The findings of the re-licensure survey conducted 08/01/22 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 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

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 revisit to the re-licensure survey of 08/04/22, conducted 11/28/22 through 11/29/22, 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 and OARs 411 Division 57 for Memory Care Communities.

2. Resident 3 was admitted to the facility in 2019 with a diagnosis of dementia.

Resident 3's records were reviewed during survey and indicated the following:

a. In a progress note dated 06/12/22, staff noted the resident had a "red scab on right forearm. Wound was not actively bleeding, but was red and causing the resident to worry." Staff then cleaned the wound and applied a Band-Aid.

There was no documented evidence the injury of unknown cause was investigated to rule out abuse/neglect.

During an interview on 08/03/22, Staff 2 (RN) stated she was not informed of the incident. She was unable to find any other documentation related to the wound. Staff 2 then assessed the resident's skin and reported the scab had resolved.

b. Incident reports dated 06/08/22 through 08/01/22 were reviewed during survey and showed Resident 3 was involved in six resident-to-resident altercations.

Investigations dated 06/08/22, for two incidents of physical altercations between Resident 3 and another resident, were not reviewed by the administrator until 06/28/22.

There was no documented evidence the administrator reviewed investigations for resident-to-resident altercations on the following dates:

* Two incidents on 07/02/22;

* 07/19/22; and

* 07/26/22.

Additionally, the facility's investigations did not include follow-up actions to help minimize or prevent reoccurrence.

The need to ensure injuries of unknown cause were investigated and reported to the local SPD office if abuse could not be ruled out and to ensure all investigations included follow-up actions, and were reviewed by the administrator in a timely manner, was discussed with Staff 1 (Administrator) on 08/03/22. She acknowledged the findings. Per the survey team's request, the facility reported the incident of unknown cause to the local SPD office on 08/03/22. Confirmation of the report was provided 08/04/22.

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, and failed to have documented evidence of an administrator review and follow-up action by the facility, for 2 of 2 sampled residents (#3 and 4). Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 02/2022 with diagnoses including dementia.

Review of Resident 4's record identified the following:

* On 06/20/22, Resident 4 was involved in a resident to resident altercation. The altercation was investigated; however, there was no documentation of follow-up actions taken by the facility to minimize the reoccurrence of resident-to-resident altercations.

* On 07/02/22, Resident 4 was involved in two separate resident-to-resident altercations. The altercations were investigated; however, there was no documented evidence of an administrator review of the altercations.

On 08/04/22, the need to ensure all allegations of abuse and neglect were reviewed in a timely manner by the facility administrator and follow-up actions were taken to minimize reoccurrences was discussed with Staff 1 (Administrator) and Staff 2 (RN). They acknowledged the findings.

1. Staff will be trained to write temporary service plans after each altercation with new interventions. Staff will be trained to properly note skin issues.

2. Temporary service plans will include a list of common interventions to help staff select a new intervention each time there is an altercation.

3. Temporary service plans and skin notes will be audited weekly so coaching may be provided to employees.

4. The RCC or RN will audit.

5. System updates will be completed by 9/2/22. Staff training will be completed by 9/9/22. First Audit will be completed 9/16/22.

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 (#2) whose move-in evaluation was reviewed. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 05/2022.

Resident 2's move-in evaluation was completed on 05/23/22, and failed to address the following elements:

* Personality, including how the person copes with change and challenging situations; and

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

On 08/04/22, the failure to address all required elements on the move-in evaluation was discussed with Staff 1 (Administrator) and Staff 2 (RN). They acknowledged the findings.

1. The move in evaluation in the system will be updated to include all required questions. RN will be trained on evaluation form when updates are completed.

2. The system will be updated to include all required questions. An audit will be performed to verify all sections are completed.

3. Audit will be completed within two business days of move in so coaching may be provided to employee.

4. Administrator will audit.

5. System updates will be completed by 9/16/22. First Audit will happen after a new resident moves in.

2. Resident 4 was admitted to the facility in 02/2022 with diagnoses including dementia.

Resident 4's record was reviewed for changes of condition and the following resident-to-resident altercations were identified:

* On 06/20/22, at 1:30 pm, an unsampled resident grabbed and pushed Resident 4. There was no documented evidence the facility implemented interventions to minimize further resident-to-resident altercations.

