The findings of the re-licensure survey conducted 02/07/22 through 02/08/22 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, 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

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 re-visit to the re-licensure survey of 02/08/22, conducted on 06/02/22 through 06/03/22, 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 and Home and Community Based Services Regulations OARs 411 Division 004.

Based on interview and record review, it was determined the facility failed to ensure falls with injury, injuries of unknown cause, and resident to resident altercations were promptly investigated to rule out abuse and reported to the local SPD office as required for 1 of 3 sampled residents (#2) whose incidents were reviewed. Findings include, but are not limited to:

Resident 2 was admitted to the facility in November 2021 with diagnoses including dementia and paranoid delusions.  

The resident's service plan dated 12/02/21 and interviews with care staff between 02/07/22 and 02/08/22 indicated the resident could ambulate on his/her own and utilized a walker. The resident was unable to consistently direct his/her own care, had a history of falls, and aggression towards others.

Review of incident investigations and progress notes from 11/09/21 through 02/07/22 showed the following:

* A progress note dated 11/16/21 indicated a bruise to the resident's mid back was found without a cause indicated. An investigation dated 11/16/21 was started but was not completed.

* A progress note dated 11/25/21 indicated the resident experienced a fall, hit his/her face and had a red area under the right eye. An investigation dated 11/25/21 was started but was not completed.

* A progress note dated 12/08/21 and 12/09/21 indicated the resident was on alert for an injury fall on 12/07/21. A bruise to the right buttock was noted. No investigation of the incident was completed.

* A progress note dated 12/22/21 indicated the resident was found on the footrest of his/her recliner with the chair tipped. The resident had a reddened area and scrapes noted to the back. No investigation of the incident was completed.

* A progress note 12/22/21 indicated Resident 2 was entering multiple resident rooms and "flashing" residents. Resident 2 entered a resident's room, "pulled [his/her] pants and depends down and bent/squatted over to show privates." Resident 2 was found naked in another resident's room and attempted to strike and pull down care staff who offered assistance. An investigation of the incident was started but was not completed and the incident was not reported to the the local SPD office.

* A progress note dated 12/06/21 indicated the resident self reported s/he had fallen and "cracked head open." There was no sign of injury. No investigation of the incident was completed.

* Progress notes dated 12/09/21 and 12/31/21 indicated the resident experienced non injury falls. No investigations was completed for either fall.

The need to ensure resident incidents were promptly investigated to rule out abuse and neglect and reported when required was discussed with Staff 1 (Executive Director) and Staff 2 (Health Services Director) on 02/08/22. The staff acknowledged the findings.

The facility reported the requested incidents involving injuries and exposed genitals to the local SPD office on 02/08/22. Confirmation of the reports were provided prior to survey exit.

Community acknowledged incomplete investigations and lack of reporting for incidents that met reporting criteria for Resident #2 for the dates in question (11/16/2021, 11/25/2021, 12/6/2021, 12/7/2021, 12/9/2021, 12/22/2021 and 12/31/2021). Community completed required reporting prior to survey exit on 2/8/2022. Community to conduct in-service training with staff on Abuse Reporting and Investigation Guidelines for Providers by March 31, 2022. Executive Director and/or Designee will be responsible for conducting investigations and meeting reporting requirements on an ongoing basis. Random compliance audits will be conducted by regional team (VPO and/or Nurse Consultant) on a bi-annual basis.

2. Resident 2 was admitted to the facility in November 2021 with diagnoses including dementia.

Observations of the resident and interviews with staff from 02/07/22 to 02/08/22 and review of the service plan dated 12/02/21, showed the service plan was not reflective of the resident's current care needs, was not consistently followed by staff and/or did not provide clear direction to staff in the following areas:

* Dressing, repeated clothing changes and current sleep schedule;

* Toileting assistance, incontinence care and toileting in inappropriate areas;

* Psychotropic use;

* Grooming related to facial hair;

* Meal assistance, health shakes and fluid needs; and

* Falls and safety interventions including fall mat.

