The findings of the Facility Enhanced Oversight and Supervision survey conducted 04/11/22 through 04/14/22 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 the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first re-visit to the Facility Enhanced Oversight and Supervision survey on 04/14/22, conducted on 07/27/22 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.

Based on observation, interview and record review, it was determined the facility failed to report physical injuries of unknown cause to the local SPD office or the local AAA as suspected abuse, unless an immediate facility investigation reasonably concluded and documented the physical injury was not the result of abuse, for 2 of 2 sampled residents (#s 2 and 4) with injuries of unknown cause. Findings include, but are not limited to:

1. Resident 2 was admitted to the MCC in 04/2019 with diagnoses including dementia, Alzheimer's disease and anxiety disorder. During the survey, the resident was observed to self-propel around the facility through the hallways in his/her manual wheelchair. The resident often moved along the walls and bumped the wheelchair into the hand rails and doorframes. The resident had minimal capacity to respond to questions verbally.

Review of Resident 2's progress notes, Incident Reports, evaluations, service plans and Interim Service Plans indicated the facility lacked an effective system for identifying and investigating injuries of unknown cause as follows:

a. On 01/15/22, an injury described as a "nickel size skin tear" located on the "right arm" was added to the facility's skin log.

b. On 03/02/22, an injury described as a "skin tear" located on the "right forearm just below elbow" was added to the facility's skin log.

c. On 03/11/22, an injury described as a "skin tear" located on the "left back of hand" was added to the facility's skin log.

There was no other documentation indicating how the injuries occurred. These represented injuries of unknown cause.

There was no documented evidence the facility conducted an immediate investigation which reasonably concluded and documented the physical injury was not the result of abuse, or that the injury was reported to the local office as suspected abuse.

The need to immediately investigate injuries of unknown cause and document how abuse was reasonably ruled out or report the injuries to the local office was reviewed with Staff 1 (ED) and Staff 2 (RN) on 04/14/22. They acknowledged the facility did not identify the injuries as injuries of unknown cause and did not investigate or report them.

2. Resident 4 was admitted to the MCC in 01/2022 with diagnoses including dementia, cellulitis and chronic peripheral venous insufficiency. During the survey, the resident was observed to spend the day in his/her room seated in a recliner napping or watching TV. The resident had minimal capacity to respond to questions verbally.

Review of Resident 4's progress notes, Incident Reports, evaluations, service plans and Interim Service Plans indicated the facility lacked an effective system for identifying and investigating injuries of unknown cause as follows:

a. On 03/11/22, an injury described as a "skin tear" located on the "right leg" was added to the facility's skin log.

b. On 04/09/22, an injury described as a "bruise" located on the "right outer forearm" was added to the facility's skin log.

There was no other documentation indicating how the injuries occurred. These represented injuries of unknown cause.

There was no documented evidence the facility conducted an immediate investigation which reasonably concluded and documented the physical injury was not the result of abuse, or that the injury was reported to the local office as suspected abuse.

The need to immediately investigate injuries of unknown cause and document how abuse was reasonably ruled out or report the injuries to the local office was reviewed with Staff 1 (ED) and Staff 2 (RN) on 04/14/22. They acknowledged the facility did not identify the injuries as injuries of unknown cause and did not investigate or report them.

1.Resident # 2- Injuries of unknown cause were reported as

"late report" to APS on 4/25/22- Incident report was completed for skin injuries on 1/15/22, 3/2/22, 3/11/22

Resident #1- Injuries of unknown cause were reported as "late report" to APS on 4/25/22- Incident report completed for skin injuries on 3/11/22, 4/9/22.

2. ED/Clinical team(RN,Medroom Manager) will review skin logs for new reported skin concerns during Clinical meeting that occurs each Morning M-F. ED/Clinical team (RN, medroom manager) will verify that all new entries reported on skin log have an incident report completed for Resident injury.Immediate investigations of unknown cause of injury will be completed. How abuse abuse was ruled out will be documented on Incident report. If investigation of IUC detemines that Abuse can not be ruled out, ED or designee will report APS. Training will be provided to Medtechs and Caregivers on Policy and procedures to ensure  incident reports are completed for injuries of unknown cause for all noted skin related concerns.

