The findings of the re-licensure survey conducted 12/13/21 through 12/15/21 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the revisit to the re-licensure survey of 12/15/2021, conducted 02/28/22 through 03/01/22, 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 and Home and Community Based Services Regulations OARs 411 Division 004.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the second re-visit to the re-licensure survey of 12/15/21, conducted on 04/19/22, 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.

2. Resident 5 moved into the facility in September of 2020 with a diagnosis of cerebral vascular accident.

Review of Resident 5's record revealed s/he experienced a skin tear to the top of his/her left hand on 12/01/21.

There was no incident report written until 12/06/21 and final Administrator review was not completed until 12/07/21.

Interview with Staff 2 (Health and Wellness Director) on 12/14/21, about the incident on 12/01/21, revealed the facility failed to promptly investigate this incident.

The need to ensure resident incidents were investigated timely including administrative review was discussed with Staff 1 (Executive Director) on 12/14/21. He acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure resident incidents were thoroughly investigated in a timely manner and/or reported to the local Seniors and People with Disability (SPD) office for 2 of 3 sampled residents (#s 2 and 5) who were reviewed for injuries of unknown cause and a medication error. Findings include, but are not limited to:

1. Resident 2 moved into the facility in October 2021 with a diagnosis of congestive heart failure.

Review of Resident 2's record revealed s/he was administered the wrong medications on 11/24/21.

Interview with Staff 1 (ED) on 12/14/21, about the incident on 11/24/21, determined the facility failed to report the medication error to the local SPD office and the administrator review was not completed until 11/30/21, six days after the incident occurred. The surveyor requested Staff 1 report the incident to the local SPD office. Confirmation of the self report to the local SPD office was received on 12/14/21.

The need to ensure resident incidents were thoroughly investigated, including timely administrative review and reported to local SPD office when abuse and neglect could not be ruled out was discussed with Staff 1 on 12/14/21. He acknowledged the findings.

1)  APS notified on 12/14/2021 for resident 2 receiving the incorrect medication.  Resident 5 incident report and investigation related to skin tear completed on 12/6/2021.

2)  At daily clinical meeting incident reports will be reviewed and investigations completed.  APS will be notified immediately when appropriate.  ED, RN and RCC will be trained on abuse reporting policy by Area Nurse Manager during the week of 1/10/2022.

3)  This will be evaluated daily at clinical meeting.

4) Health and Wellness Director and Executive Director, or designee.

2. Resident 1 was identified as a smoker during the acuity interview on 12/13/21.

Resident 1's service plan, dated 10/01/21, stated resident was a smoker.

An interview with Staff 5 (RCC) on 12/15/21 confirmed Resident 1 smoked daily.

Although smoking was documented on the service plan, there was no documented evidence a smoking safety evaluation had been completed since the initial move in on 08/17/21.

An interview with Staff 2 (Health and Wellness Director) on 12/13/21 verified that no quarterly smoking evaluation had been completed for resident.

The facility's failure to complete a quarterly smoking evaluation was discussed with Staff 1 (Executive Director), Staff 2 (Health and Wellness Director) and Staff 12 (Area Nurse Manager)  on 12/15/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure a move-in evaluation was completed addressing all elements, was updated within 30 days, and quarterly evaluations were completed for 2 of 4 sampled residents (#s 1 and 2) whose new move-in evaluation and quarterly evaluations were reviewed.  Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 10/2021 with diagnoses including congestive heart failure.

The resident's move-in evaluation was incomplete, as the following areas were not addressed and/or answered:

* Visits to health practitioner, ER, hospital, or nursing facility in the past year;

* History of dehydration or unexplained weight loss or gain; and

* Recent losses.

At the time of the survey, the 30 day update had not been completed and was overdue by 16 days.

The need to ensure all elements in the move-in evaluation were addressed and ensuring the evaluation was updated within 30 days was discussed with Staff 1 (Executive Director), Staff 2 (RN) and Staff 3 (Area Nurse Manager) on 12/13/21. Staff 2 completed the 30 day update during the survey.

1)  Missing documentation for resident 2 has been completed and 30 day service plan updated was completed on 12/13/2021.  Smoking evaluation for resident 1 has been completed on 1/3/2022.

