Print Inspection: 2YPZ

The findings of the re-licensure survey, conducted 9/20/21 through 9/22/21 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 Home and Community Based Services Regulations OARs 411 Division 004.

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 first re-visit survey to the re-licensure survey of 09/22/21, conducted 12/20/21, 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 for 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 second re-visit to the re-licensure survey of 09/22/21, conducted on 03/09/22, 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 004 Home and Community Based Services.

Based on observation and interview it was determined the facility failed to ensure infection control practices related to Oregon Health Authority recommended COVID-19 precautions were consistently implemented for all staff. Findings include, but are not limited to:

Observations of common areas and the kitchen between 9/20/21 and 9/22/21 showed the following:

* On 9/20/21 and 9/22/21 housekeeping staff were observed with masks below noses or chins while working on the second floor of the facility.

* On 9/20/21 three kitchen staff were observed in the kitchen with cloth masks in place, one of which had stains/discoloration on the outside of the mask and one staff was observed with no mask in place.

The staff were instructed to change their masks to disposable procedure masks and were observed to do so.  Additional observations of the kitchen approximately 60 minutes later showed staff had masks underneath noses or chins.

* On 9/22/21 three kitchen staff were observed in the kitchen with no masks in place.

The staff were again instructed to put on a disposable procedure mask. The staff were instructed to keep masks in place during their duties and that masks could be removed when in a break area for meals and to consume fluids. The staff were additionally reminded to wash or sanitize their hands each time after touching their masks.

The need to ensure that disposable masks were in place and worn properly was discussed with Staff 1 (ED) on 9/20/21 and 9/22/21. Staff 1 acknowledged the findings.

1: ED has performed an all staff meeting on 10-6-2021 to ensure all are refreshed in Infection Control.  

2: Infection control binder at front desk to ensure everyone has access to it. ED placed

3: " Please wear your mask at all times" signs all over the community. ED placed

4: Inservice on importance of Masks, hand hygiene and benefits from all.  All inservice done by ED and BOD

5. BOD or designee will perform random audits to ensure proper infection control is being followed 6 times a month.

6. BOD will report these audits to QAPI monthly for 3 months or until deficient practice is resolved.

All residents, staff and visitors are at risk for this deficient practice.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was kept clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:

Observations of the kitchen on 9/20/21 showed the following:

* Multiple walls, doors and door frames had chips, dings, dirt/dust accumulation, gouges and/or spills;

* Edges of the floor had black dust/dirt accumulation underneath the lower cupboards and at doorways;

* Lower cupboards under the beverage station had exposed, untreated wood and missing laminate pieces;

* Multiple cabinets and drawers had dirt, spills, splatters on the outside surfaces, and/or spills and debris inside the cupboards and drawers;

* Refrigerator and freezer units had spills and debris under shelves, on the bottoms of the units, on the doors and vents;

* Metal shelving units in the dry storage and refrigerator units had flaking/peeling paint hanging from several shelves, exposed rust, dark accumulation gathered on the shelves and caked on food debris;

* Multiple areas of the kitchen floor were black with a dark accumulation around the edges of equipment and equipment legs;

* Lights throughout the kitchen had splatters on the outside, debris inside the fixtures and the ceiling had orange/brown splatters over the prep area;

* A large roll of butcher paper was stored directly on the floor with accumulated debris on the top of the roll;

* A large, white cutting board surface on top of the canned good cart was black/gray in multiple areas; and

* Drains under the sink and the dishwasher had food debris, accumulation of dark matter and garbage.

The need to ensure the kitchen was kept clean and in good repair was discussed with Staff 1 (ED) and Staff 11 (Culinary Services Director) on 9/20/21. The staff acknowledged the findings.

1: Racks have been ordered and will be replaced. Ordered on 9-10-2021. Awaiting arrival. ED ordered

2:Walls and paint have been deep cleaned and repainted by Kitchen staff. CD responsible for sign off. Will turn in an audit to QAPI 1x per month or until deficient practice is complete.

3: Inservice with Kitchen on nightly tasks held by CD on 11-01-2021

4: Kitchen cleaning task to ensure nightly routine is in place.

5: Culinary director will ensure weekly oversight of the kitchen to sign off on tasks.

6: Lower cabinets have been replaced.On order and awaiting arrival. ED ordered.

7. The Maintenance Director is responsible for ensuring all lights are taken down and cleaned. Will continue this practice monthly.

8. All floors were deep cleaned on 10-10-2021. Will be deep cleaned annually as well as needed.

9. CD will perform a monthly audit of all kitchen areas and ensure all surfaces are cleanable and in good repair. Will bring audits to QAPI monthly.

All residents, staff and visitors are at risk for this deficient practice.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements and failed to complete a 30 day evaluation for 1 of 1 sampled resident (#4) whose evaluations were reviewed. Findings include, but are not limited to:

Resident 4 was admitted to the facility in July 2021.

The resident's move-in evaluation, dated 7/8/21, was reviewed. There was no documented evidence the following required elements were addressed prior to move-in:

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

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

The facility failed to complete an additional evaluation 30 days after admission.

The need to ensure move in evaluations contain all required elements and 30 day evaluations were completed timely was discussed with Staff 1 (ED) on 9/22/21. She acknowledged the findings.

1-Nurse consultant team or their designee to perform audits on all resident assessments and service plans to include move in evals and 30 day evals with required elements. ED will bring to the monthly QAPI meeting .

2-ED created a tracker to ensure all assessments, change of conditions and necessary needs are met to ensure that the care plan states all needs will be met. Clinical team will review daily in standup.

3- ED will assign appropriate tasks found to be completed by clinical team members.

4- RSC or designee to read all TSP and CSP sheets at every change of shift to ensure they are met and signed off on by floor staff.

