The findings of the relicensure survey conducted 10/18/21 through 10/20/21 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, 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
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 first re-visit to the re-licensure survey of 10/21/21, conducted 01/19/22 through 01/20/22, 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 second re-visit to the re-licensure survey of 10/21/21, conducted on 03/14/22, 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 3rd revisit to the re-licensure survey of 10/20/21, conducted 05/09/22 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, OARs 411 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 ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (# 3) and failed to complete quarterly evaluations for 1 of 1 sampled resident (# 4), whose records were reviewed. Findings include, but are not limited to:
1. Resident 3 was admitted to the facility in 07/2021.
Resident 3's move-in evaluation failed to address the following required elements:
* Mental health issues, including history of treatment and effective non-drug interventions;
* Personality, including how the person copes with change or challenging situations;
* Activities of daily living, to include personal hygiene and ambulation;
* Nutrition habits, fluid preferences and weight if indicated; and
* Environment factors that impact the resident's behavior including, but not limited to lighting, room temperature.
The facilities failure to complete all required elements for Resident 3's new move -in evaluation was discussed with Staff 1 (Administrator), Staff 2 (MT/Life Enrichment Director) and Staff 4 (Regional Director of Operations) on 10/20/21. They acknowledged the findings.
2. Resident 4 was admitted to the facility in 04/2020.
The evaluation available to the staff and survey team during the survey was last reviewed and updated on 04/20/21.
On 10/20/21, the need to ensure that the facility performed evaluations at least quarterly, to correspond with the quarterly service plan updates was discussed with Staff 1 (Administrator), Staff 2 (MT/Life Enrichment Director) and Staff 4 (Regional Director of Operations). They acknowledged the findings.
Service Plan Team will Review service plan for Res #3, #4 and ensure all elements are addressed according to
OAR 411-054-0034.
Going forward service plans will be audited on initial move in, at 30 days, quarterly, and change of condition for required elements according to OAR 411-054-0034
Service plans will be audited on an ongoing basis to ensure accuracy.
RCC or Executive Director will be responsible for monitoring corrections.
Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (# 7) whose move-in evaluation was reviewed. This is a repeat citation. Findings include, but are not limited to:
Resident 7 was admitted to the facility in 12/2021.
Resident 7's move-in evaluation failed to address the following required elements:
* Spiritual and cultural preferences;
* Customary routines, hobbies, social and leisure activities;
* Personality, including how the person copes with change or challenging situations;
* Cognition, including memory and confusion;
* Activities of daily living, to include personal hygiene and ambulation;
* Nutrition habits, fluid preferences and weight if indicated; and
* Environment factors that impact the resident's behavior including, but not limited to lighting, room temperature.
The need to ensure new move-in evaluations addressed all required elements was discussed with Staff 3 (Regional Director of Operations) and Staff 17 (RCC) on 1/20/22. They acknowledged the findings.
Service Plan Team will Review service plan for Res #7 and ensure all elements are addressed according to
OAR 411-054-0034. Executive Director, Registered Nurse and Director of Sales were in-serviced on movin in process to include regulatory requirements, move in paper work, move in process and move in policies and procedures.
Service plans will be audited on initial move in, at 30 days, quarterly, and change of condition for required elements according to OAR 411-054-0034.
The Resident Care Coordinator or designee will perform a move-in audit utilizing the Resident Move-In Marketing and Clinical Checklist within 24 hours of move-in, 48 hours' post-move in and at 30 days.
2. The Resident Move-In Marketing and Clinical Checklist will be brought to stand-up and status communicated, to ensure all items are completed by those responsible for tasks.
Service plans will be audited on a regular and ongoing basis to ensure accuracy.
RCC, Nurse, or Executive Director will be responsible for monitoring corrections.
There are no detail notes for this visit.
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 to staff regarding the delivery of services, for 2 of 4 sampled residents (#s 1 and 3), whose service plans were reviewed. Findings include, but are not limited to:
1. Resident 1 was admitted to the facility in 02/2019 with diagnoses including dementia.
Observations of Resident 1, his/her apartment and interviews with staff were conducted throughout the survey. The resident's 10/12/21 service plan and 07/22/21 through 10/18/21 facility Progress notes were reviewed.
The resident's current service plan was not reflective and did not include clear instruction for staff in the following areas:
* The resident no longer used a transfer pole;
* A two-person transfer;
* The use of bilateral side rails;
* Four-wheel walker was no longer used; and
* The diet changed from regular to mechanical soft.
