The findings of the re-licensure survey conducted 08/15/23 through 08/18/23 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 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 of the re-licensure survey of 08/18/23, conducted 01/02/24 through 01/04/24, 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 second re-visit survey to the re-licensure survey on 08/18/23, conducted 05/01/24 through 05/03/24, 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 for 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
Three situations were identified where there was a failure of the facility to comply with the Department's rules that was likely to cause residents serious harm. Immediate plans of correction were requested in the following areas:
OAR 411-054-0025 (R) - Reasonable Precautions
OAR 411-054-0300 (8) - Heating & Ventilation
OAR 411-054-0300 (11-13) - Call System
The facility put immediate plans of correction in place during the survey, and the situations were abated.
The findings of the third re-visit to the re-licensure survey of 08/18/23, conducted 07/08/24 through 07/11/24, 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 fourth revisit to the re-licensure survey of 08/18/23, conducted on 09/23/24, 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 observation, interview, and record review, it was determined the licensee failed to provide effective oversight for the operation of the facility and to ensure the quality of services rendered in the facility. Findings include, but are not limited to:
During the second re-visit to the re-licensure survey, conducted 05/01/24 through 05/03/24, administrative oversight to ensure adequate services rendered in the facility was found to be ineffective based on the severity of the citations.
1. Situations were identified which constituted an immediate threat to the health and safety of the residents in the following areas:
* OAR 411-054-0025 (R) - Reasonable Precautions: The facility failed to protect residents from the behaviors of another resident.
* OAR 411-054-0300 (8) - Heating & Ventilation: The facility failed to ensure all resident units had a working heating and ventilation system.
* OAR 411-054-0300 (11-13) - Call System: The facility failed to have an operable call system.
The facility developed and implemented immediate plans of correction during the survey to address the threat to residents' safety, and the situations were abated.
2. Refer to the deficiencies in the report.
Refer to POC C160, C640, C655
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to notify the Department related to severe interruptions of physical plant services and of the unusual death of a resident within 72 hours. Findings include, but are not limited to:
The following concerns were identified during survey:
* The facility's call system had been inoperable since 03/21/24;
* The facility's heating and ventilation system had not been fully functional since 03/02/24; and
* A resident had died unexpectedly of a heart attack in the facility on 04/02/24.
In interviews with Witness 2 (Facility Policy Analyst) on 05/01/24 and 05/02/24, she reported to the survey team that the facility had not notified her within 72 hours that the call system was no longer working, the heating system was no longer working, or a resident died unexpectedly of a heart attack while the call system wasn't functioning.
The need for the facility to notify the Department of interruptions of physical plant services and unusual resident deaths within 72 hours was discussed with Staff 2 (ED), Staff 18 (Administrator), Staff 24 (Resident Services Coordinator/LPN), and Staff 28 (Regional Director of Operations) on 05/03/24. They acknowledged the findings.
All notifications were made to licensing.
Administrator was given additional training in when notifications are to be made to licensing.
1. We are reviewing our internal process for what constitutes an unusual death and when and how to report to licensing.
2. We are reviewing our internal process for plant failures and what needs to be reported and who will be responsible for reporting in line with the OAR.
RDO will be responsible for creating the policies, educating everyone on policies and ensuring that the policies are followed going forward.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to implement effective methods of responding to and resolving resident complaints. Findings include, but are not limited to:
A group interview was conducted on 08/16/23 at 10:00 am. Nine residents attended the interview and provided information on services received in the community. Residents expressed concerns in areas including, but not limited to:
* A lack of consistent housekeeping services;
* A lack of activities during evening and weekend hours;
* Long delays for call light response;
* Concerns regarding food service, alternate menu items unavailable for breakfast and dinner meals;
* Availability of enough staff for scheduled showers;
* A general feeling that the administration did not support resident's individuality, dignity and choice.
Residents confirmed these concerns had been reported to various facility staff through a variety of communication techniques including one to one, in-person meetings, hand written notes, group meetings and through use of the facility "grievance form".
On 08/17/23, Staff 2 (ED) provided documentation of grievances. Resident complaint/concern forms, dated 05/18/23 through 07/23/23 written by facility staff revealed the following resident concerns:
* Long wait time for call response - in excess of two hours;
* Housekeeping services not provided - trash pick up;
* Reports of ants in resident units;
* A verbal incident between two residents; and
* A missing item.
a. The documented complaints of residents were discussed with Staff 2 and Staff 3 (RN/Resident Services Coordinator) on 08/18/23 at 2:00 pm. Staff 2 was aware of the concerns, however there was inconsistent documentation of investigations and efforts made to address and resolve the variety of resident complaints.
b. During the group interview conducted on 08/16/23, multiple residents stated having to wait long periods of time for call lights to be answered. Residents reported that some of the care staff did not carry pagers to alert them to call lights. Call light records were requested on 08/18/23. Staff 1 and Staff 2 (ED) reported the call light system was not able to produce a report that showed the length of time between a call light activation and response. Staff 2 stated the facility pagers provided to care staff were used to determine call light response times.
During a tour of the facility with Staff 2 on 08/18/23 at 2:30 pm, there were three direct care staff on duty. Staff 6 (MT) had a pager. Staff 6 reported there were two CG's on duty and one of them had a pager. A facility pager was obtained from Staff 16 (CG) and reviewed with Staff 2. Upon review of the pager settings, Staff 2 confirmed the pager was not set up with the required date or time information in order to track and review the call response times. Staff 2 was unable to confirm whether the facility consistently provided enough pagers for all care staff.
The need to ensure the facility developed and implemented written policies and procedures that promote high quality services, health and safety for residents, and incorporate the community-based care principles of individuality was discussed with Staff 2 and Staff 3 on 08/18/23. No further information was provided.
Housekeeping scheduled for each resident and they have signed and agreed on the date and time.
Life Enrichment Director has met with residents and designed activities for evenings and weekends that they state they will participate in.
Staff training was completed on performing activities with residents in the evenings and weekends.
Call light audit will be completed randomly by Administrator or designee on every shift at least 10 times/week to observe call light response time. Staff educated re: call light system and the use of pagers and walkie-talkies to properly communicate with co-workers regarding call-lights.
Alternate "Available anytime" menus printed out and posted in dining room. Residents educated on the available items and asked for their input on items they would like to have available.
Re-education provided on showering residents and documenting of refusals. Staffing is adequate according to updated ABST to allow residents to be showered appropriately and at the time they prefer.
Administrator met with residents to hear their concerns. She is meeting weekly for the first 60 days (monthly following) with residents to ensure that their likes/dislikes, individuality, dignity and choice are being met and they are feeling heard and responded to. Administrator will meet with staff twice monthly to discuss results and ways they are succeeding in addition to items needing addressed.
Administrator and Resident Services Coordinator will be responsible for implementing an internal, anonymous satisfaction survey to be used to determine improvement or items needing to be addressed more thouroughly. This will be distributed monthly and returned. These results will be discussed during meeting with staff. This will be in addition to the required satisfaction survey that is already scheduled.
Executive Director will be responsible for monitoring and ensuring that these are completed.
There are no detail notes for this visit.
