Print Inspection: 644C

The findings of the re-licensure survey conducted 03/04/24 through 03/06/24 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities 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 relicensure survey of 03/06/24, conducted 05/17/24, 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 Home and Community Based Services Regulations OARs 411 Division 004.

Based on interview and record review, it was determined the facility failed to ensure actions or interventions needed for a resident following a short term change of condition and monitoring of the condition with weekly progress noted until resolution was documented in a way that they could be made part of the resident's record, for 2 of 3 sampled residents (#s 2 and 3) who had multiple changes of condition requiring monitoring. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 01/2021 with diagnoses including vascular dementia with behavioral disturbance and cerebrovascular disease.

Review of resident progress notes indicated on 12/13/23 Resident 2 was diagnosed with a urinary tract infection (UTI) and prescribed an antibiotic medication.

There was no evidence the facility determined and documented what actions or interventions were needed for the resident and no evidence the facility documented monitoring weekly on the condition until it was determined the condition was resolved.

In an interview on 03/05/24, Staff 2 (RN) stated she could not find a copy of a Temporary Service Plan (TSP) form that she said should have been used to instruct direct care staff as to what to monitor and document regarding the resident's UTI and new medication. She explained that the facility often documented information about resident issues on a white board and acknowledged this method of documentation was not permanent and the information could not be made part of the resident record. She also reported that staff often documented on a resident's status in the "24-hour book" rather than in the resident's individual electronic progress notes. She acknowledged that documentation via this method also prevented its inclusion in the resident's individual record because the form included information about multiple residents and represented a confidentiality issue.

The need to establish a process for documenting what actions or interventions were needed for a resident in response to a change of condition, documenting monitoring of the progress of the condition at least weekly until resolved and ensuring all documentation could be made part of the resident's record was discussed with Staff 1 (Administrator) and Staff 2 on 03/06/24. They acknowledged the findings.

2. Resident 3 was admitted to the facility in 2023 with diagnoses including intestinal obstruction, congestive heart failure and schizophrenia.

Review of resident progress notes indicated Resident 3 experienced several changes of condition requiring monitoring. The following were identified:

a. 12/10/23: the resident received seasonal flu and COVID 19 vaccines. The temporary service plan (TSP) that was completed for staff did not indicate which vaccines the resident received. Though the TSP directed staff to document on the status of the resident every shift, there was no documented monitoring in the resident's individual record and no documentation that the condition was eventually considered to be resolved.

b. 02/05/24: the resident developed two wounds to the right upper rear thigh and buttocks from abrasion from his/her briefs. No actions or interventions were documented for staff and there was no weekly documentation of the status of the wounds. Records indicated HH provided wound care. A progress note on 03/06/24 by Staff 2 (RN) noted the wounds were resolved.

c. 03/05/24: the resident was prescribed a new supplement medication. The TSP instructed staff to document monitoring of the resident's status in the "24-hour book." Documentation via this method would have prevented the information from being made part of the resident's individual record because the forms included information about multiple residents and represented a confidentiality issue.

The need to ensure the facility determined and documented what actions or interventions were needed for a resident following a change of condition and documented progress of the condition at least weekly until resolved in a way that could be made part of the resident's record was reviewed with Staff 1 (Administrator) and Staff 2 on 03/06/24. They acknowledged the findings.

1. A. Resident 2 has been treated for UTI diagnosis with antibiotics. A progress note recapping the situation has been completed. Due to the fact this has already occurred, immediate further correction is not needed.                                      2. A. Going forward, the system will be as follows: TSP completed for UTI diagnosis, New Medication. Residents will be placed on alert. Alert charting flow sheet now in 24 hour report book, under the alert charting tab. Alert charting will be completed each shift, documenting in the resident progress notes in the facility E.H.R. system. RN will review new on set and resolved issues for residents experiencing ST COC.                                                                                             1. B. Resident 3 record has been updated with the name of vaccines given.                                                                                  2. B. Going forward, the system will be as follows: Residents will be placed on alert. Alert charting flow sheet now in 24 hour report book, under the alert charting tab. Alert charting will be completed each shift, documenting in the resident progress notes in the facility E.H.R. system. RN will review new on set and resolved issues for residents experiencing ST COC.                                                                                                1. C. Residents' wounds are resolved. RN completed a progress note in residents record, recapping skin issues.                                                                               2. C. Staff will complete an Incident Report for resident skin concerns. ED/LN or designee, will complete incident investigation and add resident to alert charting. Skin issues will be documented on the skin flow sheet, kept in a 24 hour report book. Skin issues and treatment will be communicated to staff via TSP or change of service. If skin concern warrants a significant COC, RN will complete within 48 hours. This will include any HH recommendations. TAR will be updated with any treatment orders.  LN/RN will complete skin rounds weekly. May accompany HH during the visit.                                                                                                   3. All systems above, will be evaluated daily at clinical review.                                                                                                    4. Person responsible: ED/LN/RN       