2)  New move in checklist will be utilized for all new residents, including but not limited to, areas noted in statement of deficiencies.  Quarterly evaluation checklist will be completed with each service plan update to ensure all ancillary evaluations are completed at the time of review.

3)  Review will occur daily at clinical meeting.

4)  Health and Wellness Director and Executive Director, or designee.

Based on observation, interview and record review, it was determined the facility failed to ensure resident service plans were reflective of resident needs and provided clear direction to staff regarding the delivery of services for 2 of 6 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to:

1.  Resident 1 was admitted to facility August of 2021 with diagnosis of history of alcoholism.

Resident 1 was observed sleeping in room with door open daily throughout survey. Multiple beer cans were observed in the resident's sink and table next to recliner.

In an interview with Staff 5 (RCC) on 12/15/21 at 10:35 am, she verified that the resident drank daily which led to falls and missed medications when the resident did not want to be woken up.

A review of the resident's most recent service plan, dated 10/01/21, revealed it was not reflective of daily alcohol consumption, falls that were related to resident's drinking, or inappropriate comments to staff while drinking.

The need to ensure the service plan was reflective of the resident's status and care needs was discussed with Staff 1 (Executive Director), Staff 2 (RN) and Staff 12 (Area Nurse Manager) on 12/15/21. They acknowledged the findings.

2.  Resident 2 was admitted to the facility in 10/2021 with diagnoses including congestive heart failure.

During an interview and observations with Resident 2 on 12/14/21 at 9:30 am, the resident was observed to have the left lower leg wrapped. Resident 2 stated hospice was helping care for his/her leg however, was unable to state what had happened.

In an interview with Staff 5 (RCC) on 12/15/21 at 1:15 pm, she verified that the resident had an open wound on the left lower leg and that s/he had multiple incidents of confusion, an incident of disturbance of other residents, diminished orientation to time, and periods of anxiety.

Resident 2's most recent service plan, dated 12/13/21 did not provide clear instructions to staff on the delivery of care and services and was not reflective of the resident's current status in the following areas:

* Skin concerns related to wound care and monitoring; and

* Cognitive status related to orientation, confusion and anxiety.

The need to ensure the service plan was reflective of the resident's status and provided clear instructions for staff was discussed with Staff 1 (Executive Director), Staff 2 (RN) and Staff 12 (Area Nurse Manager) on 12/15/21. They acknowledged the findings.

1)  Care plan for resident 1 was updated on 1/3/2022 to reflect daily alcohol consumption, alcohol related falls and reported inappropriate comments while drinking.  Care plan for resident 2 was updated on 1/3/2022 to provide clear instruction to staff on cognitive changes and skin monitoring.

2)  All care plans will be reviewed by care plan team and resident/family to ensure accuracy and updates will be made as needed.  TSP's and 3rd party notes will be reviewed at clinical meeting and written onto care plans as appropriate.  Training has been scheduled the week on 1/10/2022 with the Area Nurse Manager to review service plans with ED, RN and RCC.  Community RN has also been scheduled to complete the next scheduled Role of the RN in Community-Based Care training through OHCA from 3/1/2022-3/3/2022.

3)  Daily at clinical meeting and with each care plan update.

4)  Health and Wellness Director and Executive Director, or designee.

2. Resident 5 was admitted to the facility in 09/2020 with a diagnosis of cerebral vascular accident.

Observations, interviews and review of the resident's current service plan, temporary service plans and weight records were conducted during the survey.

Resident 5 had the following significant change of condition:  

* Weight records dated 01/05/21 through 10/08/21 were reviewed and indicated the resident experienced a 22 pound unplanned weight loss between 07/28/21 and 10/13/21. Resident 5's records revealed the following weight's:

* 07/28/21: 219.6 lbs.; and

* 10/13/21: 197.6 lbs.

This loss of over 10% of body weight constituted a significant change of condition for severe weight loss.

There was no documented evidence interventions were reviewed for effectiveness, new interventions determined, documented and communicated to staff regarding the weight loss.

The need to ensure changes of condition were evaluated, actions and interventions determined and monitored for effectiveness was discussed with Staff 1 (Executive Director) and Staff 2 (RN) and Staff 12 (Area Nurse Manager) on 12/15/21. They acknowledged the findings.

Refer to C 280.