The need to ensure resident service plans were reflective of current care needs, provided direction to staff and were followed was discussed with Staff 1 (Executive Director) and Staff 2 (Health Services Director) on 02/08/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current needs and status, provided clear direction to staff regarding the delivery of services, were followed and updated quarterly for 3 of 4 sampled residents (#s 1, 2 and 4) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in June 2021 with diagnoses including dementia, diabetes and was receiving hospice services.

a. Review of Resident 1's 09/26/21 service plan, current MAR, progress notes dated 11/12/21 through 02/07/22, observations of the resident and interviews with staff revealed the service plan was not reflective in the following areas:

* Anti Coagulation therapy;

* Turning every two hours; and

* Mouth swab and ointment to lips every two hours.

b. The last update of the service plan occurred on 09/26/21, not quarterly as required.

The need to ensure service plans were reflective of the resident's current status and care needs and were updated quarterly was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Director) and Staff 4 (Resident Care Coordinator) on 02/08/22. They acknowledged the findings.

3. Resident 4 was admitted to the facility in September 2021 with diagnoses including dementia and COPD.

Review of Resident 4's 12/19/21 service plan, progress notes 11/12/21 through 02/07/22, observations of the resident and interviews with staff identified the service plan was not reflective of assistance needed in transferring the resident.

On 02/08/22, the need to ensure service plans were reflective of the resident's current status and care needs was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Director), and Staff 4 (Resident Care Coordinator). They acknowledged the findings.

1. What actions will be taken to correct the rule violation for each example/resident?Resident #1: Upon further record review resident did have service plan completed in computer system on 12/25/2021 which meets the quarterly requirement; however, was not reviewed signed and completed by responsible party/resident and community and did not contain items listed in citation.  

Resident #1 will have review of service plan and update to reflect current care needs (such as Anti-coagulant therapy, turning and positioning, oral care and use of lip ointment) and completed by 3/31/2022.

Resident #2 will have review of service plan and update to reflect current care needs (such as Dressing with repeated clothing changes, sleep schedule, toileting assistance, incontinent care, and toileting in inappropriate places, use of psychotropic medication, grooming of facial hair, meal assistance, health shakes, fluid needs, fall and safety interventions to include fall mat)  and completed by 3/31/2022.

Resident #4 will have review of service plan and update to reflect current care needs (such as assistance needed with transfers) and completed by 3/31/2022.

All Resident's services plans will be reviewed, with ISP or handwritten changes that are initial and dated implemented for any care needs not addressed in service plan by 4/8/2022. Changes to be fully incorporated into service plan with next comprehensive service plan (quarterly or change in condition).

ED, RCC and HSD will be re-educated on completed timely and comprehensive service plans by VPO or Nurse Consultant by 3/1/2022.

Staff to be educated on utilization of service plans for providing care by 4/1/2022.

ED and/or HSD to review service plans prior to locking to ensure they reflect the Resident current care needs on an ongoing basis.  

Random SP audits to be conducted by Health Service Department during QA process at least monthly.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that consisted of the resident, the resident's legal representative if applicable, any person of the residents choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services, for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose service plans were reviewed.  Findings include, but are not limited to:

Resident 1, 2, 3 and 4's most recent service plans lacked evidence that a Service Planning Team reviewed and participated in the development of the service plans.

On 02/08/22, the need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Director), and Staff 4 (Resident Care Coordinator). They acknowledged the findings.

Resident #1,2,3 & 4 will have service plans reviewed by Service Plan Team that will consist of the following members at a minimum: Executive Director, Health Service Director, Resident Care Coordinator, Lifestyles Director, Resident/Responsible Party will be invited to attend and participate as part of this team.  Other team member will be included on a Resident-by-Resident basis to include: Caseworker, Hospice, and other Third-Party Providers as appropriate.

Executive Director and/or HSD will oversee compliance by reviewing Service Plans prior to locking.