Based on observation, interview, and record review, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety, or welfare of sampled and unsampled residents throughout the facility due to the actions of 1 of 1 sampled resident (#10) who demonstrated threatening verbal and physical behaviors toward multiple residents and staff. This placed the residents at risk and constituted an immediate threat to the residents' health and safety. Findings include, but are not limited to:
Resident 10 was admitted to the facility in 02/2014 with diagnoses including diabetes mellitus, history of traumatic brain injury, and post-traumatic stress disorder.
Interviews were conducted with staff and residents and Resident 10's clinical record was reviewed, including physician orders, service plan, outside provider communication, and progress notes. The following was noted:
A behavior support services provider assessed the resident on 01/28/24 and provided the facility with recommendations regarding development of a behavior plan to address behaviors that "historically have frightened staff and other residents." The suggestions stated the facility should create a crisis and/or safety plan to have on hand for all staff to reference if there was concern for the stability and/or safety of the staff or other residents. The assessment stated the plan could include:
* Behavior that warranted enacting the plan;
* Interventions to attempt before outreaching;
* Steps to take to ensure the safety of Resident 10, other residents, and/or staff; and
* Who to call.
On 05/01/24 and 05/03/24, Staff 18 (Administrator) and Staff 24 (Resident Services Coordinator/LPN) stated that any information regarding addressing the resident's behaviors was in his/her service plan and that no crisis/safety plan had been created addressing the suggestions from the behavior support services provider.
On 05/03/24, multiple staff stated that Resident 10 exhibited daily behaviors which threatened the health and safety of other residents, including:
* Threatening to "beat up" other residents;
* Cursing and/or screaming at other residents;
* Smashing dishes;
* Smoking in his/her room;
* Miming "shooting" other residents with his hand; and
* Making verbal threats to other residents including, "I really want to kill someone today."
When asked what to do if Resident 10 began exhibiting threatening verbal or physical behaviors, multiple staff stated they had been instructed to "just walk away."
During various one-on-one interviews on 05/03/24, unsampled facility residents made the following statements regarding Resident 10's behaviors:
* "I don't feel safe walking around [the facility] because I'm scared to be near [Resident 10].";
* "[Resident 10] told me, 'I'm going to kick your a**.";
* "[Resident 10] has threatened to 'beat me up' three times.";
* "No one seems to be doing anything about it. It doesn't feel safe here."; and
* "I'm afraid [Resident 10] is going to hurt one of us [residents]."
Residents and staff stated they believed Staff 18 was aware of the behavior as it frequently occurred in the doorway to her office or in the dining room directly adjacent to her office.
On 05/03/24 Resident 10 was observed walking into Staff 18's office and yelled "What the hell do you think you're doing?"
The above threatening behaviors exhibited repeatedly, without a plan enacted to ensure the safety of other residents, constituted a significant risk to resident health and safety and required an immediate plan of correction.
The facility submitted a plan of correction to the survey team at 6:11 pm on 05/03/24. The immediate jeopardy situation was abated.
The need to ensure the facility exercised reasonable precautions against any condition which could threaten the health, safety, or welfare of residents was discussed with Staff 2 (ED), Staff 18, Staff 24, and Staff 28 (Regional Director of Operations) on 05/03/24. They acknowledged the findings.
1.*1:1 staff to be implemented without the knowledge of the resident to stay within line of site.
*Any escalation would be reported immediately to the crisis line, APS, and Licensing.
*Any escalation endangering another resident or staff will be reported to 911 immediately.
*Shift to shift talk at the end/beginning of each shift to discuss triggers and behaviors.
*Add to community bulletin board on PCC with triggers and interventions
*TSP with triggers and interventions will be in place. This was put in place in addition to his BSP and Crisis Plan.
2.How will the system be corrected so these violations will not happen again:
*Retraining will be provided for the Administrator and Executive Director on Abuse and Reporting.
3. How often will the area needing correction be evaluated:
*Daily and as needed.
4.Who will be responsible to see that the corrections are completed?
*Executive Director
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure licensees and facility personnel did not act as a resident's guardian. Findings include, but are not limited to:
Resident 10 was admitted to the facility in 02/2014 with diagnoses including diabetes mellitus, history of traumatic brain injury, and post traumatic stress disorder.
During an interview with Staff 18 on 05/01/2024, she stated she met the resident while working at the facility as a MT, and later, while not employed by the facility, she became the resident's guardian. She stated she was not related to the resident. She stated she returned to working at the facility in 10/2023.
The facility's staff list showed Staff 18 was hired on 10/22/23. Documents provided by Staff 28 (Regional Director of Operations) on 05/31/24 show that Staff 18 assumed guardianship of the resident on 11/09/23. Staff 18 became guardian for the resident after she was hired by the facility.
The need to ensure licensees and facility personnel did not act as a resident's guardian was reviewed with Staff 2 (ED), Staff 18, and Staff 28 on 05/03/24, and again with Staff 28 on 05/31/24. They acknowledged the findings.
1. Ashly Allen has been removed from the Administrator position and will not work in the assisted living and will have no oversite responsibilities for the community. An interim Administrator will be assigned and an exception for a shared Administrator will be submitted to the department.
2. We are implementing an internal policy restricting employees from acting as legal gaurdians with the exception of family as outlined in the OAR. All Adminsitration staff will be trained regarding this policy.
3. This will be reviewed during the hiring process of any Administrative staff.
4. Executive Director and Regional Director will be responsible.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to investigate incidents of possible abuse and/or neglect and failed to report incidents of abuse and/or neglect to the local Seniors & People with Disabilities (SPD) office for 1 of 1 sampled resident (#10). Findings include, but are not limited to:
Resident 10 was admitted to the facility in 02/2014 with diagnoses including history of traumatic brain injury, major depressive disorder, post-traumatic stress disorder, and panic attacks.
The resident's facility record was reviewed, and interviews were completed. The following was identified:
* 03/12/24 - MT noticed cigarette smoke and a strong odor of cigarette smoke coming out of the resident's bathroom, after the resident had exited the bathroom.
* 04/15/24 - Resident threw a coffee cup into a sink in the dining room. Staff reported residents in the dining room "looked scared."
* 04/16/24 - Resident had a verbally abusive altercation with another resident, who reported Resident 10's "tone of voice was very aggressive." Resident 10 then threatened physical harm to the other resident.
There was no documented evidence these incidents were investigated by the facility to rule out abuse and/or neglect, nor was there documented evidence the incidents had been reported to the local SPD office.
The facility was instructed to report the incidents on 05/03/24. Confirmation of the report was received prior to survey exit.
On 05/03/24, the need to immediately report all incidents of suspected abuse and/or neglect to the local SPD office and to promptly investigate all reports of abuse and suspected abuse was discussed with Staff 2 (ED), Staff 18 (Administrator), Staff 24 (Resident Services Coordinator/LPN), and Staff 28 (Regional Director of Operations). They acknowledged the findings.
All incidents have been reported to APS.
Training was provided for all staff, including management regarding verbal abuse and reporting requirements.
All incidents will be reported to APS within 24 hours of incident. Investigation will be completed and findings will be documented for all incidents.
Administrator will be responsible for ensuring that this requirement is met.
There are no detail notes for this visit.
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 (#4) whose evaluation was reviewed. Findings include, but are not limited to:
Resident 4's move-in evaluation, dated 08/08/23, lacked information regarding the following required elements:
* Customary routines: sleeping, eating, bathing;
* Interests, hobbies, social, leisure activities;
* Current diagnosis;
* Unsuccessful prior placements; and
* Environmental factor that impact the resident's behaviors including, but not limited to noise, lighting, room temperature.