The need to ensure service plans were reflective of the resident's current health status and provided clear instruction to staff was discussed with Staff 1 (Administrator), Staff 2 (MT/Life Enrichment Director), and Staff 3 (Regional Director of Operations) on 10/20/21. They acknowledged the findings.
2. Resident 3 was admitted to the facility in 07/2021 with diagnoses of dementia, anxiety, hallucinations and was identified as an elopement risk.
Observations of Resident 3 during the survey, interviews with staff and review of the service plan, progress notes and general records revealed the service plan was not reflective in the following areas:
* How often safety checks were to be performed for elopement risk;
* Hallucinations and anxiety lacked description of behaviors and interventions/instructions for staff;
* Fall history and interventions;
* Finger nail and foot care instructions; and
* Dietary preferences.
The need to ensure service plans were reflective and provided clear instructions to staff was discussed with Staff 1 (Administrator), Staff 2 (MT/Life Enrichment Director) and Staff 4 (Regional Director of Operations) on 10/20/21. They acknowledged the findings.
Service plans will be reviewed for residents 1 and 3 to ensure all elements are addressed according to
OAR 411-054-0036
Going forward service plans will be audited on initial move in, at 30 days, quarterly, and change of condition for required elements according to OAR 411-054-0034
Service plans will be audited on an ongoing basis to ensure accuracy.
RCC or Executive Director will be responsible for monitoring corrections.
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 documentation a Service Planning Team reviewed and participated in the development of the service plans.
The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (Administrator), Staff 2 (MT/Life Enrichment Director) and Staff 4 (Regional Director of Operations) on 10/20/21. They acknowledged the findings.
For residents 1, 2, 3, 4 Serivce Plan Team will review the service plan for accuracy and add any additional input that is pertinant to residents care.
Care Conferences will be scheduled regularly with the Service Plan Team
Service plans will be audited on an ongoing basis to ensure accuracy.
RCC or Executive Director will be responsible for monitoring corrections.
Based on interview and record review, it was determined the facility failed to ensure short-term changes of condition were evaluated and monitored to resolution, and failed to determine and document actions or interventions and communicate those to staff for 1 of 4 sampled residents (# 3) who experienced changes of condition. Findings include, but are not limited to:
Resident 3 was admitted to the facility in 07/2021 with a diagnoses of dementia, anxiety and hallucinations. Resident 3's record was reviewed during the survey and the following was revealed:
* 08/03/21 Resident 3 reported fear, thinking another resident was going to hurt him/her; and
* 09/13/21 Resident 3 had a fall resulting in an eye contusion and left hip and arm pain.
There was no documented evidence the facility evaluated, put interventions in place and/or monitored the above changes of condition to resolution.
The need to ensure short-term changes of condition were evaluated, interventions developed and changes of condition were monitored through resolution was discussed with Staff 1 (Administrator), Staff 2 (MT/Life Enrichment Director) and Staff 4 (Regional Director of Operations) on 10/20/21. They acknowledged the findings.
Service plans will be updated to reflect any Change of Condition for resident number 3.
Will follow company policy related to Change of Condition.
Change of Condition will be audited during monthly CQI meetings.
RCC or Executive Director will be responsible for monitoring corrections.
Based on interview and record review, it was determined the facility failed to ensure the RN performed an assessment, developed interventions based on the condition of the resident, and updated the service plan for 1 of 1 sampled resident (# 1) who experienced a significant change of condition. Findings include, but are not limited to:
Resident 1 was admitted to the facility in 02/2019 with diagnoses including dementia.
During interviews on 10/18/21 with Staff 2 (MT/Life Enrichment Director) and Staff 15 (MT), Resident 1 was identified to have had a decline resulting in a hospitalization and subsequent admission to hospice care.
In interviews on 10/19/21 with Staff 13 (MT) and Staff 15, the resident was identified to have gone from a one-person transfer using a transfer pole to a two-person Hoyer lift transfer and from ambulating with a walker to using a wheelchair. The resident also declined in ability to eat a regular texture diet to needing a mechanical soft diet and was now receiving hospice services.
Progress notes dated 07/22/21 through 10/18/21, and interviews with care staff on 10/18/21 through 10/20/21 showed the resident had an overall decline as follows:
* On 8/19/21 a progress note identified the resident went from being a one-person transfer to a two-person transfer using a Hoyer lift.
* A progress note dated 8/20/21 identified the resident had been sent out to the hospital related to "signs of nausea and vomiting" and "uncontrollable shaking."