Based on observation, interview and record review, it was determined the facility failed to coordinate care with outside providers and ensure documentation of visits were maintained in the residents' records for 1 of 2 sampled residents (#2) who were receiving home health services from outside providers. Findings include, but are not limited to:

Resident 2 was admitted to the facility in November 2021 with diagnoses including dementia.  

During the review of the resident's record it was determined the resident received outside provider services related to Physical Therapy (PT).  

Observations of the resident, interviews with staff, and review of outside provider notes and progress notes from 11/09/21 through 01/26/22 were completed.

The resident was admitted to PT services on 12/13/21 for strengthening and ambulation. PT visits were to occur once a week for six weeks.

PT visit notes were not consistently documented. Two notes were documented between 12/13/21 and 01/26/22 when the resident was discharged from PT services.

The need to ensure on-going coordination of care was maintained, documented and recommendations were implemented was discussed with Staff 1 (Executive Director) and Staff 2 (Health Services Director) on 02/08/22. They acknowledged the findings.

idents # 1 & 2 will have outside provide records requested and reviewed. Any recommendations not currently implemented will be initiated and documented within medical record by 3/31/2022.  

HSD and/or ED will meet with current outside providers to review protocol for exchange of information and coordination of care.  

Staff will be provided additional education on coordination of care with outside providers by 3/31/2022.

Review of outside provider documentation will be conducted weekly during High-Risk Resident Meeting with follow-up by HSD/RCC as needed.  

Random chart audit for coordination of care will be conducted during QA process by Health Service Team.

Based on interview and record review, it was determined the facility failed to ensure signed provider orders were documented in the resident's record for all medications for 1 of 4 sampled residents (#4) whose orders were reviewed. Findings include, but are not limited to:

Resident 4's physician orders and the 01/01/22 through 02/07/22 MAR were reviewed during survey. Resident 4's MAR indicated that s/he was receiving sertraline (for depression) 50 mg by mouth once daily. There were no signed physician order for this medication found in the resident record.

On 02/09/22, the need to ensure signed provider orders were documented in the resident's record for all medications was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Director), and Staff 4 (Resident Care Coordinator). They acknowledged the findings.

Resident #4 order for Sertraline 50 mg was received from the pharmacy prior to survey exit on 2/8/2022.  All Resident MARs reviewed and compared to current orders to ensure signed orders are in-house conducted and completed by 3/15/2022.  

Re-education for medication technicians regarding process for verifying medication orders prior to administration. Verification of order validation process by RCC/HSD and re-education to be completed by Nurse Consultant.  All Re-education to be completed by 3/31/2022.

Monthly Sample of 5-10% of Resident for MAR to Order audits by Health Service Department and quarterly pharmacy consultant reviews for QA purposes.

Based on interview and record review, it was determined the facility failed to ensure staff documented non-pharmacological interventions that were attempted with ineffective results prior to administering PRN psychotropic medications, common side effects, and when to contact a health professional regarding side effects for 1 of 3 sampled residents (#4) who was prescribed PRN medications. Findings include, but are not limited to:

Resident 4 was admitted to the facility in September of 2021.

Resident 4 had a physician's order for Alprazolam 0.25 mg as needed for anxiety and agitation.

Resident 4's 01/01/22 through 02/07/22 MAR indicated the resident was administered Alprazolam on 11 separate occasions. There was no documented evidence staff had attempted non-drug interventions with ineffective results prior to administering the psychotropic medication.

There was also no documented evidence in the resident's record related to possible side effects of the medication.

On 02/08/22, the need to attempt non-drug interventions prior to administering PRN psychotropic medications and documentation of side effects related to specific psychotropic medications was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Director), and Staff 4 (Resident Care Coordinator). They acknowledged the findings.

Resident # 4 MAR will be updated to reflect need for documentation of non-drug interventions prior to administration of PRN Psychotropic Medications and service plan to address potential side effect monitoring.  

All Residents all PRN Psychotropic Medications will be reviewed to ensure their MAR reflects non-drug intervention utilization prior to administration and service plans are reflective as side effect monitoring by 4/8/2022.  