* 07/02/22, 1:09 pm: Staff documented Resident 3 was upset and banging on walls. Resident 3 then "made [his/her] way to A side of [facility] and began to hit the walls." Resident 4 asked Resident 3 to stop. When Resident 3 did not stop, Resident 4 pushed Resident 3 on the shoulder. A temporary service plan instructed staff to "Please keep them separated when they are together on the same unit."

* 07/02/22, 7:09 pm: Staff responded to Resident 3 shouting "Ouch! [s/he] hit me" as Resident 3 came out of a shared restroom. Staff documented at that time Resident 4 was witnessed exiting the same restroom. A temporary service plan was developed but did not provide new interventions.

* 07/19/22, 6:37 pm: Staff documented hearing yelling and a loud bang coming from Resident 4's room. Staff discovered Resident 3 lying on his/her left side and holding his/her head with the other resident standing over him/her with their hands up. Resident 3 continued to yell "s/he hit me and was crying".

The failure to evaluate Resident 4's behaviors, identify and implement interventions to reduce further resident-to-resident altercations and monitor the interventions for effectiveness, which placed Resident 4 and other residents in the facility at repeated risk of physical abuse, and the behaviors continued.

On 08/04/22, the need to monitor the effectiveness of interventions and develop new interventions as needed was discussed with Staff 1 (Administrator) and Staff 2 (RN). They acknowledged the findings.

3. Resident 2 was admitted to the facility in 05/2022 with diagnoses including dementia.

Resident 2's record was reviewed for changes of condition and identified the following:

* On 07/16/22, Resident 2 had an unwitnessed fall from a recliner in the living room area. There was no documented evidence the facility evaluated the resident to determine what actions or interventions were needed to minimize further falls.

On 08/04/22, the need to ensure the facility evaluated residents that who experienced a change of condition was discussed with Staff 1 (Administrator) and Staff 2 (RN). They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure residents who experienced changes of condition were evaluated, necessary actions/interventions were determined, documented, and communicated to staff and the residents' condition, including effectiveness of interventions, was monitored weekly through resolution for 3 of 4 sampled residents (#s 2, 3 and 4) who had documented changes of condition. Resident 3 displayed repetitive episodes of intrusive behaviors and both Resident 3 and Resident 4 were involved in repeated episodes of physical altercations with other residents, which placed the residents at risk of injury. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 2019 with diagnoses including dementia, depression and anxiety.

Resident 3's records were reviewed during the survey. The current service plan, dated 07/14/22, stated Resident 3 was independent with transfers and mobility, displayed short- and long-term memory loss and his/her cognition status was "total dependence" on staff.

The mood/behavior section of Resident 3's service plan stated Resident 3 displayed behaviors of becoming frustrated with others, paranoia, anxiety and yelling. The service plan provided the following information and directions to staff:

* Watch interaction between Resident 3, Resident 4 and [non-sampled resident], if "you notice them having a negative interaction separate them right away to avoid escalation that may lead to physical aggression."

* "When [Resident 3] is anxious, relocating [Resident 3] to a quiet space and spending 1:1 time can be helpful. Has a baby doll that at times can be comforting. Redirection by taking [Resident 3] outside for a walk in the courtyard can be helpful as well as reassurance. [Resident 3] enjoys being pampered. Likes having nails done and makeup done, and this is usually relaxing for [Resident 3] when feeling overwhelmed. Enjoys physical attention from staff such as a hug."

A. Resident 3's records, including progress notes dated 05/02/22 through 07/31/22, service plans, temporary service plans and incident reports, included documentation of Resident 3's involvement in physical altercations with other residents.

1. In incident reports dated 06/08/22, staff documented Resident 3 was involved in two episodes of physical aggression with another resident.

* 7:02 pm: Resident 3 was coming out of another resident's room, blocking the other resident's doorway. Staff then attempted to redirect Resident 3 and s/he became more frustrated and hit the other resident on the back. No injury was noted. There was no documented evidence the facility developed interventions related to the incident.

* 8:00 pm: Resident 3 was upset because s/he missed their spouse and was talking to the above-noted resident in the hallway. The other resident ignored Resident 3, who then hit the other resident on the back. No injury was noted. A temporary service plan instructed staff to, "Please try to keep these two separated."

2. Two incident reports dated 07/02/22 and one dated 07/19/22 indicated Resident 3 was involved in three physical altercations with Resident 4.

