Print Inspection: 9TCZ

The findings of the re-licensure survey conducted 11/07/22 through 11/09/22 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

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 to the re-licensure survey of 11/09/22, conducted 03/07/23 through 03/10/23, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

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

Based on observation, interview and record review, it was determined the facility failed to provide effective administrative oversight to ensure quality of care and services rendered in the facility. Findings include, but are not limited to:

During the relicensure survey, conducted 11/07/22 through 11/09/22, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number of citations.

Refer to deficiencies in the report.

#1 - A full time Director of Assisted Living was employeed on 11/7/2022.

#2 - The Director of Assisted Living will be responsible for administrative oversight to verify compliance with quality of care and that services rendered at the community are effective.  

A 4x a week stand up meeting with community department managers and/or directors will be attended by the Director of Assisted Living or designee to review Assisted Living daily operations and discuss identified concerns with community leadership.  A weekly Assisted Living team meeting will be led by Director of Assisted Living or designee and attended by Assisted Living key leaders to review resident care and community services.  Quarterly Quality Improvement Committee Meetings will be held and attended by the Director of Assisted Living or Designee to review quality of care concerns.  The Quality Improvement Committee will review concerns brought to the committee, develop and monitior plans of correction.

#3 & #4 - The Executive Director or designee will audit stand up meeting checklist and Assisted Living Team Meeting Agenda weekly for 4 weeks to verify compliance.

Based on interview and record review, it was determined the facility failed to conduct an investigation of an injury of unknown cause, to rule-out abuse or neglect, and to report the injury as suspected abuse to the local SPD office, for 1 of 2 sampled residents (#3) who were identified to have an injury of unknown origin. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 09/2017 with diagnoses including hypertension, depression and atrial fibrillation.

Review of the resident's progress notes, dated 08/06/22 through 11/07/22 identified the following:

On 09/29/22 the resident reportedly had a "left pinkie finger red and purple, with bruising".

This incident represented an injury of unknown cause.

There was no documented evidence the facility immediately investigated this injury to rule out abuse or neglect. The facility did not report the injury to the local SPD office as suspected abuse or neglect.

In an interview on 11/09/22, Staff 2 (Administrator 2) confirmed the physical injury had not been investigated nor reported to the local unit. The surveyor requested the incident be reported to the local SPD office. Confirmation the incident had been reported was provided to the survey team on 11/09/22.

On 11/09/22 the need to ensure injuries of unknown cause were investigated promptly and reported if necessary was discussed with Staff 1 (Administrator 1) and Staff 2 (Administrator 2). They acknowledged the findings.

#1 - Resident #3, injury of unknown origin was reported to Adult Protective Services on 11/9/2022 by the Director of Assisted Living.  On 11/10/2022, the Health and Wellness Coordinator (HWC) interviewed Resident #3 in regards to injury of unknown origin. Resident #3 indicated she did not remember how injury to her finger occurred.  Resident #3 further indicated she felt safe and nobody had harmed her.   Based on investigation, the injury of unknown origin was unsustantiated for abuse and neglect. The injury of unknown origin was reported to the Med Tech on 9/29, reported to Hospice on 9/29 and Hospice evaluated resident #3 on 9/30.  

#2 - On 11/11/2022 The HWC re educated med techs and nurses on reporting accidents and injuries including injuries of unknown origin to the HWC or designee.

HWC or designee will audit progress notes from 9/29/2022 -12/5/2022 to identify accidents and injury including injury of unknown origin by 12/15/2022.

The HWC or Designee will review the 24hr report 5 days a week for 90 days to identify resident accidents and injuries to verify injuries of unknown origin were reported to HWC or designee per policy and procedure.  The HWC or Designee will conduct an investigation of identified accidents and injuries including injuries of unknown origin.  The HWC or Designee will report accidents and injuries to the Director of Assisted Living, responsible party and provider.  The Director of Assisted Living will report accidents and injuries including injuries of unknown origin to regulatory authorities as indicated based on investigation findings.

#3 & #4 - The Director of Assisted Living or Designee will perform a progress note audit weekly for 90 days to verify compliance with identification, investigation and reporting of accidents and injuries including injuries of unknown origin.   The Director of Assisted Living or Designee will report the results of the audit to the Quality Improvement Committee at the Quarterly Meeting to evaluate compliance and determine if additional auditing is necessary.

Based on interview and record review, it was determined the facility failed to ensure quarterly evaluations were completed for 2 of 4 sampled residents (#s 1 and 5) whose evaluations were reviewed. Findings include, but are not limited to:

1. Resident 1 moved into the facility in 11/2021. The most recent evaluation provided by the facility was dated 11/10/21.

In an interview on 11/08/22, Staff 1 (Administrator 1) and Staff 4 (Health and Wellness Coordinator/RN) confirmed the 11/10/21 evaluation was the most current evaluation they were able to locate and no quarterly review evaluations were available.

The need to ensure evaluations were completed at least quarterly and were used as a basis to develop the service plan was discussed with Staff 1, Staff 2 (Administrator 2), and Staff 4 on 11/08/22. They acknowledged the findings.

2. Resident 5 failed to have a quarterly evaluation completed at the time of their last service plan update effective 09/30/22.

On 11/08/22 at 3:15 pm, in an interview with Staff 4 (RN), she verified the resident's quarterly evaluation had not been completed.

On 11/09/22 at 3:00 pm, in an interview with Staff 1 (Administrator 1), Staff 2 (Administrator 2) Staff 3 (LPN) and Staff 4, the need for the facility to ensure quarterly resident evaluations were completed, in the resident's file and available to staff was discussed. They acknowledged the findings.

#1 - The service plan and quarterly evaluation for resident #1 was updated on 10/2/2022. This plan was reviewed and signed on 11/30/2022 by the resident and the service planning team.  The service plan and quarterly evaluation for resident #5 was updated on 9/30/2022. This plan was reviewed and signed on 11/30/2022 by the resident and the service planning team.

#2 - On 11/30/2022 the Director of Assisted Living and Health & Wellenss Coordinator audited current Assisted Living resident's service plans to verify current residents had an up to date service plan.  A tracking tool was then created to capture assessment due dates.

#3 & #4 - The tracking tool will be reviewed by Health and Wellness Coordinator or designee weekly x12 weeks.  The Director of Assisted Living or designee will audit service plan tracking tool weekly X 12 weeks to verify assessments are completed by the due date. The Director of Assisted Living or Designee will report the results of the audit to the Quality Improvement Committee at the Quarterly Meeting to evaluate compliance and determine if additional auditing is necessary.  

The Director of Assisted Living and Health & Wellenss Coordinator audited current Assisted Living service plans to verify completion on 11/30/2022.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were available to direct care staff, reflective of current care needs, provided clear instruction for staff regarding delivery of services, and were followed for 4 of 4 sampled residents (#s 1, 2, 3, and 5) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 09/2017 with diagnoses including hypertension, depression and atrial fibrillation.

Resident 3's current service plan, dated 10/06/22 was not available to staff, reflective of current care needs or did not provide clear instruction for staff in the following areas:

*showering/bathing;

*toileting;

*scoop mattress; and

*bedside fall mat.