3. Skin log will be reviewed during daily Clinical stand up M-F.

4. ED/ RN/ Medroom Manager will be responsible to ensure that skin injuries are investigated. ED will provide oversight.

Based on interview and record review, it was determined the facility failed to ensure the initial evaluation contained information about all the required elements, for 1 of 1 sampled resident (#4) whose move-in evaluation was reviewed and failed to ensure quarterly evaluations accurately reflected the resident's status for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose quarterly evaluations were reviewed. Findings include, but are not limited to:

1. Resident 4 was admitted to the MCC in 01/2022 with diagnoses including dementia, cellulitis and chronic peripheral venous insufficiency. The resident's move-in evaluation failed to adequately address the following required elements:

* Customary routines: sleeping and bathing; and

* Risk indicators: unexplained weight loss or gain.

The initial evaluation was reviewed with Staff 1 (ED) and Staff 2 (RN) on 04/14/22. They acknowledged the information that was not included in the evaluation.

2. Resident 1, 2, 3 and 4's quarterly evaluations were reviewed, observations were made of the residents and staff were interviewed. The following inaccuracies were identified in the quarterly evaluations:

a. Resident 1's quarterly evaluation did not accurately reflect the assistance the resident needed for dressing.

b. Resident 2's quarterly evaluation did not accurately reflect the level of assistance needed for eating.

c. Resident 3's quarterly evaluation did not include a thorough description of situations that could trigger the resident to act aggressively toward others.

d. Resident 4's quarterly evaluation did not accurately reflect the level of assistance the resident needed for transfers or the resident's clothing preferences.

The need to ensure evaluations were thorough and accurate was discussed with Staff 1 (ED) and Staff 2 (RN) on 04/14/22. They acknowledged the findings.

1. Resident # 4- An ISP (Interim Service plan) was completed to include the residents customary routines for sleeping and bathing, clothing preferences and transfer assistance updates. These will be added to the quarterly evaluation/Service plan on the due date of for quarterly review.

Resident #1- ISP completed for assistance with dressing instructions/steps.

Resident #2- ISP completed for assistance with eating instructions.

Resident #3- ISP completed for situations and triggers for aggressive behaviors- Interventions were reviewed.

2. Audit of all Resident Quarterly evaluations will be completed to review accuracy. Any noted corrections will be hand written signed & dated. Updates will be entered on evaluation during next quarterly review. Staff training will be provided to Caregivers and medtechs on reporting changes or inaccuracies noted on the Eval/service plan to the clinical team immediately. During Shift huddles, caregivers will report any inaccuracies or changes needed for care/instructions to the eval/SP.

3. The ED/Clinical team will meet each Wednesday and review all evaluations/ service plans that are due during IDT (Interdisciplinary Team meeting). During IDT ED/Clinical Team will update customary routine for all new residents is accurate as well as current residents is updated to reflect their current customary routines. example: (how often, time of day, shower or bath, etc.) and eating routine (eats all three meals or skips some, prefers to eat some meals in the room, snacks during the day, etc. During IDT meetings ED/Clinical will also make sure all residents eval/SP have documenation speaking to if their have a history of weight loss or weight gain and that it is also included on all new admission evaluations prior to admit. ED/Clinical will also make sure the boxes marked weight gain or weight loss are clicked as pertaining to that specific resident.

4.ED will provide oversight.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and included a description of the services to be provided, for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose service plans were reviewed. Findings include, but are not limited to:

Resident 1, 2, 3 and 4's current service plans were reviewed. Observations were made of the resident and interviews were conducted with caregivers and, if possible, with the resident. The following deficiencies were identified:

1. Resident 1's record and staff interviews indicated the resident could be stubborn and resistant to allowing caregivers to assist with ADLs.

The service plan did not accurately reflect that Resident 1 needed encouragement from caregivers to don a fresh set of clothes each day and did not offer strategies for addressing times when the resident resisted changing clothes or taking regular showers.

2. Resident 2's record, observations of the resident and interviews with staff indicated the resident was unable to effectively feed him/herself and staff were now physically feeding the resident.

The service plan did not accurately reflect Resident 2's inability to feed him/herself or provide instructions for staff regarding physical feeding.

3. Resident 3's record and staff interviews indicated the resident could escalate quickly in situations where s/he felt a peer was being mistreated, resulting in aggressive altercations with other residents.

The service plan did not fully describe situations that could trigger aggressive behavior. Interventions were included in the Activities section of the service plan but not in the section where behaviors and behavior interventions were discussed.