5-RSC or their designee will audit weekly to ensure all TSP and CSP are signed. Will bring all audits to QAPI monthly.

6-Required elements of 30 day and move-in evals have been updated by nurse consultant and Yardi creators for programs.

7- RSD will complete  a new evaluation for resident 4 and update SP accordingly.  

8- Weekly clinical meeting to ensure all needs are met.

All residents are at risk for this deficient practice

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (#7) and failed to ensure quarterly evaluations were completed for 3 of 3 sampled residents (#s 5, 8 and 9). This is a repeat citation. Findings include, but are not limited to:

1. Resident 7 was admitted to the facility in 12/2021 with diagnoses including chronic obstructive pulmonary disease and diabetes.

The move-in evaluation failed to address the following elements:

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

* Hearing, vision, speech, and assistive devices;

* Ability to use call system;

* Housework;

* Transportation;

* Recent losses;

* Elopement risk or history; and

* Alcohol and drug use.

The need to address all required elements in the move-in evaluation was discussed with Staff 1 (ED) on 12/20/21. She acknowledged the findings.

2. Clinical records for Residents 5, 8, and 9 were reviewed and revealed there were no current quarterly evaluations.

In an interview 12/20/21, Staff 1 (ED) reported she was unable to locate current quarterly evaluations for the residents.

The need to complete resident evaluations every quarter was discussed with Staff 1 on 12/20/21. She acknowledged the findings.

-Nurse consultant team or their designee to perform audits on all resident service plans to include move in evals and 30 day evals with required elements. ED will bring to the monthly QAPI 1x per month or until deficient practice is complete.

2-ED created a tracker to ensure all assessments, change of conditions and necessary needs are met to ensure that the care plan states all needs will be met. Clinical team will review daily in standup.

3- ED will assign appropriate tasks found to be completed by clinical team members.

4- RSC or designee to read all TSP and CSP sheets at every change of shift to ensure they are met and signed off on by floor staff.

5-RSC or their designee will audit weekly to ensure all TSP and CSP are signed. Will bring all audits to QAPI monthly.

6-Required elements of 30 day and move-in evals have been updated by the nurse consultant team and Yardi creators for programs.

All residents are at risk for this deficient practice      

2. Resident 1 was admitted to the facility in February 2020 with diagnoses including dementia.

Observations of the resident, interviews with staff and review of the service plan, dated 7/20/21, showed the service plan was not reflective of the resident's current care needs, was not consistently followed by staff and/or did not provide clear direction to staff in the following areas:

* Foot wounds and slipper use;

* Transfers, dressing and toileting;

* Edema and weight changes;

* Bathing/shower assistance twice a week;

* Falls, spouse assisted transfers and safety interventions; and

* Wheelchair and walker use.

The need to ensure resident service plans were reflective of current care needs, provided direction to staff and were followed was discussed with Staff 1 (ED) and Staff 3 (LPN) on 9/21/21. They acknowledged the findings.

3. Resident 3 was admitted to the facility in April 2020 with diagnoses including diabetes and congestive heart failure.

Observations of the resident, interviews with staff, and review of the resident's service plan, dated 7/17/21, and temporary service plans dated 6/1/21 through 9/20/21 showed the service plan was not reflective of the resident's current care needs and/or did not provide clear direction to staff in the following areas:

* Dressing, grooming and toileting assistance;

* Walker use;

* Edema and weight changes;

* Bathing/shower assistance twice a week;

* Right side rail placement; and

* Wheelchair and walker use.

The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (ED) and Staff 3 (LPN) on 9/21/21. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were completed, reflective of residents' needs, provided clear direction regarding the delivery of services and/or was followed by staff for 3 of 4 sampled residents (#s 1, 3 and 4). Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in July 2021 with diagnoses of chronic pain and anxiety.

Observations and interviews with staff and the resident were conducted during survey and identified that Resident 4 was independent with mobility and ADLs. The resident called for staff assist when s/he needed it.

There was no documented evidence a service plan was completed at the time of the resident's admission to the assisted living facility from the memory care.   

The need to ensure service plans were completed prior to a residents move-in was discussed with Staff 1 (ED) and Staff 3 (LPN) on 9/21/21.  They acknowledged the findings.

1 Nurse consultant team or their designee to perform audits on all resident service plans to include move in evals and 30 day evals with required elements. ED will bring to the monthly QAPI meeting  

2-ED created a tracker to ensure all assessments, change of conditions and necessary needs are met to ensure that the care plan states all needs will be met. Clinical team will review daily in standup.

3- ED will assign appropriate tasks found to be completed by clinical team members.

4- RSC or designee to read all TSP and CSP sheets at every change of shift to ensure they are met and signed off on by floor staff.

5-RSC or their designee will audit weekly to ensure all TSP and CSP are signed. Will bring all audits to QAPI monthly.

6-Required elements of 30 day and move-in evals have been updated by nurse consultant and Yardi creators for programs.

7- RSD will complete new  service plans to ensure residents' current updated needs and preferences for residents 2,3 and 4.

Resident 1 has been discharged.  

8- Weekly clinical meeting to ensure all needs are met.

All residents are at risk for this deficient practice

2. Resident 8 was admitted to the facility in 06/2020 with diagnoses including diabetes, chronic kidney disease, and decubitus ulcer.

Resident 8's service plan dated 02/23/21, 12/01/21 through 12/20/21 MAR/TAR, and progress notes dated 11/20/21 through 12/20/21 were reviewed. Observation of and interview with Resident 8 and interviews with Staff 1 (ED) and Staff 22 (CG) were completed. The service plan was not reflective and did not provide instruction to staff in the following areas:

* Side rails;

* Heel wound;

* Lower extremity edema;

* Outside provider services for wound care and physical therapy;

* Pain;

* Preference to have all meals in room;

* Use of electric wheel chair; and

* ADL assistance for lower body dressing.

