The findings of the re-licensure survey, conducted 06/06/22 through 06/08/22, are documented in this report. The survey was conducted to determine compliance with 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 revisit to the re-licensure survey of 06/08/22, conducted on 10/10/22, are documented in this report. The survey was conducted to determine compliance with 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 second revisit to the re-licensure survey of 06/08/22, conducted on 12/21/22, are documented in this report. The survey was conducted to determine compliance with 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 third revisit to the re-licensure survey of 06/08/22, conducted 04/13/23, are documented in this report. It was determined the facility was in compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004.
Based on observation and interview, it was determined the facility failed to ensure the kitchen was kept clean and food was prepared in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:
Observations of the kitchen and meal preparations on 06/06/22 and 06/07/22 showed the following:
* Multiple walls and shelves throughout the kitchen and dishware areas had dried spills, splatters and food debris;
* Baseboards and floors throughout the kitchen and dishware areas had food debris and black grime build-up;
* Shelves and floors in the walk-in freezer and reach-in refrigerators had dried spills and food debris;
* One of the garbage cans in the kitchen, used for food disposal, did not have a lid or cover;
* There were multiple dented cans of pears and chicken dumplings in the dry storage;
* The range hood vent and grates above the stove had an accumulation of grease and thick layer of dust;
* The floor drains had food particles and a build-up of sludge and green matter;
* The wall above the steam table had some build-up of dust particles;
* Kitchen staff were observed resting the probe thermometer on the bottom of food pans in the steam table when obtaining food temperatures and did not sanitize the probe between foods while temperatures were obtained; and
* Kitchen staff were observed using the same gloved hands between touching clean and dirty surfaces without changing gloves.
The need to ensure the kitchen was kept clean and proper sanitization and food handling techniques were used was discussed with Staff 1 (ED) and Staff 6 (Dietary Manager) on 06/07/22. They acknowledged the findings.
1. Dented cans were removed. Hood and vents were professionally cleaned. Kitchen was cleaned. Kitchen staff were educated on proper temping techniques and sanitation with temping and food handling. Community replaced garbage can with one that has a lid.
2. The Dietary Manager will implement daily, weekly, and monthly cleaning assignments. Kitchen staff have been educated on checking for dented cans and sending them back to the supplier.
3. The Dietary Manager and/or a designee will verify that cleaning schedule is being implemented and completed daily, weekly, and monthly.
4. The Dietary Manager and Executive Director are responsible for this plan of correction.
Based on observation, interview and record review, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to:
Observations of the facilities kitchen, food storage areas, food preparation and food service on 10/10/22 revealed:
* Splatters, spills, drips and debris noted on:
- Surfaces and underneath storage shelves, and cabinets throughout the kitchen;
- Storage shelves throughout the kitchen;
- Cookware stored on open shelving;
- Drains throughout the kitchen;
- Interiors of reach in freezers;
- Flooring of the walk in refrigerator;
- Walls throughout the kitchen;
- The dishwashing area walls, floors, and equipment;
- Both sides and the interior of the range, grill, and oven;
- Behind and underneath appliances;
- The surface and underneath the tray line steam table; and
- Food delivery carts.
* Unlabeled and undated food items were noted in the refrigerators; and
* Raw eggs were stored above ready to eat foods.
The areas in need of cleaning and the food storage concerns were reviewed with Staff 1 (ED) and Staff 6(Dietary Manager). They acknowledged the findings.
1. Dented can was removed. Kitchen was scrubbed and cleaned prior to survey exit. Kitchen staff were educated on cleaning schedule. All items were fixed; labeled and dated and stored properly.
2. The Dietary Manager will implement daily, weekly, and monthly cleaning assignments. Kitchen staff have been instructed to place any dented cans in a separate area to notify supplier when putting order away.
3. The Executive Director or designee will conduct walk throughs of kitchen a minimum of three times a week for 60 days. Executive director or designee will review cleaning schedule three times a week with walk through.
4. The Dietary Manager and Executive Director are responsible for this plan of correction.
Based on observation and interview it was determined the facility failed to ensure the kitchen was clean and maintained in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to:
Observation of the facilities kitchen on 12/21/22 revealed food splatters, spills, drips, and debris on the following areas:
- Underneath storage shelves, and cabinets throughout the kitchen;
- Interiors of drawers;
- Bakery racks;
- Cookware stored on open shelving and in bakery racks;
- Drains throughout the kitchen;
- Interiors of reach in freezers;
- The dishwashing area walls, shelving, and equipment;
- Top and sides of the ice machine; and
- Garbage cans.
The areas in need of cleaning were reviewed with Staff 1 (ED) and Staff 26 (Dietary Manager). They acknowledged the findings.
1. Kitchen was scrubbed and cleaned after survey exit. Kitchen staff were educated on cleaning schedule. All items were fixed; new dining manager educated on cleaning expectations.
