Print Inspection: 2O33

The findings of the relicensure survey, conducted 10/31/23 through 11/02/23, 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.

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 revisit to the re-licensure survey of 11/03/23, conducted 01/10/24, 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 and interview, it was determined the facility failed to ensure resident's right to privacy and dignity related to providing ADL care for 1 of 4 sampled residents (# 1) and multiple non-sampled residents during meal service. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 09/2016 with diagnoses including late onset Alzheimer's Disease. Observations and interviews with staff during the survey identified s/he relied on staff for incontinence care needs.

On 10/31/23 at 2:19 pm, surveyor observed Staff 10 (Universal Worker) approach Resident 1 in the dining area where other residents and staff were present and inquired in a loud voice about his/her toileting needs.

The need to ensure residents were treated with dignity and respect was discussed with Staff 1 (Executive Director) and Staff 3 (Regional Director). They acknowledged the findings.

2. Meal observations were conducted on five occasions on 10/31/23, 11/01/23, and 11/02/23. Multiple care staff were observed feeding residents while standing over them in the dining room.

The need to ensure residents were treated with dignity and respect was discussed with Staff 1 (Executive Director) on 11/02/23. She acknowledged the findings.

1. Staff will be provided with documented training on the proper steps to preserve the resident's rights regarding privacy, dignity, and respect when providing assistance with meals and toileting.  Resident #1 Service Plan will be adjusted to reflect the proper procedure when attempting to provide toileting assistance in a private manner.

2. During new hire training the staff can demonstrate an understanding of the resident's rights. Clear instructions on the resident's service plans.

3. Random daily, weekly audits

4. Administrator or designee will be responsible for ensuring compliance.

3. Resident 2 was admitted to the facility in October 2022 with diagnoses including early onset Alzheimer's disease with behavioral disturbance.

The resident's current service plan dated 10/16/23 and progress notes dated 07/29/23 to 10/31/23 were reviewed, interviews were conducted, and observations were made. The resident's service plan was not reflective and/or did not provide clear direction to staff in the following areas:

* Assistance with transfers;

* Meal assistance;

* Level of independence with mobility; and

* Devices including alternating pressure mattress.

The need to ensure the resident's service plan reflected his/her needs and provided clear direction was discussed with Staff 1 (Executive Director) and Staff 3 (Regional Director) on 11/02/23. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans reflected residents' needs and preferences, provided clear direction regarding the delivery of services, and included a written description of who shall provide the services and what, when, and how, and how often the services shall be provided for 3 of 4 sampled residents (#s 2, 3, and 4) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 09/2016 with diagnoses including dementia, functional quadriplegia, and aphasia (difficulty speaking).

The resident's current service plan dated 09/12/23 and progress notes dated 07/31/23 to 10/31/23 were reviewed, interviews were conducted, and observations were made.

Resident 3's service plan was not reflective of his/her needs and preferences, did not provide clear direction regarding the delivery of services, and/or did not include a written description of who shall provide the services and what, when, and how, and how often the services shall be provided in the following areas:

* How the resident expressed pain;

* Devices including a tilt-in-space wheelchair and a bed mat;

* Treatments including dermasaver leg tubes and nutritional shakes;

* Lighting and temperature control assistance;

* Transfers;

* Repositioning and cushioning in bed and in the wheelchair; and

* Activities.

The need to ensure the resident's service plan reflected his/her needs and provided clear direction including who shall provide the services and what when, and how, and how often the services shall be provided was discussed with Staff 1 (Executive Director) and Staff 4 (Regional Director) on 11/02/23. They acknowledged the findings.

2. Resident 4 was admitted to the facility in 09/2023 with diagnoses including dementia.

The resident's current service plan dated 10/14/23 and progress notes dated 09/13/23 to 10/31/23 were reviewed, interviews were conducted, and observations were made. The resident's service plan was not reflective and/or did not provide clear direction to staff in the following areas:

* Behaviors;

* Use of devices including a commode; and

* Communication assistance.

The need to ensure the resident's service plan reflected his/her needs and provided clear direction was discussed with Staff 1 (Executive Director) and Staff 4 (Regional Director) on 11/02/23. They acknowledged the findings.

1. Resident 2, 3, and 4 evaluations and service plans will be reviewed and updated.

Resident 2 service plan will reflect:

- assistance with transfers;

- meal assistance;

-  level of independence with mobility;

and

- devices including alternating pressure

mattress.

Resident 3 service plan will reflect:

- how the resident expressed pain;

- devices including a tilt-in-space

wheelchair and a bed mat;

- treatments including derma saver leg

tubes and nutritional shakes;

- lighting and temperature control

assistance;

- transfers;

- repositioning and cushioning in bed

and in the wheelchair; and

- activities.

