The findings of the re-licensure survey, conducted 01/30/23 through 02/03/23, 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, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for 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 revisit to the re-licensure survey of 02/03/23, conducted 05/02/23 through 05/03/23, 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 interview and record review, it was determined the facility failed to conduct investigations of injuries of unknown cause to rule-out abuse or report the injuries as suspected abuse to the local Seniors and People with Disabilities (SPD) office, for 1 of 1 sampled resident (#2) with injuries of unknown cause. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 2018 and was dependent on staff for all ADL care needs. His/her clinical record revealed the following:

* On 12/10/22, staff documented that the resident had an "abrasion on [his/her] right outer wrist."; and

* On 01/22/23, the resident was found with a "skin tear on [his/her] left ring finger."

There was no documented evidence the facility immediately investigated and documented that the injuries were not the result of abuse or neglect. The facility did not report the injuries to the local protective services office as suspected abuse/neglect.

The need to ensure injuries of unknown cause were investigated promptly or reported if necessary was discussed with Staff 1 (Administrator) on 02/02/23 at 2:20 pm. She acknowledged the facility had not investigated to rule out abuse/neglect. The surveyor directed Staff 1 to self-report the incidents. Verification that the facility had reported the incidents to the local SPD office was received during the survey.

Resident #2 passed on 2/5/23. Memory care administrator sent APS report for skin issues on 2/2/23, an APS worker by the name of Lisa came out to follow up on 2/3/23. Memory care administrator and facility RN will review skins at a JUMP meeting once a month. Memory care administrator will review skins once a week on Fridays to ensure pcp has been notified and a incident report has been made prn.

Based on interview and record review, it was determined the facility failed to ensure resident move-in evaluations addressed all required elements for 1 of 1 sampled resident (#3) whose new move-in evaluation was reviewed. Findings include, but are not limited to:

Resident 2 was admitted to the MCC in 08/2022 with diagnoses including Alzheimer's disease, heart valve replacement and constipation.

The new move-in evaluation failed to address the following elements:

* Cultural preferences and traditions; and

* Pain, pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort.

The need to ensure move-in evaluations included all required elements was discussed with Staff 1 (Administrator) on 02/03/23. She acknowledged the findings. No further information was provided.

Resident #2 - memory care administrator updated care plan on 2/23/23 to reflect current needs. Health services will be reviewing service plans once weekly at our JUMP meetings going forward. Memory care administrator and facility RN will be responsible to ensure this happens every week.  

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 regarding the delivery of services for 3 of 3 sampled residents (#s 1, 2 and 3) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the MCC in 07/2018 with diagnoses which included dementia.

Interviews with care staff and observations of Resident 2 during the survey revealed s/he was incontinent, dependent on staff for ADL care, did not use a call light to summon assistance, and needed meal assistance.

Resident 2's service plan, dated 11/02/22, revealed it was not reflective of the resident's needs and lacked clear direction regarding the delivery of services in the following areas:

* Fall mat;

* Perimeter scoop mattress;

* Pillows used for positioning;

* Activities;

* Use of compression stockings;

* Oral care; and

* Frequency of fluids offered.

The need to ensure the service plan was reflective of Resident 2's current care needs and provided clear direction to staff was discussed with Staff 1 (Administrator) during an interview on 02/02/23 at 2:20 pm. She reviewed the service plan and acknowledged it needed to be updated. No further information was provided.

2. Resident 1 was admitted to the MCC in 12/2020 with diagnoses including Alzheimer's disease.

Interviews with care staff and observations of Resident 1 during the survey revealed s/he was incontinent, dependent on staff for ADL care and did not use a call light to summon assistance.

Resident 1's service plan, dated 12/28/22, revealed it was not reflective of the resident's needs and lacked clear direction regarding the delivery of services in the following areas:

* Activity;

* Use of socks at night;

* Toileting assistance status;

* Frequency of fluids offered; and

* Transfer status with 2-staff assistance.

The need to ensure the service plan provided clear instruction to staff and was reflective of the resident's needs was discussed with Staff 1 (MCC Administrator) and Staff 3 (Resident Service Coordinator) on 02/02/23. They acknowledged the findings.

