The findings of the re-licensure survey, conducted 09/19/22 through 09/20/22, 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, Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.
Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.
Abbreviations possibly used in this document:
ADL:activities of daily living
bid:twice a day
CBG:capillary blood glucose or
blood sugar
CG:caregiver
cm:centimeter
ED:Executive Director
F:Fahrenheit
HH:Home Health
LPN:Licensed Practical Nurse
MA: Medication Aide
MAR:Medication Administration
Record
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 revisit to the re-licensure survey of 09/20/22, conducted 01/11/23, 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, Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.
Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.
Abbreviations possibly used in this document:
ADL:activities of daily living
bid:twice a day
CBG:capillary blood glucose or
blood sugar
CG:caregiver
cm:centimeter
ED:Executive Director
F:Fahrenheit
HH:Home Health
LPN:Licensed Practical Nurse
MA: Medication Aide
MAR:Medication Administration
Record
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 09/20/22, conducted 04/19/23, 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.
3. Resident 2 was admitted to the facility in August 2022 with diagnoses including dementia.
The resident's service plan, dated 09/02/22, and interviews with care staff between 09/19/22 and 09/20/22 indicated the resident required full assistance of two staff for transfers with use of a gait belt. The resident required extensive assistance for ADLs. The resident could make needs known but was forgetful.
Review of incident investigations and progress notes from 06/19/22 through 09/19/22 showed the following:
An incident report was completed regarding a skin tear to the resident's upper right arm on 09/05/22.
A thorough investigation was not completed regarding the skin tear. The incident report/investigation did not include information on how staff ruled out abuse and neglect, staff response at the time of the incident, description of what occurred, and follow up action taken.
The facility was asked to report the skin tear to the local SPD office, and confirmation was provided prior to the survey exit.
The need to ensure resident incidents were thoroughly investigated to rule out abuse and neglect was discussed with Staff 1 (Executive Director) and Staff 2 (RN) on 09/20/22. The staff acknowledged the findings
4. Resident 3 was admitted to the facility in August 2021 with diagnoses including Alzheimer's disease.
The resident's service plan, dated 07/14/22, and interviews with care staff between 09/19/22 and 09/20/22 indicated the resident required full assistance from staff for care after a recent decline over the last few months. The resident previously was independent with transfers. The resident would not initiate care and staff anticipated the resident's needs.
Review of incident investigations and progress notes from 06/19/22 through 09/19/22 showed the following:
Incident reports were completed for unwitnessed, non-injury falls on 07/21/22, 07/30/22, and 09/15/22.
The incident reports/investigations did not include information on how staff ruled out abuse and neglect. The investigations did not consistently include information regarding staff response at the time of the incident, description of what occurred, follow-up action taken, and administrator review.
The need to ensure resident incidents were thoroughly investigated to rule out abuse and neglect was discussed with Staff 1 (Executive Director) and Staff 2 (RN) on 09/20/22. The staff acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure injuries of unknown cause and unwitnessed falls were promptly investigated to rule out suspected abuse and/or neglect and were reported to the SPD as needed for 4 of 4 sampled residents. Findings include, but are not limited to:
1. Resident 1 was admitted to the facility in 09/2016 with diagnoses including dementia and stroke.
The resident's clinical record from 06/30/22 through 09/19/22, including progress notes, temporary service plans, and incident reports, was reviewed, and interviews with staff were conducted.
On 09/14/22 staff completed an incident report for a skin tear on the resident's right forearm. The incident was not investigated to rule out abuse and/or neglect, nor was it reported to the local SPD office.
The surveyor requested the RN report the incident on 09/20/22. Confirmation was provided of the reports prior to survey exit.
The need to investigate injuries of unknown cause to rule out abuse and/or neglect, and to report the incident to the local SPD office if abuse and/or neglect could not be ruled out, was discussed with Staff 1 (ED) and Staff 2 (RN) on 09/20/22. They acknowledged the findings. The surveyor received confirmation the facility reported the incident on 09/20/22 prior to survey exit.
2. Resident 4 was admitted to the facility in 08/2022 with diagnoses including dementia.
The resident's facility record was reviewed, including progress notes, temporary service plans, and incident reports dated from 08/15/22 through 09/18/22, and interviews with staff were conducted.
A 09/04/22 progress note indicated staff discovered a skin tear on the resident's lower right arm on 09/03/22. Staff documented on 09/06/22 the resident "did not remember how it happened." There was no documented evidence the facility investigated the injury of unknown cause to rule out abuse and/or neglect, nor did they report the injury to the local SPD office.