* Staff 15 (MT) wrote a progress note on 08/22/21 that the resident may be returning to the facility on hospice services and another note on 08/24/21 noted the resident had been hospitalized for sepsis.
* On 8/27/21 a progress note and ISP (Interim Service Plan) identified the resident had returned to the facility with a catheter, new pain medication, discontinuation of some of his/her medications, fluid enhancement and staff were to do frequent checks.
* Further progress notes included staff monitoring of the resident for the return from the hospital and additional medication changes.
On 8/7/21 Staff 16 (RN) wrote a brief progress note which indicated the resident had returned to the facility, but was unable to start on hospice services until 08/03/21. There was no assessment of Resident 1's change of condition, interventions determined and no updated to the service plan.
The facility failed to ensure an RN assessment was completed related to the resident's decline and the hospice admission which documented findings, resident status and interventions made as a result of the assessment.
The need to ensure an RN assessment was completed for significant changes in condition which documented findings, resident status and interventions made as a result of the assessment was discussed with Staff 1 (Administrator), Staff 2 and Staff 3 (Regional Director of Operations) on 10/20/21. They acknowledged the findings.
Ensure the LN/RN reviews and updates service plan for resident #1 change of condition.
Going forward will follow company policy as well as OAR 411-054-0045 (1)(a-f)(A)(C-F)
Will be audited in monthly CQI meeting.
Executive Director/RCC will be responsible for monitoring.
3. Resident 2 was admitted to the facility in 06/2020 with diagnoses including Alzheimer's disease.
Resident 2's signed physician orders and 10/01/21 through 10/18/21 MAR were reviewed. The following was identified:
The resident had been receiving Mirtazapine (antidepressant) 15 mg one time daily. Review of the resident record revealed there was no signed order. At the request of the surveyor, the facility obtained a copy of the order on 10/20/21 to put in the record.
On 10/20/21, the need to ensure singed physician orders were in the resident record was discussed with Staff 1 (Administrator), Staff 2 (MT/Life Enrichment Director) and Staff 3 (Regional Director of Operations). They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure signed physician's orders were in place for all medications administered to the residents for 3 of 4 sampled residents (#s 2, 3 and 4) whose MARs were reviewed. Findings include, but are not limited to:
1. Resident 3 was admitted to the facility in 07/2021 with diagnoses including dementia, hypertension and angina (chest pain). The resident's 10/01/21 through 10/18/21 MARs and physician's orders were reviewed.
The following medications had no documented evidence of a physician's order in the resident's medical chart:
* Amlodipine (for hypertension);
* Calcium Carbonate Antacid (supplement);
* Centrum Silver Multivitamin-Minerals;
* Cholecalciferol (supplement);
* Culturelle (for digestive health);
* Isosorbide Mononitrate ER (for angina);
* Losartan Potassium ( for hypertension);
* Pravastatin (for chloresterol);
* Famitodine (antacid);
* Metoprolol Tartrate (for hypertension);
* Potassium Chloride (for low potassium);
* Ranolazine ER (for chronic angina);
* Albuterol inhaler PRN (for congestive obstructive pulmonary disease);
* Nitroglycerin PRN (for angina); and
* Zofran PRN (for nausea/vomiting).
At the request of the surveyor, the facility obtained a copy of the order on 10/19/21 to put in the record.
The need to ensure signed physician's orders were in place for all medications administered was discussed with Staff 1 (Administrator), Staff 2 (MT/Life Enrichment Director) and Staff 4 (Regional Director of Operations) on 10/20/21. They acknowledged the findings.
2. Resident 4 was admitted to the facility 04/2020 with diagnoses including dementia and diabetes and received insulin injections daily. The resident's 10/01/21 through 10/18/21 MARs and physician's orders were reviewed.
The following medications had no documented evidence of a physician's order in the resident's medical chart:
* Discontinuation of Novolog Insulin, ordered to be administered in the pm daily; and
* Insulin Aspart sliding scale, administered before dinner daily based on the resident's blood glucose levels.
The need to ensure signed physician's orders were in place for all medications administered was discussed with Staff 1 (Administrator), Staff 2 (MT/Life Enrichment Director) and Staff 4 (Regional Director of Operations) on 10/20/21. They acknowledged the findings.
The facility obtained a copy of the order on 10/19/21 and put into resident #3 record. Facility obtained a copy of the order on 10/20/21 and put into resident #2 record. Will obtain orders for resident #4.
