Print Inspection: 2CQ1

The findings of the re-licensure survey conducted 04/24/23 through 04/26/23 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 04/26/23, conducted 07/26/23, 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.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 2 of 2 sampled residents (#s 1 and 2) and failed to ensure the initial evaluation was updated and modified as needed during the 30 days following the resident's move into the facility for 1 of 1 sampled resident (#3) whose evaluations were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 03/2023 with diagnoses including abnormal weight loss, weakness and a fractured right femur. The Initial Resident Intake/Assessment form dated 03/27/23 and preadmission hospice notes dated 03/27/23 and 03/28/23 were reviewed. The following elements were not addressed:

* Customary routines including sleep, eating and bathing;

* Interests, hobbies, social, leisure activities;

* Communication and sensory including hearing, vision, assistive devices and ability to understand and be understood;

* Activities of daily living including grooming and personal hygiene;

* Ability to manage medications;

* Ability to use the call system;

* Housework and laundry assistance;

* Indicators of nursing needs including potential for delegated nursing tasks;

* Emergency evacuation ability;

* Recent losses; and

* Elopement risk or history.

The need to ensure move-in evaluations addressed all required elements was discussed with Staff 3 (RN) on 04/25/23 at 2:30 pm. She acknowledged the findings.

2. Resident 3 was admitted to the facility in 01/2023 with diagnoses including chronic kidney disease and chronic heart failure.

There was no documented evidence the initial evaluation was updated and modified as needed during the 30 days following the resident's move into the facility.

On 04/26/23 at 8:35 am, Staff 8 (Certified Nurse's Assistant) confirmed Resident 3 had the following changes since move-in:

* Customary routine relating to breakfast time;

* Falls and interventions;

* Meal set up; and

* Days in which facility staff offer assistance with bathing.

The need to ensure the initial evaluation was updated and modified as needed during the 30 days following the resident's move into the facility was discussed with Staff 2 (Administrative Officer) and Staff 3 (RN) on 04/26/23 at 11:30 am. They acknowledged the findings.

3. Resident 1 was admitted to the facility in 04/2023 with diagnoses including Stage IV decubitis ulcer and right foot gangrene. The Initial Resident Intake/Assessment form dated 04/04/23 and preadmission hospice notes dated 02/17/23 were reviewed. The following elements were not addressed:

* Customary routines, including sleeping, eating and bathing;

* Interests, hobbies, and social and leisure activities;

* Mental health issues, including presence of depression, thought disorders or mood problems, history of treatment, and effective non-drug interventions;

* Cognition, including memory and decision-making abilities;

* Personality, including how the person copes with change or challenging situations;

* Communication and sensory, including hearing, vision, speech, assistive devices and the ability to understand and be understood;

* Activities of daily living, including grooming, dental status, and assistive devices for eating;

* Independent activities of daily living, including ability to manage medications, ability to use call system, housework and laundry and transportation;

* Pain, including non-pharmaceutical interventions and how the person expresses pain or discomfort;

* Nutrition habits, fluid preferences and weight if indicated;

* List of treatments;

* Review of risk indicators, including emergency evacuation ability, complex medication regimen, history of dehydration or unexplained weight loss or gain, recent losses, elopement risk or history; and

* Environmental factors that impact the resident's behavior, including but not limited to noise, lighting, room temperature.

The need to ensure new move-in evaluations addressed all required elements was discussed with Staff 3 (RN) on 4/26/23. She acknowledged the findings.

We have updated the move-in and quarterly evaluation form based on the feed back provided to us by the inspection team.  Admitting staff will utilize the updated form going forward.  Given we admit individuals needing end-of-life care we will perform a review upon admission to determine any changes that are required for their care needs.

The nurses will monitor that the form is being appropriately used and the Quality Assurance Committee will monitor ongoing compliance at bi-monthly meetings.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were person centered, reflective of residents' needs, and provided clear direction to staff for 3 of 3 residents (#s 1, 2 and 3) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 04/2023 with diagnoses including Stage IV decubitis ulcer and right foot gangrene.

The resident's 4/10/23 service plan, progress notes, and temporary service plans were reviewed, observations were made, and the resident and staff were interviewed. The service plan was not reflective and/or lacked clear direction to staff in the following areas:

* Use of devices, including wheelchair, side rails, and air mattress;

* Cognition, including memory status;

* Routines, including preferred wake-up time and bedtime routine;

* Activity interests, including playing cards; and

* Nonpharmaceutical pain interventions.

The need to ensure service plans were reflective and provided clear direction to staff was discussed with Staff 3 (RN) on 04/26/23. She acknowledged the findings.

2. Resident 2 admitted to the facility in 03/2023 with diagnoses including abnormal weight loss, weakness and a fractured right femur.

The resident's medical record was reviewed, the resident was interviewed and staff were interviewed. The service plan lacked a person centered approach, lacked clear direction to staff regarding the delivery of services, or was not reflective in the following areas:

* Ability to make needs known;

* When staff assisted with bathing needs;

* The frequency of hospice visits and what care they provided;

* Meal set up;

* The use of dentures;

* Pressure relieving air mattress;

* Siderail use;  

* Catheter care;

* Evacuation assistance needed;

* Pain management; and

* Leisure activity preferences.

