The findings of the re-licensure survey, conducted 03/25/24 through 03/27/24, 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 re-visit to the re-licensure survey of 03/27/24, conducted on 07/01/24 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 and Home, OARs 411 Division 57 for Memory Care Communities and Community Based Services Regulations OARs 411 Division 004.

2. Resident 2 was admitted to the facility in 08/2023 with diagnoses including dementia and subdural hemorrhage.  

During caregiver interviews on 03/25/24, staff stated Resident 2's service plan was located in a closet in the central hallway, and that caregivers referred to the service plan for instructions.  

Review of the service plan that was available for staff showed it was last updated on 10/31/23, and did not include current information about Resident 2's care needs in the areas of:

* Incontinence;

* Toileting assistance;

* Need for one staff person meal assistance;

* Anxiety and overstimulation; and

* Hospice services.

In interview on 03/27/24, Staff 1 (Executive Director) stated the service plan had been reviewed on 02/20/24, however, the updated plan was not provided to staff in the service plan book.

The need to ensure the current service plans were readily available to staff and provided clear direction regarding the delivery of services was discussed with Staff 1 (Executive Director), Staff 2 (LPN), and Witness 2 (RN Oversight/Elderwise) on 03/27/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were readily available to staff, provided clear direction regarding the delivery of services, handwritten changes were dated and initialed, and the services were being implemented for 2 of 4 sampled residents (#s 2 and 3). Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 05/2019 with diagnoses including Alzheimer's disease.

Resident 3's service plan, updated 03/15/24, and interim service plans were reviewed. Interviews with care staff were conducted and observations of the resident were made. The resident's service plan failed to provide clear instruction to staff or was not implemented in the following areas:

* Ability to make self understood;  

* Ability to follow simple instructions depending on his/her mood;

* Interventions for when the resident refused care;

* Staff to stand on left side due to vision loss;

* Transfer assistance including a gait belt and mechanical lift;

* Preference of bathing time;

* Use of the spa bathtub;

* Full assistance with all grooming and oral hygiene tasks;

* Portable oxygen when in the dining room;

* Meal assistance needed depending on the resident's ability;

* How the resident communicated pain;

* Ability to self initiate activities;

* Preference of being in the dining room; and

* Conflicting information relating to which company provided the resident's oxygen and supplies (e.g. tubing, filters, cannulas, etc.).

Additionally, there was a handwritten update on the service plan that was not dated or initialed.  

The need to ensure service plans were reflective, provided clear direction regarding the delivery of services, and updates on the service plan were initialed and dated was discussed with Staff 1 (Executive Director), Staff 2 (LPN), and Witness 2 (RN Oversight/Elderwise) on 03/27/24. They acknowledged the findings.

1. Resident 2 & 3 from Survey have been reviewed and updated. All service plans will be reviewed and update to reflect individualized service needs.To include Able to make self understood, Ability to follow instructions, Assistance needed with ADL's, Transfer assistance, Preference of bathing time, spa or shower,Meal assistance and assistance and preference with Activities.

2. Going forward we have a new tool to gather information from staff in all departments. This will also occur when a resident has a Significant Change of condition.  

3. This will be evaluated weekly by ED and WD .

4. WD, ED or designee

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a service planning team that included the resident, the resident's case manager or legal representative if applicable, any person of the resident's choice, the Administrator or designee, and at least one other staff person who was familiar with, or who was going to provide services to the resident, for 2 of 3 sampled residents (#s 2 and 3) whose service plans were reviewed. Findings include, but are not limited to:

The most recent service plans for Residents 2 and 3 were reviewed during the survey. The records lacked documented evidence that the service plans were developed by a service planning team.

On 03/27/24 at 12:21 pm, Staff 1 (Executive Director) confirmed the residents did not have a service planning team.

The need to ensure service plans were developed by a service planning team was discussed with Staff 1, Staff 2 (LPN) and Witness 2 (RN Oversight/Elderwise) on 03/27/24. They acknowledged the findings.

1. Resident 2 & 3 Service plan meeting has been Scheduled. Service Plan Meeting Schedule in place to ensure all residents have a Service plan meeting.

2. ED, WD and RSDs will look at Service Plan Scehdule for the week and the month weekly. Significant Change of Condition will be reviewed in Clinical meeting to ensure that Service Plan team meets timly to review. Service plan team will include, Resident, Family Member (POA), Health Care Team and Medicaid Care Worker as appropriate.