2. The Dietary Manager will implement daily, weekly, and monthly cleaning assignments. Kitchen staff have been instructed to sign off daily on cleaning tasks.
3. The Executive Director or designee will conduct walk throughs of kitchen a minimum of three times a week for 60 days. Executive director or designee will review cleaning schedule three times a week with walk through.
4. The Dietary Manager and Executive Director are responsible for this plan of correction.
There are no detail notes for this visit.
2. Resident 2 was admitted to the facility in 01/2021 with diagnoses of dementia.
On 06/06/22, there was no service plan available to staff for Resident 2. A copy was printed and provided to the surveyor.
The service plan, dated 04/20/22, lacked clear direction for staff for the evacuation needs of Resident 2 in the event of an emergency.
The need to ensure service plans were available to staff and provided clear direction was reviewed with Staff 1 (ED), Staff 3 (Health and Wellness Director LPN), and Staff 19 (Regional RN) on 06/06/22 and 06/07/22. They acknowledged the findings.
3. Resident 3 was admitted to the facility in 04/2022 with diagnoses including dementia.
On 06/06/22, there was no current service plan available to staff for Resident 3. A copy of the current service plan was printed and provided to the surveyor.
The service plan, dated 05/21/22, lacked clear direction for staff for the evacuation needs of Resident 3 in the event of an emergency.
The need to ensure service plans were available to staff and provided clear direction was reviewed with Staff 1 (ED), Staff 3 (Health and Wellness Director LPN), and Staff 19 (Regional RN) on 06/06/22 and 06/07/22. They acknowledged the findings.
4. Resident 4 was admitted to the facility in 01/2018 with diagnoses including dementia. Resident 4 was observed in bed at all times and relied on staff for all ADL care.
Observations of the resident, interviews with staff, review of the current service plan and clinical records during the survey, from 06/06/22 thru 06/08/22, revealed Resident 4's service plan was not reflective of the resident's status, did not provide specific directions to staff, and staff did not follow the plan in the following areas:
* Activity status;
* Ambulation status: use of wheelchair vs. bed bound;
* Behaviors status;
* Toileting status;
* Oral Care status;
* Emergency evacuation ability; and
* Wandering status.
On 06/07/22, the service plan was discussed with Staff 1 (ED) and Staff 3 (Health and Wellness Director LPN). They acknowledged the service plan was not reflective of the resident's status and did not provide clear direction.
5. Resident 5 was admitted to the facility in 03/2020 with diagnoses including Alzheimer's disease.
Observations of the resident, interviews with staff, review of the current service plan and clinical records during the survey, from 06/06/22 thru 06/08/22, revealed Resident 5's service plan did not provide instruction to staff and staff did not follow the service plan as outlined in the following areas:
* Activity status;
* Hand hygiene prior to breakfast with finger food;
* Oral Care status;
* Shower instruction: bed bath vs. shower with hospice services;
* Fall risk and interventions; and
* Emergency evacuation ability.
On 06/08/22, the service plan was discussed with Staff 1 (ED). She acknowledged the service plan did not provide clear direction and staff did not follow morning care as outlined.
Based on observation, interview and record review, it was determined the facility failed to ensure service plans were updated after a significant change of condition, were reflective of the care needs and preferences of the resident, provided clear direction regarding the delivery of services, and were readily available to staff for 5 of 5 sampled residents (#s 1, 2, 3, 4 and 5), whose service plans were reviewed. Findings include, but are not limited to:
1. Resident 1 was admitted to the facility in 07/2021 with diagnoses including dementia.
The resident's 05/05/22 service plan and temporary care plans were reviewed. The service plan was not reflective of the resident's current care needs and did not provide clear caregiving instruction in the following areas:
* Precautions needed for ADL care with a dislocated right shoulder (when providing dressing, toileting, and transfer assistance);
* Evacuation status and ability; and
* Ability to use call system.
Resident 1 had a significant change of condition on 01/16/22 related to a dislocated right shoulder.
There was no documented evidence Resident 1's service plan had been updated with information related to increased care needs and precautions needed to prevent further injury or discomfort during ADL care.
The need to ensure service plans were reflective of the residents' current needs, provided clear caregiving instruction, and were available to staff was discussed with Staff 1 (ED), Staff 3 (Health and Wellness Director LPN) and Staff 19 (Regional RN), on 06/07/22. They acknowledged the findings.
1. The service plans for Residents 1,2,3,4,5 have been reviewed and updated to reflect residents current status.
2. Remaining resident service plans will be reviewed to confirm that each is reflective of current status. Resident changes in condition will be discussed during daily staff stand up and reviewed by the clinical team during daily clinical meeting to assure interventions are developed if needed, appropriate updates are made to service plans and documentation is reflected in the resident record. As part of the routine service plan process, the Licensed Nurse or designee will conduct a record review and obtain feedback from caregivers working directly with the resident prior to updating the service plan. All service plans will be readily available to all staff to reflect current care needs.