The surveyor requested the RN report the incident on 09/20/22. Confirmation was provided of the report prior to survey exit.
The need to thoroughly investigate injuries of unknown cause was discussed with Staff 1 (ED) and Staff 2 (RN) on 09/20/22. They acknowledged the findings.
1.a An investigaion was conducted and an APS report filed for resident's 1, 2 and 4 on 9/21/22. A post fall investigation was completed for resident 3.
2.a. Education was immediately provided to Med Tech's and caregivers at stand up and at shift change. In addition it will be provided to staff at our mandatory ALL STAFF meeting on 10/19/22 and at Med Tech meeting 10/20/22 regarding incidents of unknown origin and importance of reporting and documentation completion. Review of BAIRS form and process. See attendance log. Hand outs provided to staff unable to attend.
2.b. Executive Director, Health and Wellness Director, Clinical Coordinator and Resident Care Coordinator to review "conducting abuse investigation" module to be completed by 10/19/22
2 c. A review of all incidents has been conducted to determine whether others meet reporting criteria.
3. Incidents to be reviewed at clinical meeting 3-5x/week to ensure thorough investigations are completed.
3.The Health and Wellness Director, Clinical Coordinator and Executive Director are responsible for this plan of correction,
Based on interview and record review, it was determined the facility failed to ensure injuries of unknown cause and unwitnessed falls were promptly investigated to rule out suspected abuse and/or neglect and were reported to SPD as needed for 1 of 2 sampled residents (#6) reviewed with incidents. Findings include, but are not limited to:
Resident 6 was admitted to the facility in 12/2021 with diagnoses including dementia.
Progress notes reviewed from 11/20/22 through 01/11/23 noted the following:
*11/21/22 Resident was placed on alert charting for a non-injury fall;
*11/25/22 Discoloration was noted on the top of the resident's left buttock;
*12/09/22 Resident was placed on alert charting for a non-injury fall; and
*12/14/22 Discoloration was noted on the resident's buttocks.
Incident reports were completed for 11/21/22 and 12/09/22 noting unwitnessed non-injury falls. There was no documented evidence of investigations for the discoloration, injuries of unknown cause, that were noted on the resident on 11/25/22 and 12/14/22.
The incident reports/investigations were either not completed or did not include information on how staff ruled out abuse and neglect. The investigations did not consistently include information regarding staff response at the time of the incident, description of what occurred, follow-up action taken, and Administrator review.
Thoroughly investigating injuries of unknown cause and non-injury unwitnessed falls to rule out abuse and neglect and reporting as necessary to SPD was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 16 (Health and Wellness Director) on 01/11/23 at 1:20 pm. Staff acknowledged the findings.
The surveyor requested Staff 16 report the incident on 11/21/22 and 12/09/22 to the local SPD. Confirmation of the reports was provided prior to the end of the day.
1. Incidents on 11/21/2022 and 12/09/2022 were provided to local SPD on 1/11/2023. Education was immediately provided to Med Tech's and caregivers at stand up and at shift change 1/13/2023.
2. Staff received education on incidents of unknown origin, documentation and reporting requirements on 1/25/2023. Executive Director, Health and Wellness Director, Clinical Coordinator and Resident Care Coordinator will review OR Abuse Reporting & Investigation guide to be completed by 2/10/2023. Incidents from the past 30 days have been reviewed to assure reporting as required by rule.
3. Resident incidents will be discussed at daily stand-up meeting and reviewed in detail during routine clinical meeting 3-5 times per week to assure follow-up investigation, and/or APS reporting occurred as needed. Executive Director will regularly review incident documentation to evaluate for effective follow up and assure reporting has occurred.
4.The Executive Director is 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 ensure service plans were reflective of residents' needs and provided clear direction to staff regarding care and services for 1 of 4 sampled residents (#3) whose service plans were reviewed. Findings include, but are not limited to:
Resident 3 was admitted to the facility in August 2021 with diagnoses including Alzheimer's disease.
Observations of the resident, interviews with staff, and review of the service plan dated 07/14/22 showed the service plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas:
* Behaviors including uncontrolled weeping/sadness;
* Transfers and ambulation;
* Walker and wheelchair use;
* Full feeding assistance, straw use and supplements; and
* Falls and safety interventions.
The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (Executive Director) and Staff 2 (RN) on 09/20/22. The staff acknowledged the findings.