On 12/20/21 the need to ensure service plans were reflective of residents'  current needs and status and provided clear direction to staff regarding the delivery of services was discussed with Staff 1. She acknowledged the findings.

3. Resident 5 was admitted to the facility in 11/2018 with diagnoses including dementia.

a. The service plan available to staff and the survey team during the survey was last reviewed and updated on 02/25/21. The facility failed to review the service plan quarterly.

b. Observations and an interview with the resident, interviews with staff, and review of the clinical record revealed the service plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas:

* Current skin status and treatment; and

* Discontinuation of Home Health services.

The need to ensure resident service plans were reflective of current care needs, provided clear direction to staff, and were updated at least quarterly was discussed with Staff 1 (ED) on 12/20/21. She acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current status and needs, provided clear direction regarding the delivery of services, and were updated quarterly for 3 of 3 sampled residents (#s 5, 8, and 9). This is a repeat citation. Findings include, but are not limited to:

1. Resident 9 was admitted to the facility in 12/2020 with diagnoses including Alzheimer's disease and stroke.

Review of the resident's most recent service plan, dated 04/26/21, interviews with staff and the resident, and observations of the resident during survey revealed the service plan was not reflective in the following areas:

* History of stroke with left-sided hemiparesis;

* Home health services; and

* Preference for female caregivers.

In an interview on 12/20/21, Staff 1 (ED) reported she was unable to locate a current service plan for the resident.

The need to ensure service plans were reflective of residents' current needs, provided clear direction to staff, and were completed quarterly was discussed with Staff 1 on 12/20/21. She acknowledged the findings.

-Nurse consultant team or their designee to perform audits on all resident service plans to include move in evals and 30 day evals with required elements. ED will bring to the monthly QAPI 1x per month or until deficient practice is complete.

2-ED created a tracker to ensure all assessments, change of conditions and necessary needs are met to ensure that the care plan states all needs will be met. Clinical team will review daily in standup.

3- ED will assign appropriate tasks found to be completed by clinical team members.

4- RSC or designee to read all TSP and CSP sheets at every change of shift to ensure they are met and signed off on by floor staff.

5-RSC or their designee will audit weekly to ensure all TSP and CSP are signed. Will bring all audits to QAPI monthly.

6-Required elements of 30 day and move-in evals have been updated by the nurse consultant team and Yardi creators for programs.

All residents are at risk for this deficient practice        

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that consisted of the resident, the resident's legal representative if applicable, any person of the resident's choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services, for 3 of 4 sampled residents (#s 1, 3 and 4) whose service plans were reviewed.  Findings include, but are not limited to:

Residents 1, 3 and 4's most recent service plans lacked documentation a Service Planning Team reviewed and participated in the development of the service plans.

The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (ED) and Staff 3 (LPN) on 9/21/21. They acknowledged the findings.

1- Facility will ensure a Service planning team is present for new changes and existing plans for resident 3, 4 as 1 was discharged.

2- Team will consist of ED/PD, RSD, RSC, resident and family. Floor staff will sign new updated forms to acknowledge that needs are met.

3-Nurse consultant or their designee to perform audits on all resident service plans to include move in evals and 30 day evals with required elements and signatures of the service planning team. ED will bring to the monthly QAPI meeting until deficient practice is resolved.

All residents are at risk for this deficient practice

Based on interview and record review, it was determined the facility failed to ensure a service planning team, consisting of the resident, the resident's legal representative, if applicable, any person of the resident's choice, the facility administrator or designee, and at least one other staff person who was familiar with, or who was going to provide services to, the resident, was involved in creating service plans for 3 of 3 sampled residents (#s 5, 8, and 9) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

Residents 5, 8, and 9's most recent service plans lacked documentation a service planning team reviewed and participated in the development of the service plans.

The need to ensure service plans were developed by a service planning team was discussed with Staff 1 (ED) on 12/20/21. She acknowledged the findings.

- Facility will ensure a Service planning team is present for new changes and existing plans for residents.

2- Team will consist of ED/PD, RSD, RSC, resident and family. Floor staff will sign new updated forms to acknowledge that needs are met.

3-Nurse consultant or their designee to perform audits on all resident service plans to include move in evals and 30 day evals with required elements and signatures of the service planning team. ED will bring to the monthly QAPI meeting until deficient practice is resolved.

All residents are at risk for this deficient practice

Based on interview and record review, it was determined the facility failed to ensure residents who had short term changes of condition were evaluated, resident-specific instructions or interventions were developed, and the condition was monitored to resolution at least weekly for 4 of 4 sampled residents (#s 1, 2, 3 and 4) who experienced changes of condition.  Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in February 2020 with diagnoses including dementia.

The resident's 7/20/21 service plan, 6/2/21 through 8/13/21 progress notes, temporary service plans and physician communications were reviewed. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness and/or lacked resident-specific directions to staff in the following areas:

* Falls;

* Hospitalization;

* Weight fluctuations;

* Neck pain;

* Swollen knee; and

* New medications and medication changes.

The need to ensure short-term changes of condition had documentation to reflect monitoring to resolution at least weekly and provided clear, resident-specific directions to staff was discussed  with Staff 1 (ED) and Staff 3 (LPN) on 9/21/21. The staff acknowledged the findings.

2. Resident 3 was admitted to the facility in April 2020 with diagnoses including diabetes and depressive disorder.

The resident's 7/17/21 service plan, 6/27/21 through 8/23/21 progress notes, temporary service plans and physician communications were reviewed. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness and/or lacked resident-specific directions to staff in the following areas:

* Weekly weights and weight fluctuations;

* Low blood pressures;

* Hip pain; and

* New medications and medication changes.