Based on observation, interview and record review, it was determined the facility failed to determine and document what action or intervention was needed, communicate resident-specific interventions to staff and document weekly progress until the condition was resolved for 2 of 5 sampled residents (#s 2 and 5) who were reviewed for changes of condition. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 10/2021 with a diagnosis of congestive heart failure and was receiving hospice services.

Observations, interviews and review of the resident's current service plan and temporary service plans were conducted during the survey. Resident 2's initial service plan identified the resident as a fall risk and universal fall precautions were service planned.

Resident 2 had the following short-term changes of condition:

* Fall on 11/09/21;

* Fall on 11/17/21;

* Wrong medications administered on 11/24/21; and

* Change in cognition on 12/01/21 and 12/04/21.

There was no documented evidence that interventions were reviewed for effectiveness, new interventions determined, documented and communicated to staff after each fall. In addition, the changes of condition related to administration of the wrong medications and changes in cognition were not monitored weekly until resolved.

The need to ensure changes of condition were evaluated, actions and interventions determined with weekly progress of the condition until resolved was discussed with Staff 1 (Executive Director) and Staff 2 (RN) and Staff 12 (Area Nurse Manager) on 12/14/21. They acknowledged the findings.  

1)  APS notified on 12/14/2021 of wrong medication for resident 2.  Fall interventions have been reviewed for effectiveness and change of condition has been completed.  Change of condition has been completed for unplanned weight loss for resident 5.

2)  Daily at clinical meeting, resident changes, including but not limited to, weight and fall interventions will be reviewed and followed up on as appropriate.  Community wil also complete a collaboritive care review each month in which every resident will be reviewed by department head team.  ED, RN and RCC received training on change of condition monitoring from DDCS/RN.

3)  Daily for any resident changes and monthly for all residents

4)  Health and Wellness Director and Executive Director, or designee.

Based on observations, interview and record review, it was determined the facility failed to ensure an RN assessment was completed for 1 of 1 sampled resident (#5) who experienced a significant change of condition related to weight loss. Findings include, but are not limited to:

Resident 5 was admitted to the facility in September 2020 with diagnoses including cerebral vascular accident.

Weight records dated 01/05/21 through 10/08/21 were reviewed and indicated the resident experienced a 22 pound unplanned weight loss between 07/28/21 and 10/13/21.

Resident's weight record revealed:

* 07/28/21 at 219.6 lbs; and

* 10/13/21 at 197.6 lbs.

The loss of over 10% of body weight constituted a significant change of condition for severe weight loss.

A progress note dated 10/13/21 stated the RN was aware of the weight loss. The facility failed to ensure an RN assessment was completed with documented findings, resident status and interventions made as a result of the assessment.

Multiple observations of the resident between 12/13/21 and 12/15/21 showed the resident eating in the dining room independently.

In an interview on 12/15/21, Resident 5 stated s/he was unaware of the weight loss. The resident stated s/he "would love to lose weight".

The need to ensure an RN assessment was completed which included the required components of documented findings, resident status and interventions made as a result of the assessment was discussed in interview on 12/14/21 with Staff 2 (Health and Wellness Director) and Staff 12 (Area Manager RN). Staff 2 noted that Resident 5 did not like to be weighed and often refused.

In an interview on 12/15/21, Staff 1 (Executive Director), Staff 2 and Staff 12 acknowledged the findings.

1)  Change of condition for resident 5 has been completed regarding unplanned weight loss and reviewed with resident.

2)  Resident health changes will be reviewed and discussed daily at clinical meeting.  All residents will be reviewed monthly by department head team at collaboritive care review.  ED, RN and RCC have scheduled training with DDCS/RN including RN assessment and change of condition monitoring.

3)  Daily for resident changes and monthly for all residents.

4)  Health and Wellness Director and Executive Director, or designee.

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 1 sampled resident (#2) who was receiving services from outside providers. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 10/2021 with diagnoses including congestive heart failure and was receiving hospice services.

A review of Resident 2's clinical record identified the following hospice recommendation was not implemented:

* 12/6/21, MT to observe and monitor left lower leg bandage for saturation or dislodgement of the bandage. Notify hospice.

There was no documented evidence the recommendation was communicated to staff, made part of the resident's service plan, or implemented.