In an interview with Staff 1 (Administrator) on 08/16/23, he stated the activities coordinator completed the customary routines and interest portions which were then added to the evaluation. He acknowledged that he failed to complete the listed areas and that customary routines and interests were left blank.
The need to ensure the move-in evaluation included all required elements was reviewed with Staff 1 on 08/16/23. He acknowledged the findings.
Administrator training provided for new Administrator by OHCA Admin class as well as by Executive Director on accurately creating evaluations and service plans.
Administrator and Resident Service Coordinator will be responsible for creating accurate evaluations and service plans including all required elements.
Executive Director will randomly audit new move-ins monthly for accuracy and to ensure all required elements are included in the evaluation and service plans.
Executive Director
There are no detail notes for this visit.
2. Resident 2 was admitted to the facility in December of 2019 with diagnoses including multiple sclerosis, dysphagia, difficulty in walking, and major depressive disorder.
Observations were made of the resident's care on 08/17/23. Interviews with facility staff and the resident's spouse were conducted. The current service plan dated 06/18/23 was reviewed.
Resident 2 stated his/her spouse accompanied the resident every day from 10 am to 5 pm Monday through Friday to assist with ADLs and other minor chores.
Resident 2's service plan was not reflective of the resident's current needs and lacked clear instructions to staff in the following areas:
* Presence of depression, thought disorders, behavioral and mood problems;
* Memory and orientation;
* Personality, including how the person copes with change or challenging situations;
* Hearing and use of assistive devices;
* Ability to understand and be understood;
* Toileting;
* Dental status;
* Non-pharmaceutical interventions for pain, including how a person expresses pain or discomfort;
* Electric wheelchair equipment precautions and instructions for proper maintenance;
* Delivery of services during hours when family members were not present; and
* Recent losses.
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 2 (ED), and Staff 3 (RN/Resident Services Coordinator) on 08/18/23 at 10:36 am. They acknowledged the findings. No further information was provided.
Based on observation, interview and record review, it was determined the facility failed to ensure resident service plans were reflective of resident needs and provided clear direction to staff regarding the delivery of services for 2 of 3 sampled residents (#s 2 and 3) whose service plans were reviewed. Findings include, but are not limited to:
1. Resident 3 was admitted to the facility in October of 2017 with a diagnosis of multiple sclerosis.
Interviews with staff and review of the resident's clinical record, including a review of the most recent service plan, dated 06/12/23, showed the service plan was not reflective of the resident's status and lacked clear instructions to staff in the following areas:
* Mobility;
* Side rail use as a mobility device;
* Tilt-n-space wheelchair as a mobility device; and
* Outside services, specifically home health RN for catheter care.
Observations of Resident 3's room on 08/17/23 verified Resident 3 used a hospital bed with two side rails and a tilt-n-space wheelchair.
The need to ensure service plans were reflective and included clear direction to staff was discussed with Staff 1 (Administrator), Staff 2 (ED), and Staff 3 on 08/18/23. They acknowledged the findings.
Service Plan Acknowledgement forms have been re-implemented.
These will be signed by all members of the service planning team and management will document who is involved and any distribution of service plan to family, POA or guardian if not available to sign. This will be kept in a binder located in the Administrator's office.
This will be audited weekly by Resident Service Coordinator and Administrator and as needed to ensure that Service Plan team is documented accurately and timely.
Resident Service Coordinator and Administrator.
2. Resident 6 was admitted to the facility in 10/2023 with diagnoses including Parkinson's, chronic pain, chronic obstructive pulmonary disease, and falls.
The resident's 12/28/23 service plan and the daily Task List Report were reviewed. Staff and the resident were interviewed. The following areas of the service plan were not implemented, not reflective of the resident's current care needs, or did not provide clear direction to staff which included a written description of who shall provide the services and what, when, how, and how often the services should be provided:
* Preference on where s/he received meals;
* Activity reminders;
* Transfer assistance;
* Laundry schedule;
* Bathing assistance;
* Instructions related to oxygen use (i.e. what company supplied it, how many liters per minute, tubing and filter changes);
* Reminders to use the seat belt when in electric wheelchair;
* Safety checks;
* What to monitor for relating to smoking and when it was no longer safe for the resident to smoke independently;
* Self administration of over the counter PRN medications;
* Interventions for when the resident was resistive to care;
* Nail assistance (fingernails were observed to be very long);
* All outings to include the resident's dog;
* Assistance needed with making coffee in the morning; and
* Who provided nutritional supplements three times a day.
On 01/04/24, the need to ensure service plans were implemented, were reflective of resident needs, and included clear direction to staff was discussed with Staff 2 (ED) and Staff 18 (Administrator in Training). They acknowledged the findings.
3. Resident 8 was admitted to the facility in 07/2018 with diagnoses including anxiety and dementia.
The resident's 01/02/24 service plan and the daily Task List Report were reviewed. Staff were interviewed. The following areas of the service plan were not reflective of the resident's current care needs or did not provide clear direction to staff which included a written description of who shall provide the services and what, when, how, and how often the services should be provided:
* Specific instruction relating to which activities the resident will attend outside of their apartment;
* Personal hygiene and which specific supplies staff need to set up for the resident;
* Use of a bedside commode;
* Non-drug interventions relating to pain;
* Direction relating to the resident's right arm;
* Instruction to staff relating to the cleaning of the catheter and changing the bags;
* Placement of catheter bag when in bed and when up in electric wheelchair;
* Resident specific behavior interventions (i.e. changing the subject, explaining step by step instructions with care);
* Ability to use seatbelt relating to the resident's right arm;
* Using the bedside commode in the shower; and
* Laundry schedule.
On 01/04/24, the need to ensure service plans were reflective of resident needs and included clear direction to staff was discussed with Staff 2 (ED) and Staff 18 (Administrator in Training). They acknowledged the findings.
4. Resident 9 was admitted to the facility in 01/2022 with diagnoses including encephalopathy.
The resident's 12/12/23 service plan and the daily Task List Report were reviewed. Resident 9's room was observed and staff were interviewed.
The monitoring of the resident's left, quarter side rail was not reflective in the resident's service plan. In addition, there was no documentation of clear direction to staff on who to report to if the side rail was loose or in disrepair.
On 01/04/24, the need to ensure service plans included clear direction to staff was discussed with Staff 2 (ED) and Staff 18 (Administrator in Training). They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to ensure service plans were implemented, reflective of residents' current care needs, and provided clear instructions to staff for 4 of 4 sampled residents (#s 6, 7, 8 and 9) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:
1. Resident 7 was admitted to the facility in 10/2021 with diagnoses including epilepsy and osteoarthritis.
The resident's service plan, dated 12/04/23, and the daily Task List Report were reviewed. Staff and resident interviews were conducted. The service plan was not reflective of the resident care needs and did not provide clear direction to staff which included a written description of who shall provide the services and what, when, how, and how often the services should be provided in the following areas:
* Toileting and bowel care;
* Transfers;
* Dietary texture;
* Personal hygiene related to shaving and hair care; and
* PT and OT services provided.
On 01/04/24, the need to ensure service plans were reflective of resident needs and included clear direction to staff was discussed with Staff 2 (ED) and Staff 18 (Administrator in Training). They acknowledged the findings.
