The findings of the re-licensure survey, conducted  12/13/22  through 12/15/22 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

MCCMemory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first re-visit to the re-licensure survey of 12/15/22, conducted on 03/02/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the second revisit to the re-licensure survey of 12/15/22 conducted 04/05/23 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.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were consistently followed by staff for 1 of 4 sampled residents (# 2) whose service plans were reviewed. Findings include, but are not limited to:

Resident 2 was admitted to the facility in November 2022 with diagnoses including Parkinson's disease.  

Observations of the resident, interviews with staff and review of the service plan dated 11/17/22, showed the resident was dependent on staff for care, had frequent falls and a pressure wound on his/her left heel. The service plan was not consistently followed by staff in the following areas:  

* Floating heels;

* Foam booties for both feet;

* Fluids within reach; and

* Bed in the lowest position;

The need to ensure resident service plans were consistently followed was discussed with Staff 1 (Administrator), Staff 2 (ED), Staff 4 (RCC), Staff 5 (RN) and Staff 19 (Director of Nursing Services) on 12/14/22. They acknowledged the findings.

1) Reviewed service plan requirements for resident #3 with all direct care staff.  Required all to sign the current service plan.

2) All direct care staff will sign the service plan at beginning of shift, and any tsps in the service plan binder. Binder will be kept at RCC/Reception counter. LN/Admin will audit staff compliance to the service plan weekly.

3) Audit compliance weekly X1 month, then monthly thereafter.

4) LN/RN/RCC/Admin

Based on observation, interview and record review, it was determined the facility failed to ensure an RN assessment was completed for 1 of 1 sampled resident (#3) who experienced significant changes of condition related to pressure ulcers. Findings include, but are not limited to:

Resident 3 was admitted to the facility in November 2022 with diagnoses including Parkinson's disease.  

Review of progress notes, wound assessments, temporary service plans and hospice notes dated 12/01/22 through 12/13/22 and the service plan dated 11/17/22 showed the following:

* A progress note dated 11/23/22 indicated Staff 3 (LPN) was notified of a blister to resident's left heel.

* A wound assessment dated 12/02/22 indicated an intact blister, 4.0 cm in diameter was present on the left heel.

* A wound assessment dated 12/09/22 indicated the wound had black eschar (dead tissue), no drainage or change in size.

There was no assessment completed by the RN when the wound was discovered on 11/23/22.

In interview on 12/14/22, Staff 5 (RN) indicated the area on the resident's heel was not present on admission. The blister started as a stage 2 pressure area. Staff 5 stated the heel wound transitioned to an unstageable pressure area, but was making improvements. Staff 5 stated she had not completed a significant change of condition assessment related to the resident's pressure area.

The facility failed to ensure an RN assessment was completed for the pressure wound which documented findings, resident status and interventions made as a result of the assessment.

The need to ensure an RN assessment was completed which documented findings, resident status and interventions made as a result of the assessment was discussed with Staff 1 (Administrator) and Staff 5. The staff acknowledged the findings.

1) RN has completed significant COC assessment for resident #3

2) LN to consult with RN and complete the assessment with RN via phone consultation if RN not on campus.

3) Audit each Significant COC weekly X1 month, then 3X a month, then quarterly there after for inclusion of all elements.

4) RCC/Admin

Based on interview and record review, it was determined the facility failed to ensure PRN medications used to treat a resident's behavior had written, resident-specific parameters and non-drug interventions for staff to attempt prior to administering a PRN psychoactive medication, for 2 of 2 sampled residents (#s 2 and 3) who were prescribed PRN medications to address behaviors. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in November 2022 with diagnoses including Parkinson's disease.

Review of the resident's 11/17/22 through 12/13/22 MARs and progress notes and 12/07/22 physician orders showed the following:

* Lorazepam 0.5 mg (anti-anxiety medication), one tablet every two hours PRN for anxiety or difficulty breathing.

The Lorazepam was administered nine times between 12/01/22 and 12/13/22.  

* Haloperidol lactate 2 mg/ml, take 1.0 ml every two hours PRN for agitation.

The Haloperidol was not administered between 12/01/22 and 12/12.

The MARs did not contain resident-specific parameters for staff describing how the resident expressed anxiety, distress or agitation. Additionally, there was no documentation of what non-drug interventions were attempted prior to administration of the medication.

The need to ensure resident-specific information on how the resident expressed anxiety/agitation and that non-drug interventions were attempted and documented prior to administration of the medication was discussed with Staff 1 (Administrator), Staff 2 (ED), Staff 4 (RCC), Staff 5 (RN) and Staff 19 (Director of Nursing Services) on 12/14/22. The staff acknowledged the findings.

On 12/15/22, Staff 1 indicated Hospice was now discontinuing the resident's Haloperidol.

2. Resident 3 was admitted to the facility in December 2022 with diagnoses including multiple myeloma.

Review of the resident's 12/07/22 through 12/13/22 MARs and progress notes and 12/10/22 physician orders showed the following:

* Lorazepam 0.5 mg (anti-anxiety medication), one tablet every two hours PRN for anxiety, agitation and/or nausea.  

The Lorazepam was not administered between 12/01/22 and 12/13/22.  

The MARs did not contain resident-specific parameters for staff describing how the resident expressed anxiety or agitation. Additionally, there was no documentation of what non-drug interventions were attempted prior to administration of the medication.

The need to ensure resident-specific information on how the resident expressed anxiety/agitation and that non-drug interventions were attempted and documented prior to administration of the medication was discussed with Staff 1 (Administrator), Staff 2 (ED), Staff 4 (RCC), Staff 5 (RN) and Staff 19 (Director of Nursing Services) on 12/14/22. The staff acknowledged the findings.