The need to ensure the resident's service plan was person centered, provided clear instruction to staff, and was reflective of current care needs was discussed with Staff 3 (RN) on 04/25/23 at 2:30 pm. She acknowledged the findings.

3. Resident 3 was admitted to the facility in 01/2023 with diagnoses including chronic kidney disease and chronic heart failure.

The resident's medical record was reviewed and staff were interviewed. The service plan lacked a person centered approach, lacked clear direction to staff regarding the delivery of services or was not reflective in the following areas:

* Bathing schedule;

* Hospice services received;

* Food preferences;

* Meal set up assistance provided;

* Customary routine relating to breakfast;

* Fall interventions;

* Trapeze use and what staff should monitor;

* Assistance needed with oxygen;

* Staff assistance needed during an evacuation; and

* Leisure activity preferences.

The need to ensure the resident's service plan was person centered, provided clear instruction to staff, and was reflective of current care needs was discussed with Staff 2 (Administrative Officer) and Staff 3 (RN) on 04/26/23 at 11:30 am. They acknowledged the findings.

We plan to update the service plans with each change of condition (see plan of correction for C270).  Service plan will be reviewed and updated on the 30 day and quarterly review.  We have activated the notice for when they plans are due so we can complete them on a timely basis.

The nurses will monitor that the service plan reviews are being completed and the Quality Assurance Committee will monitor ongoing compliance at bi-monthly meetings.

Based on interview and record review, it was determined the facility failed to evaluate the resident to determine and document what actions or interventions were needed for changes of condition, communicate those actions or interventions to staff on each shift, and include the documentation of resident specific staff instructions or interventions in the resident's record with weekly progress noted until resolved for 1 of 3 sampled residents (#3) who experienced changes of condition. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 01/2023 with diagnoses including chronic kidney disease and chronic heart failure.

The resident's medical record was reviewed and staff were interviewed. Resident 3 experienced the following changes of condition:

* 03/14/23 - slipped out of the chair by his/her computer;

* 03/31/23 - tripped on oxygen tubing returning to bed from using the bathroom;

* 04/11/23 - the facility took over the administration of PRN narcotics due to the resident's increased confusion;

* 04/14/23 - fell returning to bed from using the bathroom;

* 04/15/23 - fall staff suspected sustained returning to bed from using the bathroom; and

* 04/20/23 - fall that was under investigation.

There was no documented evidence the facility evaluated Resident 3 in order to determine and document what actions or interventions were needed, communicate those actions or interventions to staff on each shift, and include the documentation of resident specific staff instructions or interventions in the resident's record with weekly progress noted until the condition resolved.

On 04/26/23 at 11:30 am, Staff 3 (RN) confirmed the lack of monitoring for the resident's falls and medication administration change.

The need to ensure the resident was evaluated in order to determine and document what actions or interventions were needed, communicate those actions or interventions to staff on each shift, and include the documentation of resident specific staff instructions or interventions in the resident's record with weekly progress noted until the condition resolved was discussed with Staff 2 (Administrative Officer) and Staff 3 on 04/26/23. They acknowledged the findings.

Staff will be educated and encourage to utlize the "Alert Charting" in our electronic medical records which will address the Change of Condition requirement.  Our Alert Charting process will update our service plan which will assist in maintaining a "current" service plan. This process will assist in maintaining our service plan requirement as address in our C260 citation.

The nurses will monitor that the alert charting is completed which will address the change of condition requirement.  The Quality Assurance Committee will monitor ongoing compliance at bi-monthly meetings.

Based on observation, interview and record review, it was determined the facility failed to ensure an RN, PT or OT conducted a thorough siderail assessment and included documentation of the use of supportive devices with restraining qualities in the service plan for 3 of 3 sampled residents (#s 1, 2 and 3) who were reviewed for using devices with restraining qualities. Findings include, but are not limited to:

Residents 1, 2 and 3 were identified during the acuity interview on 04/24/23 to have siderails on their beds. Observations were made of the residents' siderails during the survey. Review of all three residents' clinical records revealed the following were lacking from the record:

* An RN, PT or OT assessment;

* Documentation of other less restrictive alternatives evaluated prior to the use of the device; and

* Documented instructions for staff on the correct use and precautions related to the use of the device.

The need to complete all required elements related to use of a device with restraining qualities was discussed with Staff 2 (RN) on 04/26/23. She acknowledged there was no siderail assessment and the documented instruction for staff was missing in the service plans.

We have updated our restraint and supportive device assessment form to appropriately assess the need to use side rails for our resident population.  Our goal will be to reduce the need of bed side rails and maintain the safety of our residence who receive end-of-life care.  This assessment tool will be utilized going forward.

The nurses will complete the assessment form and the Quality Assurance Committee will monitor ongoing compliance at bi-monthly meetings.