The need to ensure the facility coordinated care with outside service providers and implemented recommendations was discussed with Staff 1 (Executive Director), Staff 2 (RN) and Staff 12 (Area Nurse Manager). They acknowledged the findings.  During the survey, Staff 12 added the recommendation with three times per day monitoring to the December MAR.

1)  During survey the care plan and MAR for resident 2 were updated to reflect instructions from outside provider.

2)  Outside provider notes will be reviewed at daily clinical meeting and updates will be made to resident records as appropriate.  ED, RN and RCC have scheduled training the week of 1/10/2022 with Area Nurse Manager including outside provider follow up.

3)  Daily at clinical meeting.

4)  Health and Wellness Director and Executive Director, or designee.

Based on interview and record review, it was determined the facility failed to notify the physician when a resident refused to consent to orders for 1 of 1 sampled residents (#1) who had documented medication refusals. Findings include, but are not limited to:

Resident 1's clinical records and MARs were reviewed during the survey and revealed the resident had multiple medication refusals between 11/06/21 and 12/04/21.

There was no documented evidence the facility notified the physician when the resident refused consent to their orders.

On 12/15/21 the failure to notify physicians of the documented medication refusals was reviewed with Staff 1 (Executive Director), Staff 2 (Health and Wellness Director) and Staff 12 (Area Manager RN). They acknowledged the findings.

1)  Physician was notified of medication refusals by resident 1.

2)  Med Techs received training from Area Nurse Manager on 12/14/2021 on notifying physicians of every refused medication and documentation.  Daily at clinical meeting all medication refusals and notifications will be reviewed for completion.  Any missed notifications will be completed at this time.

3)  Daily at clinical meeting.

4)  Health and Wellness Director and Executive Director, or designee.

Based on observation, interview and record review, it was determined the facility failed to have a sufficient number of caregivers to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to:

The facility was licensed as a Residential Care Facility (RCF) that was home to 70 residents. The RCF had three floors accessible by stairs and elevators.  

1. During the entrance conference on 12/13/21, the following was identified regarding resident care needs:

* Two residents needed two-person assist with transfers or Hoyer;

* Two residents were on hospice; and

* Six residents were identified as having recent falls.

2. Observations and interviews conducted between 12/13/21 and 12/15/21 showed the following:

* During interviews, several staff confirmed the facility was short staffed;

* Caregivers were observed doing laundry for residents, providing tray service to rooms during mealtimes, and assisting the kitchen to serve meals in the dining room;

* In an interview with a non-sampled resident on 12/14/21, s/he said "Most of the time on night shift we only have one caregiver and one MT for all three floors. I don't usually use my call light for help, but one night I choked, and it took one and half hours before someone came to help me. I don't feel safe here.";

* Interview with non-sampled resident on 12/14/21, s/he said "I'm in a lot of pain, so I don't go to the dining room for meals, it's too difficult. I get a meal tray and you're taking chances on it being hot. I don't call for help because it takes 30 minutes or more to get help here and I don't have time to wait.";

* Interview with non-sampled resident on 12/14/21, s/he stated "When I fill out my ticket for a meal tray I either don't get the tray or it's cold when I get it.";

* During an interview with Resident 5 on 12/15/21, s/he stated there aren't enough staff here". Resident 5 stated "on every shift" when asked if it was at a specific time of day; and

* During an interview with Staff 13 (CG) on 12/15/21, s/he said "We have three caregivers and two MT's on shift today, but usually we only have three caregivers and one MT on first shift.".

3. The staffing plan for November 2021, provided by the facility was as follows:

The staffing plan that was posted at the time survey entered was as follows:

Day: 4 CG's and 2 MT, total 6 staff;

Swing: 3 CG's and 2 MT, total 5 staff; and

Night: 3 CG's and 1 MT, total 4 staff.

The November staffing schedule noted the following dates were not staffed accordingly:

Day shift: 11/1/21 -11/6/21,  11/8-11/13 and 11/15 -11/27/21 noted three to four staff were scheduled (two to three staff short).

Swing shift: 11/1/21 -11/5, 11/8 -11/13, 11/15-11/23, 11/25-11/30/21 noted three to four staff were scheduled (one to three staff short).

Night shift: 11/1/21 -11/5, 11/8 -11/12, 11/15-11/19, 11/22 -11/26 and 11/29 -11/30/21 noted three staff were scheduled (one staff short).

