Print Inspection: 0FJR

The findings of the re-licensure survey, conducted 05/20/24 through 05/23/24 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 OARs 411 Division 004 Home and Community Based Services Regulations.  

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 first re-visit to the re-licensure survey of 05/23/24, conducted 11/20/24 through 11/21/24, 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 OARs 411 Division 57 for Memory Care Communities.

Based on observation, interview, and record review, it was determined the facility failed to evaluate the resident, refer to the facility nurse, document the change and update the service plan as needed for 1 of 1 sampled resident (#1) who experienced a significant change of condition and failed to determine what action or interventions were needed following short-term changes of condition, communicate the interventions to staff and document weekly progress until resolved for 1 of  5 sampled residents (#1) who experienced short-term changes of condition. Resident 1 experienced ongoing, severe weight loss.  Findings include, but are not limited to:

Resident 1 was admitted to the facility in 11/2018 with diagnoses including Alzheimer's disease and frontotemporal dementia.

The resident's 05/14/24 service plan, 02/26/24 through 05/22/24 progress notes, temporary service plans, and weight records were reviewed.

a. The service plan indicated Resident 1 became anxious while waiting for meals and required "assistance with eating/encouragement to eating and regularly prompting at meals," and was on a pureed diet "to avoid choking."  Resident 1 was on thin liquids.

Resident 1's weight record was reviewed during the survey and revealed the following:

* 02/02/24: 150 pounds;

* 03/03/24: 136.5 pounds;

* 04/02/24: 135 pounds;

* 05/01/24: 132 pounds;

* 05/13/24: 126.5 pounds; and

* 05/21/24: 125.5 pounds (requested during the survey).

Between 02/02/24 and 03/03/24 the resident experienced a loss of 13.5 pounds, or 9% of his/her total body weight, in one month. This constituted a severe loss and was considered a significant change of condition. There was no documented evidence the facility evaluated the resident, referred the significant weight loss to the facility nurse for assessment, documented the weight loss and updated the service plan.

Weights documented after 03/03/24 revealed the resident experienced another significant weight loss of 18 pounds, or 12% of his/her body weight in three months, from 02/02/24 to 05/01/24.

There was no documented evidence following the weight loss on 05/01/24 that the facility evaluated the resident, referred the significant weight loss to the facility nurse for assessment, documented the weight loss and updated the service plan.  Resident 1 continued to experience severe weight loss.

During the survey the following was observed:

* On 5/20/24 Resident 1 was served pureed apple-glazed chicken, white rice and carrots. Staff cued him/her to eat slowly as she delivered the plate of food. The resident quickly took four large bites of food, stood up, drank a few sips of water and exited the dining room to a chair in the hallway. S/he ate about 25% of the meal. Resident 1 sat outside the dining room for the next 20 minutes before staff removed his/her plate of food.  Staff were not observed to invite the resident to return to the dining room or offer the resident more food or an alternative food item.

* On 5/21/24 prior to lunch arriving, Resident 1 was served four ounces of a supplement shake and a grape drink at 12:05 pm. S/he took a few sips of the shake and after finishing the grape drink s/he began coughing, stood up and exited the dining room. Staff 5 (HR Assistant/MT) sat with Resident 1 in the hallway and cued  him/her to cough and clear his/her throat. The resident returned to his/her room and was overheard coughing for another 10 minutes until s/he independently returned to the dining room. The lunch had not arrived, s/he waited four minutes, and at 12:47 pm s/he stood up and stated "I don't want my lunch," exited the dining room and sat in the hallway.  Ten minutes later Resident 1's meal arrived, s/he returned to the table, was served pureed beef tips, buttered noodles and cauliflower while staff provided cues to eat slowly as the plate was served.  Resident 1 quickly took three bites of food, stood up, drank another gulp of his/her grape drink and left the dining room. Staff cued Resident 1 to swallow his/her food before s/he exited. Resident 1 ate 10% of his/her food, 100% of the grape drink and 2 oz of the healthy shake.

Between 05/01/24 and 05/13/24 Resident 1 lost another 5.5 pounds, or 4% of his/her total body weight.

In an interview on 05/21/24, Staff 2 (RN) acknowledged Resident 1 had not been evaluated and referred to the facility nurse for the severe weight loss identified on 03/03/24 until 05/14/24.

The resident experienced severe weight loss, was not evaluated or referred to the facility RN and continued to loose weight.

b. The following short-term changes lacked documented evidence that actions or interventions were determined, documented, communicated to all staff on all shifts and/or monitored until resolution:

* 05/11/24 - return from the hospital; and

* 05/13/24 - dosage change for Zyprexa.

On 05/23/24 the need to evaluate changes of condition, refer changes to the facility nurse when needed, determine actions or interventions and communicate them to staff, and monitor through resolution, with at least weekly documentation, was discussed with Staff 1 (ED), Staff 15 (Chief Operations Officer) and Staff 16 (Corporate Administrator). They acknowledged the findings.

Resident 1 Change of Condition for her weights were completed, MD notified with interventions in place.