The need to ensure short-term changes of condition had documentation to reflect monitoring to resolution at least weekly and provided clear, resident-specific directions to staff was discussed with Staff 1 (ED) on 9/21/21. She acknowledged the findings.

3. Resident 2 was admitted to the facility in August 2015.

Resident 2's progress notes dated 6/15/21 through 9/19/21 and an incident report dated 6/11/21 identified the following change of condition:

The resident sustained a skin tear to the right shin on 6/11/21. S/he was sent to the ER on 6/15/21 with complaints of pain to the right leg. The resident returned and was started on an antibiotic for an infection of the leg wound.

There was no documented evidence the facility determined and documented what action or interventions were needed for the resident's wound and had communicated  to staff on each shift. There was no documented evidence the resident's medical condition related to the infection was monitored weekly to resolution.

The need to ensure the facility had a system for documenting changes of condition and monitoring until resolved was reviewed with Staff 1 (ED) on 9/22/21. She acknowledged the findings.

4. Resident 4 was admitted to the facility in July 2021 with diagnoses including anxiety and chronic pain.

Resident 4's record was reviewed for short term changes of condition that occurred  7/12/21 through 9/19/21 and the following were identified:  

* New admission to the facility;

* Lower extremity cellulitis with antibiotic treatment; and

* Medication error.

There was no documented evidence the changes of condition were evaluated or monitored through resolution.

The need to monitor short term changes of condition to resolution and evaluate interventions was reviewed with Staff 1 (ED) on 9/21/21. She acknowledged the findings.

1- Resident 1 is discharged.

ED and the facility team reviewed a 24 hour process.

2-ED Held in service on short term COC and what to look for, charting and adding to TSPS.

3- RSD or designee will audit the 24 hour book 5 days a week to ensure all short term COC are placed on alert and TSP on alert.

4- Clinical services team will review documentation weekly to ensure information is documented. WIll bring audits to monthly QAPI meeting

5-RSD will ensure that the completion of the triple check system to ensure all short term COC are noted and charted appropriately.

6- RSD or designee will alert RN of any short term COC that is not resolving to trigger a comprehensive COC.

7- For residents 2,3,4 the last 2 weeks were reviewed to rule out any short term change of conditions. Any changes of condition identified will be further evaluated.

8- Nurseconsultant team will do a random 5 resident charts  sample audit of current residents to ensure COC are captured if needed and steps followed. Results will be brought by ED to QAPI monthly meeting.  

All residents are at risk for this deficient practice

2. Resident 8 was admitted to the facility in 06/2020 with diagnoses including diabetes, chronic kidney disease, and anxiety disorder.  

The resident's 02/23/21 service plan, 11/20/21 through 12/20/21 progress notes, temporary service plans, and physician communications were reviewed. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution:

* Hypoglycemic event;

* Missed psychotropic medication; and

* Increase in Humalog insulin to 40 units three times a day with meals.

The need to ensure short-term changes of condition had documentation to reflect monitoring to resolution at least weekly was discussed  with Staff 1 (ED) on 12/20/21. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure short-term changes of condition were monitored and progress was documented at least weekly through resolution for 2 of 2 sampled residents (#s 8 and 9) who experienced changes of condition. This is a repeat citation. Findings include, but are not limited to:

1. Resident 9 was admitted to the facility in 12/2020 with diagnoses including Alzheimer's disease and stroke.

Review of the resident's clinical record, including the current service plan dated 04/26/21, temporary service plans, hospital discharge records, progress notes, and home health visit notes, in addition to interviews with staff and the resident, revealed the following:

* Resident 9 was sent to the hospital 11/16/21 and diagnosed with a stroke;

* S/he returned from the hospital 11/17/21 with hemiparesis of the left side;

* Occupational and physical therapies were initiated 11/22/21 and 11/26/21, respectively;

* A temporary service plan dated 11/17/21 directed staff to check on the resident frequently, ensure the call button was within his/her reach at all times, and toilet the resident during the night; and

* One progress note, dated 12/01/21, referred to the resident returning from the hospital, wanting meals in his/her room, staff assisting with toileting and nighttime needs, and assisting him/her to meals and back.

There was no documented evidence the resident was being monitored for signs or symptoms of stroke or that his/her hemiparesis was being monitored by staff.

The need to monitor short-term changes of condition through resolution with at least weekly documentation was discussed with Staff 1 (ED) on 12/20/21. She acknowledged the findings.

1- ED and the facility team reviewed a 24 hour process.

2-ED Held in service on short term COC and what to look for, charting and adding to TSPS.

3- RSD or designee will audit the 24 hour book 5 days a week to ensure all short term COC are placed on alert and TSP on alert.

4- Clinical services team will review documentation weekly to ensure information is documented. WIll bring audits to monthly QAPI meeting

5-RSD will ensure that the completion of the triple check system to ensure all short term COC are noted and charted appropriately.

6- RSD or designee will alert RN of any short term COC that is not resolving to trigger a comprehensive COC.

7- Nurseconsultant team will do a random 5 resident charts  sample audit of current residents to ensure COC are captured if needed and steps followed. Results will be brought by ED to QAPI monthly meeting.  

All residents are at risk for this deficient practice

Based on observation, interview and record review, it was determined the facility failed to ensure the RN performed an assessment, developed interventions based on the condition of the resident, and updated the service plan for 1 of 2 sampled residents (#1) who experienced a significant change. Findings include, but are not limited to:

Resident 4 was admitted to the facility in February 2020 with diagnoses including dementia and congestive heart failure.

Progress notes and physician communications dated 6/14/21 through 9/14/21, and interviews with care staff on 9/14/21 and 9/15/21 indicated the resident required one person assistance with care. The resident had a decline in July 2021 when s/he experienced a fall with fracture. The resident was noted to have intermittent edema and fair meal intake.

a. Review of the resident's weekly weight records from 3/1/21 through 9/20/21 showed the following:

* On 6/22/21 and 6/29/21 the resident's weight was noted at 125 lbs.

