Print Inspection: 7UOI

The findings of the re-licensure survey conducted 10/02/23 through 10/04/23 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the re-visit to the re-licensure survey of 10/04/23, conducted on 06/26/24, 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

communicate actions or interventions for short-term changes of condition to staff on each shift for 1 of 2 sampled residents (# 2) who experienced a fall with injury. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 06/2021 and was noted to have a history of falls.

The resident's 07/01/23 through 10/02/23 progress notes, 08/02/23 service plan,

09/29/23 fall investigation documentation and interim service plans (ISP's) were reviewed and revealed the following:

On 09/28/23 the resident experienced a fall, which resulted in a large skin tear to his/her right arm.

A 09/29/23 investigation into the fall noted an intervention to complete safety checks four times per shift. There was no documented evidence the fall intervention had been communicated to staff on each shift.  

The need to ensure interventions for short-term changes of condition were communicated to staff on each shift was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (RCC) on 10/04/23. They acknowledged the findings.

The RCC, RN, and/or ED will ensure that ISP's are in place for all short-term Change of Conditions. This will be communicated to all care staff during shift change and to ensure the that the ISP's are complete & signed by care staff.

For residents who experience a short-term change of condition; staff will initial a care sheet each time they enter the apartment to check on and/or provide care for the resident.

This system will be evaluated quarterly.

RN & ED to monitor system to ensure ISP's are in place.

Based on interview and record review, it was determined the facility failed to ensure non-pharmacological interventions were attempted prior to the administration of psychotropic medications for 1 of 1 sampled resident (#4) who was prescribed psychotropic medications. Findings include, but are not limited to:

Resident 4 was admitted to the facility in 01/2021 with diagnoses including anxiety.

Review of Resident 4's MAR dated 09/01/23 through 10/02/23 and physician orders revealed the following:

Resident 4 was prescribed PRN buspirone for anxiety, and it was documented as administered to the resident on six occasions between 09/01/23 and 10/02/23. The MAR included instructions to attempt non-pharmacological interventions prior to administering the medication. Staff documented "none" for interventions attempted on four of the above occasions.

The need to ensure staff attempted non-pharmacological interventions prior to administering PRN psychotropic medications was discussed with Staff 1 (ED) and Staff 2 (RN) on 10/04/23. They acknowledged the findings.

Medication Tech will offer non-pharmacological interventions that are resident specific prior to offering and/or giving a psychotropic medication.

The non-pharmacological interventions will be resident specific such as offering to sit with, talk with, or walk with the resident, offer breathing exercises, and/or music/tv to help calm resident. If no, interventions are successful; then Medication Tech will then offer the psychotropic medication. All interventions will be charted by the Med Tech, and reviewed by RN.

This system will be evaluated quarterly.

RN & ED to monitor system to ensure ISP's are in place.

Based on interview and record review, it was determined the facility failed to ensure all pre-service orientation training was completed prior to providing care to residents for 2 of 3 newly hired staff (#s 4 and 8) whose training records were reviewed. Findings include, but are not limited to:

Staff training records were reviewed on 10/04/23 and the following was identified:

a. There was no documented evidence Staff 4, hired 09/12/23, completed pre-service training in the areas of resident rights and values of CBC care and specific aspects of dementia including addressing pain, providing food/fluids, preventing wandering and use of person-centered approach.

b. There was no documented evidence Staff 8, hired 04/04/23, completed abuse reporting requirements and dementia training in the area of strategies for addressing social needs and engaging them in meaningful activities prior to beginning job duties.

The need to ensure all new staff completed the required pre-service training within the specified time frames was discussed with Staff 1 (ED) and Staff 3 (RCC) on 10/04/23. They acknowledged the findings.

Staff 4 will complete the pre-service training for resident rights, values of CBC care, and dementia training to address pain, providing food/fluids, preventing wandering, and using person-centered approach

Staff 8 will complete abuse reporting requirements, dementia training to include areas of strategies for addressing social needs and engaging them in meaningful activities

Moving forward the ED & BOM will ensure required pre-service is completed prior to any staff being scheduled to work the floor.

This system will be evaluated monthly.

ED & BOM to monitor to ensure required training is completed.

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 sampled newly-hired staff (#s 5 and 8) demonstrated knowledge and performance in all required areas within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed on 10/04/23 and the following was identified:

Staff 5 (CG), hired on 03/03/23, and Staff 8 (CG), hired on 04/04/23, lacked documented evidence of demonstrated knowledge and performance in the following areas:

* Changes associated with normal aging; and

* First aid/abdominal thrust.

The need to ensure newly hired direct care staff demonstrated knowledge and performance in all required training topics within 30 days of hire was discussed with Staff 1 (ED) and Staff 3 (RCC) on 10/04/23. They acknowledged the lack of training documentation.

Staff 5 will complete the required training to include changes associated with normal aging & 1st Aide/Abdominal thrust

Staff 8 will complete the required training to include changes associated with normal aging & 1st Aide/Abdominal thrust

Moving forward the ED & BOM will ensure required 30-day training/compentency is completed.

This system will be evaluated quarterly.

RN & ED to monitor system to ensure ISP's are in place.

This system will be evaluated monthly.

ED & BOM to monitor to ensure all 1st aide/Abdominal Thrust are completed

Based on interview and record review, it was determined the facility failed to ensure unannounced fire drills included all required components and fire and life safety instruction was provided to staff on alternate months of fire drills. Findings include, but are not limited to:

Facility fire drill records dated 04/2023 through 10/2023 were reviewed with Staff 1 (ED) on 10/03/23. The facility lacked documented evidence all fire drills included the following components:

* Escape route used;

* Problems encountered, comments relating to residents who resisted or failed to participate in the fire drills;

* Evacuation time needed;

* Number of occupants evacuated; and

* Evidence alternative routes were used during fire drills.

The need to ensure unannounced fire drills included all required components was discussed with Staff 1 on 10/04/23. She acknowledged the findings

Staff 1 & ESD will ensure that fire drills include all components including, but not limited to, documenting the escape route; problems encountered during the drill; evacuation time/s; number of occupants that were evacuated; and evidence of alternative route used.

We will ensure this is completed using the CBC Fire & Life Safety Review in addition to Frontier's fire drill document.

This system will be evaluated quarterly.

ED & ESD to monitor to ensure all required components are included

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

The facility was toured on 10/02/23 at 1:30 pm. The following areas were observed to need cleaning and/or repair:

* Carpet throughout the facility including the resident dining room and elevator had black and brown stains; and

* Fabric covered benches throughout the facility had spills and brown stains.

The need to ensure the facility was clean and in good repair was discussed with Staff 1 (ED) on 10/04/23. She acknowledged the findings.

Staff 1 & ESD will ensure this rule is met by ensuring the monthly shampooing of the carpet is completed for upstairs and downstairs on alternating months; will ensure scheduling cleaning for downstairs on odd months and upstairs scheduled for even months.

The flooring in the elevator will be replaced with VCT floor tiles to ensure cleanliness of the elevator.

The benches in the hallways will be shampooed once a month, as well as be spot cleaned throughout the month to ensure it is clean and free from stains. New bench covers have also been ordered. Cleaning task to be completed by housekeeper.

This system will be evaluated quarterly.

ED & ESD to monitor system to ensure carpets & benches are clean throughout the building