SP will be reviewed with each resident surveyed and remaining residents. SP to ensure all care & health needs, preferences, outside services provided, laundry & bathing schedule are accurate and are provided in the service plan for staff direction. SP team will ensure that the plan is reflective of the care needs, provides clear direction to staff and includes the what, when, how and how often the services should be provided.
When completing nursing assessments, the nurse will be responsible for entering information accurately in the service plan with the Administrator to ensure that assistive devices, alternative measures and diagnosis are accurately documented in the service plan.
This will be audited weekly by Resident Service Coordinator and Administrator and as needed to ensure that Service Plan is accurate and information is being provided to care staff.
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 the delivery of services, and were implemented for 3 of 3 sampled residents (#s 3, 10, and 11). This is a repeat citation. Findings include, but are not limited to:
1. Resident 10 was admitted to the facility in 02/2014 with diagnoses including diabetes mellitus, history of traumatic brain injury and post-traumatic stress disorder.
Observations of the resident, interviews with staff, and review of the service plan, dated 04/03/24 and progress notes dated 03/01/24 through 05/01/24, 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 implemented in the following areas:
* Behavior identification, including triggers;
* Crisis and/or safety plan for behaviors;
* Care preferences and needs;
* Pain, including how resident expressed pain and non-pharmacological interventions; and
* Monitoring of skin conditions, including casting of left foot.
The need to ensure service plans were reflective of residents' needs, provided clear direction to staff regarding the delivery of services, and were implemented was discussed with Staff 2 (ED), Staff 18 (Administrator), Staff 24 (Resident Services Coordinator/LPN), and Staff 28 (Regional Director of Operations) on 05/03/24. They acknowledged the findings.
2. Resident 3 was admitted to the facility in 10/2017 with diagnoses including multiple sclerosis, dementia, and bipolar disorder.
The resident's 04/26/24 service plan was reviewed, and interviews with the resident and staff were completed. The resident's service plan was not reflective of his/her needs, did not provide clear direction to staff regarding the delivery of services, and/or was not implemented in the following areas:
* Cognition;
* Ability to use call pendant;
* Toileting/incontinence care;
* Pain location and non-pharmacological interventions;
* Type of assistance required with meals; and
* Evacuation assistance.
The need to ensure service plans were reflective of residents' needs, provided clear direction to staff regarding the delivery of services, and were implemented was discussed with Staff 2 (ED), Staff 18 (Administrator), Staff 24 (Resident Services Coordinator/LPN), and Staff 28 (Regional Director of Operations) on 05/03/24. They acknowledged the findings.
3. Resident 11 was admitted to the facility in 01/2021 with diagnoses including abnormalities of gait and mobility and cystoid macular degeneration.
Review of the resident's 02/23/24 service plan, and interviews with the resident and staff were completed. The resident's service plan did not provide clear direction to staff regarding the delivery of services in the following area:
* Evacuation assistance needed.
The need for service plans to provide clear direction to staff regarding the delivery of services was discussed with Staff 2 (ED), Staff 18 (Administrator), Staff 24 (Resident Services Coordinator/LPN), and Staff 28 (Regional Director of Operations) on 05/03/24. They acknowledged the findings.
Service plan for resident 10, 3, 11 have been updated.
All service plans will be reviewed for accuracy in all areas including evacuation assist, cognition, Ability to use pendant/call light, toileting, pain location and non-pharmacological interventions, assistance required with meals, monitoring of skin conditions, crisis and/or safety plan for behaviors, care preferences and needs, behavior identification, including triggers.
Service plans will be reviewed quarterly and as needed for change of conditions, etc.
Administrator and Resident Services Coordinator will be responsible for ensuring these are completed on schedule.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed for 1 of 3 sampled residents (#1) whose orders were reviewed. Findings include, but are not limited to:
Resident 1 was admitted to the facility in October of 2017 with diagnoses including hypertension and type 2 diabetes mellitus.
Review of Resident 1's current physician orders and MARs/TARs from 07/01/23 through 08/15/23 revealed the following:
* Humulin R 500U/ml Kwik pen was ordered for administration starting 07/26/23, 80 units subcutaneously in the morning, 40 units subcutaneously in the evening, and 20 units subcutaneously before nighttime snack. There was no documented evidence the 20-unit dose was administered 07/27/23 through 08/14/23. During the period when the 20-unit dose was not administered, the resident's CBG levels were within acceptable limits.
The finding was shared with Staff 3 (RN/Resident Services Coordinator) on 08/15/23 at 1:45 pm. Staff 3 acknowledged the finding and confirmed the 20 unit dose had not been administered. The resident's MAR was corrected to add the 20-unit dose on 08/15/23 for accurate administration.
The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (Administrator), Staff 2 (ED), and Staff 3 on 08/18/23 at 10:36 am. They acknowledged the findings. No further information was provided.
Current and correct order for resident's insulin was received on 8/18/23. Additional training was completed with each med tech regarding correct orders and notifying RSC or Lead Med Tech when orders are not matching, not complete, or not correct.
Lead Med Tech and Resident Services Coordinator will review and approve orders prior to administration. If order is incorrect, MD will be contacted and med will not be administered until corrected order is in place.
This will be documented in binder in Administrator's office and findings will be reviewed minimum of once weekly with Administrator, Resident Service Coordinator and Lead Med Tech.
Administrator will be responsible for ensuring that audits are completed.
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 3 sampled residents (#s 6 and 8) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to:
1. Resident 6 was admitted to the facility in 10/2023 with diagnoses including Parkinson's and chronic pain.
A review of the resident's current physician orders and MARs dated from 12/01/23 through 01/02/24 revealed the following:
The facility did not administer the following medications as the resident was sleeping:
* Acyclovir (for antivirals) on 12/30/23 at 8:00 am;
* Carb/Levo (for Parkinson's) on 12/08/23 at 2:00 pm and on 12/30/23 at 8:00 am;
* Carisoprodol (for pain) on 12/08/23 at 2:00 pm and on 12/30/23 at 8:00 am;
* Ensure (for nutrition) on 12/08/23 at 2:00 pm and on 12/30/23 at 8:00 am;
* Hydroxyzine (for anxiety) on 12/08/23 at 2:00 pm and on 12/30/23 at 8:00 am;
* Midrodrine (for low blood pressure) on 12/08/23 at 2:00 pm and on 12/30/23 at 8:00 am; and
* Stiolto Respimat inhaler (for asthma) on 12/30/23 at 8:00 am.
On 01/04/24 at 12:09 pm, Resident 6 stated s/he was "always hurting" and wanted the staff to "wake me up" relating to pain medication.
On 01/04/23, the need to ensure physician orders were carried out as prescribed was reviewed with Staff 2 (ED) and Staff 18 (Administrator in Training). They acknowledged the findings.
2. Resident 8 was admitted to the facility in 07/2018 with diagnoses including anxiety and dementia.
A review of the resident's current physician orders and MARs dated from 12/01/23 through 01/02/24 revealed the following:
The facility did not administer the following medications per documentation that the administration of the medication was "past time frame":
* 12/06/23 at 4:00 pm - lorazepam (for anxiety) and oxycodone (for pain);
* 12/07/23 at 12:00 pm - oxycodone, potassium (for supplement), spironolactone (for fluid retention), and lorazepam; and
* 12/24/23 at 12:00 pm - oxycodone and lorazepam.