Resident 1 has not had short term change of conditions. Will montior and place on alert with TSP to montior for short term change of condition

Monthly weights will be completed by the 5th of every month. RN and Admin will review the weights of all residents. Re-weights will be done as needed. RN, RCC and Admin will complete a weight meeting to review all weight loss and gain, discuss interventions and notifications by the 10th of every month. Weight meeting will be recorded on Clinicl Meeting Sheet. Once the RN and Admin determine a Change of Condition is needed, RN will complete Change of Condition in 24 hours. Admin will confirm.

Monthly and as needed for siginficant change of conditions and daily for short term change of conditions

Admin, RN and RCC

Based on observation, interview, and record review, it was determined the facility failed to ensure an RN assessment included documented findings, resident status, and interventions made as a result of the assessment for 1 of 1 sampled resident (#1) who experienced a significant change of condition. Resident 1 continued to experience ongoing severe weight loss. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 11/2018 with diagnoses including Alzheimer's disease and frontotemporal dementia.

The resident's 05/14/24 service plan, 02/26/24 through 05/22/24 progress notes, temporary service plans, and weight records were reviewed.

Resident 1's weight record was reviewed during the survey and revealed the following:

* 02/02/24: 150 pounds;

* 03/03/24: 136.5 pounds;

* 04/02/24: 135 pounds;

* 05/01/24: 132 pounds;

* 05/13/24: 126.5 pounds; and

* 05/21/24: 125.5 pounds (requested during the survey).

Between 02/02/24 and 03/03/24 the resident experienced a loss of 13.5 pounds, or 9 % of his/her total body weight, in one month. This constituted a severe loss and was considered a significant change of condition for which an RN assessment was required.

There was no evidence the facility RN conducted and documented an assessment which included findings, resident status and interventions made as a result of the assessment.

Between 02/02/24 and 05/01/24 the resident experienced a loss of 18 pounds, or 12% of his/her total body weight in three months. This constituted a severe loss and was considered a significant change of condition for which an RN assessment was required.

There was no evidence the facility RN conducted and documented an assessment which included findings, resident status and interventions made as a result of the assessment.

The need to ensure significant changes of condition were assessed by an RN and included findings, resident status, and interventions made as a result of the assessment, as well as ensuring they were completed in a timely manner, was discussed with Staff 1 (ED), Staff 15 (Chief Operations Officer) and Staff 16 (Corporate Administrator) on 05/23/24. They acknowledged the findings.

Refer to C 270.

Tag C280 is in reference to tag C270. The actions taken to address tag C270, as set out in the POC, will be taken to address the concerns set out in tag C280

The actions taken to address tag C270 as set out in this POC, will be taken to address the concerns set out in Tag C280

The same schedule as set out in POC for Tag C270

The same person identified in POC Tag C270

Based on observation and interview, it was determined the facility failed to provide a lockable storage space (e.g. drawer, cabinet or closet) for the safekeeping of a resident's small valuable items and to provide lockable doors for all resident apartments. Findings include, but are not limited to:

a. During the environmental inspection of multiple occupied resident apartments on 05/20/24 and 05/21/24, there was no lockable storage space identified in several apartments.

In interviews with unsampled residents on 05/22/24, multiple residents on the third floor stated they had no lockable storage space in their apartments.  

Observations of rooms 308, 309, and 310 with Staff 1 (Executive Director) at 11 am on 05/23/24 confirmed the second floor rooms did have locking cabinets or lock boxes, however the rooms on the third floor did not have locking storage.

b. During the environmental inspection of multiple occupied resident apartments on 05/20/24 and 05/21/24, there were no door locks for rooms 208, 209, and 224.

Interviews with Staff 1 (ED) and Staff 15 (Chief Operations Officer) on 05/23/24 confirmed the three units were without lockable doors.

On 05/23/24 the need to ensure the facility provided a lockable storage space that was secure, and all rooms had a locking door was discussed with Staff 1 and Staff 15. They acknowledged the findings.

full Inventory for lockable storage done for the 3rd floor and 2nd floor. Maintenance has ordered lockable storage for all missing units and door lock handles for 3 rooms that were missing. Room 208 admin has already completed HCBS form for expection to not have a locking door handle.

All the equiment will be installed and secured in closets; and all residents doors will have lockable handles unless an HCBS execption summited by 7/22/2024.

Upone move in and move out aduits and querterly

Maintenance Director and Admin.  

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 515.

Tag Z142 is in references to tag C 515. The actions taken to address tag C 515, as set out in the POC, will be taken to address the concerns set out in Tag Z142

The actions taken to address tag C515 as set out in this POC, will be taken to address the concerns set out in Tag Z142

The same schedule as set out in POC for Tag C515

The same person identified in POC Tag C515

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 sampled newly-hired direct care staff (#s 9, 12, and 14) had demonstrated knowledge and performance in all required areas within 30 days of hire. Findings include, but are not limited to:

Staff training records were requested and received on 05/21/24. A review of the records provided revealed the following:

Staff 9 (CG) was hired 03/01/24, Staff 12 (MT) was hired 04/09/24, and Staff 14 (CG) was hired 03/26/24.