Will follow company policy regarding order processing.
Weekly MAR audits will be done.
RN and Executive Director
2. Resident 1 was admitted to the facility in 02/2019 with diagnoses including dementia.
Resident 1's signed physician orders and 10/01/21 through 10/18/21 MAR were reviewed. The following deficiency was identified:
Resident 1 had a physician's order for Lorazepam (sedative) 0.5 mg every two hours and needed for anxiety.
There was no information for staff how the resident exhibited signs and symptoms of anxiety, or what non-pharmacological interventions were to be attempted prior to administering the psychotropic medication.
The need to attempt non-drug interventions prior to administering PRN psychotropic medications was reviewed with Staff 1 (Administrator), Staff 2 (MT/Life Enrichment Director) and Staff 3 (Regional Director of Operations). They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure PRN psychotropic medications used to treat a resident's behaviors and anxiety had written, resident-specific parameters and non-drug interventions for staff to attempt prior to administering the medication for 2 of 2 sampled residents (#s 1 and 3) who were prescribed PRN medication to address behaviors. Findings include, but are not limited to:
1. Resident 3 was admitted to the facility in 07/2021 with diagnoses including dementia, hallucinations and anxiety.
Review of the resident's 10/01/21 through 10/18/21 MAR and 09/01/21 physician order showed the following psychotropic medication:
* Quetiapine 25 mg (a psychotropic medication) one tablet a day as needed for agitation.
The facility administered the Quetiapine on three occasions between 10/01/21 and 10/18/21.
The MAR stated the medication was for "behaviors" and did not contain resident specific parameters for staff describing what behaviors or how the resident expressed the behaviors. Additionally, there was no documentation of what non-drug interventions were attempted prior to administration of the medications.
The need to ensure there were resident-specific descriptions of the behaviors for administration of a PRN psychotropic medication, how the resident expressed the behavior and that non-drug interventions were attempted and documented prior to administration of the medication was discussed with Staff 1 (Administrator), Staff 2 (MT/Life Enrichment Director) and Staff 4 (Regional Director of Operations) on 10/20/2021. The staff acknowledged the findings.
For residents 1 and 3 MAR will be updated to be compliant with OAR 411-054-0055
In Service training on use of non pharmacological interventions for psychoactive meds and effectiveness of PRN use.
Facility to do weekly MAR audits
RCC/Executive Director
Based on observation, interview and record review, it was determined the facility failed to ensure an assessment by a PT, OT or RN was completed for assistive devices with potentially restraining qualities for 1 of 1 sampled resident (# 1) reviewed who had a supportive device. Findings include, but are not limited to:
Resident 1 was admitted to the facility in 02/2019 with diagnoses including dementia.
During the entrance conference on 10/18/21, Resident 1 was identified as having bilateral side rails on his/her bed. Observations of the resident and the residents room showed the side rails were on the bed.
Review of Resident 1's record revealed there was no documented evidence an assessment of the side rails had been completed by an RN, PT or OT nor were the devices with restraining qualities included on the resident's service plan.
The lack of assessment and service planning for devices with restraining qualities was discussed with Staff 1 (Administrator), Staff 2 (MT/Life Enrichment Director) and Staff 3 (Regional Director of Operations) on 10/20/21. They acknowledged the findings.
Supportive device assessments to be done, documentation of the use of supportive device to be updated in the Service Plan of resident #1.
Will follow company policies regarding supportive devices w/ restraining qualities to be audited weekly
Through review at our monthly CQI meetings and quarterly assessments.
RN and Executive Director.
Based on observation, interview and record review, it was determined the facility failed to ensure an assessment by a PT, OT or RN was completed for assistive devices with potentially restraining qualities for 1 of 1 sampled resident (# 5) who had a supportive device. This is a repeat citation. Findings include, but are not limited to:
Resident 5 was admitted to the facility in 11/2014 with diagnoses including dementia.
During the entrance conference on 01/19/22, Resident 5 was identified as having bilateral siderails on his/her bed.
Observations of the resident and the resident's room showed the siderails were on the bed.
Review of Resident 5's record revealed there was no documented evidence an assessment of the siderails had been completed by an RN, PT or OT.
In an interview on 01/19/22 at 12:30 pm, Staff 16 (RN) stated no assessment had been completed for Resident 5's siderails.
The lack of an assessment for the resident's siderails was discussed with Staff 3 (Regional Director of Operations) and Staff 17 (RCC) on 01/20/22. They acknowledged the findings.