On 11/09/22 the need to ensure service plans were developed for all residents, were reflective of current resident status, provided clear instructions for staff, and were followed was discussed with Staff 1 (Administrator 1) and Staff 2 (Administrator 2). They acknowledged the findings.

2. Resident 1 was admitted to the facility in 11/2021. A review of the resident's clinical record showed the most current service plan was the initial plan, dated 11/10/21.

a. During the entrance interview on 11/07/22, facility staff reported service plans were stored in the "care plan binder" for direct care staff to review. Upon observation of the binder stored in the medication room, the service plan for Resident 1 was not available in the binder.

During an interview on 11/08/22 with Staff 1 (Administrator 1) and Staff 4 (RN) the lack of a current service plan was discussed. Staff 1 provided a copy of the 11/10/22 service plan for review as the current service plan.

b. Upon review of the service plan, dated 11/10/22, the following areas were not reflective of the resident's needs:

* Use of a catheter; and

* Evacuation needs.

On 11/09/22 the need to ensure service plans were developed for all residents, were reflective of current care needs, provided clear instructions for staff, and were followed was discussed with Staff 1 (Administrator 1) and Staff 2 (Administrator 2). They acknowledged the findings.

3. Resident 2 was admitted to the facility in 11/2021 with diagnoses including history of a stroke with right sided weakness.

a. A review of the resident's clinical record showed the most current service plan, dated 10/06/22, was not available to direct care staff for review.

b. In an interview with Resident 5 on 11/08/22, a transfer pole was observed near his/her bed and the resident used hand gestures and facial expressions to communicate.

The 10/06/22 service plan was not reflective of care needs and did not provide direction to staff in the following areas;

* Individualized fall interventions;

* Transfer techniques for one person transfers;

* Use of a transfer pole;

* Effective communication techniques; and

* Evacuation needs.

The need to ensure current service plans were available to direct care staff, provided clear direction for staff to follow and were reflective of resident care needs was discussed with Staff 1 (Administrator 1), Staff 2 (Administrator 2), and Staff 4 (RN) on 11/09/22. They acknowledged the findings.

4. Resident 5 was admitted to the facility in 05/2022. A review of the resident's clinical record showed the most current service plan was dated 09/30/22. The service plan was not available to direct care staff for review.

The resident's 09/30/22 service plan was reviewed and was not reflective of the resident's current needs and lacked clear direction to staff in the following areas:

* Hands on assistance with bathing;

* Night shift toileting assistance; and

* PT had been discontinued.

The need to ensure service plans were available to care staff, reflective of residents current needs and provided clear direction to staff was discussed with Staff 1 (Administrator 1), Staff 2 (Administrator 2), Staff 3 (LPN) and Staff 4 (RN) on 11/09/22. They acknowledged the findings.

#1 - On 11/30/2022 and 12/1/2022 the Health and Wellness Coordinator conducted a personal service assessment and updated the personal service plan for Residents #1, #2, #3 & #4.  The personal service plans were reviewed with the resident and / or responsible party and signatures were obtained.

#2 - The Director of Assisted Living or Designee will re educate the Health and Wellness Coordinator on conducting personal service assessments and creating / updating the personal service plan prior to admission, within the first 30 days of residency, upon change of condition and at minimum of quarterly.  The Health and Wellness Coordinator or Designee  will conduct personal service assessments, create/update the personal service plan and replace the old service plan on the resident's chart with the most current personal service plan.

The Director of Assisted Living will conduct an audit of current Assisted Living resident's chart to verify current residents have a current service plan on their record that is accessible to associates providing resident care.  

#3 & #4 - The Director of Assisted Living or designee will audit 2 charts weekly X 12 weeks to verify current service plans have been placed in the resident record. The Director of Assisted Living or Designee will report the results of the audit to the Quality Improvement Committee at the Quarterly Meeting to evaluate compliance and determine if additional auditing is necessary.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of resident needs, provided clear direction to staff regarding the delivery of services and available to staff for 3 of 3 sampled residents (#s 7, 8 and 9) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 8 was admitted to the facility in 11/2022 with diagnoses including polyneuropathy.

a. Resident 8's service plan was not available to caregiving staff. The CGs were using a "Care Profile" which did not include the use of a private CG, the days the CG was in the facility, or the services provided by the private CG.

b. Resident 8's service plan was printed off and reviewed during the survey. The service plan was lacking information and direction for care givers in the following area:

* Coordination between staff and a private CG.

Failure to ensure service plans were available and provided clear direction to staff was discussed with Staff 2 (Administrator) and Staff 23 (Health and Wellness Coordinator, RN) on 03/10/23. They acknowledged the findings and no further information was provided.

3. Resident 9 was admitted to the facility in 07/2021 with diagnoses including hemiplegia, chronic obstructive pulmonary disease and depressive disorder.

Observations of and interviews with the resident, interviews with staff and a review of the resident's personal service plan, dated 01/17/23, revealed the personal service plan was not reflective and/or did not provide clear direction to staff in the following areas:

* Hot and cold packs for pain relief, including instructions for how long to use each modality and relevant skin monitoring;

* Arm and leg brace, including instructions for donning and doffing and relevant skin monitoring;

* BiPAP/CPAP machine;

* Shower bench;

* Front wheeled walker and hemi-walker, including instructions for when to use each device;

* Depression and monitoring around depression;

* Visual impairment, light sensitivity, lighting preferences and potential need for reading assistance; and

* Ability to self-propel wheelchair short distances.

The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 2 (Administrator) and Staff 23 (Health and Wellness Coordinator/RN) on 03/10/23 at 11:50 am. They acknowledged the findings.

2. Resident 7 was admitted to the facility in 12/2022 with diagnoses including anxiety, major depressive disorder and atherosclerotic heart disease. During the acuity interview on 03/07/23, the resident was identified with a right arm fracture.

Observations of and interviews with the resident, interviews with staff and a review of the resident's care profile, dated 02/10/23, revealed the detailed service plan was not available to staff and the care profile was not reflective and failed to provide clear direction to staff in the following areas:

* Arm brace and sling, including instructions for repositioning, donning and doffing and relevant skin monitoring;

* Preference for a bed bath;

* Anxiety and depression including monitoring instructions and interventions for anxiety and depression;

* Ability to self-propel wheelchair short distances;

* Intended weight loss and plan; and

* Current falls and fall interventions.

The need to ensure resident service plans were available to staff, were reflective of current care needs and provided clear direction to staff was discussed with Staff 2 (Administrator) and Staff 23 (Health and Wellness Coordinator/RN) on 03/10/23. They acknowledged the findings.

Immediate action:

In regards to resident #8, the service plan was located in the resident chart and available to staff. The service plan/care profile and resident evaluations for current residents were moved to 2 binders labeled "Service Plans/Care Profiles and Evaluations". The service plan for resident #8 was updated on 3/16/2023 to include the days that the private caregiver is in the facility and which services she provides.

In regards to resident #7, the service plan will be updated to reflect her care prior to her return to Assisted Living.