There was no documented evidence if the facility administered the following medications on 12/29/23:
* Furosemide (for fluid overload);
* Gabapentin (for pain);
* Oxycodone;
* Sertraline (for depression); and
* CalProtect external ointment (for skin breakdown prevention).
On 01/04/23, the need to ensure physician orders were carried out as prescribed was reviewed with Staff 2 (ED) and Staff 18 (Administrator in Training). They acknowledged the findings.
Retraining provided to all med staff to attempt to give medications at least three times prior to marking as refused, not given or sleeping. Administrator, Resident Services Coordinator and doctor notified anytime a medication is not given for any reason.
Administrator and Resident Services Coordinator will be responsible for auditing that all medications were given, attempted to be given and documented correctly with notifications being complete.
This will be audited twice weekly to ensure that physician orders were administered as prescribed and documentation/notification were completed as directed.
Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 1 of 3 sampled residents (#3) whose records were reviewed. This is a repeat citation. Findings include, but are not limited to:
Resident 3 was admitted to the facility in 10/2017 with diagnoses including multiple sclerosis, dementia, and bipolar disorder.
Resident 3's MAR, dated 04/01/24 through 04/30/24, and physician orders were reviewed.
Physician orders, signed 03/05/24, included the following instructions:
* Acetaminophen 325 mg, "use first for pain"; and
* Oxycodone 5 mg, "for pain not relieved by non-opioid agents."
The resident's MAR showed:
* Acetaminophen was not administered;
* Oxycodone was administered 58 times.
During an interview on 05/03/24, Staff 24 (Resident Services Coordinator/LPN) stated he was not aware the physician order was not being followed, although he said he did believe the resident could self-direct his/her pain medication if needed. After reviewing the resident's most recent evaluation, Staff 24 acknowledged it did not include information specifying whether the resident could self-direct PRN pain medication.
The need to ensure medication orders were carried out as prescribed was reviewed with Staff 2 (ED), Staff 18 (Administrator), Staff 24, and Staff 28 (Regional Director of Operations) on 05/03/24. They acknowledged the findings.
Medication order was clarified for resident 3. An order has been obtained allowing resident to self-direct medication preference for pain.
All prn medications will be audited by lead med tech and resident service coordinator for use as directed by the order.
These audits will be completed weekly.
Administrator will be responsible monthly for overseeing that these audits are completed and that medications are being given as directed by the order.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to notify the physician or other practitioner when a resident refused consent to orders for 2 of 2 sampled residents (#s 6 and 8), who had documented medication refusals. Findings include, but are not limited to:
1. Resident 6 was admitted to the facility in 10/2023 with diagnoses including Parkinson's and chronic pain.
The resident's MARs dated from 12/01/23 through 01/02/24, physician's orders, and the resident's clinical record were reviewed.
On 12/11/23, Resident 6 refused hydroxyzine (for anxiety), midodrine (for low blood pressure), Carb/Levo (for Parkinson's), carisoprodol (for pain), and Ensure (for nutrition).
There was no documented evidence the resident's refusals to consent to orders were communicated to the physician.
The need to ensure the facility notified the physician or other legally recognized practitioner of medication refusals was reviewed with Staff 2 (ED) and Staff 18 (Administrator in Training) on 01/04/24. They acknowledged the findings.
2. Resident 8 was admitted to the facility in 07/2018 with diagnoses including anxiety and dementia.
The resident's MARs dated from 12/01/23 through 01/02/24, physician's orders, and the resident's clinical record were reviewed. The following refusals were identified:
* 12/17/23 - lorazepam (for anxiety) and oxycodone (for pain);
* 12/20/23 - potassium (for supplement);
* 12/23/23 - lorazepam, oxycodone, potassium, and spironolactone (for fluid retention);
* 12/24/23 - oxycodone, potassium, and spironolactone; and
* 12/26/23 - potassium.
There was no documented evidence Resident 8's refusals to consent to orders were communicated to the physician.
The need to ensure the facility notified the physician or other legally recognized practitioner of medication refusals was reviewed with Staff 2 (ED) and Staff 18 (Administrator in Training) on 01/04/24. They acknowledged the findings.
Doctors were notified of medications that were refused for the surveyed residents.
Staff inservice was completed regarding the residents right to consent or refuse medications. Training was provided on notification of physician or other practitioner when a medication is refused. Staff were trained to notify facility on-call phone of any refusals.
This will be audited by Administrator and Resident Services Coordinator twice weekly to ensure proper notification and documentation were completed.
There are no detail notes for this visit.
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 2 sampled residents (#3) who had devices with potentially restraining qualities. Findings include, but are not limited to:
Observation of Resident 3's room on 08/16/23 at 2:30 pm, revealed there were two full length side rails in the raised position on the bed and a tilt-n-space wheelchair.
Review of the resident's clinical record revealed the following:
* No documented evidence of an assessment completed by an RN, PT or OT for the use of the side rails or wheelchair; and
* No documented evidence other less restrictive alternatives had been attempted prior to use.
In an interview Resident 3 stated s/he was unable to adjust the position of the wheelchair independently but was able to request staff assistance with wheelchair positioning as needed.
The need to complete an assessment and the required components for the use of devices with potentially restraining qualities prior to use was discussed on 08/17/23 with Staff 1 (Administrator) and Staff 3 (RN/Resident Services Coordinator). They acknowledged the findings.
All resident rooms have been audited for devices with restraining qualities. Resident's service plans have been updated to reflect these devices. Assessment of supportive devices with restraining characteristics have been accurately completed by facility RN. Clear instructions for use have been included in the service plan.
Staff were retrained to notify management/nursing using the Communication Binder for any use of possible devices with restraining qualities.
Audit will be completed weekly by Resident Services Coordinator or designee of resident rooms to ensure there are no devices with restaining qualities that have been implemented that are not captured previously.
This will be the responsibility of the Administrator to ensure this is completed and monitored.
There are no detail notes for this visit.
Based on observation, interview, and record review, it was determined the facility failed to ensure a thorough RN, PT, or OT assessment was completed prior to the use of a supportive device with restraining qualities, document other less restrictive alternatives evaluated prior to the use of the device, instruct caregivers on the correct use and precautions related to the use of the device, and include the use of the supportive device on the service plan for 1 of 1 sampled resident (#3) who used a supportive device with restraining qualities. Findings include, but are not limited to:
Resident 3 was admitted to the facility in 10/2017 with diagnoses including multiple sclerosis.
On 07/08/24, Resident 3 was observed laying in a hospital bed with half-length siderails in the up position.
Review of Resident 3's record indicated there was no documented evidence of:
* An assessment completed by an RN, Physical Therapist or Occupational Therapist;
* Other less restrictive alternatives attempted prior to their use;
* Instruction to caregivers on the correct use and precautions related to use of the device; and
* Service plan directions for the use of the siderails.
On 07/11/24 at approximately 10:15am, the lack of an assessment and documentation requirements for siderails was discussed with Staff 24 (Resident Services Coordinator/LPN) and Staff 30 (Administrator). They acknowledged the findings.
1. An assessment was completed by an RN prior to the survey team leaving on 7/11/2024. Service plan was updated to provide instructions to caregivers on the correct use and precautions related to use of the device.
2. Audits will be completed monthly to ensure there are no restrictive devices in the community that do not have an assessment and are not reflected on the service plan.