3. The WD, ED and RSD will monitor this weekly looking at a month ahead and inviting others via email or phone call.

4. WD, ED and RSD

Based on interview and record review, it was determined the facility failed to carry out orders as prescribed, for 2 of 2 sampled residents (#s 2 and 3) whose orders were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 08/2023 with diagnoses including dementia and subdural hemorrhage.

The resident's 03/01/24 through 03/25/24 MAR and physician's orders dated 03/05/24 were reviewed.

Resident 2 was prescribed Haloperidol (psychotropic) 4 mg by mouth three times a day.

Review of the MAR showed the medication was not given at 12:00 pm or 5:00 pm on 03/24/24, and again not given at 7:00 am on 03/25/24. The missed doses were documented as not given due to out of stock.

The need to ensure physician orders were carried out as prescribed was discussed with Staff 1 (Executive Director), Staff 2 (LPN), and Witness 2 (RN Oversight/Elderwise) on 03/27/24. They acknowledged the findings.

2. Resident 3 was admitted to the facility in 05/2019 with diagnoses including Alzheimer's disease and chronic obstructive pulmonary disease (COPD).

The resident's 01/01/24 through 03/25/24 MARs and physician's orders were reviewed. The following was identified:

a. On 01/12/24, Resident 3 returned from the hospital with a signed order directing staff to weigh him/her once a day.

The resident's weight information was provided, but there was no documented evidence of the weight being recorded daily from 01/12/24 through 03/25/24.

On 03/26/24 at 1:42 pm, Staff 11 (MT) confirmed Resident 3 had not been weighed daily after returning from the hospital.  

On 03/27/24 at 12:21 pm, additional documentation relating to the daily weights or a physician's order to discontinue the daily weights was requested from Staff 1 (Executive Director) and Staff 2 (LPN). No additional information was provided.

b. The following medications and treatments were not administered per physician's orders:

* Coconut oil (for dryness) was not administered on 01/12/24 per staff documentation of "just showed up on MAR" and on 03/11/24 through 03/13/24 as the facility was "awaiting for delivery" from the pharmacy;

* On 01/12/24, the resident did not receive the 8:00 pm dose of Breyna inhaler (for COPD) and Atrovent inhaler (for COPD) due to the facility "awaiting delivery" from the pharmacy; and

* On 01/12/24, Resident 3 was not administered atrovastatin (for high cholesterol) and docusate sodium (for constipation) due to the medication "just showed up on MAR".  

The need to ensure physician orders were carried out as prescribed was discussed with Staff 1, Staff 2, and Witness 2 (RN Oversight/Elderwise) on 03/27/24. They acknowledged the findings.

1. Resident 2 & 3 MARS and orders where audited and updated as needed per physician orders including Parameters. All Resident MAR & physician Orders will be audited and updated as needed per review.

2. Clinical meetings to include a review of Medication Variances with RSD's or Nursing follow up as need.  Additional and ongoing training provided to med associates monthly and as needed regading Missed medications and Paramters. Triple check system is in place with Nursing oversite of all orders.

3. Clinical meeting including a review of 3rd checks to be completed at least three days a week by clinical team.  

4. WD and ED

2. Resident 3 was admitted to the facility in 05/2019 with diagnoses including Alzheimer's disease and chronic obstructive pulmonary disease.

The resident's 01/01/24 through 03/25/24 MARs were reviewed. The following was identified:

Resident 3 returned from the hospital on 01/12/24. The MAR was updated and instructed staff to "please take [oxygen] saturation and pulse twice daily. Notify the [Licensed Nurse or Physician] if [oxygen saturation percentage] is less than 88% or greater than 92%."

On 03/27/24 at 10:09 am, Staff 11 (MT) reported he would notify nursing if Resident 3's oxygen saturation levels were under 90%.

There were 127 instances when the staff should have contacted the Licensed Nurse (LN) or the physician as the resident's oxygen saturation levels were outside of the nursing parameters. There was no documented evidence staff notified the LN or physician per instruction.

Additionally, on 03/23/24 at 8:00 pm Resident 3's oxygen saturation was not completed as staff were "unable to find pulse oximeter".

On 03/27/24 at 12:21 pm, Staff 1 (Executive Director) and Staff 2 (LPN) indicated they were unaware of the nursing parameters relating to monitoring and reporting the resident's oxygen saturation levels.

The need to ensure MARs were accurate and complete was discussed with Staff 1, Staff 2, and Witness 2  (RN Oversight/Elderwise) on 03/27/24. No additional information was received.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate, complete, and included resident-specific parameters and instructions for 2 of 4 sampled residents (#s 3 and 4) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 12/2023 with diagnoses including dementia.