In regards to resident #9, the service plan was not updated regarding hot/cold pack usage as this order was discontinued by the doctor on 3/18/2023.

The service plan was updated on 3/16/2023 to specify that resident #9 has a CPAP and who manages the care and cleaning of the CPAP. The service plan was updated on 3/18/2023 with the resident preference to use the pre-installed shower bench in her shower. The service plan was updated on 3/18/2023 to indicate when resident #9 uses her wheelchair/4 wheel walker and Hemi-walker.

The service plan for resident #9 was updated on 3/18/2023 with monitoring guidelines for depression. The service plan was updated with resident #9's lighting preferences and potential need for reading assistance.

The Associate Executive Director in-serviced the Health and Wellness Director and the Health and Wellness Coordinator on 3/21/2023 regarding Service Plans and how they must reflect the resident's needs as identified in the evaluation. The service plans will be updated accordingly and will remain accessible to staff.

System to be put in place: The Health and Wellness Coordinator or Designee will conduct a one time audit for all current Assisted Living service plans for accuracy and add more resident specific information. Following the one time audit, service plans will continue to be updated at change of condition and at required intervals. This audit will be completed by 3/25/2023.

The Associate Executive Director or Designee will report the results of the audit to the Quality Improvement Committee at the Quarterly Meeting to evaluate compliance and determine if additional auditing/re-education is necessary.  

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that included the resident, the resident's legal representative if applicable, any person of the resident's choice, the Administrator or designee, and at least one other staff person who was familiar with or who was going to provide services to the resident for 4 of 5 sampled residents (#s 1, 3, 4 and 5) whose service plans were reviewed. Findings include, but are not limited to:

Review of Resident 1, 3, 4 and 5's most recent service plans determined the documents lacked evidence a Service Planning Team reviewed and participated in the development of the service plans.

On 11/09/22 the need to ensure service plans were developed by a Service Planning Team that included the resident, the resident's legal representative if applicable, any person of the resident's choice, the Administrator or designee, and at least one other staff person who was familiar with the resident was discussed with Staff 1 (Administrator 1) and Staff 2 (Administrator 2) . They acknowledged the findings.

#1 - On 12/1/2022, the Service Planning team which included the resident, Director of Assisted Living, Activity Coordinator and the Health and Wellness Coordinator reviewed and revised the Serice Plan for resident # 4 and #5.    

#2 - On 11/22/2022 The Director of Assisted Living identified and educated the service planning team members on the purpose and process of the Service Planning Team. The service planning team consists of the Health and Wellness Coordinator, resident, resident representative, Assisted Living Administrator, Activity Coordinator and direct care associates.

The Health and Wellness Coordinator or designee will schedule Service Plan team meetings and invite the resident, resident representative as applicable, Assisted Living Director, Activity Coordinator and at least one additional associate that is familiar with or who will provide services to the resident.

#3 & #4 - The Director of Assisted Living or designee will conduct audits weekly X12 weeks of residents with service plans due for the upcoming week to verify compliance with schedule and notification.

The Director of Assisted Living or designee will conduct audits weekly X12 weeks of service plan meeting sign in sheets for compliance with attendance of service planning team members. The Director of Assisted Living or Designee will report the results of the audit to the Quality Improvement Committee at the Quarterly Meeting to evaluate compliance and determine if additional auditing is necessary.

Based on interview and record review, it was determined the facility failed to identify and evaluate changes of condition, determine actions or interventions needed, provide written communication of those interventions to staff on each shift, and/or monitor the conditions to resolution for 2 of 4 sampled residents (#s 2 and 3) who experienced changes of condition.  Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 09/2017 with diagnoses including hypertension and chronic urinary tract infection (UTI).

Review of Resident 3's service plan, dated 10/06/22, progress notes, dated 08/06/22 through 11/07/22 and temporary service plans identified the following:  

*On 08/09/22 a progress note stated "[He/she] has been complaining of burning during urination. Hospice was notified and peri-care is being encouraged by the caregivers. Continue to monitor for further symptoms of a UTI and the need for a UA [urine sample]". There was no documented evidence a UA was ever collected, or that resident-specific instructions were provided for staff, regarding delivery of care; and

*On 09/29/22 Resident 3 was reported to have a "left pinkie swollen, slightly red and purple, with bruising". There was no documented evidence this condition was monitored at least weekly to resolution.

The need to evaluate short-term changes of condition, determine actions or interventions needed, provide clear instructions to staff and monitor the conditions to resolution was discussed with Staff 1 (Administrator 1) and Staff 2 (Administrator 2). They acknowledged the findings.

2. Resident 2 was admitted to the facility in 2021 with diagnoses including a history of stroke.

Progress notes, dated 08/10/22 through 11/06/22, and a review of any temporary services plans (TSP) available during the same time period noted the resident experienced a change of condition as follows:

On 10/05/22, a significant weight loss of 5% was documented in the progress notes and the resident was placed on "alert charting". While staff documented "on alert for weight loss, encouraging high protein snacks, will continue to monitor" consistently from 10/05/22 through 10/16/22, the record lacked information on what or how to monitor the weight loss and any interventions that were being tried and whether they were effective.

Weight records provided showed the following:

*06/05/22: 182 pounds;

*07/09/22: 181.5 pounds;

*08/05/22: 182.4 pounds;

*09/06/22: 180.5 pounds;

*10/04/22: 169.6 pounds; (loss of 10.9 pounds or 6% of body weight in 30 days);

*10/21/22: 167.8 pounds; and

*11/03/22: 168.8 pounds.

Following the 10/05/22 progress note, there was no TSP providing instruction to staff on what to monitor, any interventions to try and the record lacked information as to whether the condition was resolved.

The weight loss identified on 10/05/22 constituted a significant change of condition. The facility failed to document monitoring of the change and identify interventions from 10/05/22 through 10/21/22 when the facility RN completed a TSP.

The need to monitor changes of condition, identify and communicate interventions and monitor the interventions for effectiveness was discussed with Staff 1 (Administrator 1) and Staff 2 ( Administrator 2) on 11/08/22. They acknowledged the findings.  

#1 - On 11/10/2022 an alert charting audit was conducted by the Director of Assisted Living.  Progress notes on residents that were on alert charting at that time were up to date.

On 11/11/2022 the Health and Wellness Director re educated medication technicians and nurses on alert charting procedures per community policy.

#2 - Residents identified by the Health and Wellness Coordinator or designee via associate report and/or 24 hour report review as requiring alert charting will be added to the alert charting log which will include the reason for alert charting, the direction for monitoring resident, frequency, and date resident to be removed from alert charting.

#3 & #4 - The Health and Wellness Coordinator or designee will audit 3 resident records for residents on alert charting weekly X12 weeks for compliance with alert charting procedures.The Director of Assisted Living or Designee will report the results of the audit to the Quality Improvement Committee at the Quarterly Meeting to evaluate compliance and determine if additional auditing is necessary.  

2. Resident 9 was admitted to the facility in 07/2021 with diagnoses including hemiplegia following cerebral infarction and chronic obstructive pulmonary disease.