* The resident's weights in May 2021 and July 2021 were between 100 and 102 pounds.

* The resident experienced a 24 lb weight gain from 5/25/21 to 6/22/21, which constituted a 23% weight gain in one month.

* The resident experienced a 22.2 pound weight loss from 6/22/21 to 7/13/21 which constituted a 17.26% weight loss.

An RN assessment dated 7/24/21 indicated there was a 22.2 lb weight loss and a reweigh would be obtained. There was no additional information regarding the weight loss. An additional RN assessment dated 8/15/21 indicated staff were asked to "evaluate the 6/21 weight as they seemed to be outliers." There was no additional documentation regarding the potentially inaccurate weights.

Observations of the resident on 9/20/21 and 9/21/21 showed the resident ate both in the dining room and in her/his apartment with their spouse. The resident did not independently seek out food or fluids during observations but was able to feed herself/himself without assistance once items were provided. The resident's intake was approximately 50% of the items provided, though s/he did eat 100% of pudding and yogurt that was offered.

The facility failed to ensure an RN assessment was completed timely for the potential weight loss and gain with documented findings, resident status and interventions made as a result of the assessment.

b. On 8/4/21 skilled nursing through hospice was completed for pressure wounds to the resident's feet and daily treatment direction was provided. Ongoing hospice visits were to occur 1-3 times per week for wound care. Hospice notes indicated the areas were stage 2 pressure wounds.

An RN assessment dated 8/15/21 indicated it was a change of condition for "pressure injuries." The assessment indicated during a record review the RN came across the hospice note from 8/4/21. The RN was not previously made aware of the pressure injuries and requested additional information from hospice. Measurements of the left and right foot were documented and reference made to the treatment plans established by hospice.

The facility failed to ensure an RN assessment was completed timely for the pressure wound which documented findings, resident status and interventions made as a result of the assessment.

The need to ensure an RN assessment was completed timely, related to significant changes in condition which documented findings, resident status and interventions made as a result of the assessment was discussed with Staff 1 (ED) and Staff 3 (LPN) on 9/21/21. The staff acknowledged the findings.

The need to ensure a thorough RN assessment was completed timely was discussed with Staff 2 (RN) on 9/22/21, via phone. No additional information was provided.

1- Resident 1 was discharged.

2- ED has completed an audit of RN COC completed for the last 30 days to ensure that the facility staff have reviewed the assessments and updated the service plans accordingly.

3-RSD or designee will update service plans based on the RN COC assessments.

4- RN is adding to her COC assessment that Service plans updates will be completed by needed staff.

RN will review COC service plans monthly to ensure proper updates are completed. Report results to ED for completion and Audit findings for QAPI meeting.

All residents are at risk for this deficient practice

Based on interview and record review, it was determined the facility failed to coordinate care with outside providers, ensure documentation of visits were maintained in the residents' records, and that recommendations were implemented for 2 of 3 sampled residents (#s 1 and 4) who were receiving home health services from outside providers. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in February 2020 with diagnoses including dementia and congestive heart failure.  

During the acuity interview on 9/20/21, Resident 1 was identified as receiving outside provider services related to hospice and wound care.  

Review of the record indicated the resident sustained a fall with a hip fracture on 7/16/21. The resident returned from the hospital on 7/22/21 with hospice services in place.  The resident was noted to have bilateral wounds to her/his feet which were discovered on 8/4/21, hospice began treatment of the wounds. Hospice nursing visits were to occur 1-3 times per week.

Hospice nursing visit notes were not consistently documented and/or recommendations were not implemented as follows:

* There were no visits documented from 7/16/21-7/31/21, nursing visits were documented on two occasions between 8/1/21-8/31/21 and two occasions between 9/1/21 and 9/20/21;

* Nursing recommendations on 8/4/21 indicated staff were to remind the resident's spouse "not to use slippers that created wounds;" and

* Nursing recommendations on 8/17/21 indicated the facility could provide pressure relief boots and staff were not to put slippers on the resident's feet.

There was no evidence the recommendations were implemented and/or communicated to staff.

The need to ensure on-going coordination of care was maintained, documented and recommendations were implemented was discussed with Staff 1 (ED) and Staff 3 (LPN) on 9/21/21. The staff acknowledged the findings.

2. Resident 4 was admitted to the facility in July 2021.

During the acuity interview on 9/20/21, the resident was reported to receive nursing services from an outside service provider for recurrent lower extremity cellulitis.

Review of Resident 4's 7/13/21 through 9/20/21 facility record revealed the following home health nursing communications were not reviewed for follow up and were not added to the service plan and communicated to staff:

* 7/28/21 "Keep legs clean and dry with compression (medigrips G) in place from foot to knee bend;"

* 7/31 "Leave stockinet in place till next visit;"

* 8/9/21 "Reinforce or change dressing if wet, soiled or damaged. Minimal tape usage. Xeroform to open areas only;" and

* 8/17/21 "Encourage resident to wash and lotion legs two times a day."

On 9/21/21 Staff 1 (ED) reported the resident was independent with all lower extremity care and treatments.

The failure of the facility to coordinate care with outside providers, ensure recommendations were reviewed, recommendations were added to the service plan and communicated to staff was discussed with Staff 1 on 9/22/21. She acknowledged the findings.

1- Resident 1 is discharged.

2- Resident number 4 ED has reviewed and noted all current outside provider documentation and updated the chart accordingly.

3-Outside provider documents are being reviewed in standup daily. RSD or designee will note them daily and follow up with documentation accordingly, to include alert charting and TSP.

4- Nurse consultant team will perform a 5 resident chart audit of outside documentation to ensure orders are in place and report monthly to ED for QAPI.