The resident's 03/01/24 through 03/25/24 MAR and signed physicians orders, dated 12/12/23, were reviewed and the following was noted:

a. Resident 4 was prescribed three medications to treat pain:

* Acetaminophen 325 mg every six hours as needed for pain;

* Acetaminophen 650 mg suppository every six hours as need for pain/fever; and

* Morphine 5 mg every hour as needed for pain/shortness of breath.

The PRN pain medications lacked clear parameters relating to which medication should be given first.

b. Resident 4 was prescribed two medications to treat anxiety:

* Haloperidol 0.5 mg every two hours as needed for anxiety; and

* Lorazepam 0.5 mg every two hours as needed for anxiety.

The PRN psychotropic medications lacked clear parameters for which medication should be administered first.

In an interview with Staff 11 (MT) on 03/27/24 at 10:15 am, the surveyor confirmed the electronic MAR contained no additional information. Staff 11 stated he relied upon his experience to determine which medication should be administered first.

The need to ensure MARs included resident-specific parameters for PRN medications was discussed with Staff 1 (Executive Director) and Staff 2 (LPN) on 03/27/24. The findings were acknowledged.

1. Resident 3 PRN Parameters and Notification Paremeters have been reviewed and updated to provide clear instructions.  Mar AUDIT will be completed on all residents to ensure parameters are in place. Res 4 no longer resides in facility  

2. With all 90 day Order review, nursing will ensure that PRN and notification parameters are accurate and with any new orders they will be reviewed during the 3rd check process. PRN's will be reviewed during clinical meeting.

3. Clinical meeting to include PRN review at least three times a week by clinical team.

4. WD and ED  

2. Resident 2 was admitted to the facility in 08/2023 with diagnoses including dementia and subdural hemorrhage.

Review of Resident 2's MAR, dated 03/01/24 through 03/25/24, indicated the resident was prescribed the following PRN psychotropics:

* Haloperidol Lactate 2mg/ml by mouth every two hours as needed for anxiety; and

* Lorazepam .5 mg tablet sublingually by mouth every four hours as needed for anxiety.

Review of Resident 2's MAR, dated 03/01/24 to 03/25/24 showed the Haloperidol had been given 12 times in the month of March 2024, with no documented non-pharmacy interventions listed.

In interview on 3/26/24, Staff 15 (MT) stated he had administered some of the PRN doses to Resident 2, and confirmed there were no non-pharmacy interventions to attempt before giving the psychotropic medication.

The need to ensure PRN medications given to treat a resident's behaviors had written non-pharmacological interventions which had been tried with ineffective results documented prior to administration was discussed with Staff 1 (Executive Director) and Staff 2 (LPN) on 03/27/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure PRN medications used to treat residents' behaviors had non-pharmacological interventions that had been tried with ineffective results prior to administering PRN psychotropic medications for 2 of 2 sampled resident (#s 2 and 4) who were prescribed a PRN psychotropic. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 12/2023 with diagnoses including dementia.

Review of Resident 4's MAR, dated 03/01/24 through 03/25/24, indicated the resident was prescribed the following PRN psychotropics:

* Haloperidol 0.5 mg by mouth every two hours as needed for anxiety/agitation/nausea; and

* Lorazepam 0.5 mg by mouth every two hours as needed for anxiety/agitation.

In an interview with Staff 11 (MT) on 03/26/24 at 10:20 am it was confirmed there was no documented evidence non-pharmacological interventions were tried and found to be ineffective prior to administration of PRN haloperidol on 03/21/24.

The need to ensure PRN medications given to treat a resident's behaviors had written non-pharmacological interventions which had been tried with ineffective results prior to administration was discussed with Staff 1 (Executive Director) and Staff 2 (LPN) on 03/27/24. They acknowledged the findings.

1. Resident 2 MARs are updated to include clear insturctions. Including non pharmacological intervention and direction on what of the same class of medication to be used 1st, 2nd and ect. All other residents MARS will  be audited and updated by nurses to ensure parameters are in place. Resident 4 no longer resides in facility

2. All new orders for PRN psycotropic medication will be reviewed by nursing. Nursing will also ensure  that needed parameters are in place for all PRN medications and treatments.

3. Druing clinical meeting at least three times weekly

4. WD and ED

2. Resident 1 was admitted to the facility in 03/2024 with diagnoses including dementia and neck fracture.

During an observation on 03/25/24, Resident 1's hospital bed was observed to have a quarter-length siderail on both sides of the bed. Both siderails were in the up position and securely fastened to the bed.