Resident 9's clinical record and charting notes, reviewed from 01/19/23 through 03/06/23, revealed the following:

a. Resident 9 had an order for atorvastatin calcium 10 mg by mouth once a day (for hemiplegia following cerebral infarction). The medication was not administered on 02/05/23, 02/06/23 and 02/15/23 due to not being available.

b. Resident 9 had an order for Symbicort aerosol 160-4.5 two puffs BID (for asthma). The medication was not administered on 02/04/23 due to not being in the med cart.

c. Resident 9 had an order for triamcinolone acetonide cream 0.1% apply BID to affected areas (for itching). The medication was not administered 18 times in 02/2023 due to waiting for delivery from the pharmacy.

There was no documented evidence the facility monitored the resident's condition for potential complications due to not receiving his/her routine doses of topical corticosteroid, high cholesterol medication or asthma inhaler.

The need to ensure the facility monitors short-term changes of condition through resolution was discussed with Staff 2 (Administrator) and Staff 23 (Health and Wellness Coordinator/RN) on 03/10/23 at 11:50 am. They acknowledged the findings, and no additional documentation was provided.

Based on observation, interview and record review, it was determined the facility failed to identify and evaluate changes of condition, determine actions or interventions needed, provide written communication of those interventions to staff on each shift, and/or monitor the conditions to resolution for 2 of 3 sampled residents (#s 7 and 9) who experienced changes of condition. Resident 7 had multiple unwitnessed falls including a fall with multiple fractures. This is a repeat citation. Findings include, but are not limited to:

1. Resident 7 was admitted to the facility in 12/2022 with diagnoses including atherosclerotic heart disease. Resident 7 was evaluated at move-in as a high fall risk. During the acuity interview Resident 7 was identified as having sustained a fall with a right arm fracture.  

Observations of and interviews with the resident, interviews with staff, review of the "care profile", dated 02/10/23, progress notes, dated 01/08/22 through 03/06/23, and a review of temporary services plans (TSP) available during the same time period noted the resident experienced six unwitnessed falls:

* 01/05/23 non-injury fall;

* 01/09/23 non-injury fall;

* 01/09/23 second non injury fall on the same day;

* 02/06/23 fall with fracture to right forearm and nose;

* 02/13/23 non-injury fall (resident fell on his/her previously fractured right forearm); and

* 03/09/23 fall with emergency room visit and the resident was admitted to skilled nursing.

During an interview with Staff 2 (Administrator) on 03/07/23 at 1:53 pm, it was reported "staff have access to the care profiles not the detailed personal service plans."

Review of the 02/10/23 care profile that was available to staff, failed to document and instruct staff of Resident 7's individualized fall interventions.

A TSP was written on 01/05/23 and provided the following information: observe and report pain, new injuries and discoloration, "encourage resident to call for help and use cane. Also encourage to take breaks while walking in the community."

One TSP was written for both 01/09/23 falls and provided the following information: observe and report pain, new injuries and discoloration.

There was no documented evidence the facility reviewed previous fall interventions for effectiveness, determined actions or interventions needed to minimize the risk of future falls after the first of two falls on 01/09/23. Resident 7 continued to fall which resulted in multiple fractures, unnecessary pain and discomfort.

The resident sustained a fourth unwitnessed fall on 02/06/23. The fall resulted in an emergency room visit due to a fractured nose requiring sutures and fractured right arm.  

A TSP written on 02/06/23 provided the following information: observe and report pain, new injuries and discoloration, take vitals daily "ongoing until resolved" and "will call for assistance with ADLs as needed."

During an interview on 03/09/23 with Staff 10 (MT), it was reported Resident 7 didn't have daily vitals taken. An interview with Staff 2 (Administrator) on 03/09/23 confirmed monthly vitals were taken and vitals were taken after each fall, but not daily.

Following the 02/06/23 fall, the facility failed to review fall interventions for effectiveness and implement new interventions, as appropriate. The facility failed to follow monitoring instructions consistently and document daily vitals until the fall resolved and failed to monitor the resident's nose fracture and sutures with weekly progress documented until resolved.

Resident 7 had a fifth unwitnessed fall on 02/13/23. The resident reported s/he had fallen on the previously fractured arm which resulted in unnecessary pain and discomfort.

The facility failed to determine actions or interventions needed after the 02/13/23 fall, review previous fall interventions for effectiveness, provide written communication of those interventions to staff on each shift, and monitor the condition to resolution.

On 03/03/23, a home health PT provider note documented instructions to "walk with assistance due to fluctuating dizziness and high fall risk".

There was no documented evidence the facility communicated the home health PT instructions and/or intervention to staff, updated the service plan or implemented the fall intervention.

During an observation and interview with Staff 23 (Health and Wellness Coordinator/RN) and the resident on 03/08/23 at 3:15 pm, the resident wasn't wearing his/her call pendant. The resident's cane was observed leaning against the couch on the other side of the room out of reach. Resident 7 stated s/he didn't want to wear his/her pendant because it got caught in the arm sling. The resident wasn't wearing any socks or shoes and was wearing a long garment. When the resident stood up the garment touched the ground. The resident stated s/he was wearing a similar garment during a previous fall.  

Six days later during the survey, on 03/09/23, the resident fell again and was sent to the emergency room. During an interview on 03/09/23, Staff 2 was unable to confirm any injuries sustained from the fall however, she confirmed the resident was admitted to skilled nursing.

On 03/09/23 at 2:00 pm, the survey team requested a safety plan for Resident 7 to mitigate the risk for future falls upon his/her return from skilled nursing. The safety plan was received and approved by the survey team on 03/10/23, prior to survey exit.

The need to ensure the facility determined actions or interventions needed, provided written communication of the interventions to staff, monitored and documented weekly progress until the conditions resolved was discussed with Staff 2 and Staff 23 (Health and Wellness Coordinator/RN) on 03/09/23. They acknowledged the findings.

Immediate action:

In regards to interview with Staff 2: Detailed service plans were located in individual charts in the medication room at the time of the re-visit survey. The individual service plans were removed during the re-visit and placed in binders labeled "Service Plans/Care Profiles and Evaluations" for ease of access to Assisted Living staff.

In regards to resident #7's service plan, this service plan will be updated prior to re-admission to assisted living.

In regards to resident #9, the missed Atorvastatin Calcium 10mg on 2/5/2023, 2/6/2023 and 2/25/2023 doctor notifications were faxed on 3/17/2023.

The missed Symbicort Aerosol 160-4.5 on 2/4/2023 doctor notification was faxed on 3/17/2023.

The missed Triamcinolone Acetonide Cream 0.1% in February of 2023 doctor notifications were faxed on 3/17/2023.

The Associate Executive Director in-serviced the Health and Wellness Director and the Health and Wellness Coordinator on 3/21/2023 regarding change of condition monitoring

System to be put in place: Temporary Service Plans will be completed for missed medications or refused medications.The Health and Wellness Director or designee will monitor the Point Click Care Dashboard daily for medications not administered.

The Associate ED completed a Medication Administration audit for the months of February and March of current Assisted Living residents. Missed medication notifications to doctors were either verified faxed or faxed on 3/17/2023.

