan dated 06/26/22, temporary service plans, incident investigations and progress notes dated 05/01/22 through 08/01/22 were reviewed. The service plan indicated the resident frequently transferred on his/her own, had frequent falls, had some confusion and could utilize the call light to gain staff assistance.

a. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness and/or lacked resident-specific directions to staff in the following areas:

* Falls;

* Hospitalization and ER visits;

* Catheter output, tubing placement and stoma condition;

* Leg pain, skin breakdown and excessive itching;

* Increased weakness and confusion;

* Elevated blood pressures; and

* New medications and medication changes.

b. Review of the resident's progress notes and investigations showed the following:

* A progress note dated 05/07/22 indicated the resident had a witnessed fall. No injuries were noted.

* A progress note dated 06/26/22 indicated the resident had a unwitnessed, non injury fall. The resident complained of back pain.
 

There was no investigation documented related to the two falls.

* On 05/04/22 the resident had a non injury fall, one hour checks were implemented;

* On 06/01/22 the resident had a non injury fall, no new interventions were noted;

* On 07/10/22 the resident experienced a fall at 1:15 am, 8:15 pm and 4:40 pm, one hour checks were noted after the 1:15 am fall. No additional interventions were implemented. The resident was noted to have increased leg weakness. The resident was sent to the hospital after the third fall;

* On 07/31/22 the resident had a non injury fall due to leg weakness, no new interventions were noted;

Investigations were completed but documentation did not reflect thorough investigations of the falls to determine the cause, minimize reoccurrence, develop and implement interventions and to re-evaluate existing interventions for appropriateness and effectiveness.  

The resident experienced an additional fall on 08/02/22 and 08/03/22. No injuries were noted, investigations were in process. No new interventions were documented on facility temporary service plans or communicated to staff.

The need to ensure short-term changes of condition had documentation to reflect monitoring at least weekly to resolution, provided clear, resident-specific directions to staff and that interventions were evaluated for effectiveness was discussed with Staff 1 (Executive Director), Staff 2 (Assisted Living Director), Staff 3 (RN) and Staff 5 (Regional Director of Operations) on 08/03/22. The staff acknowledged the findings.

2. Resident 3 was admitted to the facility in March 2021 with diagnoses including Autism.

Observations of the resident, interviews with staff, review of the service plan dated 07/06/22, temporary service plans and progress notes dated 05/01/22 through 08/01/22 were reviewed. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness and/or lacked resident-specific directions to staff in the following areas:

* Skin injuries and scratches;

* Choking episode; and

* Missed medications.

The need to ensure short-term changes of condition had documentation to reflect monitoring to resolution at least weekly and provided clear, resident-specific directions to staff was discussed with Staff 1 (Executive Director), Staff 2 (Assisted Living Director), Staff 3 (RN) and Staff 5 (Regional Director of Operations) on 08/03/22. The staff acknowledged the findings.

3. Resident 1 was admitted to the facility in 05/2022 with diagnoses including mild cognitive impairment.

Review of the 06/25/22 service plan, 5/25/22 through 08/01/22 progress notes and skin monitoring sheets revealed the resident experienced short-term changes of condition related to skin and allergies. There was no documented evidence the facility determined and documented what actions and interventions were needed for the resident when s/he experienced the changes, communicated to them to staff, and monitored them at least weekly through resolution.

The need to determine and document what actions and interventions were needed for the resident when s/he experienced short-term changes of condition, communicate to them to staff, and monitor them at least weekly through resolution was discussed with Staff 1 (Executive Director), Staff 2 (Assisted Living Director), Staff 3 (RN) and Staff 5 (Regional Director of Operations) on 08/03/22. They acknowledged the findings.

1) Resident #1, #2 & #3: Evaluations of residents changes in the last 30 days and closure documentation noted in their progress notes.  A review of remaining resident's progress notes for the last 14 days was completed to verify completion of documentation of monitoring and closure of short term changes of condition.

2)  Re-education will be provided to MT staff on the alert charting process.  New ALD has received training on the community's alert charting process to asure understanding and role driven oversight.  Progress notes and resident occurrent related documentation will be reviewed routinely to assure assessments notes are present as applicable and staff monitoring notes are present while resident is on active alert.

3)  Progress notes and occurrence related documentation will be reviewed daily.  ED will verify completion of noted audits during weekly meetings with ALD and nurse.

4)  ALD, Nurse and ED  

2. Resident 2 was admitted to the facility in March 2021 with diagnoses including diabetes and had a suprapubic catheter.   