All residents are at risk for this deficient practice

2. Resident 3 was admitted to the facility in April 2020 with diagnoses including neuropathy and chronic pain.

The resident's signed physician orders dated 9/4/21 and 9/16/21 included the following orders:

* Tramadol 50 mg every six hours PRN for pain; and

* Hydrocodone/APAP 5-325 mg every eight hours PRN for pain.

The resident's Controlled Substance Disposition logs and MARS, reviewed from 8/1/21 through 9/20/21 showed the following:

* On 8/2/21 and 8/11/21 Tramadol doses were signed out on the disposition log, but were not on the MAR;

* An 8/3/21 Tramadol dose was signed out on the MAR, but was not on the disposition log;

* A partially filled out line on the disposition log indicated one Tramadol was given but contained no date, time or signature of the staff that signed out the medication;

* A 9/14/21 Tramadol dose was signed out on the MAR, but was not on the disposition log;

* A medication card for acetaminophen/codeine 300-30 mg every four hours PRN for pain was located in the medication cart. The medication was discontinued on 6/3/21, disposition logs showed the medication was last given on 6/2/21. The card and log gave no indication the medication was discontinued.

Comparison of the medication dosing cards to the disposition logs, showed the amount of medication left was reflected accurately on the log.  

The need to ensure narcotic disposition logs accurately reflected the medications administered and that discontinued medications were removed from the medication cart and destroyed in a timely manner was discussed with Staff 1 (ED) and Staff 3 (LPN). Staff 1 indicated normally medications were destroyed within 72 hours but sometimes there was a delay. Staff 1 had no other information related to the delay in destroying the acetaminophen with codeine. The staff acknowledged the findings.

Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility and to ensure discontinued controlled substances were disposed of in a timely manner for 2 of 3 sampled residents (#s 3 and 4) whose MARs and Controlled Substance Disposition logs were reviewed. Findings include, but are not limited to:

1. Resident 4 was admitted in 2021 and had diagnoses which included chronic pain.

Resident 4 had an order for Oxycodone (narcotic analgesic) 5 mg, one tablet every six hours for pain management.

Resident 4's Controlled Substance Disposition Logs and MARs, reviewed from 9/1/21 - 9/20/21, revealed two occasions when staff signed on the MAR that the Oxycodone was administered. However, the drug disposition log lacked documentation that the resident received the medication.  

On 9/7/21 Oxycodone was signed out on the drug disposition log five times. The MAR documentation showed the medication was administered four times that day.

The inconsistencies between the MARs and Controlled Substance Disposition logs were reviewed with Staff 1 (ED) on 9/21/21. She reviewed the documentation and acknowledged the discrepancies.

1-Resident 3, and 4 reviewed current orders and documentation to ensure sufficient controlled substances to meet the orders.

2- ED held inservice to ensure all med techs are following med room processes adequate to ensure.     

3- RSD or designee will perform a narcotic count audit monthly to include a 5 charts  resident sample matching administration to MAR of narcotic administration record. will bring to QAPI 1x per month or until deficient practice is complete.

4-RSD or designee to audit bi monthly the narcotic drawers to ensure all medications are active orders and destroy  meds per policy that are not.

All residents are at risk for this deficient practice

Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused to consent to orders for 3 of 3 sampled residents (#s 1, 3 and 4) who had documented medication and/or treatment refusals. Findings include, but are not limited to:

Resident 1, 3 and 4's 8/1/21 through 9/20/21 MARs were reviewed. The residents' records showed multiple medication and/or treatment refusals.

There was no documented evidence the facility notified the physician/practitioner each time the resident refused to consent to the orders.  

On 9/22/21, the need to ensure the facility notified physicians/practitioners of medication and/or treatment refusals was discussed with Staff 1 (ED). She acknowledged the findings.

1- Resident is discharged

2- RSD or designee for residents 3and 4 will review last 30 days of med administrations and refusals and report to PCP

3- ED sent a fax to every PCP regarding notification of refusals. RSD will update info orders to include refusals.

4-RSD will audit 5 of resident population of monthly and report refusals to PCP and bring results to QAPI 1x per month or until deficient practice is complete

All residents are at risk for this deficient practice

3. Resident 4's 9/1/21 through 9/20/21 MARs were reviewed and revealed the following orders:

* Milk of Magnesia two times daily as needed for constipation;

* Docusate Sodium every day as needed for constipation;

* Bisacodyl Suppository every day as needed for constipation;

* Miralax every day as needed for constipation; and

* Senna/Docusate twice daily as needed for constipation.

The MAR lacked clear direction and instruction to staff regarding which medications to administer first, second, third etc. for constipation, or when to notify the health care provider if ineffective.

The need to ensure MARs included clear parameters and direction to staff for medication administration was discussed with Staff 1 (ED) on 9/22/21. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was maintained for all facility administered medications, including resident-specific parameters for PRN medications for 3 of 4 sampled residents (#1, 3 and 4) whose medication records were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in February 2020 with diagnoses including dementia.

Review of the resident's 6/2/21 through 8/13/21 progress notes, physician communications, and the 8/1/21 through 9/20/21 MARs showed the following:

* Lorazepam Intensol 2 mg/ml, give 0.25 ml to 1.0 ml every four hours, PRN anxiety.

There were no parameters to direct staff on what dose to give from the dosage range listed and no direction on what the resident's anxiety looked like.

* Morphine Sulfate 20 mg/ml give 0.25 ml to 1.0 ml every 30 minutes, PRN for pain and shortness of breath.

There were no parameters to direct staff on what dose to give from the dosage range listed.

* Morphine, Hydrocodone and Tylenol were ordered PRN for pain.

There were no parameters to direct staff which pain medication to give to the resident and in what order.