The Associate Executive Director or Designee will report the results of the audit to the Quality Improvement Committee at the Quarterly Meeting to evaluate compliance and determine if additional auditing is necessary.  

Based on interview and record review, it was determined the facility failed to ensure significant changes of condition were assessed timely by a facility RN for 2 of 2 sampled residents (#s 1 and 2) reviewed for significant changes of condition. Findings include, but are not limited to:

1. Resident 1 was admitted in 11/2021 with diagnoses including tachycardia.

In an interview on 11/08/22, Resident 1 stated s/he had surgery in early October 2022 and returned to the facility with a catheter in place and lifting restrictions. This constituted a significant change in condition requiring an RN assessment.

A review of the clinical record, including progress notes from 08/15/22 through 10/24/22, the current service plan and any temporary service plans revealed no documented evidence the facility RN conducted an assessment.

During an interview with Staff 4 (RN) on 11/07/22, the lack of an RN assessment was confirmed.

2. Resident 2 was admitted in 11/2021 with diagnoses including history of a stroke.

A review of the clinical record including progress notes from 08/10/22 through 11/06/22, the current service plan and temporary service plans revealed Resident 2 experienced a significant change in condition of at least 5% weight loss in 30 days.

Weight records provided showed the following:

*06/05/22: 182 pounds;

*07/09/22: 181.5 pounds;

*08/05/22: 182.4 pounds;

*09/06/22: 180.5 pounds;

*10/04/22: 169.6 pounds; (loss of 10.9 pounds or 6% of body weight in 30 days);

*10/21/22: 167.8 pounds; and

*11/03/22: 168.8 pounds.

A progress note, dated 10/05/22, documented the resident had lost weight and was "not eating as much" and the "campus RN was notified for RN assessment." The progress notes contained a documented RN assessment of the weight loss on 10/21/22 (sixteen days later). Following the RN assessment, a TSP was created with interventions for staff to implement. The resident was weighed weekly and showed an increase in weight on 11/03/22.

The weight loss and RN assessment was discussed with Staff 4 (RN) on 11/08/22 and she acknowledged the assessment was not conducted timely.

The need to ensure significant changes of condition were assessed by an RN and that the assessments were done timely was discussed with Staff 1 (Administrator 1) and Staff 2 (Administrator 2) on 11/09/22. They acknowledged the findings.

#1 - RN assessment completed for resident #1 on 10/24/2022 by the interim Health and Wellness Director.  

#2 - A Licensed Nurse will complete a focus assessment for residents identified as experiencing a significant change of condition via verbal notification or the 24 hour report.  If the Licensed Nurse is a Licensed Practical Nurse (LPN) the LPN will consult with a Registered Nurse (RN) for review and sign off of the focused assessment.  

#3 & #4 - The Director of Assisted Living or designee will audit 3 resident progress notes with significant change of condition weekly x 12 weeks to identify compliance with LPN assessment, focused progress note, RN consult and RN sign off of focused progress notes. The Director of Assisted Living or Designee will report the results of the audit to the Quality Improvement Committee at the Quarterly Meeting to evaluate compliance and determine if additional auditing is necessary.  

Based on interview and record review, it was determined the facility failed to coordinate care with outside providers in order to ensure the continuity of care for 1 of 2 sampled residents (# 2) who received outside services. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 11/2021 with diagnoses including a history of stroke and diverticulosis.

A review of outside provider notes from 08/18/22 through 11/02/22 identified the following home health provider recommendations lacked evidence they were reviewed by the facility and were not communicated to staff to monitor or follow:

* 08/18/22: decreased ability for the resident to feed him/her self;

* 08/22/22: right sided weakness increasing, and resident will be receiving PRN Lorazepam;

* 08/30/22: "monitor to rule out gas pain vs. fistula" pain;

* 09/09/22: use of new communication techniques;

* 09/16/22: "encourage use of communication app"; and

* 09/23/22: worsening right upper extremity (RUE) edema.

Resident 2's home health recommendations were not documented in progress notes, temporary service plans or added to the current service plan.

In an interview on 11/08/22, Staff 1 (Administrator 1) stated outside provider recommendations were usually reviewed and signed by nursing staff for any recommendations. No other information was provided.

The need to ensure the facility coordinated care with outside service providers and communicated recommendations for staff to follow was discussed with Staff 1 and Staff 2 (Administrator 2) on 11/09/22. They acknowledged the findings.  

#1 - Outside provider notes for resident #2 were reviewed by the interim Health and Wellness Director on 11/8/2022.

On 11/10/2022, the Director of Assisted Living contacted and re-educated outside providers currently providing services to community residents on the process for providing written coordination of care documents to the community. Outside providers have been asked to place their notes in the designated box at the front desk at the completion of each visit.  The Director of Assisted Living re-educated the Health and Wellness Coordinator on reviewing coordination of care documents every shift, addressing any issues identified and entering progress notes as indicated in the resident record.

#2 - The Health and Wellness Coordinator or Designee will check the provider box each day worked to review documentation and verify documentation was received on the day of the outside provider visit.

#3 & #4 - The Director of Assisted Living will audit 2 records of residents receiving care from outside providers weekly X12 weeks to identify compliance with coordination of care process.The Director of Assisted Living or Designee will report the results of the audit to the Quality Improvement Committee at the Quarterly Meeting to evaluate compliance and determine if additional auditing is necessary.

2. Resident 9 was admitted to the facility in 07/2021 with diagnoses including hemiplegia.

During the acuity interview on 03/07/23, the resident was identified to receive home health physical therapy services.

Resident 9's outside provider notes, dated 01/30/23, and progress notes, dated 01/19/23 through 03/06/23, were reviewed during the survey and revealed the following recommendation:

* 01/12/23 - "Some grip tape would be beneficial for the shower grab bar for [him/her]."

Upon inspection of the resident's shower on 03/09/23 at 12:02 pm, there was no grip tape visualized. Additionally, there was no documented evidence staff was informed of the new intervention to increase the resident's safety during shower transfers.

The need to ensure staff were informed of new interventions identified by outside providers was discussed with Staff 2 (Administrator) and Staff 23 (Health and Wellness Coordinator/RN) on 03/10/23. They acknowledged the findings, and they provided no additional documentation.

Based on observation, interview and record review, it was determined the facility failed to coordinate care with outside providers in order to ensure the continuity of care for 2 of 3 sampled residents (#s 7 and 9) who received outside services. This is a repeat citation. Findings include, but are not limited to:

1. Resident 7 was admitted to the facility in 12/2022 with diagnoses including atherosclerotic heart disease. During the acuity interview on 03/10/23, the resident was identified as a high fall risk and had a fall with right arm fracture.

A review of outside provider notes from 02/02/22 through 03/03/23 identified the following home health provider recommendations:

* 02/22/23 - Non-weight bearing on the right upper extremity (RUE); and

* 03/03/23 - "Walk with assistance due to fluctuating dizziness and high fall risk".

Resident 7's home health recommendations lacked evidence they were communicated to staff, were added to the current service plan and were followed.