3. Resident 3 was admitted to the MCC in 08/2022 with diagnoses which included Alzheimer's disease, constipation and falls.

Interviews with care staff and observations of Resident 3 during the survey revealed s/he was incontinent, dependent on staff for ADL care and did not use a call light to summon assistance.

Resident 3's service plan, dated 01/26/23, was not reflective of the resident's needs and lacked clear direction regarding the delivery of services in the following areas:

* Hearing aid care;

* How the resident expressed pain;

* Fall history and current interventions;

* Frequency of fluids offered; and

* Resident-specific instructions for providing meal assistance, transfers for bathing and how toileting/incontinent care was provided.

The need to ensure the service plan was reflective of Resident 3's current care needs and provided clear direction to staff was discussed with Staff 1 (Administrator) during an interview on 02/03/23 at 10:00 am. She reviewed the service plan and acknowledged it needed to be updated. No further information was provided.

Resident #1,#2,#3 - Resident #2 and resident #3 passed 2/5/23 and 2/15/2023. In our system, point click care, there are promps during the evaluation to seek information for individualized service plans. Training has been provided to the RSC to use those prompts to find more information to individualize the service plan. This will be reviewed upon each move in of a resident and every quarter to ensure care plans are up to date and accurate. Facility RN and MCC will be responsible to see that the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements for residents were met. Findings include, but are not limited to:

Fire drill records from 07/30/22 through 01/30/23 were reviewed on 02/02/23 with Staff 1 (MCC Administrator). The facility lacked documentation of the following required elements:

* Evidence residents who were able to follow instructions were given instructions on fire and life safety procedures (including in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building) within 24 hours of admission and re-instructed at least annually with a written record including the content and residents attending.

The need to have documented evidence of all fire and life safety training components was discussed with Staff 1 (MCC Administrator) and Staff 7 (Director of Plant Operations) on 02/02/23. They acknowledged the findings.

Memory care administrator added clear instructions to each resident's MAR stating whether or not each resident can participate in the facility fire and safety procedures. To ensure this system is corrected so the violation does not happen again, MCC will determine if a resident is aware enough to participate in this and add it to their MAR upon move in and quarterly.  

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 and C 422.

Refer to C 231 and C 422

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to C 252 and C 260.

Refer to C 252 and C 260

Based on observation, interview and record review, it was determined the facility failed to ensure individualized nutrition and hydration plans for each resident was developed and included in service plans for 2 of 3 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to:

Resident 1 and 2's current service plans were reviewed during survey. Each of the service plans lacked information and staff instructions related to individualized nutrition and hydration status and needs.  

The need to develop individualized service plans addressing residents' nutrition and hydration needs was discussed with Staff 1 (Administrator) during interviews on 02/02/23. She acknowledged the findings.

Resident #1, MCC added a hydration pass during med pass times - med techs to offer 120ML with pills. Resident #2 passed on 2/5/23. Going forward, MCC will add hydration passes to resident's MAR and care plans upon move in and quarterly. Snack are offered daily between meals at 10am and 2pm.  

Based on observation, interview and record review, it was determined the facility failed to ensure activity evaluations addressed all required components and individualized activity plans were developed for 3 of 3 sampled residents (#s 1, 2 and 3) whose activity plans were reviewed. Findings include, but are not limited to:

Resident 1, 2 and 3's records were reviewed, and observations were made during the survey. There was no documented evidence activity evaluations addressed the required components, and that service plans had been individualized to reflect the following:

* Current abilities and skills;

* Emotional/social needs and patterns;

* Adaptations needed to participate;

* Identification of activities for behavioral interventions; and

* There was no specific activity plan which detailed what, when, how and how often staff should offer and assist each resident with individualized activities.

The need to ensure activity evaluations addressed all required components and individualized activity plans were developed was discussed with Staff 1 (Administrator) during interviews on 02/02/23 and 02/03/23. She acknowledged the findings.

Resident #1, MCC updated the activity section on resident's care plan. Resident #2 and #3 passed away. MCC/RSC will review careplans upon move in and quarterly to ensure the activites are kept up to date. MCC/RSC will be responsible to ensure that the activity section is updated correctly.