Resident 4 service plan will reflect:

- behaviors;

- use of devices including a commode;

- communication assistance

Service planning team involvement will be documented in the resident record. Management staff will be trained on requirements for service planning. All resident evaluations and service plans will be reviewed and updated, and service planning team involvement documented in the resident record.

2. Review of service planning team documentation will be reviewed with each service plan update and when there are any changes.

3. Monthly and with any changes.

4. The administrator and designee are responsible for maintaining compliance.

Based on observation, interview, and record review, it was determined the facility failed to ensure actions or interventions were communicated to staff on each shift, made part of the resident record, and changes were monitored to resolution for short-term changes of condition for 3 of 3 sampled residents (#s 1, 2, and 3) who experienced short-term changes. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 09/2016 with diagnoses including late onset Alzheimer's Disease.

Resident 1's 07/30/23 through 10/31/23 progress notes, care plans, and MARs were reviewed.

The following short-term changes of condition lacked documentation of communication of the determined actions or interventions to staff on all shifts:

* 10/05/23 - Increased weakness; and

* 10/16/23 - Redness to right side of face and ear.

The following short-term changes of condition lacked documentation of communication of the determined actions or interventions to staff on all shifts and documentation of resolution:

* 10/05/23 - Multiple medication changes; and

* 10/16/23 - Right thumb redness.

The need to ensure actions or interventions for short-term changes of condition were documented, communicated to staff on each shift, and the changes of condition were monitored through resolution was discussed with Staff 1 (Executive Director) and Staff 3 (Regional Director) on 11/02/23. They acknowledged the findings.

2. Resident 2 was admitted to the facility in 10/2022 with diagnoses including early onset Alzheimer's disease.

Resident 2's 07/29/23 through 10/31/23 progress notes, care plans, and MARs were reviewed.

The following short-term changes of condition lacked documentation of communication of the determined actions or interventions to staff on all shifts:

* 09/12/23 - Fall with left elbow skin tear;

* 09/20/23 - Change in haloperidol (a psychotropic) medication; and

* 10/09/23 - Low blood pressure with dizziness and difficulty walking.

The need to ensure actions or interventions for short-term changes of condition were documented and communicated to staff on each shift was discussed with Staff 1 (Executive Director) and Staff 3 (Regional Director) on 11/02/23. They acknowledged the findings.

3. Resident 3 was admitted to the facility in 09/2016 with diagnoses including dementia.

Resident 3's 07/31/23 through 10/31/23 progress notes, care plans, and MARs were reviewed. The following changes of condition were identified:

* On 10/15/23, a skin tear on his/her right heel and right elbow. The incident report included instructions to "put pillows on both sides [between arms and wheelchair] and thick tubbing [sic] socks on legs." There was no documented evidence the interventions had been communicated to staff on all shifts.

The need to ensure instructions or interventions for short term changes of condition were communicated to staff on each shift and made part of the resident record was discussed with Staff 1 (Executive Director) and Staff 3 (Regional Director) on 11/02/23. They acknowledged the findings.

1. Residents 1, 2, and 3 will be assessed by the RN, any changes of condition noted with follow-up, and the evaluations and service plans updated. Resident 1, 2, 3 with short-term changes of condition will be documented and communicated to staff on each shift using an intermediate service plan.

Resident 1 ISP will train staff on:

- increased weakness

- redness on her right face and ear

- medication change

- any skin issue

Resident 2 ISP will train staff on:

- medication change

- fall

- skin issues

Resident 3 ISP will train staff on:

- skin issues

2. Staff will be trained on change of condition and monitoring requirements, fall interventions, skin assessment and monitoring, new medication response, catheter care and UTI response, behavioral response and interventions, and weight change assessment and interventions. Resident change of condition will be reviewed in clinical meetings held multiple times per week by the administrator, licensed nurses, and resident care coordinators. The Intermediate Service Plan will reviewed, redeveloped, and implemented with staff training. Staff will be taught how to read and follow an ISP and to notify the licensed nurse when required. Med techs will be taught how to document.

3. Daily, weekly.

4. Administrator, licensed nurses.  

2. Resident 2 was admitted to the facility in 10/2022 with diagnoses including early onset Alzheimer's disease and was identified during the acuity interview as receiving home health nursing and physical therapy services.

Progress notes and treatment orders dated 07/29/23 to 10/31/23 were reviewed, observations were made, and interviews were conducted. The following was identified:

a. Progress notes indicated a home health nurse visited the resident at least one time, and the physical therapist visited at least four times between 09/28/23 and 10/31/23. During an interview on 11/02/23 at 11:50 am, Staff 1 (Administrator) confirmed there was no written information left by the outside providers that addressed the services being provided.

b. Observation of the resident on 11/01/23 revealed s/he had wound dressings applied to the right leg. S/he also had an alternating pressure mattress. There was no documented evidence the facility nurse reviewed the service plan changes made as a result of the provision of on-site services.