Based on interview and record review, it was determined the facility failed to document non-pharmacological interventions had been tried with ineffective results prior to administering a PRN psychotropic medication, for 1 of 1 sampled resident (#2) whose MAR was reviewed. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 01/2021 with diagnoses including vascular dementia with behavioral disturbance and cerebrovascular disease.

The resident was prescribed lorazepam (sedative to treat anxiety) 0.5 mg tablet - give 1 tablet every 4 hours as needed for nausea, agitation and/or anxiety. Review of the 02/2024 MAR indicated Resident 2 was administered one dose of the medication on 02/25/24.

There was no documentation indicating non-pharmacological interventions were attempted and were ineffective prior to the administration of the medication.

The need to ensure the facility documented that non-pharmacological interventions had been tried with ineffective results prior to administering a PRN psychotropic medication was reviewed with Staff 1 (Administrator) and Staff 2 (RN) on 03/05/24. They acknowledged the findings.

1. A. Person centered, non-pharmacological interventions have been added to the MAR. Staff have been trained to document if interventions were ineffective prior to administering resident's prescribed lorazepam. B. Resident is on hospice.                                                               2. Facility consultant requested guidance from CBC policy analyst (PA) as resident mentioned is on hospice. PA stated a MD order stating to for-go nonpharmacological interventions was acceptable. Facility has requested orders/clarification form hospice MD if nonpharmacological interventions are needed or not. All non-hospice residents with PRN psychotropic medications have had person centered, non-pharmacological interventions added to the MAR.                        3. System will be evaluated at daily clinical review. Dashboard will be reviewed for any residents who have received PRN psychotropics, to ensure interventions were attempted and effectiveness documented appropriately.                                                                                 4. Person(s) responsible: ED/LN/RN/Medication Aide.

Based on interview and record review, it was determined the facility failed to complete an acuity-based staffing tool (ABST) assessment for each resident that addressed all the required ADLs and the amount of staff time required to provide care, and ensure the ABST effectively determined appropriate staffing levels for the facility. Findings include, but are not limited to:

The facility's ABST was reviewed on 03/06/24 with Staff 1 (Administrator) and Staff 2 (RN). They provided print outs of the time required for staff to complete ADLs for each of the current residents and a summary of the total staff care time required for each day of the week per shift (days, evenings and overnight). However, the ABST assessment for each resident did not include the time required to provide care for all 22 required ADLs. Therefore, the tool did not accurately determine the correct amount of staff time required to provide care to the residents that could be used to develop the facility staffing plan.

The findings were reviewed with Staff 1 and Staff 2 on 03/06/24. They acknowledged the ABST assessments for each resident were incomplete, the tool was not reflective of the actual staff time required to provide care and the tool did not provide accurate information for the facility to use to determine appropriate staffing levels.

1. Facility has worked with E.H.R., Point Click Care (PCC) to establish ABST tool. All 22 required ADL's have been addressed, as well as the determined time to meet staffing levels.                                                                     

2. The ABST tool will be reviewed weekly and updated when residents care needs change. All resident move ins and move outs will also be updated to the ABST.

3. Weekly, each Friday.                                                            

4. Executive Director or designee.  

Based on interview and record review, it was determined the facility failed to ensure residents were re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire and a written record of fire safety training, including content of the training sessions and the residents attending, was kept. Findings include, but are not limited to:

Fire safety training records for residents was reviewed on 03/05/24 with Staff 2 (RN). She explained that the facility provided fire safety training to residents at admission but acknowledged the facility did not have a process for re-instructing the residents at least annually and documenting the content of the instruction.

The need to develop a process for re-instructing residents at least annually on fire safety procedures, and documenting the content of the training, was reviewed with Staff 1 (Administrator) on 03/05/24. He acknowledged the findings.

1. All residents have been re-trained for fire safety training.                                                                                       

2. April of each year, annual training for all residents will occur. Each resident has a Fire Safety training document, including date, content of training and signature. Training documents are kept in residents record.                                                                                         3. Upon addmission of new move in and annually, each April.

4. Executive Director