4. Resident 4's record, observations of the resident and interviews with staff indicated three caregivers were often used to transfer the resident, the resident resisted ADL assistance when woken from sleep and strongly preferred not to wear pants.

The service plan did not accurately reflect Resident 4's transfer needs, did not offer instructions for staff regarding the best times to offer ADL assistance and did not include the resident's clothing preference and instructions for staff for ensuring the resident's privacy and dignity was protected.

The need to ensure service plans reflected the residents' current needs and included instructions for staff for providing services was reviewed with Staff 1 (ED) and Staff 2 (RN) on 04/14/22. They acknowledged the information that was inaccurate or lacking from the service plans.

1. Resident # 1 Service plan has been updated to include strategies/ interventions for dressing and bathing when resident is resistive to caregiver assistance.

Resident # 2 Service plan was updated to include physical assist with eating and instructions.

Resident # 3 Service plan was updated to include noted triggers for situations that could cause escalated behaviors and aggression with other residents

Resident #4 Service plan was updated to include transfer assist changes, strategies and instructions for resisting ADL's, and clothing preferences.

2. Audit of all Resident Service plans will be completed to review accuracy. Any noted corrections will be hand written signed & dated. Updates will be entered on the service plan during next quarterly review. Staff training will be provided & documented to Caregivers and medtechs on reporting changes or inaccuracies noted on the service plan to the clinical team immediately. During Shift huddles, caregivers will report any innacuracies or changes needed for care/instructions to the eval/SP.

3. The ED/Clinical team will meet each Wednesday and review all evaluations/ service plans that are due during IDT (Interdisciplinary Team meeting).

4. ED will be responsible to provide oversight.

Based on observation, interview and record review, it was determined the facility failed to monitor each resident timely and consistent with his or her evaluated needs and service plan, for 3 of 4 sampled residents (#s 2, 3 and 4) who experienced changes of condition including injuries, falls, weight loss and resident altercations. Findings include, but are not limited to:

Resident 2, 3 and 4's records were reviewed from 01/14/22 through 04/13/22. The records included progress notes, Incident Reports, evaluations, service plans and Interim Service Plans. The following deficiencies were identified:

1. Resident 2 was admitted to the MCC in 04/2019 with diagnoses including dementia, Alzheimer's disease and anxiety disorder. During the survey, the resident was observed to self-propel around the facility through the hallways in his/her manual wheelchair. The resident often moved along the walls and bumped the wheelchair into the hand rails and doorframes. The resident had minimal capacity to respond to questions verbally.

a. The resident experienced a significant weight loss on 07/27/21. Significant change of condition progress notes reviewed from 01/14/22 through 04/13/22 failed to monitor whether service-planned interventions were being implemented and were effective in addressing the weight loss, or if new interventions needed to be developed.

b. The resident had a fall on 03/11/22 and sustained abrasions to the bridge of the nose and over the right eye. The facility failed to determine and document what was needed for the injuries and there was no evidence the facility monitored and documented on the progress of the conditions until resolved.

c. The facility failed to complete a timely follow-up of falls that occurred on 01/22/22, 01/29/22 and 03/12/22 to monitor whether the service plan was being followed at the time of the falls or if new interventions needed to be implemented to try to prevent additional falls.

The need to ensure changes of condition were reviewed timely and were monitored was reviewed with Staff 1 (ED) and Staff 2 (RN) on 04/14/22. They acknowledged the findings.

2. Resident 3 was admitted to the MCC in 10/2021 with diagnoses including dementia, depression and chronic lower back pain. During the survey, the resident spent time walking around the facility and talking to other residents, staff and his/her friends and family who visited.

The facility failed to complete a timely follow-up of altercations Resident 3 had with other residents that occurred on 01/26/22, 03/05/22 and 03/31/22 to monitor whether the service plan was being followed at the time of the incidents or if new interventions needed to be implemented to try to prevent further altercations.

The need to ensure changes of condition were monitored timely was reviewed with Staff 1 (ED) and Staff 2 (RN) on 04/14/22. They acknowledged the findings.

3. Resident 4 was admitted to the MCC in 01/2022 with diagnoses including dementia, cellulitis and chronic peripheral venous insufficiency. During the survey, the resident was observed to spend the day in his/her room seated in a recliner napping or watching TV. The resident had minimal capacity to respond to questions verbally.