3. The Executive Director and/or designee will randomly audit resident service plans twice weekly for 60 days to assure ongoing compliance.
4. The Executive Director and Licensed Nurse are responsible for this plan of correction.
Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of the care needs and preferences of the resident and provided clear direction regarding the delivery of services for 2 of 2 sampled residents (#s 6 and 7), whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:
1. Resident 6 was admitted to the facility in 02/2022 with diagnoses including dementia and was receiving hospice services for end of life care. Resident 1 was observed in bed at all times and relied on staff for all ADL care.
Observations of the resident, interviews with staff, review of the current service plan and clinical records, revealed Resident 6's service plan was not reflective of the resident's status, preferences, and did not provide clear directions to staff in the following areas:
* Toileting status;
* Sleeping preferences;
* Hospice services including bathing assistance;
* Use of a fall mat; and
* Use of an air mattress for pressure relief.
On 10/10/22, the service plan was discussed with Staff 1 (ED) and Staff 8 (RCC). They acknowledged the service plan was not reflective of the resident's status and did not provide clear direction.
2. Resident 7 was admitted to the facility in 05/2015 with diagnoses including dementia.
Observations of the resident, interviews with staff, review of the current service plan and clinical records, revealed Resident 7's service plan was not reflective of the resident's status and did not provide clear directions to staff in the following areas:
* Hospice services including bathing assistance;
* Use of a fall mat; and
* Use of an air mattress for pressure relief.
On 10/10/22, the service plan was discussed with Staff 1 (ED) and Staff 8 (RCC). They acknowledged the service plan was not reflective of the resident's status and did not provide clear direction.
1. The service plans for Residents 6 and 7 have been reviewed and updated to reflect resident's current status.
2. Residents receiving hospice services will be reviewed to confirm that each service plan is reflective of current status. Resident changes in condition will be discussed during routine staff stand up and reviewed by the clinical team during routine clinical meeting to assure interventions are developed if needed, appropriate updates are made to service plans and documentation is reflected in the resident record. As part of the routine service plan process, the Licensed Nurse or designee will conduct a record review and obtain feedback from caregivers working directly with the resident prior to updating the service plan. All service plans will be readily available to all staff to reflect current care needs. Routine clinical meetings will be held at least 4 times per week.
3. The Executive Director or designee will randomly audit three service plans per week for 60 days.
4. The Executive Director and Licensed Nurse are responsible for this plan of correction.
There are no detail notes for this visit.
Based on observation, interview and record review, it was determined the facility failed to evaluate and monitor residents specific to evaluated needs and service planned interventions for 2 of 2 sampled residents (#s 3 and 5) reviewed for falls. Findings include but are not limited to:
1. Resident 3 was admitted to the facility in 04/2022 with diagnoses of dementia and was evaluated to be at risk for falls.
Resident 3 was observed during the survey to utilize a four wheeled walker independently for mobility.
Resident 3's current service plan indicated the resident was a fall risk and provided interventions to reduce falls.
Resident 3's clinical record revealed the resident was noted to have fallen four times between 04/23/22 and 05/26/22.
There was no documented evidence Resident 3's fall interventions were evaluated with each instance and monitored for effectiveness.
The need to monitor interventions related to the ongoing falls experienced by Residents 3 was reviewed with Staff 1 (ED), Staff 3 (Health and Wellness Director LPN), and Staff 19 (regional RN) on 06/07/22 and 06/08/22. They acknowledged the findings.
2. Resident 5 was admitted to the facility in 03/2020 with diagnoses of Alzheimer's disease and dementia and was evaluated to be at risk for falls.
Resident 5 was observed during the survey to utilize a wheel-chair independently for mobility.
Resident 5's current service plan indicated the resident was a fall risk and provided interventions to reduce falls.
Resident 5's clinical record revealed the resident was noted to have fallen seven times between 03/20/22 and 06/06/22.
There was no documented evidence Resident 5's fall interventions were evaluated with each instance and monitored for effectiveness.
The need to monitor interventions related to the ongoing falls experienced by Resident 5 was reviewed with Staff 1 (ED) and Staff 3 (Health and Wellness Director LPN) on 06/07/22. They acknowledged the findings.
1. Service plans for 3 and 5 have been reviewed and updated. Resident 3 and 5's fall history have been reviewed and service plan updated to include interventions to address fall risk.
2. Resident records for those with a known pattern of falls will be reviewed to assure proper evaluation, preventative measures and documentation included in the resident record. Associates will be educated on proper reporting for changes in condition and associated documentation. Medication Technicians will be educated on the community alert charting policy and associated documentation on 6/23/2022. Licensed nurses educated on the need to monitor interventions
related to the ongoing falls experienced
by any resident.