Care staff will have training on identifiying and notifying of any restrictive devices that are new or different than what is on the service plan.
3. This will be audited monthly by the RN and/or Resident Services Coordinator (LPN).
4. Administrator and RN will be responsible for ensuring that these are completed/monitored.
There are no detail notes for this visit.
Based on observation, interview, and record review, it was determined the facility failed to have sufficient number of direct care staff to meet the 24-hour scheduled and unscheduled needs of each resident and to compensate for staff duties beyond direct resident care. Findings include, but are not limited to:
During the entrance conference on 08/15/23 the following was identified:
* The facility had 26 residents;
* Five residents needed two-person assistance with transfers and/or for all or part of their care;
* Two residents were identified to have frequent resident to resident altercations;
* Two residents were receiving hospice or palliative care;
* Four residents were identified as "heavy care" and needed full assistance with ADLs related to physical abilities, cognitive deficits and/or behaviors; and
* Multiple residents were identified with behavioral issues needing constant cueing, monitoring and/or redirection.
The direct care staff on all shifts were identified as universal workers based on interviews with Staff 1 and Staff 2 (ED) who stated staff duties included housekeeping, meal service, and activities.
In an interview on 08/15/23, Staff 1 (Administrator) explained the facility had a special needs contract for four residents that required two CG's and 0.5 MT on all shifts. The two CG's and 0.5 MT provided ADL assistance to the four contracted residents only. Staff 1 stated, if time allowed, those designated care staff could provide services to other residents such as trash pick up. This plan designated one CG and 0.5 MT for the remaining 22 residents, not part of the special needs contract, that included residents requiring heavy care, two-person transfers and hospice care.
The current posted staffing plan:
* Day shift: 3 CG's and 1 MT;
* Swing shift: 3 CG's and 1 MT; and
* Noc shift: 2 CG's and 1 MT.
During a group interview conducted on 08/16/23, multiple residents stated having to wait long periods of time for call lights to be answered. Residents also stated showers were not provided as scheduled "when there was not enough staff."
On 08/18/23, the need to ensure an adequate number of staff to meet the scheduled and unscheduled needs of residents was discussed with Staff 1, Staff 2 and Staff 3 (RN/Resident Services Coordinator). They acknowledged the findings.
*Refer to C361 Acuity Based Staffing Tool
ABST is updated and accurate on the ODHS provided tool. This will be updated
(a) Before a resident moves in, with amendments as appropriate within the first 30 days to address a resident's needs.
(b) Whenever there is a significant change of condition
(c) No less than quarterly, preferably at the same time the resident's service plan is updated
ABST has been separated by Special Contract residents and assisted living residents to ensure that proper staffing is obtained for both Special Contract and assisted living.
The Administrator and Resident Services Coordinator are responsible for updating the ABST as stated above and reviewing weekly to ensure they are staffing accordingly.
The Executive Director and/or Regional Director of Operations will audit monthly to ensure timely changes are occuring and that the current staffing levels are met.
There are no detail notes for this visit.
Based on interview, and record review, it was determined the facility failed to have a sufficient number of direct care staff to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to:
During the acuity interview on 05/01/24, Staff 18 (Administrator), Staff 24 (Resident Services Coordinator/LPN), and Staff 25 (CG) identified two assisted living residents needing the assistance of two staff for all transfers.
A review of the facility's assisted living staffing plan, as well as interviews with staff, identified there were one and one-half staff scheduled for the assisted living residents on day and swing shifts and one staff for the overnight shift.
On 05/03/24 the need to have at least two people on each shift when there were residents requiring two-person transfers was discussed with Staff 2 (ED), Staff 18 (Administrator), and Staff 24 (Resident Services Coordinator/LPN). They acknowledged the findings.
Staffing was increased to meet the requirement that there is always two staff on shift due to a two-person transfer.
Two care staff will be scheduled each shift as long as resident(s) requiring a two person transfer reside at the community.
Staff level will be reviewed monthly after service plan reviews and with changes in care needs.
The Administrator will be responsible for ensuring that the staffing is adequate and meets the needs of our residents.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to use an acuity-based staffing tool (ABST) that showed all residents with the 22 required care elements with staff time to complete them. Findings include, but are not limited to:
ABST record system was reviewed with Staff 1 (Administrator) on 08/17/23 at 10:00 am. Staff 1 stated the facility was using "Point Click Care" to record the 22 required care elements and staff time to complete them.
A record review of the ABST information provided by Staff 1 revealed the following:
* ABST did not address all the required activities of daily living (ADLs) for each resident;
* ABST did not include the amount of staff time needed to provide care for the resident sample picked for the survey: and
* The facility did not provide evidence that the acuity-based staffing tool was being used to develop and routinely update the facility's staffing plan.
In an interview on 08/18/23 at 3:30 pm, the need for the ABST tool to show all residents with the 22 required care elements with staff time to complete them, ensuring ABST provided data so the facility could develop a 24-hour schedule and an individualized task list was discussed with Staff 1, Staff 2 (ED) and Staff 3 (RN/Resident Services Coordinator). They acknowledged the findings.
ABST updated and accurate on the ODHS provided tool to ensure all 22 required care elements are met.
This will be updated daily as needed by the Resident Service Coordinator or Administrator.
Executive Director to audit weekly to ensure that the corrections are completed and monitored ongoing.
Executive Director.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure that 3 of 3 sampled newly hired employees (#s 11, 13 and 14), completed required pre-service orientation training prior to beginning their job responsibilities. Findings include, but are not limited to:
Staff training records were reviewed on 08/16/23 at 12:10 pm with Staff 1 (Administrator) for Staff 11 (CG), hired 06/09/23, Staff 13 (CG), hired 04/24/23 and Staff 14 (CG), hired 01/19/23.
Staff 11, 13 and 14 lacked evidence of the following required pre-service training related to components of Infectious Disease Prevention training:
* Transmission of communicable disease and infections;
* Standard precautions;
* Hand hygiene;
* Use of personal protective equipment;
* Cleaning of physical environment, linens;
* Isolating and cohorting of residents during a disease outbreak; and
* Rights and responsibilities of employees to report disease outbreaks.
The need to ensure newly hired staff completed all components of approved infectious disease prevention training was discussed on 08/18/23 with Staff 1, Staff 3 (RN/ Resident Services Coordinator) and Staff 5 (Resident Care Coordinator). They acknowledged the findings.
All required Infections Disease Prevention staff training completed for each of the newly-hired staff and existing staff.
Business Office Manager will be responsible for tracking these trainings and ensuring that they are completed prior to bringing their job responsibilities and on-going.
Infectious Disease Prevention training template has been updated to reflect all required training and each staff has been assigned and completed training in Relias.
BOM will audit this tracking weekly to ensure all staff have required pre-inservice and on-going training.
Administrator and/or Executive Director will audit Business Office Manager's tracking records going forward on a monthly basis.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly-hired direct care staff (#s 11, 13 and 14) had demonstrated competency in all required areas within 30 days of hire. Findings include, but are not limited to:
On 08/16/23, training records were reviewed with Staff 1 (Administrator) and Staff 5 (Resident Care Coordinator) and revealed the following:
Staff 11 (CG), hired on 06/09/23, failed to have documented evidence of competency demonstrated within 30 days of hire in the following areas:
* Role of service plans in providing individualized care;
* Providing assistance with ADLs;
* Changes associated with normal aging;
* Identification, documentation and reporting of changes of condition;
* Conditions that require assessment, treatment, observation and reporting; and
* General food safety, serving and sanitation.
