The findings of the re-licensure survey conducted 02/13/23 through 02/15/23 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first revisit to the re-licensure survey of 02/15/23, conducted 05/16/23, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Based on observation, interview and record review, it was determined the facility failed to ensure resident specific interventions were developed, communicated to staff on each shift and reviewed for effectiveness for 1 of 2 sampled residents (# 1) whose records were reviewed. Resident 1 continued to experienced injury and non-injury falls. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 2018 with diagnoses including Parkinson's disease and a history of falling.

The resident's most recent service plan included the following fall interventions:

* Care staff to remind the resident to use assistive adaptive devices;

* Care staff to remind resident to use call pendant;

* Care staff to keep apartment free of clutter and debris which could cause resident to fall;

* Report to Med Tech any noticeable changes in the resident's unsteadiness, dizziness or resident's increased risk of falling; and

* Caregivers: full vitals once a shift until removed from alert.

A review of the resident's 11/23/22 evaluation, 03/06/22 service plan, service plan updates, post-fall evaluations and 11/20/23 through 02/13/23 progress notes indicated the resident had fallen five times between 11/22/22 and 01/20/23. The following incidents were documented:

* 11/20/22 - "resident lost [his/her] balance getting up out of [his/her] desk chair and [s/he] fell and cut [his/her] R forearm in five places";

* 11/21/22 - "resident was found to have three broken ribs: right 10th, 11th and 12th ribs";

* 12/06/22 - "resident slipped off [his/her] bed onto the floor";

* 12/20/22 - "resident has two new skin tears sustained from a fall";

* 01/04/23 - "resident seen this morning post unwitnessed fall with head [laceration] ...1.5 cm Y shaped laceration noted above R orbital crest"; and

* 01/20/23 - "resident was found on the floor on [his/her] bottom between wheelchair and bed ...when assessing for post fall injuries, there was a 0.25 inch X 0.25 inch skin tear on bottom right forearm."

Review of service plan updates and post-fall evaluations revealed the following:

After falls on 11/20/22, 12/05/22 and 12/19/22, the facility again implemented the interventions listed above in service plan updates. There was no evidence the facility reviewed the interventions for effectiveness prior to re-implementation.

After falls on 01/04/23 and 01/20/23, the facility developed the following resident specific interventions:

* "Discussed rearranging [apartment] to make less obstacles for [him/her] to ambulate around [his/her] Parkinson's [disease]"; and

* "...Will continue to offer [wheelchair] as option for seating while at desk/dining table."

The facility lacked documented evidence the interventions were communicated to staff on each shift.

Observations made on 02/13/23, 02/14/23 and 02/15/23 noted Resident 1 to utilize an electronic mobility device throughout the course of the survey. An electronic device was not mentioned as an intervention on the service plan or service plan updates.

There was no documented evidence the facility implemented resident specific interventions after the falls on 11/20/22, 12/05/22 and 12/20/22 and communicated the interventions to staff on each shift after the falls on 01/04/23 and 01/20/23. There was no documented evidence the facility reviewed previous interventions for effectiveness.

In a 02/15/23 interview with Staff 2 (Assisted Living Manager), she stated the facility had been utilizing the same service plan template with interventions for residents experiencing falls. She acknowledged the lack of resident specific interventions for several of Resident 1's falls and the facility's failure to communicate certain interventions to staff on each shift and review implemented interventions for effectiveness.

The facility's failure to determine and document actions or resident specific interventions and communicate the actions or interventions to staff on each shift to potentially decrease the risk of future falls put the resident at risk for repeated falls, and further injury.

The need to ensure actions and resident specific interventions were developed and communicated to staff and reviewed for effectiveness for Resident 1's falls was discussed with Staff 1 (Administrator), Staff 2, Staff 3 (RN), and  Staff 4 (LPN),  They acknowledged the findings.

On 3/1/23 AL manager and AL nurse attended a training on service planning through PCC and fixed systemic issues around service planning in order to ensure Goals and Interventions from quartely evaluation form are transferred to the service plan, enabling AL care staff to reference current goals and interventions. All resident's service plans will be reviewed and updated if required, for accuracy and consistency by compliance date.

Falls for the quarter will be reviewed at QAPI to identify residents with frequent falls, review the need for new interventions and review current interventions for effectiveness, to be updated accordingly.

Moving forward 3 resident Service Plans will be reviewed quarterly at QAPI to ensure accuracy of current service plan and ensure AL care staff are able to access corresponding Service Plans on POC.  

AL manager and nurse will review temporary service plan binder weekly to be sure that service plan updates have been impletented with resident specific interventions.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired direct care staff (#s 5, 6 and 7) demonstrated competency of skills in all assigned job duties within 30 days of hire. Findings include, but are not limited to:

Training records were reviewed with Staff 2 (Assisted Living Manager) on 02/15/23 and identified the following:

1. Staff 6 (MT) hired on 09/23/22, lacked documentation of  demonstrated competency in the following required areas:

*  Changes associated with normal aging;

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

*  General food safety, serving and sanitation.

2. Staff 5 (CG) hired on 09/22/22 and Staff 7 (CG) hired on 07/06/22 lacked documented evidence of demonstrated competency in the following required areas:

*  The role of service plans in providing individualized resident care;

*  Providing assistance with the activities of daily living;

*  Changes associated with normal aging;

*  Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition;

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

*  General food safety, serving and sanitation; and

*  First Aid/abdominal thrust.

The need to ensure staff demonstrated competency in all assigned job duties within 30 days of hire was discussed with Staff 1 (Administrator), Staff 2, Staff 3 (RN) and Staff 4 (LPN) on 02/15/23. They acknowledged the findings.

On 2/20/23 an inservice was held to implement a new company wide packet of competency checklists for all AL staff, therefore all staff will have a compentency check list on file. New and up to date training documents will be completed and stored in the employee records.

New staff that were hired in the quarter will be reviewed at QAPI to check that compentencies and required trainings have been completed and returned to AL manager to file. Mandatory Relias training have also been added to Pre-Service Checklist:

-Changes associated with normal aging training have been added to the Relias requirements at new hire to be completed in the first 30 days of hire.

-General food safety, serving and sanitation has been added to the Relias requirements upon new hire to be completed in the first 30 days of hire.

- The role of service plans in providing individualized resident care has been added to the Relias requirements upon new hire to be completed in the first 30 days of new hire.

AL manager, nurse and Administrator reviewed and confirmed that the new compentency checklist has the following training requirements:

1.  Providing assistance with the activities of daily living.

2.  Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition.

3. Conditions that require assessment, treatment, observation and reporting

CPR/First Aid training abdominal thrust redemonstration are held at Mirabella monthly and new staff will complete the class within 30 days of hire if not previously completed prior to hire.