3. Resident changes in condition will be discussed during daily staff stand up and reviewed by the clinical team during daily clinical meeting to assure interventions are developed if needed, appropriate updates are made to service plans and documentation is reflected in the resident record.
4. The Executive Director is responsible for this plan of correction.
Based on observation, interview and record review, it was determined the facility failed to evaluate and monitor residents specific to evaluated needs and service planned interventions for 1 of 1 sampled resident (# 7) reviewed for falls. This is a repeat citation. Findings include but are not limited to:
Resident 7 was admitted to the facility in 05/2015 with diagnoses of dementia and was evaluated to be at risk for falls.
Resident 7 was observed during the survey to utilize a wheelchair with escort by staff for mobility.
Resident 7's current service plan and temporary service plans indicated the resident was a fall risk and provided interventions to reduce falls.
Resident 7's clinical record revealed the resident was noted to have fallen three times between 09/24/22 and 09/25/22.
There was no documented evidence Resident 7's fall interventions were evaluated with each instance and monitored for effectiveness.
The need to monitor interventions related to the ongoing falls experienced by Resident 7 was reviewed with Staff 1 (ED) and Staff 8 (RCC) on 10/10/22. They acknowledged the findings.
1. Service plans for resident 7 have been reviewed and updated. Resident's fall history have been reviewed and service plan updated to include interventions to address fall risk.
2. Resident records for those with a known pattern of falls will be reviewed to assure proper evaluation, preventative measures and documentation included in the resident record. Interventions will be assessed to ensure effectiveness and new ones implemented if needed. Med techs will be educated on collection of information at time of falls to aid in root cause analysis and intervention development.
3. Resident incidents will be discussed during routine staff stand up and reviewed by the clinical team during routine clinical meeting to assure interventions are developed if needed and monitored for effectiveness. Appropriate updates will be made to service plans and documentation will be reflected in the resident record.
4. The Executive Director is responsible for this plan of correction and will be in clinical meeting and stand up at least 4 times per week.
Based on observation, interview and record review, it was determined the facility failed to evaluate and monitor residents specific needs and service planned interventions for 1 of 1 sampled resident (# 9) reviewed for falls. This is a repeat citation. Findings include but are not limited to:
Resident 9 was admitted to the facility in 09/2020 with diagnoses including dementia.
During the acuity interview on 12/21/22, Resident 9 was identified to be at risk for falls.
Resident 9 was observed during the survey to require assistance with transfers, and required staff escort in his/her wheelchair.
In an interview with Staff 27 (Medication Tech) on 12/21/22, she explained Resident 9 was a fall risk, required assistance with transfers, and was escorted in a wheelchair for mobility.
Resident 9's current service plan 12/16/22 and temporary service plans reviewed between 12/8/22 and 12/20/22 noted the resident was a fall risk and provided interventions to reduce falls including frequent checks, pain management, and fall mat for bedside.
Resident 9's clinical record revealed the resident had fallen four times between 12/08/22 and 12/20/22.
There was no documented evidence Resident 9's fall interventions were evaluated with each fall and monitored for effectiveness.
The need to monitor interventions related to the ongoing falls experienced by Resident 9 was reviewed with Staff 1 (ED), Staff 3 (Health and Wellness Director LPN), and Staff 8 (RCC) on 12/21/22. They acknowledged the findings.
1. Service plans for resident 7 have been reviewed and updated. Resident's fall history has been reviewed and service plan updated to include interventions to address fall risk. Interventions and root cause analysis will be conducted to ensure personalized care plan and interventions related to each individual incident.
2. Resident records for those with a known pattern of falls will be reviewed to assure proper evaluation, preventative measures and documentation included in the resident record. Interventions will be assessed to ensure effectiveness and new ones implemented if needed. Med techs will be educated on collection of information at time of falls to aid in root cause analysis and intervention development.
3. Resident incidents will be discussed during routine staff stand up and reviewed by the clinical team during routine clinical meeting to assure interventions are developed if needed and monitored for effectiveness. Appropriate updates will be made to service plans and documentation will be reflected in the resident record.
4. The Executive Director is responsible for this plan of correction and will be in clinical meeting and stand up at least 4 times per week.
There are no detail notes for this visit.
2. Resident 4 was admitted to the facility in 01/2018 with diagnoses including dementia.
Observations of the resident from 06/06/22 to 06/08/22 revealed the resident required staff assistance with incontinent care and was in bed at all times.
During the survey, Staff 9 (MT/CG) reported the resident had an overall decline in status in 05/2022 in the following areas:
* Was no longer ambulating with a walker, was in bed at all times; and
* Was needing additional staff assistance with meal intake, showers, personal hygiene, and bladder and bowel management.
The multiple changes represented a significant change of condition.