The need to ensure the service plan was adjusted if necessary, outside service providers left written information in the facility that addressed the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care, and the facility nurse reviewed the resident's health-related service plan changes made as a result of the provision of on-site health services was discussed with Staff 1 and Staff 3 (Regional Director). They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure outside service providers left written information in the facility that addressed the on-site services being provided to the resident, any clinical information necessary for facility staff to provide supplemental care, the facility nurse reviewed the resident's health-related service plan changes made as a result of the provision of on-site health services, and the service plan was adjusted if necessary for 2 of 3 sampled residents (#s 2 and 3) who received outside services. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 09/2016 with diagnoses including dementia and was identified during the acuity interview as receiving home health nursing services. Progress notes and treatment orders dated 07/31/23 to 10/31/23 were reviewed, observations were made, and interviews were conducted. The following was identified:

a. Progress notes indicated a home health nurse visited the resident on at least two occasions between 07/31/23 and 10/31/23. During an interview on 11/01/23 at 2:00 pm, Staff 1 (Executive Director) confirmed visits were made on 10/17/23 and 10/25/23. There was no written information left by the outside providers that addressed the services being provided.

b. Observation of the resident on 10/31/23 revealed s/he wore thick tube socks around his/her legs. A treatment order dated 09/05/23 indicated home health nursing had ordered the socks for the resident. There was no documented evidence the facility nurse reviewed the service plan changes made as a result of the provision of on-site services. There was no documented evidence the treatment had been added to the resident's service plan.

The need to ensure the service plan was adjusted if necessary, outside service providers left written information in the facility that addressed the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care, and the facility nurse reviewed the resident's health-related service plan changes made as a result of the provision of on-site health services was discussed with Staff 1 on 11/02/23 and Staff 4 (Regional Director). They acknowledged the findings.

1. Resident 2, and 3 will be assessed to ensure documentation regarding outside services is in the resident record.

2. There is a new outside provider binder with a sign-in sheet and blank forms. The completed form will go to the administrator, resident care coordinator, or med tech and will be processed, the RN will review it and sign it. Med techs and licensed nurses will be trained on how to review, process, and document outside provider communication. Outside provider communication and follow-up documentation will be reviewed in clinical meetings. ISP will be implemented and the service plan updated as needed.

3. Daily, weekly.

4. The administrator, designee, and licensed nurses will be responsible for ensuring compliance.

Based on observation and interview, it was determined the facility failed to ensure establishment and maintenance of infection prevention and control protocols to provide a safe, sanitary and comfortable environment for 3 of 3 sampled residents (#s 1, 2, and 3) related to incontinence care and multiple non-sampled residents related to soiled laundry. Findings include, but are not limited to:

1. Observations made during the survey, 10/31/23 through 11/02/23, determined the facility failed to adhere to universal precautions for infection control in the following areas:

a. Resident 1 was admitted to the facility in 09/2016 with diagnoses including late onset Alzheimer's Disease. Observations and interviews with staff during the survey identified s/he relied on staff for incontinence care needs.

On 10/31/23 at 2:20 pm, Staff 10 (Universal Worker) was observed providing ADL incontinence care for Resident 1. During the observation, Staff 10 donned gloves without performing hand hygiene. Staff 10 proceeded to remove the soiled incontinence brief and perform perineal care with toilet paper while wearing soiled gloves. Staff 10 failed to doff soiled gloves, perform hand hygiene, and don clean gloves before touching the resident's body and clean brief.

b. Resident 2 was admitted to the facility in 10/2022 with diagnoses including early onset Alzheimer's Disease. Observations and interviews with staff during the survey identified s/he relied on staff for incontinence care needs.

On 11/01/23 at 12:40 pm, Staff  6 (Universal Worker - Designee) and Staff 11 (Universal Worker) were observed providing ADL incontinence care for Resident 2. Staff 6 and Staff 11 donned gloves without first performing hand hygiene. Staff 6 and Staff 11 assisted in transferring Resident 2 from wheelchair to bed, and then doffed his/her pants and brief. Staff 6 identified the resident's brief was soiled and removed the brief. Staff 6 then doffed her gloves and donned new gloves without performing hand hygiene. Staff 6 provided sprayed "incontinent solution" onto some toilet paper and provided perineal care to Resident 2. Staff 11 placed the soiled brief into the trash can.  Staff 6 and 11 placed a new brief while wearing soiled gloves and placed a blanket over Resident 2.

c. During an interview regarding soiled linen procedure on 10/31/23, Staff 9 (Universal Worker) stated she rinsed off linen soiled with fecal or urine matter in the resident's shower, placed the items in an uncovered plastic bin, and then placed the items directly in the washing machine. She stated she had not used the hopper. During interview on 11/01/23, Staff 1 (Executive Director) stated the hopper was recently repaired in 09/2023.