The facility failed to complete a timely follow-up of falls that occurred on 01/21/22, 01/26/22 and 02/03/22 to monitor whether the service plan was being followed at the time of the falls or if new interventions needed to be implemented to try to prevent additional falls.

The need to ensure changes of condition were monitored timely was reviewed with Staff 1 (ED) and Staff 2 (RN) on 04/14/22. They acknowledged the findings.

1. Resident #2- RN will document weekly on weight loss interventions and effectiveness until weight is stable or new baseline has been set. The RN will document weekly on Change of condition and include a full fall evaluation and update new interventions and effectiveness until resolved or new baseline is set.

Resident #3- RN will document a change of condition for behavior occurances and document weekly on current interventions and effectiveness, and update service plan with new interventions as needed.

Resident #4- RN will document a change of condition to include a full fall evaluation as well as an update on the evaluation and service plan. The RN will document weekly on the COC, effectiveness of fall interventions and update the service plan with new interventions until resolved.

2. The ED/ clinical team will review all residents with COC each morning at Clinical review meeting to assure that COC is being monitored and interventions for effectivess are documented. Training-ED/RN will review "Compliance Guidelines for Change of Condition and Monitoring.

3. ED/Clinical team will review current COC's each morning during Clinical review meeting. Incident reports, Skin logs, 24 hour log, alert charting log will be reviewed to identify new COCs needs and follow up.

4. ED will provide oversight.

Based on observation, interview and record review, it was determined the facility failed to ensure the facility RN assessed all residents with a significant change of condition, for 1 of 1 sampled resident (#2) who experienced a significant weight loss. Findings include, but are not limited to:

Resident 2 was admitted to the MCC in 04/2019 with diagnoses including dementia, Alzheimer's disease and anxiety disorder. During the survey, the resident was observed to self-propel around the facility through the hallways in his/her manual wheelchair. The resident appeared very thin and had minimal capacity to respond to questions verbally. The facility physically fed the resident at meals.

Review of the weight record from 01/11/21 to 04/04/22 indicated between 06/01/21 and 07/27/21, the resident's weight decreased from 120.0 pounds to 111.6 pounds. This was a loss of 8.4 pounds or 7% body weight in 6 weeks. This represented a significant change of condition for which an RN assessment was required.

There was no documented evidence the former RN who was assigned to Resident 4 completed an assessment of the weight loss.

On 09/22/21, the resident's weight had dropped to 107.6 pounds. This was a loss of 12.4 pounds since 06/01/21 or 10.33% body weight in just over 3 months. Again, this represented a significant change of condition.

Staff 2 (RN), who was not assigned to Resident 2, nevertheless documented the significant change of condition in a progress note dated 09/29/21. The note included the resident's current weight and indicated the resident was receiving hospice services, had no signs of difficulty chewing or swallowing and often self-propelled away from the dining table at meals. She instructed staff through an Interim Service Plan to attempt to redirect the resident back to the table and, if the resident continued to leave, to offer "food on the go" such as a sandwich or finger food the resident could eat while ambulating in the wheelchair.

While the assessment noted the weight loss and a few issues that could affect the resident's weight, it was not a comprehensive assessment that reviewed medical history, current medical conditions, medications or behaviors, or noted the use of observations and interviews, in order to develop reasoned conclusions as to why the resident was losing weight.

The need to ensure RN assessments were completed when a significant change of condition occurred and that the assessments were thorough and comprehensive was discussed with Staff 1 (ED) and Staff 2 on 04/14/22. They acknowledged the former RN had failed to conduct an assessment when the significant weight loss first occurred, and that assessments needed to be more comprehensive.

1. Resident #2- Weight loss evaluation will be completed, and weekly COC notes will include:

a.      Change of diet needed.

b.Address pain/ dental issues.

c.Address mood or behavioral issues.

d.Address physical decline.

2.  Weight report will be reviewed daily at Clinical meeting with ED/Clinical team to identify all unplanned weight changes. Training-ED/RN will review DHS guideline for Unplanned Weight change.

3. ED and Clinical team will review weight report daily during morning clinical meeting.

4. ED will provide oversight.

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 C 231.

Refer to section: 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 C 252, C 260, C 270 and C 280.

Refer to sections: C252, C260, C270, and C280.