Staff 13 (CG), hired on 04/24/23, failed to have documented evidence of competency demonstrated within 30 days of hire in the following areas:
* Role of service plans in providing individualized care;
* Providing assistance with ADLs;
* Changes associated with normal aging;
* Identification, documentation and reporting of changes of condition;
* Conditions that require assessment, treatment, observation and reporting;
* General food safety, serving and sanitation; and
* First Aid and abdominal thrust training.
Staff 14 (CG), hired on 01/19/23, failed to have documented evidence of competency demonstrated within 30 days of hire in the following areas:
* Changes associated with normal aging; and
* First Aid/Abdominal Thrust.
The need to ensure all newly hired staff had competency demonstrated and documented in all areas required within 30 days of hire was discussed on 08/18/23 with Staff 1, Staff 3 (RN/ Resident Services Coordinator) and Staff 5. They acknowledged the findings.
All required staff training completed for each of the newly-hired staff and existing staff.
Business Office Manager will be responsible for tracking these trainings and ensuring that they are completed prior to beginning their job responsibilities and on-going.
BOM will audit this tracking weekly to ensure all staff have required pre-inservice and on-going training.
Administrator and/or Executive Director will audit Business Office Manager's tracking records going forward on a monthly basis.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to have documented evidence that 12 hours of annual in-service training, including six hours related to the care of the dementia resident, was completed for 3 of 3 long-term care staff (# 7, 8 and 9) and annual infectious disease training was completed for 3 of 3 long-term care staff (# 7, 8 and 9) whose training records were reviewed. Findings include, but are not limited to:
Facility training records were reviewed on 08/17/23 and revealed the following:
1. Training records for Staff 7 (CG), hired on 06/16/21, Staff 8 (CG), hired on 06/17/22, and
Staff 9 (Life Enrichment Coordinator), hired on 01/17/19, failed to have documented evidence of completing 12 hours of required in-service training, including six hours relating to the care residents with dementia.
2. Training records for Staff 7, Staff 8 and Staff 9 failed to have documented evidence of completing the required annual infectious disease training.
The need to ensure staff completed all required annual in-service training based on anniversary dates of hire was reviewed with Staff 1 (Administrator) on 08/18/23. He acknowledged the findings.
Annual staff-training schedule has been updated to ensure it meets all training requirements.
Staff will be meeting twice monthly and all required training will be documented and filed in a binder in the Executive Director's office.
This will be tracked ongoing by the Business Office Manager monthly.
This will be monitored by the Executive Director monthly to ensure accurate tracking and that all staff are meeting the requirements.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to provide and document fire and life safety instruction to staff on alternate months from fire drills, in accordance with the Oregon Fire Code (OFC), and identify residents who were unwilling or failed to participate in drills. Findings include, but are not limited to:
The previous six months of fire drill and fire and life safety training records were reviewed on 08/16/23. The following deficiencies were identified:
* The facility lacked documented evidence fire and life safety training was provided to staff on alternate months.
* There was was no documented evidence the facility had identified residents who were unwilling or failed to participate in fire drills and made immediate changes to ensure evacuation standards were being met.
The need to ensure fire and life safety instruction was provided to staff on alternating months from fire drills and included all required components was discussed with Staff 1 (Administrator) on 08/18/23. He acknowledged the findings.
Retraining of Proper Fire Drill documentation was held with Environmental Safety staff and a sample was filled out by ESS to ensure that he understands all the components of Fire Drill Documentation.
Administrator will be involved in Fire Drills monthly and will audit Fire Drill Documentation with ESS to ensure all requirements are met and to discuss and resolve any issues that may have occurred during drill.
Administrator will audit drills monthly and ensure these are documented correctly.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure residents were instructed within 24 hours of admission and re-instructed at least annually in general safety procedures, evacuation methods, responsibilities during fire drills and designated meeting places outside the building or within the fire safe area in the event of an actual fire. Findings include, but are not limited to:
In an interview on 08/18/23, the facility's process for providing fire safety training to residents upon admission and annually was discussed with Staff 1 (Administrator).
Staff 1 stated that fire and life safety instruction was provided to residents upon admission and provided a form "Resident Orientation to Emergency Procedures". However Staff 1 was not able to provide documented evidence that the form had been used for any residents. Staff 1 did not provide any documented evidence that annual re-instruction was provided. No further documentation of resident training was provided.
The need to ensure residents were trained in fire and life safety procedures within 24 hours of admission and at least annually was reviewed with Staff 1 on 08/18/23. He acknowledged the findings.
Environmental Safety staff trained on completing Fire Safety Training that is to take place upon admission with all residents and their family.
The Fire Safety Training documentation has been added to the initial move-in paperwork and it is the responsibility of the ESS to ensure this training occurs and is documented within 24 hrs of admission.
Business Office Manager will audit to ensure this occurs with each move-in using the updated "move-in checklist".
Administrator will ensure this is completed and sign off on the updated "move-in checklist" within 24 hrs of admission.
There are no detail notes for this visit.
Based on interview, observation and review of documentation, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:
Refer to C 260 and C 303.
See POC for C 260 and C 303.
Based on observation interview and record review, it was determined the facility failed to ensure their re-visit survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include, but are not limited to:
Refer to C260 and C303.
Refer to C260 and C303
There are no detail notes for this visit.
Based on observation and interview, it was determined the facility failed to ensure all interior materials and surfaces were kept clean and in good repair. Findings include, but are not limited to:
The interior of the facility was toured on 08/17/23 at 9:24 am. The following areas were in need of cleaning or repair:
* Multiple resident rooms, including but not limited to rooms 201, 207 and 215, had debris, black stains and scuffs on carpets;
* Multiple gaps in the flooring throughout the common area hallways, allowing for build up of dirt and debris;
* Pervasive odor of urine in the common area hallway near rooms 213 through 216;
* Dining room tables and chairs were chipped, scratched, gouged and scuffed;
* Lounge chair next to room 201 had a brown stain exposing interior material;
* Lounge chair with wood arm rests next to room 210 was chipped, scratched, and rough to touch; and
* The common area hallway, in front of room 216, had an area of the flooring that was warped, causing an uneven surface in the flooring and was a tripping hazard. Staff 1 (Administrator) stated it was due to recent water damage.
The building was toured and areas needing cleaning or repair were discussed with Staff 1 on 08/18/23. He acknowledged the findings.
Room 215, 225 carpet replaced with flooring. All rooms with carpet to be replaced with flooring unless resident's decline to relocate for flooring replacement. All rooms with carpet to be placed on a weekly carpet cleaning schedule until carpets can be replaced.
Hallway gaps repaired and floor with water damage repaired outside room 216.
Lounge chairs were disposed of and repaired as needed and all chairs have been evaluated for cleanliness.
Dining room furniture has been replaced/repaired.
Environmental Safety Services to be responsible for ensuring these are cleaned and cleaning is documented on a weekly basis.
Administrator will conduct walk-through of each room and hallway at least 2 times per week and will document any flooring or other items needing attention.
There are no detail notes for this visit.