The need to establish and maintain effective infection prevention and control protocols was discussed with Staff 1 (ED) and Staff 3 (Regional Director) on 11/02/23. They acknowledged the findings.

2. Resident 3 was admitted to the facility in 09/2016 with diagnoses including dementia. Observations and interviews with staff during the survey identified s/he relied on staff for incontinence care needs.

On 10/31/23 at 12:40 pm, Staff 8 (Universal Worker) and Staff 10 (Universal Worker) were observed providing incontinence care for Resident 3. During the observation, both staff donned gloves without performing hand hygiene, transferred the resident to his/her bed, and removed his/her soiled brief. Both staff failed to doff soiled gloves, perform hand hygiene and don clean gloves before touching the resident's body and applying a clean brief for the resident.

The need to establish and maintain effective infection control protocols was discussed with Staff 1 (Executive Director) on 11/02/23. She acknowledged the findings.

1. All staff were trained on preservice infection prevention and control for community-based care (2 hours). Infection control specialist reinforced hand sanitizing, gloves change between tasks, and handling soiled items, for residents 1, 2, and 3. The infection control specialist will address soiled clothing handling in the facility and a live session on how to use the laundry sink.

2. Infection control specialist implemented for oversight, observation, and coaching of staff in proper infection control practices including hand sanitizing, gloves changes, and soiled clothing. All staff will be retrained in infection control.

3. Random daily audits.

4. The administrator, designee, the inspection control specialist will be responsible for ensuring compliance.

Based on observation and interview, 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 C200 and C295.

Refer to C200 and C295.

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 C260, C270, and C290.

Refer to C260, C270, and C290

Based on observation, interview, and record review, it was determined the facility failed to ensure a daily meal program based on resident's preferences and needs that was individualized and documented in the resident's service or care plan 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 current service plans were reviewed during survey. Each service plan lacked information and staff instructions related to the individualized nutrition and hydration status, preferences, and needs of the resident.  

The need to develop a daily meal program based on resident's preferences and needs that was individualized and documented in the resident's service or care plan was discussed with Staff 1(Executive Director) and Staff 3 (Regional Director) on 11/02/23. They acknowledged the findings.

1. An individualized nutritional plan is in place for residents 1,2,3 and 4. The individualized nutritional plan is documented in the residents' care plan, to instruct staff on how to implement it.

2. A new form of ' Individualized nutritional plan' is in place for each resident, to assess and implement nutrition and hydration plans specific to each resident.

3. Monthly and quarterly.

4. Administrator and designee.

Based on observation, interview, and record review, it was determined the facility failed to ensure activity evaluations were completed which included an individualized activity plan for each resident based on their activity evaluation and was reflective of the resident's activity preferences and needs for 4 of 4 sampled residents (#s 1, 2, 3, and 4) whose service plans were reviewed. Findings include, but are not limited to:

Although Residents 1, 2, 3, and 4's service plans offered some information about the residents' interests, the facility had not fully evaluated the residents' activity needs in one or more of the following areas:

* Current abilities and skills;

* Emotional and social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for the resident to participate; and

* Activities which could be used as behavioral interventions, if necessary.

There was no documented evidence resident-specific activity plans had been developed from activity evaluations.

Observations between 10/31/23 and 11/02/23 showed group activities being led by facility staff. Residents 1 and 3 were not observed to be invited to activities or provided adaptations to participate in the activities.

The need to ensure activity evaluations were completed for all residents and individualized activity plans that reflected the residents' preferences and needs and were developed based on their activity evaluation was discussed with Staff 1 (Executive Director) on 11/02/23. She acknowledged the findings.

1. An individualized activity plan is in place for residents 1,2,3 and 4. Resident 1 and 3 are invited to all the activity classes and staff is aware of their needs. The individualized activity plan reflects:

- current abilities and skills;

- emotional and social needs and

patterns;

- physical abilities and limitations;

- adaptations necessary for the resident

to participate; and

- activities which could be used as

behavioral interventions, if necessary.

The individualized activity plan is documented in the residents' care plan.

2. A new form of ' Individualized activity plan' is in place for each resident, to assess and implement activity plans specific to each resident.

3. Monthly and quarterly.

4. Administrator and designee.