1) Create an alternative measure list for Med Techs built into QMAR for psychotropic PRN's.

2) Weekly audits of psychotropics medication administration and interventions-LN

3) Med Techs to review and re-sign company policy and procedure for psychotropic medications

4) LN/Admin weekly X4 weekly, then monthly X3 months, then quarterly review via external pharmacy review

3. Resident 3 was admitted to the facility in December 2022 with diagnoses including multiple myeloma and chronic pain.

Observations of the resident, interviews with staff and review of the service plan dated 12/07/22, showed the resident had two half side rails at the head of his/her bed. The resident required one staff assistance for ADL care and was a fall risk due to self transfers.

Review of the resident's record showed no RN, PT or OT assessment was completed for the use of the siderails.

The need to ensure resident devices with restraining qualities, were assessed by the RN, a PT or OT was discussed with Staff 1 (Administrator), Staff 2 (ED), Staff 4 (RCC), Staff 5 (RN) and Staff 19 (Director of Nursing Services) on 12/14/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure an assessment was completed by the facility RN, PT, or OT prior to the use of a supportive device with restraining qualities and/or was evaluated quarterly for 3 of 3 sampled residents (#s 1, 3 and 4) . Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 04/2020 with diagnoses including stroke and post polio subdural hematoma.

The resident was identified to have a lap buddy during the acuity interview. The device was observed on the resident's wheel chair multiple times during survey. Staff reported the lap buddy prevented the resident from falling out of the chair.

Resident 1 was observed in the dining room on 12/13/22 at 12:15 pm, sitting in the wheel chair with a lap buddy in place. The resident was leaning to the left and forward in the wheel chair. Two care staff repositioned him/her in the wheel chair on three occasions before the lunch meal was served.

There was no documented evidence an assessment had been completed by an RN, PT, or OT prior to use of the lap buddy and there were no quarterly evaluations documented.

The need to ensure supportive devices with potentially restraining qualities were assessed prior to use and evaluated quarterly was discussed with Staff 1 (Administrator), Staff 2 (ED), Staff 5 (RN) and Staff 19 (Director of Nursing Services) on 12/14/22. They acknowledged the findings. No further information was provided.

2. Resident 4 was admitted to the facility in 09/2021 with diagnoses including chronic back pain, congestive heart failure and chronic kidney disease.

The resident was observed on 12/13/22 while up in the wheel chair to have a belt wrapped around the bottom of the wheel chair foot rest and buckled over the top of his/her feet.  

Staff 3 (LPN) stated that the belt kept the resident's feet from slipping off the footrest and the resident wanted the belt or a Velcro strap used.  

There was an  RN assessment for use dated 09/15/21, although there were no quarterly evaluations for use of the device.

The need to ensure supportive devices with potentially restraining qualities were assessed prior to use and evaluated quarterly was discussed with Staff 1 (Administrator), Staff 2 (ED), Staff 5 (RN) and Staff 19 (Director of Nursing Services) on 12/14/22. They acknowledged the findings.  No further information was provided.

1) Review OARs with all staff at staff meeting.

2) All quarterly service plans will be reviewed by LN/RN for device restraining qualities. The weekly assessment list is reviewed and updated.

3) Review 5 services plans weekly, and all new admissions, and then quarterly.

4) LN/RN/Admin

Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) that met the regulation. Findings include, but are not limited to:

During a review of the facilities ABST on 12/14/22, it was determined the tool failed to include all of the 22 required ADL components to include:

*Personal hygiene;

*Grooming;

*Dressing/undressing;

*Bathing;

*Repositioning in bed or chair;

*Ambulation, escorting to and from meals or activities;

*If multiple staff are required to assist with transferring and completing tasks in previous question, how much additional time is needed;

*Medication administration;

*Providing treatments;

*Assisting with leisure activities;

*Monitoring physical condition or symptoms;

*Assisting with communication, assistive devices for hearing, vision or speech;

*Responding to call lights;

*Completing resident specific housekeeping or laundry services performed by care staff;

*Additional care service, such as smoking assistance or pet care; and

*Ambulation assist to and from meals.

The ABST tool was reviewed and discussed with Staff 1 (Administrator), Staff 2 (ED) and Staff 19 (Director of Nursing Services) on 12/14/22 at 10:20 am. Staff acknowledged the findings.

1) Acuity tool updated to include all 22 elements per OARs.

2) All admins updated on current OAR for acuity tool.  All administrators registered to receive provider alerts to remain current and acuity tool will be reviewed annually.

3) Acuity tool to be reviewed annually for updates

4) Administrator/LN

Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) that met the regulation. This is a repeat citation. Findings include, but are not limited to:

During a review of the facilities ABST on 03/02/23, it was determined the tool failed to include all of the 22 required ADL components to include:

* Personal hygiene;

* Grooming; and

* Providing treatments (e.g., skin care, wound care, antibiotic treatment).

The ABST tool was reviewed and discussed with Staff 1 (Administrator) and Staff 2 (ED) on 03/02/23 during the survey. Staff acknowledged the findings.

C361

1) Acuity tool reviewed and correct to included all 22 elements according as listed in the OARs.

2) All Administrators educated on the current OARS and will be reviewing the Acuity Staffing Tool weekly upon each new admission/discharge/COC.

3) Administrators will review Acuity Staffing Tool weekly and update Staffing Plan as needed based on acuity number.

4) Administrators will update Acuity Staffing Tool with any new admission/discharge, change of condition, and as each care plan is reviewed to ensure accuracy.

5) Adminitrator/LN/RCC will update the Acuity Tool and Staffing Plan

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 361.

C455 - See TAG C361