Print Inspection: 154P

The findings of the change of ownership survey, conducted 03/27/23 through 03/29/23, 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, 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

MCCMemory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the re-visit survey to the change of owner survey of 03/29/23, conducted 07/05/23, 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, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations. The facility was found to be in substantial compliance with the regulations.

Based on interview and record review, it was determined the facility failed to ensure short-term changes of condition were evaluated, interventions were determined and communicated with staff, and changes were monitored until resolved for 2 of 3 sampled residents (#s 2 and 3) reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 03/2021 with diagnoses including dementia and diabetic neuropathy.

The resident's progress notes, dated 12/30/22 through 03/27/23, temporary service plans (TSPs), RN assessments, and incident reports and investigations were reviewed, and staff were interviewed. The following changes of condition were identified:

* 12/29/22 - Left buttock pressure wound;

* 01/01/23 - Non-injury fall next to bed;

* 01/11/23 - Non-injury fall next to bed;

* 02/06/23 - Non-injury fall in the bathroom;

* 02/22/23 - Burning and pain with urination;

* 02/25/23 - Non-injury fall next to bed;

* 02/27/23 - Non-injury fall next to bed; and

* 02/27/23 - Non-injury fall in resident's room.

There was no documented evidence the falls, pressure wound and pain with urination was monitored weekly until resolution.

The need to monitor changes and document progress weekly through resolution was discussed with Staff 1 (Executive Director ), Staff 2 (Regional RN), Staff 3 (Director of Health Services/RN), and Staff 4 (RCC) on 03/28/23. They acknowledged the findings. No additional information was provided.

2. Resident 3 was admitted to the memory care community in 11/2022 with diagnoses including dementia with agitation, hypertension, and diabetes.

Review of the residents progress notes, dated 12/27/22 through 03/27/23, temporary service plans, and incident reports revealed the resident had experienced the following short-term changes of condition:

* 01/19/23- Resident to resident altercation during activity game;

* 01/29/23- Injury fall near facility salon;

* 01/30/23- Non-injury fall in resident's room;

* 02/05/23- Verbal altercation in dining room;

* 02/05/23- Non-injury fall in resident's room;

* 02/16/23- Resident to resident physical altercation in common area;

* 02/23/23- Non-injury fall in resident's room;

* 02/23/23- Injury fall in hallway;

* 03/02/23- Non-injury fall in hallway;

* 03/03/23- Non-injury fall in dining room;

* 03/05/23- Non-injury fall in common room

There was no documented evidence new interventions were developed for repeated incidents, clear directions were provided to staff, or existing interventions were evaluated for effectiveness.

On 03/29/23, the need to identify changes of condition, develop resident-specific interventions, and  evaluate the interventions for effectiveness was discussed with Staff 1 (Executive Director) and Staff 2 (Regional RN). They acknowledged the findings.

1 - Residents 2 & 3 Change of Condition were reviewed and documentation completed reflecting the changes and SP updated as needed, fall interventions and any additional behavior support montioring

2 - 24 hour process will be reviewed and retrained with staff to assure that communication from staff regarding visualized changes are being documented for further follow up. RN, ED, RCCs, will review in clincical meeting daily and address/document accordingly. Training to be conducted with facility care staff

3 - Review of 24 hour binder and audit tool will be conducted Mon-Fri during clinical meetings

ED, RN, RCCs are responsible

Based on observation and interview, it was determined the facility failed to ensure the courtyard surfaces were maintained in good repair. Findings include, but are not limited to:

Observation of the secured courtyard on 3/27/23 showed drop offs along the concrete patio of up to one and one-half inches in multiple areas. The drop offs create a potential tripping/fall hazard for residents.

The courtyard was reviewed with Staff 1 ( Executive Director), Staff 5 (Maintenance Director), and Staff 18 (Regional Director of Operations) on 03/28/23. They acknowledged the findings.

1 - Exterior deficiencies noted in the 2567 have been reviewed and repaired.