* 07/02/22, 1:09 pm: Staff documented Resident 3 was upset and banging on walls. Resident 3 then "made [his/her] way to A side of [the facility] and began to hit the walls." Resident 4 asked Resident 3 to stop; when Resident 3 did not stop Resident 4 pushed Resident 3 on the shoulder. A temporary service plan instructed staff to, "Please keep them separated when they are together on the same unit."

* 07/02/22, 7:09 pm: Staff responded to Resident 3 shouting "Ouch! [S/he] hit me," as s/he came out of a shared restroom. Staff documented "at that time the aggressor was witnessed exiting the same restroom." A temporary service plan was developed but did not provide new interventions.

* 07/19/22, 6:37 pm: Staff documented hearing yelling and a loud bang coming from Resident 4's room. Staff discovered Resident 3 lying on his/her left side and holding his/her head with Resident 4 standing over him/her with their hands up. Resident 3 continued to yell s/he "hit me and was crying."

Staff initiated 30-minute neurological checks and noted there was no injury to either resident. A temporary service plan instructed staff to discourage Resident 3 "from going to unit A, if [s/he] insists staff are to provide direct supervision if [Resident 4] is in the same room. Do not allow interaction between the two residents without supervision."

3. On 07/26/22 staff reported Resident 3 was touching another resident and their walker in the hallway. The residents began pushing each other and Resident 3 then punched the other resident, who hit back. No injuries were noted. There was no documented evidence interventions were developed.

During the survey, 08/02/22 through 08/04/22, Resident 3 was observed pacing the hallways of the unit and wandering in and out of other residents' rooms on several occasions.

On 08/04/22, staff were observed redirecting Resident 3 out of another resident's room and offering Resident 3 a snack at the dining table. Resident 3 sat at the table with the snack and staff returned to the hallway. Resident 3 then got up and carried the snack with him/her while s/he paced around the unit.

During interviews on 08/02/22, when asked about interventions related to Resident 3's wandering into other resident's rooms, Staff 10 (CG) stated the staff "tries to keep an eye on [him/her] as best they can, without making the behavior worse. [S/he] does like ice cream and walks in the courtyard."

Between 06/02/22 and 07/31/22, Resident 3 was involved in six physical altercations with other residents. The facility failed to develop and monitor new interventions when Resident 3 was involved in physical altercations on 06/08/22, 7/02/22 (two altercations) and 07/26/22. The facility also failed to develop and monitor new and relevant interventions when Resident 3 displayed repeated intrusive behaviors on 06/08/22, 07/02/22 and 07/19/22. The lack of interventions for these six incidents placed Resident 3 and other residents at risk for harm.

B. In a progress note dated 06/12/22, staff documented Resident 3 had a "red scab on right forearm. Wound was not actively bleeding, but was red and causing the resident to worry." Staff then cleaned the wound and applied a Band-Aid. There was no documented evidence the facility monitored the wound weekly through resolution.

C. A progress noted dated 05/22/22 stated staff reported Resident 3 "had three earrings in mouth. Staff was able to retrieve earrings out of mouth. Per RN monitor for signs and symptoms of pain in mouth and abdomen." There was no documented evidence the facility developed interventions related to the behavior of attempting to ingest non-food items, and there was no documented evidence the facility monitored for signs and symptoms of pain in mouth and abdomen.

The need to develop and monitor actions or interventions for effectiveness when residents experienced changes of condition was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 08/03/22. They acknowledged the findings and provided a temporary service plan to address Resident 3's intrusive behaviors.

1.Staff will be trained to create temporary service plans with varying interventions then monitor effectiveness. If intervention does not work, then write a new temporary service plan with different interventions.

2. Temporary service plans will include a list of common interventions to help staff select a new intervention each time there is an altercation. (We are exploring if the system is able to allow charting on the effectiveness of the intervention, if able we want to implement but will need time to do so. As of the writing of this document, the key stakeholder is on vacation and unable to verify system limitations).

3. Temporary service plans will be audited weekly so coaching may be provided to employees.

4. RCC or RN will audit.

5. System updates will be complete by 9/2/22. Staff training will be completed by 9/9/22. First audit will be completed 9/16/22.

Based on observation, 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 C231.

Refer to C231

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 and C270.

Refer to C252 and C270

Based on interview and record review, it was determined the facility failed to evaluate and develop individualized activity plans for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose activity plans were reviewed. Findings include, but are not limited to:

Residents 1 ,2, 3 and 4's records were reviewed during the survey. There was no documented evidence an activity evaluation had been completed to reflect one or more of the following required components:

* Current abilities and skills;

* Physical abilities and limitations;

* Adaptations necessary for the resident to participate; and

* Identification of activities for behavioral interventions.