Review of Resident 1's service plan dated, 03/08/24, revealed there was no documentation of the use of supportive devices with restraining qualities included in the service plan.

On 03/26/24 at 2:00 pm, the siderail assessment documentation was requested from Staff 4 (Resident Services Director). Siderail assessment documentation was provided on 03/26/24 by Witness 3 (RN Consultant Elderwise) who stated it had been completed that morning.  

The need to ensure supportive devices with potentially restraining qualities were assessed prior to use and documentation of supportive devices with restraining qualities was included in the resident service plan was discussed with Staff 1 (Executive Director) and Staff 2 (LPN) on 03/27/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure a thorough RN, PT, or OT assessment was completed prior to the use of a supportive device with restraining qualities, document other less restrictive alternatives were evaluated prior to the use of the device, instruct caregivers on the correct use and precautions related to the use of the device, include the use of the supportive device in the service plan, and evaluated on a quarterly basis for 2 of 2 sampled residents (#s 1 and 4) who used a supportive device with restraining qualities. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 12/2023 with diagnoses including dementia.

On 03/26/24, a hospital bed was observed to have bi-lateral, quarter-length siderails in the resident's unit. The siderail on the left side of the bed was in the down position and securely fastened to the bed.

Review of Resident 4's service plan dated, 03/19/24, revealed there was no documentation of the use of supportive devices with restraining qualities included in the resident service plan.

On 03/26/24 at 11:20 am siderail assessment documentation was requested from Staff 4 (Resident Services Director). Siderail assessment documentation was provided on 03/26/24 at 12:20 pm by Witness 3 (RN Consultant/Elderwise) who stated it had been completed that morning.  

The need to ensure supportive devices with potentially restraining qualities were assessed prior to use and documentation of their use was included in the resident service plan was discussed with Staff 1 (Executive Director) and Staff 2 (LPN) on 03/27/24. They acknowledged the findings.

1. Resident 1 Supportive Device assesment completed by RN. Resident 4 no longer resides in facility. RSD's Audited the building for supportive devices, List given to nurse to evaluate each one to determine if it is the least restrictive option to meet residents needs. Once need is determined the nurse will do an assesment and obtain consent for devices used.

2. With every quarterly service plan update Supportive Device review will be completed. Staff will be trained on what to do if a supportive device is brought into the community and what a supportive devices is.

3. Quarterly and as needed by WD or designee.

4. WD, RSD's and ED

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired direct care staff (#s 12, 13 and 14) had documented evidence of training in First Aid and abdominal thrust within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed on 03/27/24.

Staff 12 (MT) and Staff 9 (CG), hired on 12/27/23, lacked documented evidence for completion of abdominal thrust training within 30 days of hire.

Staff 13 (CG) and Staff 14 (CG), hired on 01/25/24, and 01/30/24,  respectfully, lacked documented evidence of being trained in First Aid and abdominal thrust within 30 days of hire.        

The need to ensure staff completed the required training within 30 days was reviewed with Staff 1 (Executive Director) and Staff 6 (Business Office Manager) on 03/27/24. They acknowledged the findings.

1. Staff 9, 12, 13 and 14's Records have been audited and staff have been assigned the missing training identified on survey. All other Employee records will be audited for any missing training componinets and staff member will be notified and will complete training.

2. Check list for new hires will be utilized and completed prior to new hires being on the floor.

3. Monthly By the BOM

4. BOM, WD and ED

Based on interview and record review, it was determined the facility failed to provide life safety instruction to staff on alternating months and include required components on fire drill records. Findings include, but are not limited to:

Fire and life safety records dated from 09/2023 through 03/2024, were reviewed on 03/25/24 and revealed the following:

* Fire and life safety instruction was not provided to staff on alternating months; and

* Fire drills lacked the following components:

- Number of occupants evacuated; and

- Problems encountered and comments relating to residents who resisted or failed to participate in the drills.

In an interview on 03/27/24, Staff 5 (Plant Operations Director) and Staff 1 (Executive Director) acknowledged the facility failed to provide life safety instruction to staff on alternating months and fire drill records lacked the required components.

1. Evacuation Fire drill was completed on 4/10/2024. Alternate month education for fire life safety has been schdeuled.  

2. Evacuation Fire drills will be schedule twice a year. Fire and Life safety training will be scheduled in Relias for every other month.

3. ED, BOM and POD once a month

4. POD and ED

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 372 and C 420.