There was no documented evidence the facility RN conducted an assessment of the resident's overall decline which included findings, a description of the resident status, and interventions made as a result of the assessment.
The failure to conduct an RN assessment following a significant change in status was discussed with Staff 1 (ED) on 06/08/22. She acknowledged the findings.
3. Resident 5 was admitted to the facility in 03/2022 with diagnoses including Alzheimer's disease.
Resident 5 was observed during the survey to get up for the day between 10:00 am and 11:00 am, and eat in the dining room with staff assistance.
Resident 5's weight record was reviewed during the survey and revealed the following:
* 01/14/22 - 103 pounds;
* 01/24/22 - 97 pounds;
* 02/21/22 - 94.4 pounds;
* 04/11/22 - 95.9 pounds; and
* 04/18/22 - 89.2 pounds.
From 01/14/22 to 01/24/22, Resident 5 had lost 6.0 pounds or 5.8 % of his/her body weight, and from 04/11/22 to 04/18/22, s/he had lost 6.7 pounds or 6.98% of his/her body weight, which represented a significant weight loss.
Resident 5's 05/24/22 service plan indicated the resident required physical assistance while eating and would benefit from finger foods.
The facility began administering boost high protein supplement three times daily on 12/22/21. The 06/01/22 - 06/08/22 MAR indicated the supplement had not been provided on two occasions at 08:00 am because the resident was sleeping.
On 04/18/22, Staff 2 (RN) conducted an assessment of the resident's weight loss, however, did not address if the current interventions were evaluated and monitored for effectiveness.
On 06/08/22, the need to ensure the facility RN completed assessments of significant changes of condition, including reviewing interventions for effectiveness, was discussed with Staff 1 (ED). She acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to ensure a timely assessment of significant changes of condition by a facility RN which documented findings, resident status, and interventions made as a result of this assessment, and failed to update the service plan for 3 of 3 sampled residents (#s 1, 4 and 5) who were reviewed with significant changes of condition. Findings include, but are not limited to:
1. Resident 1 was admitted to the facility in 07/2021 with diagnoses including dementia. During the acuity interview on 06/06/22 the resident was identified with an injury to the right shoulder.
The clinical record, including the current service plan dated 05/05/22, progress notes dated 12/26/21 through 06/06/22, and temporary care plans, were reviewed during the survey.
On 01/16/22 an emergency room after visit summary indicated Resident 1 had a dislocated right shoulder. This represented a significant change of condition.
The facility RN documented an assessment of the change of condition on 01/16/22 however, the assessment failed to document the resident's increased care needs with dressing, toileting, ambulation, transfers and precautions needed to prevent further injury or discomfort during ADL care.
The need to ensure significant changes of condition were assessed timely by a facility RN which documented findings, resident status and service plan updates as a result of the assessment was discussed with Staff 1 (ED), Staff 3 (Health and Wellness Director LPN), and Staff 19 (Regional RN) on 06/07/22 They acknowledged the findings.
1. The records of Residents 1, 4 and 5 have been reviewed and updated as it relates to their significant change of condition.
2. All residents will be reviewed in order to identify any resident in need of a change of condition assessment by the RN. Associates will be educated on proper reporting for changes in condition and associated documentation. Resident changes in condition will be discussed during routine staff stand up and reviewed by the clinical team during routine clinical meeting to assure interventions are developed if needed, appropriate updates are made to service plans and documentation of RN assessment is reflected in the resident record. Staff stand up and routine clinical meeting will occur at least five times per week.
3. The Executive Director and/or designee will randomly audit resident records weekly for 60 days to assure ongoing compliance.
4. The Executive Director & Registered Nurse will be responsible for this plan of correction.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to coordinate care with outside providers and ensure recommendations were implemented for 1 of 2 sampled residents (# 4) who was receiving services from outside providers. Findings include, but are not limited to:
Resident 4 was admitted to the facility in 01/2018 with diagnoses including dementia and was receiving hospice services.
A review of Resident 4's clinical record identified the following hospice recommendations were not implemented:
* 05/06/22 - "Please reposition in bed if [s/he] allows...";
* 05/08/22 - staff to clean and moisturize the resident's mouth every shift; and
* 05/20/22 - discontinue non-essential medications including a thyroid hormone medication.
There was no documented evidence the recommendations were communicated to staff, made part of the resident's service plan, or implemented.
On 06/07/22, the need to ensure the facility coordinated care with outside service providers and implemented recommendations was discussed with Staff 1 (ED) and Staff 3 (Health and Wellness Director LPN). They acknowledged the findings.
1. The records of Resident 4 have been reviewed and service plan updated to include recommendations made by outside provider as appropriate. Education was provided to staff related to following recommendations and service plan related TSP's that should be processed from third party provider notes.
2. Outside provider notes will be reviewed daily in conjunction with the triple check order process during the clinical meeting to assure actions are taken as necessary.