The facility was unable to provide documentation Staff 9, 12 and 14 had demonstrated competency in the required job duties within 30 days of hire and prior to working independently.

On 05/21/24 staff training requirements were discussed with Staff 1 (ED). She acknowledged the findings.  

The employees that were missing training documents will be assigned the correct training or documents and will be completed with in 30 days

HR assistant will do a monthly audit of employee files for new employees to assure compliance. HR assistance will sumit aduit to Admin by the 15th of every month for review. Any staff not completing training will be removed from regular schedule and scheduled to complete training in house.

Monthly by HR assistant and Admin

HR assistant and Admin.  

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 270 and C 280.

Tag Z 162 references tag C270 and C280. The actions taken to address each of those tags, as set out in the POC, will be taken to address the concerns in Tag Z162

The action taken to address Tags C270 and C280 as set out in this POC, will be taken to address the concerns set out in Tag Z162

The same schedule as set out in POC re. Tags C270 and C280

The same person identified in POC Tags C270 and C280

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

Resident 1 was admitted to the facility in 11/2018 with diagnoses including Alzheimer's disease and frontotemporal dementia.

Observations of the resident during lunch meals on 05/20/24 and 05/21/24 showed Resident 1 ate quickly and left the table after taking only two to four bites of food. On 05/21/24 staff offered the resident applesauce and yogurt after exiting the dining room but s/he declined. Interviews with care staff revealed the resident often left the dining room after only a few bites and "sometimes" returned to eat a little more but "not always." Staff were also not sure what the resident liked to eat or drink other than "I know [s/he] likes chocolate pudding more than vanilla" and "maybe bananas."

Resident 1's service plan, dated 05/14/24, was reviewed. The resident's service plan indicated s/he was on a pureed diet to "prevent choking" but lacked information regarding a daily program for nutrition and hydration based upon the resident's preferences and needs. There was no information regarding resident's food and drink preferences.

The resident's clinical record showed a significant weight loss over the past three months and staff were unsure what foods to offer him/her other than applesauce or yogurt "since [s/he] is on a pureed diet."

The need to ensure an individualized nutritional plan for each resident was documented in the resident's service plan was discussed with Staff 1 (ED), Staff 15 (Chief Operations Officer) and Staff 16 (Corporate Administrator) on 05/23/24. They acknowledged the findings.

Resident 1 Service plan has been updated with Food and hyrdration preferences.

Upon move in all food and hydration preferences will be added to the service plan. Service plans will updated as needed and at scheduled reviews.

At move in, as needed, 30day, 60day and 90day service plan reviews.

RCC and Admin.

Based on interview, observation, and record review, it was determined the facility failed to ensure behavioral symptoms which negatively impact the resident and others in the community were evaluated and included on the service or care plan, for 1 of 1 sampled resident (#3) who had challenging behaviors in the MCC. Findings include, but are not limited to:

Resident 1 was admitted to the MCC in 06/05/2017 with diagnoses including dementia with behavior disturbance.

Review of progress notes, incident investigations, TSPs and MARs showed that between 03/21/2024 and 05/20/24 Resident 3 displayed the following:

* 3/21/24 "resident has been threatening to "kill" and "shoot" people today, specifically men. This med tech gave this resident a PRN lorazepam" (a psychotropic medication);

* 3/31/24 "resident stated they got in a fight." Resident 3 was confirmed to have engaged in a resident to resident altercation and suffered a bruise under side of left eye 2 inches long, bruise to right forearm 8 inches long, skin tear to right forearm, 1 inch bruise on posterior of left hand and scratches to right elbow;

* 4/8/24 "resident showing signs of aggression during regularly scheduled rounds. Resident was punching and kicking at care staff... stated s/he would bite off staff ear if they touched [him/her]";

* 4/19/24 "resident went into the dining room and started to hit another resident. Staff intervened and stopped the altercation"; and

* 5/2/24 "resident attempted to hit another resident this morning at 7:30 am."

The resident to resident altercations between 03/21/24 and 05/02/24 were noted with TSPs, however no new interventions were developed.

There was no documented evidence the MCC initiated outside consultation to assist in developing behavioral interventions.

The current service plan, dated 04/01/2024, lacked resident-specific information for staff regarding the specific behaviors of concern and lacked individualized interventions for staff to try when responding to the behaviors.

The need to ensure the facility developed individualized behavior interventions for residents who exhibited behavioral symptoms which negatively impacted the resident and others in the community was reviewed with Staff 3 (RCC) on 05/22/24, and with Staff 1 (ED) and Staff 15 (Chief Operations Officer) on 05/23/24.  They acknowledged the findings.

Resident 3 Service plan has been updated for Behavior and interventions in place.

Upon moving in, all behaviors are reviewed during initial evaluation. Behaviors with interventions will be added to the service plan. Any changes in behaviors, resident will be placed on alert with TSP with behavior montioring sheet to monitor the behavior. Then the service plan will be updated as needed and at scheduled reviews.

At move in, as needed, 30day, 60day, and 90day service plan reviews.

RCC and Admin