Supportive Device Assessments to will be done on move in and quarterly by RN, PT, or OT. Supportive device assessment was completed for resident #5.
Will follow company policy regarding supportive devices. Resident rooms will be inspected on an ongoing and regular basis to ensure all supportive devices have been identified and assessed.
Through review at our monthly CQI meetings and quarterly assessments.
RN and Executive Director.
There are no detail notes for this visit.
Based on observation, interview and record review, it was determined the facility failed to ensure its relicensure survey plan of correction was implemented and satisfied the Division. Findings include, but are not limited to:
Refer to C 252, C 340, Z 155 and Z 162.
Resurvey plan of correction will be monitored on an ongoing and regular and ongoing basis to ensure community is following plan of correction and is compliance for revisit.
Executive Director, RCC and Nurse will meet routinely to review plan of correction and ensure compliance.
Weekly review of plan of correction
Executive Director, RCC and Nurse will be responsible .
Based on observation, interview and record review, it was determined the facility failed to ensure its relicensure survey plan of correction was implemented and satisfied the Division. Findings include, but are not limited to:
Refer to Z 155.
Resurvey plan of correction will be monitored on a daily basis as well as monthly to ensure continuous compliance with the plan of correction for revisit.
Executive Director, RCC and Nurse will meet daily to review compliance status until complete
Daily review of plan of correction
ED, RCC and Nurse will be responsible for reviewing this plan of correction
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure 1 of 2 newly hired staff (# 8) completed pre-service training prior to independently providing personal care for residents. Findings include, but are not limited to:
Review of the facility's training records on 10/20/21 revealed the following:
The facility lacked documented evidence Staff 8 (CG), hired 06/29/21 completed all required pre-service training topics including:
* 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 that are important to a resident's well-being; and
* Family support and the role the family may have in the care of the resident.
The need to ensure newly hired staff completed pre-service training with all required elements was discussed with Staff 1 (Administrator), Staff 2 (MT/Life Enrichment Director) and Staff 3 (Regional Director of Operations) on 10/20/21. They acknowledged the findings.
A complete audit has been done concerning training and competency records. Trainings will be complete, and up to date for current employees no later than 12/19/21.
To prevent recurrance care staff will be required to complete the required pre-service training prior to working on the floor. Incomplete trainings will be reviewed five days a week as part of daily standup meeting to identify missing training components and to review the status of new hires and where they are at with their trainings and competencies to ensure that training is completed within 30 days of hire. Monthly in-service form has been updated to include documentation of topics covered at during in-service as well as the length of the training.
This system will be evaluated monthly as part of the facility CQI program and will include a review of the current staff members and the status of their required trainings.
The ED and Business Office Manager will be responsible for maintaining this sytem.
Based on interview and record review, it was determined the facility failed to ensure 2 of 2 newly hired staff (#s 18 and 19) completed pre-service training prior to independently providing personal care to residents. This is a repeat citation. Findings include, but are not limited to:
On 01/19/22, training records were reviewed with Staff 4 (Business Office Manager).
The facility lacked documented evidence Staff 18 (CG), hired 11/14/21 and Staff 19 (CG, hired 09/22/21, completed all required six hours of pre-service dementia care training topics including:
* Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms;
* Techniques for understanding, communicating and responding to distressful behavioral symptoms; including but not limited to, reducing the use of antipsychotic medications for non-standard uses when responding to distressful behavioral symptoms;
* Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities;
* Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: identify and address pain; provide food and fluid; prevent wandering and elopement; and use a person-centered approach;
* Environmental factors that are important to resident's well-being (e.g. noise, staff interactions, lighting, room temperature, etc.);
* Family support and the role the family may have in the care of the resident;
* How to recognize behaviors that indicate a change in the resident's condition and report behaviors that require on-going assessment;
* How to provide personal care to a resident with dementia, including an orientation to the resident and the resident's service plan; and
* The use of supportive devices with restraining qualities in memory care communities.
The need to ensure newly hired staff completed pre-service training with all required elements was discussed with Staff 3 (Regional Director of Operations), Staff 4 (Business Office Manager and Staff 17 (RCC) on 01/20/22. They acknowledged the findings.
Trainings will be complete, and up to date for current employees no later than 3/6/22.
To prevent recurrance care staff will be required to complete the required pre-service training prior to working on the floor. Incomplete trainings will be reviewed five days a week as part of daily standup meeting to identify missing training components and to review the status of new hires and where they are at with their trainings and competencies to ensure that training is completed within 30 days of hire. Monthly in-service form has been updated to include documentation of topics covered at during in-service as well as the length of the training.