3. The Executive Director and/or designee will randomly audit coordination of care notes/documentation weekly for the next 60 days then quarterly thereafter for ongoing compliance.
4. The Executive Director and Health & Wellness Director are responsible for this plan of correction.
Based on interview and record review, it was determined the facility failed to coordinate care with outside providers and ensure recommendations were implemented for 2 of 2 sampled residents (#s 6 and 7) who were receiving services from outside providers. This is a repeat citation. Findings include, but are not limited to:
1. Resident 6 was admitted to the facility in 02/2022 with diagnoses including dementia and was receiving hospice services.
A review of Resident 6's clinical record identified hospice left directions for facility staff to administer a PRN bowel medication on 10/04/22.
There was no documented evidence the recommendations were communicated to staff or implemented.
On 10/10/22, the need to ensure the facility coordinated care with outside service providers and implemented recommendations was discussed with Staff 1 (ED) and Staff 8 (RCC). They acknowledged the findings.
2. Resident 7 was admitted to the facility in 05/2015 with diagnoses including dementia and was receiving hospice services.
A review of Resident 7's clinical record identified the following hospice recommendations were not implemented:
* 09/15/22 - "Please use reclining [wheelchair] footrests to help prevent sliding.", and
* 09/25/22 - "Continue fall precautions - bed in lowest position and fall mat on floor. Please check on [patient] frequently [every 1 to 2 hours]."
There was no documented evidence the recommendations were communicated to staff, made part of the resident's service plan, or implemented.
On 10/10/22, the need to ensure the facility coordinated care with outside service providers and implemented recommendations was discussed with Staff 1 (ED) and Staff 8 (RCC). They acknowledged the findings.
1. The records of Resident 6 and 7 have been reviewed and service plan updated to include recommendations made by outside provider as appropriate. Education was provided to staff related to following recommendations and service plan related TSP's that should be processed from third party provider notes.
2. Outside provider notes received in the last 30 days will be reviewed to ensure all recommendations have been implemented as appropriate. Outside provider notes will be reviewed daily in conjunction with the triple check order process during the clinical meeting to assure actions are taken as necessary.
3. The Executive Director and/or designee will audit coordination of care notes/documentation during clinical meetings to ensure proper implementation from outside providers.
4. The Executive Director and Health & Wellness Director are responsible for this plan of correction.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 1 of 5 sampled residents (#1) whose orders were reviewed. Findings include, but are not limited to:
Resident 1 was admitted in 2021 with diagnoses which included hypertension and dementia.
A review of the clinical record identified the following signed physician orders were not administered as prescribed:
* Isosorbride Mononitrate (for Hypertensive chronic kidney disease) once daily, to be held if systolic blood pressure was below 110.
The MARs, reviewed from 05/01/22 through 06/05/22, revealed five occasions when Resident 1's systolic blood pressure was under 110 and the medication was not held.
* Omeprazole ordered for 40 mg once daily (for gastro-esophageal reflux disease) was being administered as 20 mg once daily.
The need to ensure physician orders were administered as prescribed was discussed with Staff 1 (ED), Staff 3 (Health and Wellness Director LPN), and Staff 19 (Regional RN) on 06/07/22. They acknowledged the findings.
1. The physician orders and MAR/Diet Orders for Resident 1 have been reconciled to assure accuracy.
2. Medication Technicians will be trained on following; physician orders, ancillary order entry, and the triple check review process for new orders. Transcription will be reviewed by the Health & Wellness Director or designee in conjunction with the daily clinical meeting. Quarterly MAR review process has been updated to reflect needs for accurate medication orders.
3. The Executive Director and/or designee will conduct random physician order audits weekly for 60 days to assure ongoing compliance. Thereafter audits will be conducted quarterly in conjunction with the service planning/chart review process.
4. Executive Director is responsible for compliance.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure PRN psychoactive medications were given only for specific medical symptoms and only after non-drug interventions had been attempted and were ineffective, for 1 of 1 sampled resident (# 5) who was administered a PRN psychoactive medication. Findings include, but are not limited to:
Resident 5 was admitted to the facility in 03/2020 with diagnoses including Alzheimer's disease.
Resident 5's record indicated s/he had orders for PRN Ativan for "mild agitation and anxiety".
Resident 5's 06/01/22 through 06/08/22 MAR was reviewed during the survey and revealed the following:
* The PRN Ativan was administered on five occasions;
* The MAR lacked clear instructions to non-licensed staff regarding how the resident demonstrated signs and symptoms of agitation or anxiety :
* No non-drug interventions were developed for staff to attempt prior to administering the psychoactive medication; and
* No document evidence non-drug interventions had been attempted with ineffective results prior to administering the medication.