The need to ensure the facility coordinated care with outside service providers, communicated recommendations for staff to follow and updated the service plan was discussed with Staff 2 (Administrator) and Staff 23 (Health and Wellness Coordinator/RN) on 03/10/23. They acknowledged the findings.

Immediate action:

In regard to resident #7, the service plan will be completed prior to re-admission and updated at the appropriate intervals.

In regards to resident #9, the recommendation made on 1/12/2023 for grip tape on the shower grab bar was reviewed by the Health and Wellness Director on 3/20/2023. The resident requested that we do not make any modifications to her shower grab bar at this time.

The Associate Executive Director in-serviced the Health and Wellness Director and the Health and Wellness Coordinator on 3/21/2023 regarding the review of Outside Provider notes and following up on recommendations.

System to be put in place:

The Health and Wellness Coordinator or Designee will conduct a one time audit for all current Assisted Living service plans for accuracy and add more resident specific information. Following the one time audit, service plans will continue to be updated at change of condition and at required intervals. This audit will be completed by 3/25/2023.

The Associate Executive Director or Designee will report the results of the audit to the Quality Improvement Committee at the Quarterly Meeting to evaluate compliance and determine if additional auditing is necessary.   

Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 1 of 2 sampled residents (#9) whose orders were reviewed. Findings include, but are not limited to:

Resident 9 was admitted to the facility in 07/2021 with diagnoses including hemiplegia and chronic obstructive pulmonary disease.

Resident 9's MAR dated 02/01/23 through 03/06/23, corresponding progress notes and current physician's orders were reviewed.

Records revealed the following medications were not given as prescribed on the following dates, with documentation stating the medication wasn't in the medication cart or the facility was waiting on a pharmacy delivery:

* Ascorbic acid 500 mg (for supplement) - 02/12/23;

* Atorvastatin calcium 10 mg (for hemiplegia following cerebral infarction) - 02/05/23, 02/06/23 and 02/15/23;

* GenTeal Tears (for dry eyes) - 02/03/23;

* Symbicort aerosol (for asthma) - 02/04/23; and

* Triamcinolone acetonide cream (for itching) - 02/08/23 through 02/11/23, 02/13/23 through 02/18/23, and 02/20/23.

On 03/09/22 at 12:26 pm, the surveyor and Staff 10 (MT) observed/checked the MARs and medication supply. Staff 10 was unable to verify if the above orders had been followed.

The need to ensure physician orders were carried out as prescribed was discussed with Staff 2 (Administrator) and Staff 23 (Health and Wellness Coordinator/RN) on 03/10/23. They acknowledged the findings.

Immediate action:

In regards to resident #9, the resident's doctor was notified on 3/17/2023 about the missed medications from 2/3/2023-2/20/2023.

The Associate Executive Director in-serviced the Health and Wellness Director and the Health and Wellness Coordinator on 3/21/2023 regarding missed medication monitoring and provider notifications. The current Assisted Living Med Techs will be in-serviced on the topic of missed medications by 3/25/2023.

System to be put in place:

The Associate Executive Director completed a Medication Administration audit for the months of February and March 2023 for current Assisted Living residents. Missed medication notifications were either verified faxed or faxed on 3/17/2023.

The Health and Wellness Director or designee will monitor the Point Click Care Dashboard daily for medications not administered.

The Associate Executive Director or designee will run a medication audit report 3 days a week for 30 days to verify that doctors were notified timely for missed medications.

The Associate Executive Director or Designee will report the results of the audit to the Quality Improvement Committee at the Quarterly Meeting to evaluate compliance and determine if additional auditing is necessary.  

Based on interview and record review, it was determined the facility failed to notify the physician when a resident refused to consent to orders for 1 of 1 sampled resident (# 6) who had documented medication refusals. Findings include, but are not limited to:

Resident 6's clinical records and MARs were reviewed during the survey and revealed the resident had multiple medication refusals on 10/06/22, 10/08/22, 10/26/22 and 10/28/22.

The medications refused included:

* Flomax;

* Fludrocortisone Acetate;

* Melatonin;

* Mirtazapine;

* Polyethylene Glycol;

* Quetiapine Fumarte;

* Vitamin B12;

* Famotidine;

* Midodrine HCI;

* Propafenone HCI;

* Refresh tears; and

* Carbidopa.

There was no documented evidence the facility notified the physician when the resident refused consent to their orders.

On 11/09/22 the failure to notify physicians of the documented medication and treatments refusals was reviewed with Staff 1 (Administrator 1), Staff 2 (Administrator 2), Staff 3 (LPN) and Staff 4 (RN). They acknowledged the findings. No further documentation was provided.

#1 - The physician for resident #6 was notified of the medication refusals by the Director of Assisted Living on 11/30/2022.  The Director of Assisted Living conducted a medication refusal audit for current Assisted Living residents on 11/30/2022.  On 11/11/2022 the interim Health and Wellness Director re educated Med Techs on notifying the resident's provider and supervisor of medication refusals.

#2 - The Health and Wellness Coordinator or designee will review the Medication Administration Audit Report daily 5 days a week to identify medication refusals and verify physician notification was made.   

#3 & #4 - The Director of Assisted Living or designee will audit 3 residents a week X12 weeks of residents with identified medication refusals to verify proper notification was made and documented in the medical record. The Director of Assisted Living or Designee will report the results of the audit to the Quality Improvement Committee at the Quarterly Meeting to evaluate compliance and determine if additional auditing is necessary.  

Based on interview and record review, it was determined the facility failed to notify the physician or other practitioner when a resident refused consent to orders for 1 of 1 sampled resident (#9), who had documented medication and treatment refusals. This is a repeat citation. Findings include, but are not limited to:

Resident 9 was admitted to the facility in 07/2021 with diagnoses including chronic obstructive pulmonary disease and hemiplegia.

The resident's 02/2023 and 03/01/23 through 03/06/23 MAR and TAR were reviewed and identified multiple medication refusals.

a. The following medications were refused during the 5:00 pm medication pass on 02/16/23:

* Cranberry tablet 500 mg (for urinary tract infection prevention);

* Gabapentin 300 mg (for neuropathy);

* Lactaid tablet (for lactose intolerance);

* Methenamine Hippurate tablet 1 gm (for reducing urinary tract infections); and

* Potassium-Chloride 10 meq (for anaplastic large cell lymphoma).

b. The following medications were refused during the 8:00 pm medication pass on 02/20/23 and 02/23/23:

* GenTeal Tears (for dry eyes); and

* Symbicort aerosol 160-4.5 mcg/act (for asthma).

c. The following medications were refused during the 8:00 pm medication pass on 02/21/23:

* GenTeal Tears;

* Symbicort aerosol 160-4.5 mcg/act; and

* Triamcinolone acetonide cream (for itching).

d. The following medications were refused on 02/25/23:

* Acetaminophen tablet 500 mg (for pain);

* Ascorbic acid tablet 500 mg (for supplement);

* Aspirin tablet 81 mg (for hemiplegia and hemiparesis following cerebral infarction);

* Culturelle capsule (for digestive health);

* Duloxetine HCl DR 90 mg (for major depressive disorder);

* Famotidine tablet 20 mg (for acid indigestion);

* Ferrous sulfate tablet 325 mg (for supplementation);

* Prednisone tablet 5 mg (for reducing inflammation);

* Solifenacin succinate tablet 10 mg (for overactive bladder); and

* Potassium-chloride capsule 10 meq.

e. Additional refusals:

* Triamcinolone acetonide on 02/07/23, 02/10/23 and 02/28/23; and

* Symbicort aerosol on 02/24/23.