4. The staffing plan (revised during survey) for December was as follows:

Day shift: 4 CG's and 1 MT's, total 5 staff;

Swing shift: 3 CG's and 1 MT's, total 4 staff; and

Night shift: 2 CG's and 1 MT, total 3 staff.

The December staffing schedule noted the following dates were not staffed accordingly:

Day shift: 12/2/21 -12/6/21 noted three to four staff scheduled (One to two staff short).

Swing shift: 12/2/21, 12/9/21, 12/21/21, 12/24/21, 12/25/21, and 12/26/21 noted two to three staff scheduled (one to two staff short).

Night shift: 12/1/21, 12/2/21, 12/8-12/11, 12/15- 12/16, 12/21-12/23, and 12/29/21 noted two staff were scheduled (One staff short).

During an interview with Staff 1 (Executive Director) on 12/15/21, it was reported the facility was aware that staffing was an issue. Staff 1 said the facility had six staffing agency contracts however, they were not using agency staff at this time. Staff 1 reported, when needed, all management team will cover caregiver shifts.

Upon review of the November and December staffing plan there were multiple occasions when Resident Care Coordinators (RCC) were performing MT duties rather than their assigned RCC duties, and there was no documented evidence the remaining open shifts were filled by management or other staff.

The facility's failure to ensure adequate staffing in order to meet the scheduled and unscheduled needs of the residents was shared with Staff 1, Staff 2 (RN), Staff 3 (Business office Coordinator) and Staff 12 (Area Nurse Manager) on 12/15/21. They acknowledged the findings.

1)  Staffing posting has been reviewed for accuracy and updated to reflect current staffing needs.

2)  Staff schedule will be reviewed and updated at clinical meeting daily to ensure accurate reflection of shifts worked by all staff members.  Staffing agency contracts in place and contract labor will be utilized as needed to ensure adequate staffing numbers are met.

3)  Schedule will be reviewed daily at clinical meeting.

4)  Health and Wellness Director and Executive Director, or designee.

Based on observation, interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Division. Findings include, but are not limited to:

Refer to C 513.

See POC for tag C513

Based on observation and interview, it was determined the facility failed to ensure the environment was clean and maintained in good repair. Findings include, but are not limited to:

Observations of the facility on 12/14 - 12/15/21 revealed the following areas were in need of cleaning and/or repair:

* Multiple resident apartment doors throughout the facility had black scuff marks, missing paint and/or gouges;

* The elevator entrance by apartment 104 had a gouge in the wall exposing the sheetrock below;

* The elevator by apartment 340 had black scuff marks and a panel that was broken at the bottom exposing the wood underneath; and

* The carpet in the hallway outside apartment 340 had several stains.

The environment was toured and the need to maintain interior surfaces clean and in good repair was discussed with Staff 1 (ED) on 12/15/21. He acknowledged the findings.

1)  All apartment doors have been inspected, cleaned and painted/repaired as needed.  All other areas noted in the statement of deficiencies have been corrected.

2)  Common area carpets have been placed on a cleaning schedule and will be cleaned monthly, spot cleaning will be completed as needed.  Apartment doors are on a monthly cleaning/painting schedule.  Immediate repairs will be completed as needed.  Maintenance and Executive Director will conduct a weekly walkthrough of all community common areas to note any areas in need of cleaning/repair.

3)  Scheduled cleaning/painting will occur monthly.  Weekly walkthrough will note areas of immediate need.

4)  Maintenance and Executive Director, or designee.

Based on observation and interview, it was determined the facility failed to ensure the environment was clean and maintained in good repair. This is a repeat citation. Findings include, but are not limited to:

During an environmental tour of the facility revealed the interior of the elevator, by Resident Apartment 140, had black scuff marks on the walls, and a panel was broken at the bottom exposing the wood underneath.

On 3/01/22, Staff 1 (ED) and the Surveyor toured the environment and discussed the need to ensure interior surfaces were clean and in good repair. He acknowledged the findings.

1)  Elevator cab has been inspected, cleaned and sanded to ensure no safety risks exist.

2)  Elevator cab is scheduled to be refurbished.  Currently waiting on TK Elevator to receive necessary parts to start work.

3)  Elevator cab will be inspected weekly to ensure continued safety until work to refurbish cab is completed.

4)  Executive Director, or designee, will be responsible for continued monitoring.