During the acuity interview on 08/01/22, Resident 2 was identified as receiving outside provider services related to catheter care and wound care.  

Observations of the resident, interviews with staff, and review of the service plan dated 06/26/22, progress notes and outside provider notes dated 05/01/22 through 08/01/22 were completed. The resident experienced frequent falls, had multiple areas of skin injury and required catheter care.

Home health notes related to catheter care visits, physical therapy visits and wound care showed the following:

* On 05/03/22 resident seen for physical therapy, staff were to provide stand by assist when the resident was walking in the hallways;

* A 05/06/22 wound care visit indicated resident complained of itchy skin. Resident soiled for long periods of time and says s/he does not change brief daily. Staff were to assist the resident in keeping brief clean and dry, "needs assist in applying calmoseptine to clean skin daily";

* Wound care recommendations on 05/09/22 indicated staff were to continue to help with brief changes and applying barrier cream;

* Wound care recommendations on 05/16/22 indicated staff were to encourage frequent position changes;

* Wound care recommendations on 05/19/22 indicated staff were to encourage resident not to scratch bottom and keep brief clean;

* Wound care visit on 05/24/22 indicated resident itching bottom causing bloody drainage. Recommendations indicated "Please change brief frequently to ensure it is clean and dry;"

* Wound care recommendations on 05/26/22 indicated plan of care should be updated to assist resident in brief changes and keeping clean and dry. Encourage the resident to get up and move every hour and change positions to off load pressure;

* Wound care recommendations on 05/31/22 indicated staff were to encourage the resident to change positions and stand up frequently to improve circulation and keep brief clean;

* Wound care recommendations on 06/09/22 indicated staff were to remind the resident to change positions frequently;

* Wound care recommendations on 06/16/22 indicated the resident was found to be soiled, staff to assist resident with brief changes to keep clean and dry; and

* Therapy recommendations on 07/25/22 indicated resident should not be walking without assistance.

There was no evidence the recommendations were consistently implemented and/or communicated to staff.

The need to ensure on-going coordination of care recommendations were implemented was discussed with Staff 1 (Executive Director), Staff 2 (Assisted Living Director), Staff 3 (RN) and Staff 5 (Regional Director of Operations) on 08/03/22. The staff acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to coordinate on-site health services with outside service providers for 2 of 2 sampled residents (#s 1 and 2) who received home health services. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 05/2022 with diagnoses including mild cognitive impairment.

During the acuity interview on 08/01/22, Resident 1 was identified as receiving outside provider services related to wound care.  

The resident's 06/25/22 service plan, 06/09/22 through 08/01/22 progress notes, outside provider notes and the MAR were reviewed. Resident 1 had wounds on his/her right heel and left ankle that home healthcare nursing had treated. The following recommendations were made:  

06/09/22: Daily, except for weekends, and PRN wound care;

07/18/22: Moisturize skin daily;

07/21/22: Assist resident to rotate pillows and cushion in wheelchair; and

07/25/22: Encourage water intake and off-loading of pressure (sacral).

There was no documented evidence the recommendations were implemented and/or communicated to staff.

During an interview with Staff 6 (Medication Aide), she stated that the home health RN completed the resident's wound care.

There were no entries on the 06/09/22 through 08/01/22 MAR which indicated facility staff had completed wound care.

The need to coordinate on-site health services with outside service providers was discussed with Staff 1 (Executive Director), Staff 2 (Assisted Living Director), Staff 3 (RN) and Staff 5 (Regional Director of Operations) on 08/03/22. They acknowledged the findings.

Service plans for sampled residents have been updated with outside provider care recommendations.  An audit has been conduted for remaining residents utilizing outside providers to include a review of the last 30 days worth of visits to verify recommendations have been placed on the service plans or TCP's.

Education has been provided to the ALD on the process of reviewing outside provider notes and initiating TCP's for new care recommendations to assure understanding.

ALD and RN will routinely audit to assure notes are obtained for each outside provider visit and that new recommendations are implemented as applicable using the Temporary Care plan process.  

Audits will take place weekly for residents receiving outside provider therapies

ALD/RN with ED oversight.

Based on interview and record review, it was determined the facility failed to ensure signed physicians orders were implemented as directed by the residents' physician for 2 of 3 sampled residents (#s 1 and 2) whose MARs/TARs were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in March 2021 with diagnoses including hypertension and weakness.