On 06/07/22 Resident 5's record was reviewed with Staff 1 (ED) and Staff 3 (Health and Wellness Director LPN) who acknowledged the findings.
1. PRN parameters have been reviewed for resident 5 with non pharm interventions in place to use prior to administering psychotropic medication.
2. Staff educated on policy of using non pharm interventions prior to administering psychotropic medications. Staff educated on how to properly document this in eMAR. Remaining residents with orders for as needed psychotrophic medication has been completed. Parameters, common side effects and non-pharmacological interventions have been added to the resident's medication record where needed. Psychotropic medication orders and administration will be reviewed during the routine clinical meeting for appropriate documentation.
3. Executive Director, Health & Wellness Director and/or designee will randomly audit PRN's orders weekly for 60 days then monthly thereafter for compliance.
4. Executive Director is responsible for compliance.
Based on interview and record review, it was determined the facility failed to ensure PRN psychoactive medications were given only after non-drug interventions had been attempted and were ineffective, for 1 of 1 sampled resident (# 7) who was administered a PRN psychoactive medication. This is a repeat citation. Findings include, but are not limited to:
Resident 7 was admitted to the facility in 05/2015 with diagnoses including dementia.
Resident 7's record indicated s/he had orders for:
* PRN Ativan for anxiety; and
* PRN Haloperidol for agitation.
Resident 7's 10/01/22 through 10/10/22 MAR was reviewed during the survey and revealed Resident 7 was administered both medications on 10/02/22.
There was not documented evidence non-drug interventions had been attempted with ineffective results prior to administering the psychoactive medications.
On 10/10/22 Resident 7's record was reviewed with Staff 1 (ED). She acknowledged the findings.
1. Med tech education was provided on 10/11/2022 for proper documentation on using non pharmacological interventions prior to administering medication.
2. Med techs will have ongoing education and reminders of policy for using non pharmacological interventions prior to administering psychotropic medications. Staff educated on how to properly document this in eMAR.
3. Executive Director & Health and Wellness Director will review Psychotropic medication orders and administration will be reviewed during the routine clinical meeting for appropriate documentation and follow up with med techs.
4. Executive Director is responsible for compliance.
Based on interview and record review, it was determined the facility failed to ensure resident specific reasons for use of PRN psychoactive medications were documented and given only after non-drug interventions had been attempted and were ineffective, for 2 of 3 sampled resident (#s 8 and 9) who were administered PRN psychoactive medications. This is a repeat citation. Findings include, but are not limited to:
1. Resident 8 was admitted to the facility in 04/2016 with diagnoses including dementia.
Resident 8's record indicated s/he had orders for Haldol 0.5 mg as needed for behaviors and anxiety.
Resident 8's 12/01/22 through 12/21/22 MAR was reviewed and revealed Resident 8 was administered the medication on six occasions.
There was no resident-specific parameters or specific reasons for the use of the psychotropic medication for Resident 8.
There was no documented evidence non-drug interventions had been developed and attempted with ineffective results prior to administering the psychoactive medications.
2. Resident 9 was admitted to the facility in 09/2022 with diagnoses including dementia.
Resident 9's record indicated s/he had orders for Lorazepam 0.5 mg as needed for agitation and anxiety.
Resident 9's 12/01/22 through 12/21/22 MAR was reviewed and revealed Resident 9 was administered the medication on two occasions.
There was no resident-specific parameters or specific reasons for the use of the psychotropic medication for Resident 9.
There was not documented evidence non-drug interventions had been developed and attempted with ineffective results prior to administering the psychoactive medications.
On 10/10/22, Resident 8 and 9's records were reviewed with Staff 1 (ED) and Staff 3 (Health and Wellness Director LPN). They acknowledged the findings.
1. Med tech education was provided on the day of survey for proper documentation on using non pharmacological interventions prior to administering medication. RN educated on proper PRN administration parameters and how to input in eMAR system.
2. Med techs will have ongoing education and reminders of policy for using non pharmacological interventions prior to administering psychotropic medications. Staff educated on how to properly document this in eMAR.
3. Executive Director & Health and Wellness Director will review Psychotropic medication orders and administration will be reviewed during the routine clinical meeting for appropriate documentation and follow up with med techs.
4. Executive Director is responsible for compliance.
There are no detail notes for this visit.
Based on observation, interview, and record review, it was determined the facility failed to ensure their relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:
Refer to C 240, C 260, C 270, C 290, C 330, Z 142 and Z 162.
C455 Refer to C240, C260, C270, C290, C330, Z142, Z162
Based on observation, interview, and record review, it was determined the facility failed to ensure their relicensure survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include, but are not limited to:
Refer to C 240, C 270, C 330, Z 142, and Z 162.
Refer to C240, C270, C330.
There are no detail notes for this visit.
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 240.
Z142 Refer to C240
Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:
Refer to C 240.