2 - All staff to be trained on utilizing work order system to assure needed repairs are addressed timely. As well as notification when there are areas where residents could be at risk for tripping or falling.

3 - ED and Maintenance Director to conduct weekly walk throughs, as well as monthly QA meeting audits. RDO to complete quarterly visit to complete building walk.  

4 - RDO, ED and Maintenance Director

Based on observation and interview, it was determined the facility failed to ensure the interior was clean, in good repair, and free from unpleasant odors. Findings include, but are not limited to:

Observations of the facility on 03/27/23 and 03/28/23 showed the following:

* Chipped, dinged, gouged, scratched, and scuffed walls, doors, and door frames throughout the facility, including inside resident units;

* Baseboards throughout the facility had an accumulation of dirt and debris in corners and along the perimeter;

* Multiple bathrooms had thick black accumulation along the baseboards and shower thresholds;

* Multiple toilets had stained, missing, or black spots on the caulking around the bases of the toilet;

* Multiple resident wheelchairs had torn armrests; and

* There was a strong urine odor in and around Resident Room 5 that did not dissipate.

The areas in need of cleaning and repair were shown to and discussed with Staff 1 ( Executive Director), Staff 5 (Maintenance Director), and Staff 18 (Regional Director of Operations) on 03/28/23. They acknowledged the findings.

1 - Complete room audit will be conducted on all resident apartments and common areas to assure they are in good repair to include but not limited to: scratches, dings, gauges, baseboards, build up, proper caulking, and odor free. Resident wheelchairs will be assessed and proper repairs completed or new wheelchairs ordered.

2 -  Administrator, maintenance and housekeeping will do a weekly walkthrough utilizing the environmental QA form.Work order binder to be brought to stand up daily to review and assure items are being addressed

Administrator, DHS, and RCC will review resident wheelchairs and work on replacements and/or repairs.

3) The weekly audits will be reviewed at QA for trends and QAPI opportunities

4) ED responsible

Based on observation, interview, and record review, it was determined the facility failed to provide non-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 C510 and C513.

See POC for C510 and C513

Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to C270.

See POC for C270

Based on interview and record review, it was determined the facility failed to evaluate behavioral symptoms which negatively impacted the resident or others, and include on the service plan for 1 of 3 sampled residents (#3) who exhibited challenging behaviors. Findings include, but are not limited to:

Resident 3 was admitted to the memory care community in 11/2022, with diagnoses including dementia with agitation.

In an interview on 03/27/23, Staff 1 (Executive Director) identified Resident 3 with a multitude of behavioral issues, including verbal and physical altercations with other residents.

Review of Resident 3's progress notes, dated 12/27/22 through 03/27/23, temporary service plans, and incident reports revealed the resident was involved in the following altercations:

* On 01/19/23, Resident 3 grabbed another resident during a ball toss game, and the two "exchanged blows", before staff intervened;

* On 02/05/23,  a facility nurse heard a commotion in dining room and hurried to find Resident 3 in a "loud verbal argument" with several other residents; and

* On 02/16/23, Resident 3 stated to Staff 9 (Activity Director) that another resident had been "beating [him/her] in the head".

Resident 3's service plan, dated 12/28/22, lacked documented evidence the negatively impactful behaviors were evaluated or addressed on the service plan.

On 03/29/23, the need to evaluate behaviors with negative impact, and include those behaviors on residents' service plans was discussed with Staff 1 (Executive Director) and Staff 2 (Regional RN). They acknowledged the findings.

1 - Resident 3  service plan to be updated to reflect negative behaviors and additional services requested from MD in regards to resident behavior and agitation.

2 - IRs and resident behaviors will be reviewed daily in 24 hour process clinical meeting to assure all interventions, TSPs and other needed changes to SP are addressed.

3 - Service Plans/Evals due are reviewed daily during 24 hour process . Will audit 2 service plans monthly as part of ongoing QA process

ED and DHS responsible