Review of the resident's 05/01/22 through 08/02/22 progress notes, 07/08/22 physician orders and the 07/01/22 through 08/02/22 MARs showed the following:

* A physician's order for Metoprolol Succinate 100 mg tab extended release, one tab daily.

* The medication was to be held for a heart rate less than 60.

The MAR contained no documentation the resident's heart rate was taken prior to administering the medications.

In an interview on 08/03/22, Staff 2 (Assisted Living Director) indicated staff were not recording the heart rate for the resident. Staff 2 stated there was no documentation to show if the medication needed to be held based on the physician's ordered parameters.  

The need to ensure physician orders were implemented as directed including administration and hold parameters was discussed with Staff 1 (Executive Director), Staff 2, Staff 3 (RN) and Staff 5 (Regional Director of Operations) on 08/03/22. The staff acknowledged the findings.

2. Resident 1 was admitted to the facility in 05/2022 with diagnoses including mild cognitive impairment.

Review of the resident's 05/17/22 physician order summary and the 07/01/22 through 07/31/22 MAR revealed Natrol 5-HTP (supplement) and True Energy and Clarity Dietary Supplement had been ordered by the physician, but not administered by the facility.

The need to ensure physician orders were followed was discussed with Staff 1 (Executive Director), Staff 2 (Assisted Living Director), Staff 3 (RN), and Staff 5 (Regional Director of Operations) on 08/03/22. They acknowledged the findings.

Resident #2-MD has been notified of the lacking monitoring and EMAR updated with the requested pulse monitoring.

Resident #1-MD has been notified and request made to verify resident should still be taking these supplements.  Will follow MD response.

Orders have been reviewed for remaining residents to assure requested monitoring is being provided and tracked on the EMAR as well as order accuracy compared to most recent signed med list.  

Re-education will be provided to MT's and new ALD on proper orders transcription review process to.

ALD/Nurse will complete daily order transcription review to oversee ongoing complaince.

ALD/RN with oversight from ED

Based on observation, interview and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities was assessed thoroughly by an RN, PT or OT prior to use for 1 of 1 sampled resident (#2) who had a side rail on their bed. Findings include, but are not limited to:

Resident 2 was admitted to the facility in March 2021 with diagnoses including diabetes and weakness.

Observations of the resident, interviews with staff, and review of the service plan dated 06/26/22 showed the resident had two 1/3 length side rails at the head of the bed. Resident 4 stated s/he used the rails to balance and get into or out of the bed.

Review of the resident's record showed the following:

* No documented evidence of an assessment completed by an RN, Physical Therapist or Occupational therapist for the use of the side rail;

* No documented evidence other less restrictive alternatives had been attempted prior to use; and

* There was no clear instruction to caregivers on the correct use and precautions related to use of the side rails.

The need to complete an assessment and the required components for the use of devices with restraining qualities was discussed with Staff 1 (Executive Director) and Staff 3 (RN) on 08/03/22. The staff acknowledged the findings.

Restraint evaluation has been completed for sampled resident.  An audit has been conducted of remaining residents using restratining devices to verify completion of required assessments.

Training has been provided to new ALD regarding rules and community policies r/t use of restraining devices and the requirements for initial and ongoing assesments to assure understanding.

ALD and RN will conduct routine audits to identify new and continuing use of restraint devices and presence of required assessments.  

Audits will be completed monthly as per the Health Services Review schedule document.

ALD/RN with ED oversight.

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly-hired staff (#s 7, 8, 12, and 13) completed all required pre-service orientation and dementia training prior to beginning their job responsibilities, and 2 of 3 long-term staff (#s 4 and 9) completed pre-service infectious disease prevention training prior to 07/01/22. Findings include, but are not limited to:

Review of staff training records on 08/03/22 revealed the following:

Staff 7 (Server), hired 05/25/22, Staff 12 (Medication Aide), hired 06/15/22, and Staff 13 (Housekeeping), hired 02/27/22, lacked documented evidence of completion of multiple pre-service orientation and dementia training topics or completed them late.

Staff 8 (Medication Aide), hired 06/12/22, lacked documentation any of the pre-service orientation training or pre-service dementia training had been completed.

There was no documented evidence Staff 9 (server), hired 07/14/21, had completed infectious disease prevention training. Staff 4 (Activities), hired 12/11/18, did not complete the training prior to 07/01/22 as required.

The need to ensure newly hired staff completed all required pre-service orientation and dementia training prior to beginning their job responsibilities and all long term staff completed infectious disease prevention training in a timely manner was discussed with Staff 5 (Regional Director of Operations) on 08/03/22. He acknowledged the findings.