Med Techs will be re-educated on psychotropic medications, non-drug interventions, documentation and EMAR set-up and utilization for these processes.  

HSD/RCC to oversee the compliance with documentation and implementation of ISPs/Service Plans for side effect monitoring.  

HSD or Designee to oversee compliance with by MAR audits quarterly.

Based on observation and interview, it was determined the facility failed to keep all interior materials and surfaces clean and in good repair. Findings include, but are not limited to:

A tour of the facility on 02/07/22 showed the following areas needed cleaning and/or repair:

* Concrete floor behind industrial washing machine in main laundry room had several large cracks, up to one and a half inches wide, and an accumulation of dirt and stains;

* Top surface of industrial washing machine, as well as connected tubing and venting surfaces were coated in white powder and dust;

* Linoleum flooring seam in main laundry room was separated, approximately 18 inches long and half an inch wide;

* Ceiling and walls in main laundry room had multiple areas of chipped paint, creating uncleanable surfaces;

* Utility sink in main laundry room was coated with speckled black debris, as well as gray, yellow and brown splatters;

* Doors and door jambs throughout Oak and Maple units had chipped paint and black streaks;

* Quarter round floor moldings in Oak dining room were loose and pulled away in multiple spots; and

* Built-in bookcases in activity areas in Oak and Maple units had splatters, streaks and chipped paint.

The environment was toured with Staff 1 (Executive Director) and Staff 6 (Environmental Services Director) on 02/08/22. They acknowledged the findings.

The following areas have been address as described below:

o The floor in the laundry room is being replaced all supplies have been ordered with an estimated delivery date of 4/2/2022.  Instillation has not been scheduled pending an exact delivery date.  Areas will continue to be cleaned to the best of the communities ability until replacement is finished.  

o The laundry room had sheetrock replaced and areas   re-puttied, re-painted, to repair the walls. Area cleaned and cracks sealed by 4/9/2022

o Top surface of industrial washing machine, as well as connected tubing and venting surfaces were coated in white powder and dust Washing Machine cleaned, tubing replaced, and vent areas cleaned by 4/9/2022

o Ceiling in main laundry room had multiple areas of chipped paint, creating uncleanable surfaces Area repainted and cleaned by 3/15/2022

o Utility sink in main laundry room was coated with speckled black debris, as well as gray, yellow and brown splatters Sink cleaned, and debris and splatters removed by 3/1/2022

o Doors and door jambs throughout Oak and Maple units had chipped paint and black streaks Doors and door jambs throughout Oak and Maple cleaned and repainted as needed by 4/9/2022.

o Quarter round floor moldings in Oak dining room were loose and pulled away in multiple spots.  Floor molding repaired and where unable to be repaired was replaced by 4/9/2022

o Built-in bookcases in activity areas in Oak and Maple units had splatters, streaks and chipped paint. Built-in bookcases in activity areas in Oak and Maple cleaned with splatters/streaks removed and chipped paint areas touched up. All areas above added to Preventative Maintenance Plan and routine housekeeping schedules. ED and ESD to conduct routine community physical plant inspections at least monthly to check for areas needing repairs/replacements.

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 231 and C 513.

Refer to POC for C231 and C513

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 262, C 290, C 303 and C 330.

Refer to POC for C 260, C 262, C 290, C 303 and C 330.

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 2 of 4 sampled residents (#1 and 4) whose service plans were reviewed. Findings include, but are not limited to:

Residents 1 and 4's current service plans were reviewed during survey. 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 (Executive Director), Staff 2 (Health Services Director) and Staff 4 (Resident Care Coordinator) on 02/08/22. They acknowledged the findings.

Residents # 1 & #4 will have service plans updated to reflect hydration needs.

Residents with specialized hydration needs will have services plans reviewed, with ISP or handwritten changes that are initial and dated implemented for any hydration needs not addressed in service plan by 4/8/2022. Changes to be fully incorporated into service plan with next comprehensive service plan (quarterly or change in condition).