The need to ensure MARs were complete and included clear direction to staff for PRN medication administration was discussed with Staff 1 (ED) and Staff 3 (LPN) on 9/21/21. The staff acknowledged the findings.

2. Resident 3 was admitted to the facility in April 2020 with diagnoses including diabetes and congestive heart failure.

Review of the resident's 6/27/21 through 8/23/21 progress notes, physician communications and the 8/1/21 through 9/20/21 MARs showed the following:

* A blood sugar of 11 was noted on 8/8/21. There was no other documentation regarding the blood sugar to indicate if it was an error or an accurate reading;

* Multiple blanks were noted on the MAR in August 2021 and September 2021 related to Levothyroxine, Metformin, Simvastatin, Gabapentin, Basgalar insulin, Trazodone and a gummy vitamin;

* Acetaminophen, Tramadol and Hydrocodone were ordered PRN for pain. There were no parameters for staff on which of the pain medications to give first and in what order;

* Milk of Magnesia PRN for constipation. There was no information for staff on when to start the medication; and

* An order to monitor the resident for low blood pressure twice a day. There was no information directing staff what blood pressure readings to watch for.

The need to ensure MARs were complete and included clear direction to staff for PRN medication administration was discussed with Staff 1 (ED) on 9/21/21. She acknowledged the findings.

1-Resident 1 has discharged

2-Resident 3 and 4 med administration records will be  reviewed and all needed parameters put in place by RSD or designee.

3-RSD or designee review all residents medications and treatments requesting needed parameters from PCP. RSD or designee will implement PRN parameters as directed by regulation.

4- Nurse consultant team will complete a random audit monthly to ensure all medication parameters are in place. Results will be brought to the monthly QAPI meeting until deficient practice is corrected.

All residents are at risk for this deficient practice

Based on interview and record review, it was determined the facility failed to ensure PRN psychotropic medications used to treat a resident's anxiety had written, resident-specific parameters and non-drug interventions for staff to attempt prior to administering the medication for 1 of 2 sampled residents (#4) who were prescribed PRN medication for anxiety. Findings include, but are not limited to:

Resident 4 was admitted to the facility in July 2021 with diagnoses including anxiety and post traumatic stress disorder.

Review of the resident's 9/1/21 through 9/20/21 MAR and 8/24/21 physician's orders showed the following psychotropic medication:

* Lorazepam 0.5 mg (a psychotropic medication), one tablet twice a day as needed for anxiety.

The facility administered the Lorazepam to the resident on nine occasions between 9/1/21 and 9/20/21.

The MAR did not contain resident specific parameters for staff describing how the resident expressed anxiety. Additionally, there was no documentation of what non-drug interventions were attempted prior to administration of the medications.

The need to ensure there were resident-specific descriptions of how the resident expressed anxiety and that non drug interventions were attempted and documented prior to administration of the medication was discussed with Staff 1 (ED) on 9/21/21. She acknowledged the findings.

1- Resident number 4 medications will be reviewed by the RSD and proper non pharmacological interventions will be added to try prior to administration of psychotropic medications.

2-ED performed inservice on non drug interventions and individual interventions for residents to ensure proper knowledge of psychotropic medications

3-RSD of designee will do a full resident audit and add no drug interventions for each resident for the MAR and service plan.

4- Nurse consultant team will do a 5 charts or resident audit of residents on psychotropic medications to ensure all non pharmacological interventions are in place on the MAR and service plan. ED will bring it to the QAPI meeting until deficient practice is corrected.

Based on interview and record review, it was determined the facility failed to ensure that 2 of 3 newly-hired employees (#s 5 and 9) had completed pre-service orientation or dementia care training prior to assuming their job duties. Findings include, but are not limited to:

Staff training records were reviewed on 9/21/21. The following was noted:

1. Staff 9 (CG) was hired 7/29/21. There was no documented evidence Staff 9 completed the following training requirements:

* Standard precautions for infection control;

* Fire safety and emergency procedures; and

* Pre-service dementia training.

2. Staff 5 (MT) was hired 6/29/21. There was no documented evidence Staff 5 completed the following training requirements:

* Fire safety and emergency procedures; and

* Pre-service dementia training.

The need to ensure documentation of completed pre-service training was reviewed with Staff 1 (ED) and Staff 4 (Business Office Director) on 9/21/21. Staff  acknowledged the lack of training documentation.

1-Staff 5 and 9 will complete their preservice training.

2- BOD or designee will do a full staff audit of current employees to ensure all preservice and dementia 6 hour training not completed are identified

3- All staff identified in this audit will complete all necessary training

4- ED will audit all training of staff hired to ensure proper training has been completed and brought to the QAPI meeting until deficient practice is corrected.

All residents are at risk for this deficient practice

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 5, 9 and 10) had documented demonstration of competency in all required areas and First Aid and abdominal thrust training within 30 days of hire. Findings include, but are not limited to:

Review of the facility's training records on 9/21/21 indicated the following:

1. Staff 10 (CG), hired 1/28/21, lacked documented evidence of competency completed within the first 30 days of hire in the following areas:

* Identification, documentation and reporting of changes of condition;

* General food safety, serving and sanitation; and

* First Aid and abdominal thrust training.

2. Staff 9 (CG), hired 7/29/21, lacked documented evidence of competency completed within the first 30 days of hire in the areas of :

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

* Changes associated with normal aging;

* Identification, documentation and reporting of changes of condition;

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

* General food safety, serving and sanitation; and

* First Aid and abdominal thrust training.

3. Staff 5 (MT), hired 6/29/21, lacked documented evidence of competency completed within the first 30 days of hire in the areas of:

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

* Changes associated with normal aging;

* Identification, documentation and reporting of changes of condition;

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

* General food safety, serving and sanitation; and

* First Aid and abdominal thrust training.