This system will be evaluated monthly as part of the facility CQI program and will include a review of the current staff members and the status of their required trainings.
The ED and Business Office Manager will be responsible for maintaining this sytem.
Based on interview and record review, it was determined the facility failed to ensure 1 of 1 newly hired staff (#23) completed pre-service training prior to independently providing personal care to residents. This is a repeat citation. Findings include, but are not limited to:
On 03/14/22, training records were reviewed with Staff 4 (Business Office Manager).
The facility lacked documented evidence Staff 23 (Med Tech) hired on 01/20/22 completed all required six hours of pre-service dementia care training topics including:
* Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms;
* Techniques for understanding, communicating and responding to distressful behavioral symptoms; including but not limited to, reducing the use of antipsychotic medications for non-standard uses when responding to distressful behavioral symptoms;
* Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities;
* Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: identify and address pain; provide food and fluid; prevent wandering and elopement; and use a person-centered approach;
* Environmental factors that are important to resident's well-being (e.g. noise, staff interactions, lighting, room temperature, etc.);
* Family support and the role the family may have in the care of the resident;
* How to recognize behaviors that indicate a change in the resident's condition and report behaviors that require on-going assessment;
* How to provide personal care to a resident with dementia, including an orientation to the resident and the resident's service plan; and
* The use of supportive devices with restraining qualities in memory care communities.
The need to ensure newly hired staff completed pre-service training with all required elements and the training was documented and available for review was discussed with Staff 22 (Executive Director) Staff 3 (Regional Director of Operations), Staff 4 (Business Office Manager) and Staff 17 (RCC) on 03/14/22. They acknowledged the findings.
Trainings will be complete and up to date for current employees no later than 04/13/22.
Care staff will be required to complete pre-service training during onboarding paperwork to ensure this is completed prior to working the floor. Status of new employees needing to complete 30 days of hire training will be reviewed daily during stand up meetings and identified to ensure completion of trainings and competencies.
This system will be evaluated daily as well as monthly as part of the CQI program to ensure all employees are up to date with all required trainings.
The ED and Business Office Manager will be responsible for monitoring this system.
There are no detail notes for this visit.
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, C 260, C 262, C270, C 280, C 303, C 330 and C 340.
See POC for C252, C260, C262, C270, C280, C303,
C330, and C340.
Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:
Refer to C 252 and C 340.
See POC for C252 and C340.
Based on observation, 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 1 of 1 sampled resident (#3) with documented behaviors. Findings include, but are not limited to:
Resident 3 was admitted to the facility in 07/2021, with diagnoses including dementia, anxiety and hallucinations.
Resident 3's record documented behaviors including:
* Exit seeking and elopement attempt on 08/06/21; and
* Was administered as needed Quetiapine for "behaviors" on three occasions between 10/01/21 and 10/18/21.
During an interview with Staff 11 (CG) on 10/19/21, she reported Resident 3 experienced hallucinations of seeing a family member with no extremities and seeing snakes on the floor. Staff 11 stated the resident experienced anxiety manifested by pacing, crying, rummaging through belongings, packing and anxiously standing at his/her door.
The resident's current service plan did not address these behaviors and lacked individualized interventions to assist staff in minimizing the negative impact of these behaviors.
The need to include an individualized behavior plan for residents with behavioral symptoms was discussed with Staff 1 (Administrator), Staff 2 (MT/Life Enrichment Director) and Staff 4 (Regional Director of Operations) on 10/20/21. They acknowledged the findings.
Resident #3's evaluation and service plan has been updated to include the required components and to accurately reflect the resident's current status, needs and preferences. Staff will be re-educated at All Staff Meeting regarding the importance of reporting any questions or concerns related to resident service plans. Current resident service plans were printed and will be reviewed by multiple direct care staff, Resident Care Coordinator and Executive Director and updates will be made as needed. A form was implemented for care staff to document any discrepancies between resident's service plan and actual care needs. Form is to be turned into Resident Care Coordinator immediately so that service plan can be updated.
To prevent recurrence, service plan correction form will continue to be utilized. ISPs (Interim service plan progress notes) will be reviewed daily as part of the 24hr/72hr summary review and service plans will be updated as needed.
Evaluations and service plans will be reviewed by each department upon admission, at 30 days, quarterly and with significant change of condition.
The Executive Director and Resident Care Coordinator will be responsible for maintaining this system.