Staff to be educated on hydration and inclusion of specialized hydration needs in service plans by 4/1/2022.

ED and/or HSD to review service plans prior to locking to ensure they reflect the Specialized Hydration needs (as needed) on an ongoing basis.  

Random SP audits to be conducted by Health Service Department during QA process at least monthly.

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 4) whose service plans were reviewed. Findings include, but are not limited to:

Resident 1, 2 and 4's service plans offered some information about the residents' interests, but the facility had not fully evaluated the residents':

* 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.

Observations on 02/07/22 and 02/08/22 showed multiple residents wandering the halls, some calling out and residents seated in the TV area for extended periods of time without consistent interaction or intervention from staff.

There was no specific activity plan which detailed what, when, how and how often staff should offer and assist the residents with more individualized activities.

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) and Staff 2 (Health Services Director). The staff acknowledged the findings.

Residents # 1, #2 & #4 will have service plans updated to reflect individualized activity plans.

Residents will have the following areas evaluated with each comprehensive evaluation: 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. Individualized Activity Plans to be developed in the Service Plan for each resident.  

Current residents will be reviewed and an  ISP or handwritten changes that are initial and dated implemented for individualized activity plans not addressed in service plan by 4/8/2022. Changes to be fully incorporated into service plan with next comprehensive service plan (quarterly or change in condition).

Staff to be educated on individualized activity plans and utilization of these plans by 4/1/2022.

ED and/or HSD to review service plans prior to locking to ensure they reflect the individualized activity plan on an ongoing basis.  

Random SP audits to be conducted by Lifestyles Director for QA process at least monthly.

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 2 of 2 sampled residents (#s 2 and 4) with documented behaviors. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in November 2021 with diagnoses including dementia and paranoid delusions.

Resident 2's record documented behaviors including anxiety, exit seeking, yelling, hitting staff, disrobing, hallucinations and aggression towards other residents including hitting and grabbing.

The resident's service plan, dated 12/02/21, did not address the behaviors and/or lacked individualized interventions to assist staff in minimizing the negative impact of the behaviors.  

On 02/08/22 the need to develop individualized behavior plans for residents with behavioral symptoms was discussed with Staff 1 (Executive Director) and Staff 2 (Health Services Director). The staff acknowledged the findings.

2. Resident 4 was admitted to the facility in September 2021 with diagnoses including dementia.

Resident 4's record documented behaviors including anxiety, throwing themselves onto the floor, refusing care, hallucinations, and aggressive behaviors towards other residents and staff including yelling and threats.

The resident's service plan, dated 12/19/21, did not address the behaviors and/or lacked individualized interventions to assist staff in minimizing the negative impact of the behaviors.  

On 02/08/22 the need to develop individualized behavior plans for residents with behavioral symptoms was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Director), and Staff 4 (Resident Care Coordinator). They acknowledged the findings.

Resident #2 Service Plan will be updated to reflect Behaviors to include: anxiety, exit seeking, yelling, hitting staff, disrobing, hallucinations and aggression towards other residents including hitting and grabbing and individualized interventions to minimize or mitigate the potential negative outcome from these behaviors by 3/31/2022. Resident #4 Service Plan will be updated to reflect behaviors to include: anxiety, throwing themselves onto the floor, refusing care, hallucinations, and aggressive behaviors towards other residents and staff including yelling and threats and individualized interventions to minimize or mitigate the potential negative outcome from these behaviors by 3/31/2022.

Other Residents with known behaviors will have service plans reviewed and updated as needed to reflect behaviors and individualized interventions to minimize or mitigate the potential negative outcome from these behaviors by 4/8/2022.

Staff to be provided education on utilization of service plans for minimizing and/or mitigation strategies for behaviors by 3/31/2022.

ED and/or HSD to review service plans prior to locking to ensure they reflect the individualized intervention for behaviors on an ongoing basis.  Random SP audits to be conducted by Health Service Team for QA process at least monthly.