1.Service plan for resident 3 has been updated to reflect current care needs by 10/10/22. All other residents will be reviewed and updated to ensure accuracy of service plans .
2 a.Current resident service plans will be reviewed by our service planning team as necessary to assure they are reflective of needs. The Executive Director and Health and Wellness Director have reviewed rule and community policy as it relates to the service planning process.
2. b All Med Techs will be educated in the use of TSP's for noting immediate change in care needs at our med tech meeting on 10/20/22.
3.The Executive Director, Health and Wellness Director and or Designee will conduct random audits of service plans twice monthly for 60 days.
4.The Executive Director, and Health and 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 PRN medications used to treat residents' behaviors had written, resident-specific parameters and/or non-pharmacological interventions for staff to attempt prior to administering a PRN psychotropic medication for 3 of 4 sampled residents (#s 1, 3 and 4) who were prescribed a PRN psychotropic medication. Findings include, but are not limited to:
Review of 09/01/22 through 09/19/22 MARs and physician orders revealed that Residents 1, 3 and 4 were prescribed a PRN psychotropic medication for anxiety and/or agitation. The following was identified:
1. There were no resident-specific parameters on the MARs indicating how each resident exhibited signs and symptoms of anxiety and/or agitation.
2. Resident 3's MAR did not include any non-pharmacological interventions for staff to attempt prior to administering the PRN psychotropic.
The need to include a description of how each resident exhibited signs and symptoms of anxiety and/or agitation, as well as non-drug interventions for staff to attempt before administering a PRN psychotropic medication, was discussed with Staff 1 (ED) and Staff 2 (RN) on 09/20/22. They acknowledged the findings.
1.The mars were updated and staff education was done immediately following discovery of no resident specific parameters on the mars indicating how each resident exhibited signs/symptoms of anxiety and or agitation for residents 1,3 and 4 and for non pharmacological interventions being documented for resident 3. Signs were posted in the med room and the staff on shift were trained on proper protocols.
1.b A review of all residents on prn psychotropics has been completed by 10/10/22 to ensure compliance.
2.a A med tech meeting will be held on 10/20/22 for review of education and process for documenting resident specific parameters, including non pharmacological interventions prior to administering prn psychotropic medications.
3.a During clinical meeting documentation will be reviewed for psychotropic medications to ensure that the correct documentation is being done.
3.b Executive Director, Health and Wellness Director and/or Designee will conduct random emar audits wekly for 60 days to monitor for compliance.
4.The Executive director and Health and 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 their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include but are not limited to:
Refer to C 231.
See POC 231
There are no detail notes for this visit.
Based on 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.
See C231
Based on 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.
See POC 231
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 and C 330.
See C260 and C330
Based on observation, interview and record review, it was determined the facility failed to consistently provide meaningful activities for all residents that promoted or helped sustain the physical and emotional well-being of the resident and failed to ensure an individualized activity plan was developed for each resident based on their activity evaluation, for 3 of 4 sampled residents (#s 1, 2, and 3) whose service plans were reviewed. Findings include, but are not limited to:
Resident 1, 2, and 3's service plans offered some information about the resident's interests, but the facility had not fully evaluated the resident's:
* Current abilities and skills;
* Emotional and social needs and patterns;
* Physical abilities and limitations;
* Adaptations necessary for the resident to participate; and
* Activities that could be used as behavioral interventions, if necessary.
There was no specific activity plan which detailed what, when, how, and how often staff should offer and assist the resident with more individualized activities.
Observations on 09/19/22 and 09/20/22 showed multiple small group activities being led by facility staff. Residents 1 and 3 were not consistently invited to activities or provided adaptations to participate in the activity.
The need to ensure all residents had individualized activity plans developed and implemented to engage them in meaningful activities was discussed with Staff 1 (Executive Director), Staff 2 (RN), and Staff 3 (Program Director/Activities) on 09/20/22. The staff acknowledged the findings.
1. Residents 1,2 and 3 assessments were completed for assessment of past and current interest, current abilities and skills, emotional and social needs and patterns, physical abilities and limitations, adaptations for resident participation and activities that could be used as behavioral interventions.
2. A service planning team has been assembled to review all residents service plans and to update their activities to ensure preferences, abilities and adaptations are met.
3. The Health and Wellness Director and or Designee will conduct random audits of resident service plans twice monthly for 60 days.
4. The Health and Wellness Diector and Executive Director are responsible for this plan of correction
There are no detail notes for this visit.