The need to document demonstrated competency in job duties and complete First Aid and abdominal thrust training within 30-days of hire was discussed with Staff 1 (ED) and Staff 4 (Business Office Director) on 9/21/21. They acknowledged the findings.

1-Staff 5, 9 and 10 will complete their 30 day hire competency training.

2-BOD or designee will do a full staff audit of current employees to ensure all 30 day training not completed are identified

3- All staff identified in this audit will complete all necessary training

4- ED will audit all training of staff hired to ensure proper training has been completed and brought to the QAPI meeting until deficient practice is corrected.

5- CPR and abdominal thrust  training held on 10-15.

All residents, staff and visitors are at risk for this deficient practice.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired direct care staff (#s 20, 21, and 24) demonstrated competency of skills in all assigned job duties within 30 days of hire. This is a repeat citation. Findings include, but are not limited to:

Staff training records were reviewed on 12/20/21. There was no documented evidence Staff 20 (CG), Staff 21 (MT), and Staff 24 (MT), hired 11/08/21, 11/15/21, and 10/28/21, respectively, had completed one or more of the following required competencies:

* The role of service plans in providing individualized care;

* Changes associated with normal aging;

* Identification, documentation and reporting of 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 there was documented evidence all direct care staff demonstrated competency in all assigned job duties within 30 days of hire, including first aid/abdominal thrust, was discussed with Staff 1 (ED) on 12/20/21. She acknowledged the findings.

1-Staff to complete their 30 day hire competency training.

2-BOD or designee will do a full staff audit of current employees to ensure all 30 day training not completed are identified

3- All staff identified in this audit will complete all necessary training

4- ED will audit all training of staff hired to ensure proper training has been completed and brought to the QAPI meeting until deficient practice is corrected.

All residents, staff and visitors are at risk for this deficient practice.

Based on interview and record review, it was determined the facility failed to ensure all requirements were met for Fire and Life Safety preparedness, instruction and documentation. Findings include, but are not limited to:

Fire and life safety training and fire drill records were reviewed with Staff 1 (ED) and Staff 14 (Maintenance Director) on 9/21/21.  The following was identified:

* No documented evidence the facility was providing fire and life safety instruction to staff on alternating months from fire drills;

* No documentation of escape route used;

* No documentation of problems encountered and comments relating to residents who resisted or failed to participate in the drills;

* No documentation of the evacuation time period needed;

* No documentation of the number of occupants evacuated; and

* No documented evidence of alternate routes being used during fire drills.

The need to complete life safety training on alternate months and ensure fire drill documentation contained all required components was discussed with Staff 1 (ED) and Staff 14 (Maintenance Director) on 9/21/21. They acknowledged the findings.

1-Reviewed and updated policy to ensure required need for staff education on alternating month during fire drills

2- Fire Drill tool to include all necessary information needed on form.

3-ED will audit FLS binder monthly to ensure fire drills and education are done according to regulation.

4-Bring to QAPI meeting until deficient practice is corrected.

All residents, staff and visitors are at risk for this deficient practice.

Based on observation, interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:

Refer to C 252, C 260, C 262, C 270, and C 372.

1- ED to reinspect all areas of deficant practice to ensure POC is being followed.

2- ED to ensure QAPI in place to be ready for reinspection and passing on survey.

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

Observations of the patio and pathways on 9/20/21, showed there were multiple drop-offs of 2-4 inches along pathway edges and sitting areas in the patio area.

Additionally, one section of concrete in the front pathway was lifting which created an uneven surface and potential tripping hazard.

The need to ensure pathways in the resident courtyard did not have potential safety hazards was discussed with Staff 1 (ED) on 9/20/21. She acknowledged the findings.

1-MD and ED did a full exterior walk through identifying areas in concrete needing fixed and drop off areas.

2-Landscapers will fill drop offs with gravel on 10-20-21

3-Concrete has been fixed by the MD and team to ensure safe height.

4-MD or designee will exterior walk through monthly and bring results to QAPI meeting until deficient practice is corrected.

5-Any urgent need for ED to be fixed immediately.   

All residents, staff and visitors are at risk for this deficient practice.

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

Observations of the facility on 9/20/21 and 9/21/21 showed the following areas in need of cleaning or repair:

* Multiple walls, doors and/or door frames had scrapes, splatters/drips or gouges;

* Multiple black, orange and white stains of varying sizes were noted to carpets in common areas and hallways on the first and second floor;

* Multiple sections of carpet were noted to be extremely frayed and/or pulling away from the adjoining laminate floor in multiple areas throughout both floors of the facility;

* A white substance was noted along the handrail near the upstairs activity area;

* The oven in the activity area had debris and spills along the inside of the door and the bottom of the oven;

* Utility sink in the upstairs laundry room had debris, dark stains and gray accumulation at the edges;

* Room 212 inner door frame was pulling away from the wall;

* Cobwebs, dead insects and black accumulation was noted to hallway and activity room windows on the second floor;

* A long row of cupboards in the dining room was noted to have spills and stains on the cupboard doors and untreated surfaces where missing laminate was noted;  

* Elevator walls were scraped and gouged and the flooring was gouged; and

* The baseboard near the first floor laundry was pulling away from the wall and carpet baseboard pulling away near room 241 E.

The areas in need of cleaning and repair were shown to and discussed with Staff 1 (ED) and Staff 14 (Maintenance Director) on 9/21/21. The staff acknowledged the findings.

1-MD and ED did a full facility walk through identifying areas in need of fixing to ensure they have cleanable surfaces.

2-MD team has started painting, carpet repairs and transitions being placed.

3- Housekeeping team will go through to include deep cleaning of areas.

4-MD wll perform a facility walk through audit to ensure cleanable surfaces in good repair and free from debris.

5-MD will bring all audit tools to the QAPI meeting until deficient practice is corrected.

All residents, staff and visitors are at risk for this deficient practice.