Missing training has been provided for 4 sampled staff and documentation is housed in the Orientation and Training Binder.  

An audit of all remaining staffs training files has been completed to verify complaince.  

ED, AED and ALD/MCD have reviewed training regulations and associated community policy to assure understanding.  

Audits will continue upon completion of the initial training process and at least twice monthly thereafter to oversee ongoing complaince.

ED or Designee

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 newly hired direct care staff (#s 8 and 12) demonstrated competency in all assigned job duties within 30 days of hire. Findings include, but are not limited to:

Review of staff training records on 08/03/22 revealed the following:  

Staff 8 (Medication Aide), hired 06/12/22, lacked documented evidence competency had been completed in any of the required areas, including the administration of medication.

Staff 12 (Medication Aide), hired 06/15/22, lacked documented evidence competency to administer medication had been determined.

The need to ensure newly-hired staff demonstrated competency in all assigned job duties within 30 days was discussed with Staff 5 (Regional Director of Operations). He acknowledged the findings.

The survey team instructed Staff 5 that Staff 8 and Staff 12 must demonstrate competency related to the administration of medication prior to resuming their job duties. A signed statement attesting to this was provided by Staff 5 prior to exit on 08/03/22.

Missing competencies have been completed for the 2 sampled staff and documentation is housed in the Orientation and Training Binder.  

An audit of all remaining staffs training files has been conducted to verify presence of competency check lists.  

ED, AED and ALD/MCD have reviewed training regulations and associated community policy to assure understanding.  

Audits will continue upon completion of the initial training process and at least twice monthly thereafter to oversee ongoing complaince.

ED or Designee

Based on interview and record review, it was determined the facility failed to ensure 1 of 1 long-term staff (#10) completed the minimum required 12 hours of annual in-service training related to dementia and the provision of care in a CBC setting. Findings include, but are not limited to:

Review of facility training records for Staff 10 (Medication Aide), hired 07/22/20, were reviewed on 08/03/22.  There was no documented evidence Staff 10 completed any of the required 12 hours of annual in-service training related to dementia and the provision of care in a CBC setting between 07/22/21 and 07/22/22.

The need to ensure long-term staff completed all required annual training was discussed with Staff 5 (Regional Director of Operations) on 08/03/22. He acknowledged the findings.

Missing annual training hours will be completed for the 1 sampled staff and documentation will be housed in the Orientation and Training Binder.  

An audit of all remaining staffs training files has been conducted to verify presence of required annual training.  

ED, AED and ALD/MCD have reviewed training regulations and associated community policy to assure understanding.  

Audits will continue upon completion of the initial training process and at least twice monthly thereafter to oversee ongoing complaince.

ED or Designee

Based on interview and record review, it was determined the facility failed to ensure fire and life safety instruction to staff was provided on alternate months and that documentation reflected all required fire drill components. Findings include, but are not limited to:

Fire drill and fire and life safety records were reviewed from February 2022 through August 2022. The following deficiencies were identified:

* There was no documented evidence the facility was conducting fire drills every other month on alternating shifts;

* There was no documented evidence the facility was providing fire and life safety training on alternating months for staff; and

* The evacuation/drill documentation did not contain information on the escape route used, problems encountered, evacuation time period needed, the number of occupants evacuated and alternate routes that were used.

The need to meet all requirements for fire drills and fire and life safety instruction was reviewed with Staff 1 (Executive Director) and Staff 5 (Regional Director of Operations) on 08/02/22. The staff acknowledged the findings.

Next fire drill is scheduled for:_8/24/22__________________

ED and Maintenance Director have reinstituted a rotating calendar to follow to assure drills and trainings are provided consistently and on a rotating schedule.

Fire Drill andTrainings will be audited monthly to assure compliance.  

ED and Maintenance Director

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 revealed the facility lacked documented evidence residents had received annual training in the following areas:

* General safety procedures;

* Evacuation methods;

* Responsibilities during fire drills; and

* Designated meeting places inside or outside the building..

The need to ensure residents received annual training in fire and life safety requirements was discussed with Staff 1 (Executive Director) and Staff 5 (Regional Director of Operations) on 08/02/22. The staff acknowledged the findings.

Training scheduled for residents on ___8/25/22____________

ED and Maintenance Director have added the annual resident training to the Fire Drill/Training calendar for tracking.

Resident annual training will be audited monthly to oversee ongoing compliance.

ED and Maintenance Director