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

On 08/04/2022 the need to evaluate and develop individualized activity plans, including all required components, for each memory care resident was discussed with Staff 1 (Administrator) and Staff 2 (RN). They acknowledged the findings.

1. Resident service plans will be updated to including the following: abilities & skills, physical abilities & limitations, adaptations, and activity ideas for behavior intervention

2. Activity Coordinator will assume responsibility of updating Service Plans . RN will review for completeness and accuracy.

3. Quarterly or when a significant change of condition occurrs

4. RN

5. Resident service plans will be updated by 9/30/22

2. Resident 3 was admitted to the facility in 2019 with diagnoses including dementia, depression and anxiety.

Resident 3's records were reviewed during the survey and indicated the following:

Resident 3's behavior service plan, dated 07/14/22, was not reflective of the resident's ongoing intrusive behaviors, including wandering into other resident's rooms or occupied restrooms, which sometimes led to physical altercations with other residents, and his/her history of placing potentially dangerous non food items in his/her mouth.

The need to ensure all behavioral symptoms which negatively impacted the resident and others in the community were included on the service plan was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 08/03/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure an individualized behavior plan was developed and implemented to address behaviors which negatively impacted 2 of 2 sampled residents (#s 3 and 4) and others in the community. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 02/2022 with diagnoses including dementia.

Resident 4's records were reviewed during the survey.

Resident 4's most recent service plan, dated 07/01/22, indicated she/he had no behaviors related to harming themselves or others.

Resident 4's record indicated s/he was involved in four resident-to-resident altercations from 06/20/22 through 07/19/22. There was no documented evidence the facility developed an individualized behavior plan to instruct staff on what to do when behaviors occurred and what interventions to attempt.

On 08/04/22 the need to develop individualized behavior plans for residents with behavioral symptoms was discussed with Staff 1 (Administrator) and Staff 2 (RN). They acknowledged the findings.

1. Service plans will be updated with behavior interventions when a new resident behavior is observed.

2. No corrections are needed to the system as these fields already exist. The process needs to be fixed to fill in the fields when a new behavior is observed.

3. Service plans will be audited weekly.

4. Administrator

5. Will be completed by 9/30/22

Based on observation and interview, it was determined the facility failed to ensure fences surrounding the perimeter of the outdoor recreation area were no less than six feet (or 72 inches) in height. Findings include, but are not limited to:

The facility was toured on 08/01/2022. The following was identified:

Sections of fencing surrounding the perimeter of the outdoor recreation area did not meet the six foot height requirement. The surveyor measured several sections of the fence, some of which measured 69 or 70 inches in height.

The need to ensure fences surrounding the perimeter of the outdoor recreation area were no less than six feet (or 72 inches) in height was discussed with Staff 1 (Administrator) on 08/01/22. She acknowledged the findings. During the acuity interview on 08/01/22, the facility stated there were currently no residents with exit-seeking behaviors, and on 08/02/22 Staff 2 (RN) stated there had been no past elopement attempts related to the courtyard.

1. Fence will be raised to 6'.

2. The fence will be raise to 6'.

3. NA. Once the fence is raised to the appropriate height the work is completed.

4. Maintenance Director

5. Will be completed by 9/15/22.

Based on observation and interview, it was determined the facility failed to ensure exit doors with keyed locks were not placed between a resident and the exit and were equipped with electronic quick-releasing locks. Findings include, but are not limited to:

The facility's outdoor areas were toured on 08/01/22. A perimeter fence in the outdoor courtyard was observed to have a gated door which was secured with a keyed and chained padlock.

In an interview on 08/01/22, Staff 1 (Administrator) confirmed the gate did not have an electronic quick-release option and could only be unlocked by staff with a key. Staff 1 stated all staff had been trained on the location of the key in the event of an emergency until repairs to the fence and gate could be made.

The revised plan of correction is to:

1.Replace the courtyard gate with a new gate that can be tied into our fire alarm system.

2.The existing gate will be replaced with a new gate. Electrical work will be done to tie the gate into the fire alarm system. When the fire alarm system goes off the gate will open for egress.

3.NA. Once fixed, the work is completed.

4.Maintenance Director

5.11/28/22 pending contractor availability and supplies