There was no documented evidence the facility notified Resident 9's physician of the above refusals.

On 03/10/23, the need to notify the physician or practitioner when a resident refused consent to orders was discussed with Staff 2 (Administrator) and Staff 23 (Health and Wellness Coordinator/RN). They acknowledged the findings. No additional information was provided.

Immediate action:

In regards to resident #9, the medications refused between the dates of 2/7/2023-2/28/2023 were reported to the resident's doctor on 3/17/2023.

System to be put in place:

The Associate Executive Director completed a Medication Administration audit for the months of February and March 2023 for current Assisted Living residents. Missed medication notifications were either verified faxed or faxed on 3/17/2023.

The Health and Wellness Director or designee will monitor the Point Click Care Dashboard daily for medications not administered.

The Associate Executive Director or designee will run a medication audit report 3 days a week for 30 days to verify that doctors were notified timely for missed medications.

The Associate Executive Director or Designee will report the results of the audit to the Quality Improvement Committee at the Quarterly Meeting to evaluate compliance and determine if additional auditing is necessary.  

2. Resident 1 was admitted to the facility in 11/2021 and had diagnoses including tachycardia.

During the entrance interview on 11/07/22, Resident 1 was identified as self-administering his/her own medications as well as administered medications for Resident 2 (spouse).

A review of the resident's clinical record revealed an evaluation to assure the ability to safely self-administer medications was completed on 11/18/21. An interview with Resident 1 on 11/08/22 confirmed s/he managed his/her own, as well as his/her spouse's, medications.

An interview with Staff 1 (Administrator 1) and Staff 4 (Health and Wellness Coordinator/RN) on 11/08/22 confirmed the most recent evaluation was completed on 11/18/21 (upon move-in) and there were no quarterly evaluations available.

3. Resident 2 was admitted to the facility in 11/2021 with diagnoses including a history of stroke and diverticulosis.

A review of the resident's clinical record on 11/07/22 revealed the lack of an evaluation to assure the resident's ability to safely have medications in the unit. On 11/08/22, Staff 3 (LPN) provided an evaluation, completed and dated 10/06/22. Staff 3 was unable to locate any evaluation completed prior to 10/06/22 (quarterly).

Upon review of the completed evaluation, the following discrepancies were revealed:

* the evaluation stated the resident had a physician's order to self administer medications; and

* the evaluation provided approval for the resident to self-administer their medications.

During an interview with Staff 3 on 11/08/22, the resident's evaluation was discussed. It was confirmed the resident did not have a physician's order to self-administer medications and was not self-administering his/her own medications, as the spouse/roommate was performing this duty.

The need to ensure the facility evaluated a resident's ability to safely self-administer medications at least quarterly and evaluated any roommate to ensure the resident's ability to safely have medications in the unit was discussed with Staff 1 (Administrator 1) and Staff 2 (Administrator 2) on 11/09/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure residents who chose to self-administer their medications were evaluated at least quarterly to assure ability to safely self-administer medications, for 3 of 3 sampled residents (#s 1, 2 and 5) who administered their own medications or had medications kept in their unit. Findings include, but are not limited to:

1. Resident 5 was admitted to the facility in 2022 with diagnoses including hypertension and hypothyroidism.

The resident's 10/2022 and 11/2022 MARs indicated Resident 5 was self administering all medications. The service plan indicated Resident 5 administered his/her own medications; however, there was no self-medication evaluation to determine the resident's ability to safely self administer medication and there was no physician's order for Resident 5 to self-administer his/her own medications.

The need to complete evaluations of a resident's ability to self administer medications at move-in and at least quarterly was discussed with Staff 1 (Administrator 1), Staff 2 (Administrator 2), Staff 3 (LPN) and Staff 4 (RN) on 11/09/22. They acknowledged the findings.

#1 - Self-med assessments were completed for  resident #1, resident #2 and resident #5 by the Health and Wellness Coordinator on 11/8, 11/22 and 11/8.  On 11/29/2022 the Director of Assisted Living conducted an audit of current resident's service plans which included verification of residents who self administer medication.  

#2 - Current residents who self-administer medications will be placed on a tracking tool with quarterly self-medications review assessment due dates.  The Health and Wellness Coordinator or designee will review the tracking tool weekly to identify residents with self-medication review assessments due for the upcoming week and complete assessments prior to the due date.  

#3 & #4- The Director of Assisted Living or designee will conduct a monthly audit X3 months of the resident records of residents self-administering medications to identify compliance with self-medication review assessments.The Director of Assisted Living or Designee will report the results of the audit to the Quality Improvement Committee at the Quarterly Meeting to evaluate compliance and determine if additional auditing is necessary.    

Based on observation, interview and record review, it was determined the facility failed to ensure residents who chose to self-administer their medications were evaluated for safety for 1 of 2 sampled residents (#9) who self-administered prescription medications. This is a repeat citation. Findings include, but are not limited to:

Resident 9 was admitted to the facility in 07/2021 with diagnoses including chronic obstructive pulmonary disease.

Review of Resident 9's quarterly evaluation, dated 01/24/23, revealed the resident was not capable of managing his/her medications independently.

On 03/08/23 at 9:24 am the resident's albuterol inhaler was observed on his/her bedside table. Resident 9 reported s/he was allowed to keep the rescue inhaler at bedside.

A current quarterly evaluation of the resident's ability to self-administer prescription medications was requested on 03/08/23 at 12:00 pm. The facility confirmed they did not have a self-medication evaluation for Resident 9 and completed an evaluation on 03/09/23.

The need to ensure residents who chose to self-administer medications were evaluated for safety was discussed with Staff 2 (Administrator) and Staff 23 (Health and Wellness Coordinator/RN) on 03/10/23. They acknowledged the findings.

Immediate action:

In regards to resident #9, the self-medication assessment was completed on 3/9/2023.

System to be put in place:

A self-medication audit of current Assisted Living residents was conducted by the Associate Executive Director on 3/20/2023. Self-medication evaluations are current as of 3/20/2023.

Beginning 3/16/2023, the Associate Executive Director and/or designee has been reviewing the self-medication due date spreadsheet once per week.  This process will continue for the next 30 days to make sure evaluations are completed timely.

The Health and Wellness Director or Designee will re-educate Assisted living associates to notify the Med Tech or a manager if medication is observed in a resident's possession.

The Associate Executive Director or Designee will report the results of the audit to the Quality Improvement Committee at the Quarterly Meeting to evaluate compliance and determine if additional auditing is necessary.   

Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) that determined appropriate staffing levels for the facility. Findings include, but are not limited to:

There was no documented evidence the facility was accurately using an ABST that would determine a staffing plan reflective to meet the 24-hour scheduled and unscheduled needs of residents.