Based on observation and interview, it was determined the facility failed to ensure all interior materials and surfaces were kept clean and in good repair. Findings include, but are not limited to:
Observations of the facility were made between 07/08/24 and 07/11/24, and the following areas were in need of cleaning or repair:
* Dark stained carpet in resident rooms 201, 202, 203, and 223;
* Stained furniture in common areas; and
* Gouged trim at the bottom of multiple resident doors.
The need to ensure the facility's interior materials and surfaces were kept clean and in good repair was discussed with Staff 30 (Administrator) on 07/11/24 at 10:30 am. She acknowledged the findings.
1. Carpets noted (201, 203 and 223) will be professionaly shampooed on 8/6/2024. When a room is available, residents who are willing to relocate will be moved to the room while their carpets are replaced with flooring.
Repairs are being made to the door frames as parts are delivered. All door frames have been cleaned.
Furniture has been cleaned and is stain-free. Items that were not able to be cleaned have been disposed of.
2. Audits will be completed weekly by the Environmental Services Director and repairs will be completed within a timely manner.
3. This will be audited weekly by the Environmental Services Director.
4. The Administrator will be responsible for ensuring the corrections are completed/monitored.
There are no detail notes for this visit.
Based on observation, interview, and record review, it was determined the facility failed to provide a heating system capable of maintaining 70 degrees Fahrenheit in resident areas, and failed to ensure covers, grates, or screens of wall heaters and associated heating elements did not exceed 120 degrees Fahrenheit when installed in a location subject to incidental contact by individuals. This placed residents at risk and constituted an immediate threat to the residents' health and safety. Findings include, but are not limited to:
On 05/02/24, a staff member and two unsampled residents reported in an interview that the heating system was not working in multiple resident rooms. They stated that the facility had provided residents with space heaters to use as needed.
In an interview at 3:20 pm on 05/02/24, Staff 2 (ED) stated the facility noticed on 03/02/24 that some of the rooms in the north hall of the facility did not have heat. The facility purchased space heaters and provided them to residents. Staff did not check the temperature of the cover or screen of the spacer heaters prior to or after providing them to residents. Since 04/08/24, all rooms in the north hall of the facility have been without a heating system.
Resident rooms were observed on 05/02/24, and the following was identified:
* Nine rooms contained "small" space heaters provided by the facility. The temperature of the screen was tested as high as 217 degrees Fahrenheit. An unsampled resident room was observed with the space heater in the walkway leading to the resident's bathroom. The space heater was on and the screen tested at 208 degrees Fahrenheit.
* Two rooms contained "tall" space heaters provided by the facility. The temperature of the screens was tested as high as 275 degrees Fahrenheit.
This constituted a significant risk to resident health and safety and required an immediate plan of correction.
The facility submitted a plan of correction to the survey team at 5:04 pm on 05/02/24. The immediate jeopardy situation was abated.
The need to provide a heating system capable of maintaining 70 degrees Fahrenheit in resident areas, and ensure covers, grates, or screens of wall heaters and associated heating elements did not exceed 120 degrees Fahrenheit when installed in a location subject to incidental contact by individuals, was discussed with Staff 2, Staff 18 (Administrator), and Staff 28 (Regional Director of Operations) on 05/02/24. They acknowledged the findings.
All heaters were removed immediately. An air thermometer will be used to check the temperature of each room and common areas to ensure that the temperature does not fall below 70 degrees every hour during the day and 60 degrees Fahrenheit during the evening. Extra blankets have been provided for residents who requests. Warm drinks will be offered. Fans were provided for those who requested due to warmer weather.
oEducation and training for staff and residents provided for each shift.
o We will document who is in need of and who declined extra blankets and where they are located.
* How will the system be corrected so this violation will not happen again: the system that is affected will be repaired.
* How often will the area needing correction be evaluated: Daily
* Administrator. In the absence of Administrator, the Environmental Services will be responsible for the corrections.
There are no detail notes for this visit.
Based on observation and interview, it was determined the facility failed to provide call system that connected resident units to the care staff center or staff pagers and failed to provide a manually operated emergency call system at each resident bathroom and public-use restrooms. Residents were unable to contact staff to request help when needed, constituting a threat to their health, safety, and welfare. Findings include, but are not limited to:
On 05/01/24 at 1:30 pm, Witness 1 (Outside Provider) reported to the survey team the facility's call system was inoperable. Witness 1 indicated s/he had reported the lack of a call system to the local Seniors & People with Disabilities (SPD) office on 04/03/24, on behalf of Resident 3. SPD substantiated the claim.
In an interview with Witness 2 (Facility Policy Analyst) on 05/01/24 at 4:24 pm, she stated she was aware the call system had been damaged by a flood in the facility in 01/2024, but was not aware until 04/26/24 that the call system had not yet been repaired or replaced.
Interviews with staff and residents between 05/01/24 and 05/03/24 confirmed the call system had not been working since 03/21/24. Sampled and unsampled residents reported the system had not been working and stated they were concerned about not getting assistance when needed.
During the survey, conducted 05/01/24 through 05/03/24, it was observed a bathroom accessible to visitors did not have a manually operated emergency call system. In an interview on 05/02/24 with Staff 2 (ED) and Staff 18 (Administrator), Staff 2 stated the call system in the bathrooms stopped working at the same time the resident unit call system stopped working.
The lack of a functioning call system threatened the health, safety, and welfare of the residents. The facility was requested to provide an immediate plan of correction (POC). A short-term POC was received at 5:47 PM on 05/01/24 and a long-term POC was received on 05/02/24 at 1:25 pm. The immediate jeopardy situation was abated.
The need to have an operational call system that connected residents to the care staff center or staff pagers and to have a manual emergency call system in all resident bathrooms and restrooms used by visitors was discussed with Staff 2 (ED), Staff 18 (Administrator), Staff 24 (Resident Services Coordinator/LPN), and Staff 28 (Regional Director of Operations) on 05/03/24. They acknowledged the findings.
oPalCare call light system has been ordered and is scheduled to be installed with training provided to staff 6-8 weeks from date of order (4/29/2024). The date of installation will be 6/17/2024.
oDuring the wait time for installation, pendants have been ordered for all residents and training provided for residents and staff on the use of pendants and pagers.
oSpreadsheets documenting safety checks completed no longer than one hour apart for each resident will be continued until the call light system is installed and functioning correctly. These will have the time and initial of the person completing each safety check.
oMed tech to continue to sign off at end of shift that they have verified that checks were completed.
oSafety checks will be performed no longer than one hour by a staff separate from the staff on the floor working caregiving. The staff will not perform any personal care. The staff will have a walkie talkie upon start of their shift and return at end of shift to oncoming staff. They will check each room and ensure that the resident does not have any unmet needs or safety concerns. If there is anything needed, they will notify care staff by walkie talkie so a care staff can assist.
oWe will provide evidence of a training plan and document staff already trained with the date of attendance and the topic.
oWe will provide copies of the orders for the call system and the pendants for all residents.
* How will the system be corrected so this violation will not happen again:
oWe have purchased a completely new wireless call system to prevent continued failure of the current system.
oIf the system is down for any reason, the above actions will be reinstated immediately.
* How often will the area needing correction be evaluated:
oDaily until the new system is installed and operational.
* Who will be responsible to see that the corrections are completed:
oAdministrator will be responsible for ensuring corrections are completed. In her absence, this will be overseen by Resident Services Coordinator and/or Med Tech on duty.
There are no detail notes for this visit.