Refer to C372 and C420

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 12, 13 and 14) completed all required pre-service dementia training topics prior to beginning job duties and 2 of 3 new staff (#s 13 and 14) demonstrated competency in all job duties within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed on 03/27/24.

a. There was no documented evidence Staff 12 (MT), Staff 13 (CG), Staff 14 (CG), hired 12/27/23, 01/25/24, and 01/30/24, respectively, completed all dementia care training topics prior to providing resident care and services independently:

* Dementia disease process including progression the disease, memory loss and psychiatric and behavioral symptoms;

* Techniques for understanding, communicating, and responding to distressful behavioral symptoms;

* Strategies for addressing social needs and engaging persons with dementia in meaningful activities;

* Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food/fluids, preventing wandering, use of person-centered approach;

* Environmental factors which are important to a resident's well-being (e.g., staff interactions, lighting, room temperature, noise, etc.);

* Family support and the role the family may have in the care of the resident; and

* How to recognize behaviors which indicate a change in the resident's condition and report behaviors which required on-going assessment.

b. There was no documented evidence Staff 13, or Staff 14 demonstrated competency in one or more assigned duties within 30 days of hire:

* Role of service plans in providing individualized care;

* Identification, documentation, and reporting changes of condition;

* Conditions which require assessment, treatment, observation, and reporting; and

* General food safety, serving, and sanitation.

The need to ensure all staff training was completed in the required time frames was discussed with Staff 1 (Executive Director) and Staff 6 (Business Office Manager) on 03/27/24. They acknowledged the findings.

1. Staff 12, 13 and 14 have all required pre service education and competency assigned.

2. Check list for new hires will be utilized and completed prior to new hires being on the floor.

3. Monthly By the BOM

4. BOM, WD and ED

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 303, C 310, C 330 and C 340.

Refer to C260, C303, C310, C330 and C340

Based on observation, interview, and record review, it was determined the facility failed to ensure an individualized nutritional plan for each resident was developed and included in resident's service plan for 1 of 4 sampled residents (# 3). Findings include, but are not limited to:

Resident 3 moved into the facility in 05/2019 with diagnoses including Alzheimer's disease.

The resident's service plan, updated 03/15/24, and interim service plans were reviewed. Interviews with care staff were conducted and observations of the resident were made.

Lunch meals were observed during the survey and staff provided meal assistance to Resident 3. The resident was not able to state his/her specific food or beverage preferences during the observations.

During an interview on 03/27/24 at 9:52 am, Staff 10 (CG) confirmed some of Resident 3's favorite food and beverages. The service plan was not reflective of the resident's preferences.  

Although the service plan provided some information regarding food preferences, it lacked information and staff instruction related to individualized nutrition and hydration status and needs.

The need to develop individualized nutritional plans addressing residents' nutrition and hydration preferences and needs was discussed with Staff 1 (Executive Director), Staff 2 (LPN), and Witness 2 (RN Oversight/Elderwise) on 03/27/24. They acknowledged the findings.

1. Resident 3 service nutition and hydration plan is upto date. All Residents Nutrition and Hydration plans have been updated.

2. Service plans will be updated quarterly and with Significant Change of Condition to review and update needs to maximize nutritional intake and resident preferences.

3. Quarterly and with Significant Change of Condition. WD and ED

4. WD and ED

Based on observation, interview, and record review, it was determined the facility failed to develop individualized activity plans for 4 of 4 sampled residents (#s 1, 2, 3, and 4) whose activity plans were reviewed. Findings include, but are not limited to:

Service plans and evaluations were reviewed for Residents 1, 2, 3, and 4.

There was no documented evidence individualized activity plans were developed based on the residents' activity evaluations that reflected each residents' activity preferences and needs.  

During interview on 03/26/24 at 2:00 pm, Staff 16 (Life Enrichment Director) confirmed individualized activity evaluations and individualized plans based on the the evaluation had not yet been developed for each resident.

The need to ensure the facility evaluated each resident and developed individualized activity plans was discussed with Staff 1 (Executive Director), Staff 2 (LPN), and Witness 2 (RN Oversight/Elderwise) on 03/27/24. They acknowledged the findings.

1. Resident 1, 2, and 3 chart has been audited on 4/2/2024 to locate deficiencies. Utilizing forms that state provided to collect information so Service Plan can be updated. Resident 4 no longer resides in facility.

2. Form updated with information from the state. This form will be given to move ins prior to move in so that we gather the information for the Service Plan. This will be updated 30 days after admission quarterly and with any significant change of condition.

3. LED, WD and ED