Z142 Refer to C240
Based on observation and interview it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:
Refer to C 240.
Refer to C240.
There are no detail notes for this visit.
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 260, C 270, C 280, C 290, C 303 and C 330.
Z162 Refer to C 260, C 270, C 280, C 290, C
303 and C 330.
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. This is a repeat citation. Findings include, but are not limited to:
Refer to C 260, C 270 and C 290.
Z162 Refer to C 260, C 270, C 290 and C 330.
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. This is a repeat citation. Findings include, but are not limited to:
Refer to C 270 and C 330.
Refer to 270 and C330.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan for each resident was developed and included in the service plan for 1 of 5 sampled residents (#1) whose service plans were reviewed. Findings include, but are not limited to:
Resident 1 was admitted to the facility in 07/2021 with diagnoses including dementia, diabetes, and urinary tract infections.
Resident 1's service plan, dated 05/05/22, indicated a carbohydrate-controlled diet and providing D-Mannose supplement with water, both of which had been discontinued by the physician in previous months.
The service plan lacked an individualized nutrition and hydration plan, including information related to the resident's food and fluid preferences and need for increased fluids.
The need to develop individualized service plans addressing residents' nutrition and hydration needs and preferences was discussed with Staff 1 (ED), Staff 3 (Health and Wellness Director LPN) and Staff 19 (Regional RN), on 06/07/22 They acknowledged the findings.
1. Orders for resident 1 have been updated and are accurate. Individualized nutrition and hydration plan was added to resident 1 service plan.
2. Nutrition and Hydration plans will be added for each resident and will be personalized based on their individual needs.
3. Executive Director and Health and Wellness Director will review all service plans to ensure accurate personalized nutrition and hydration plans every week for 60 days.
4. Executive Director will be responsible for compliance.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to evaluate and develop individualized activity plans for 5 of 5 sampled residents (#s 1, 2, 3, 4 and 5) whose service plans were reviewed. Findings include, but are not limited to:
Residents 1, 2, 3, 4 and 5's records were reviewed during the survey. There was no documented evidence an activity evaluation had been completed and individualized activity plans included in their service plans including:
* Residents' past and current interests;
* Current abilities and skills;
* Emotional/social needs and patterns;
* Physical abilities and limitations;
* Adaptations necessary for the resident to participate in activities; and
* Identified activities for behavior interventions.
There was no specific activity plan which detailed what, when, how, and how often staff should offer and assist each resident with individualized activities.
On 06/07/22 and 06/08/22, the need to ensure residents were evaluated and had an individualized activity plan was discussed with Staff 1 (ED), Staff 3 (Health and Wellness Director), Staff 19 (Regional RN), and Staff 20 (Program Coordinator). They acknowledged the findings.
Individualized Activity Plans
1. Individualized activity plans will be added to residents 1, 2, 3, 4 and 5.
2. Program Manager will meet with Health and Wellness Director to evaluate each resident and create individualized activity plans for every resident to meet the needs of each resident.
3. Executive Director and Health and Wellness Director will review resident's activity plans weekly to ensure accuracy and ongoing compliance.
4. Executive Director and Program Manager will be responsible for compliance.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to provide an individualized service plan for behavioral symptoms that negatively impacted the resident or others in the community for 1 of 2 sampled residents (#1) with documented behaviors. Findings include, but are not limited to:
Resident 1 was admitted to the facility in 07/2021, with diagnoses including dementia and major depressive disorder.
Resident 1's progress notes documented the following:
* 04/20/22, "Agitated behavior and delusional thinking"; and
* 04/21/22, "[S/he] got very angry with the male staff accusing and refusing care from them. Towards the end of the night [s/he] calmed down."
During an interview with Staff 21 (CG) on 06/07/22, it was reported Resident 1 experienced hallucinations of seeing things on the floor, other people in his/her room and accusations that "we are doing things to other residents." Staff 21 also reported Resident 1 hit her while she was trying to calm him/her down. Staff 21 stated "I don't know of anything that helps to calm [him/her] down."
The resident's current service plan did not address the major depressive disorder or hallucinations, and lacked individualized interventions to assist staff in minimizing the negative impact of these behaviors.
The need to include an individualized behavior plan for residents with behavioral symptoms was discussed with Staff 1 (ED), Staff 3 (Health and Wellness Director LPN), and Staff 19 (Regional RN) on 06/07/22. They acknowledged the findings.
Individualized Behavioral Plans
1. Individualized behavioral plan has been added to resident 1's care plan.
2. Program Manager will meet with Health and Wellness Director to evaluate each resident and create individualized behavior plans for residents that exhibit behavioral symptoms.
3. Executive Director and Health and Wellness Director will review resident's behavioral plans weekly to ensure accuracy and ongoing compliance.
4. Executive Director and Program Manager will be responsible for compliance.
There are no detail notes for this visit.