A review of the ABST being used by the facility and an interview with Staff 2 (Administrator 2) and Staff 4 (RN) on 11/09/22 revealed the following:

1. The facility had not conducted updates of the ABST tool for each resident as required including:

(a) Before a resident move in, with amendments as appropriate within the first 30 days to address a resident's needs;

(b) Whenever there was a significant change of condition; and

(c) No less than quarterly, preferably at the same time the resident's service plan was updated.

2. During a review of sampled resident's service plans, it was determined the ABST failed to accurately include activities of daily living and other tasks related to care due to service plans lacking updated and accurate information on resident care needs.

The requirements of the ABST were discussed with Staff 1 (Administrator 1), Staff 2 (Administrator 2) and Staff 4 (RN) on 11/09/22. They acknowledged the current acuity tool in use by the facility did not include all the required information and did not generate an accurate staffing plan.

Refer to C260.

#1 - On 11/30/2022 & 12/1/2022 for residents #1, #2, #3 and #5 the Health and Wellness Coordinator conducted personal service assessments and updated the personal service plans to reflect residents current needs to facilitate the accuracy of the community's staffing plan.  

The Director of Assisted Living re-educated the Health and Wellness Coordiantor was on conducting accurate personal service assessments and creating / updating personal service plans prior to move in, within the first 30 days of residency, upon change of condition and no less than quarterly to faciliate the accuracy of the community's staffing plan.

#2 The Health and Wellness Coordinator or designee will conduct accurate personal service assessments and create/update the personal service plan for each resident prior to move in, within the first 30 days of residency, upon change of condition and no less than quarterly to facilitate the accuracy of the community's staffing plan.

The Director of Assisted Living will conduct an audit of current Assisted Living resident's chart to verify current residents have a current service plan on their record that is accessible to associates providing resident care.

#3 & #4 - The Director of Assisted Living or designee will audit 2 resident charts weekly X 12 weeks to verify compliance with timely and accurate personal service assessments and personal service plans. The Director of Assisted Living or Designee will report the results of the audit to the Quality Improvement Committee at the Quarterly Meeting to evaluate compliance and determine if additional auditing is necessary.

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff (#s 5, 11, 13 and 16) completed required pre-service training and 2 of 2 long-term staff (#s 14 and 18) completed infectious disease prevention training by 07/01/22. Findings include, but are not limited to:

Staff training records were reviewed on 11/09/22 and revealed the following staff had not completed infectious disease prevention training as required:

* Staff  5 (MT) hired 07/19/22;

* Staff 11 (CG) hired 04/12/22;

* Staff 13 (MT) hired 07/29/22;

* Staff 14 (CG), hired 04/30/19.

* Staff 16 (MT) hired 09/13/22; and

* Staff 18 (Server) hired 08/08/16.

The need to ensure newly hired direct care staff completed all pre-service orientation topics prior to beginning job responsibilities and long-term staff completed required infectious disease prevention training was discussed with Staff 2 (Administrator 2) and Staff 9 (Human Resources Director) on 11/09/22. They acknowledged the findings.

#1 - Associates # 5, 11, 13, and 16 will complete required infectious disease prevention training by 12/6/2022. The Human Resources Director or Designee will complete an audit of current Assisted Living Associates' training records to verify completion of infectious disease prevention training.

#2 - Newly hired associates will complete pre-service and infection control trainings prior to working with residents.  

#3 & #4 - Human Resources Director or Designee will audit Assisted Living new hires weekly X12 weeks to verify pre-service training in infectious disease prevention is completed.  Human Resources Director or Designee will report the results of the audit to the Quality Improvement Committee at the Quarterly Meeting to evaluate compliance and determine if additional auditing is necessary.  

Based on interview and record review, it was determined the facility failed to verify and document that 4 of 4 newly hired direct-care staff (#s 5, 11, 13, and 16) demonstrated satisfactory performance in all assigned duties within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed on 11/09/22 with Staff 9 (Human Resources Director) and revealed the following:

Staff 5 (MT), 11 (CG), 13 (MT), and 16 (CG), hired on 7/19/22, 4/12/22, 7/29/22, and 9/13/22, respectively, lacked evidence of completing the required training or demonstrating competency in the following areas:

* Role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Identification, documentation and reporting changes of condition;

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

* Other duties (Med pass, treatments); and

* First Aid/Abdominal thrust.

The need to ensure newly hired staff completed training and demonstrated competency in all assigned duties within 30 days of hire was discussed with Staff 2 (Administrator 2) and Staff 9. They acknowledged the findings.

#1 - On 11/9/2022 the Health and Wellness Coordinator completed competency checks on staff #5, #11, #13 and #16.  

#2 The Human Resources Director or Designee will conduct an audit of current Assisted Living Associates to verify completion of 30 day competency checks.  Competency checks will be conducted on associates identified as out of compliance by 12/30/2022.  Competency checks will be conducted on new associates within the first 30 days of employment.

#3 & #4 - Human Resources Director or designee will audit new direct care associate files weekly x 12 weeks to verify competency checks have been completed within 30 days of hire. Human Resources or Designee will report the results of the audit to the Quality Improvement Committee at the Quarterly Meeting to evaluate compliance and determine if additional auditing is necessary.   

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 long-term staff (#s 14 and 15) completed the minimum required 12 hours of annual in-service training in all required topics. Findings include, but are not limited to:

Staff training records were reviewed on 11/09/22 and revealed the following:

Staff 14 (CG), hired on 04/30/19, lacked documented evidence of completing the required 12 hours of annual in-service training; and

Staff 15 (MT), hired on 10/13/20, lacked documented evidence of completing the required six hours of dementia care training.

The need to ensure all required in-service training hours were completed annually was discussed with Staff 2 (Administrator 2) and Staff 9 (Human Resources Director) on 11/09/22. They acknowledged the findings.

#1 - Staff # 14 and #15 will complete 12 hours of annual in service training in required topics by 12/30/2022.

#2 -  The Human Resources Director or Designee will conduct an audit of current Assisted Living associates to verify compliance with 12 hours of annual inservice training in required topics.  Associates identified as out of compliance will complete 12 hours of in-service training in required topics by 12/30/2022.  The Human Resources Director or Designee will assign 12 hours of annual inservice training in required topics to associates to be completed annually by their anniversary date.

#3 & #4 - The Executive Director or designee will audit 2 associate's records weekly x 12 weeks to verify compliance with annual trainining requirements.  Human Resources or Designee will report the results of the audit to the Quality Improvement Committee at the Quarterly Meeting to evaluate compliance and determine if additional auditing is necessary.

Based on interview and record review, it was determined the facility failed to ensure all required components of fire drill records were documented in accordance with the Oregon Fire Code (OFC) and fire and life safety instruction to staff was provided on alternate months. Findings include, but are not limited to:

Fire and Life Safety records from 06/01/22 to 11/07/22 were reviewed on 11/08/22. The following deficiencies were identified:

1. One of two Fire drill records did not include the following required information:

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

* Staff who participated in the drill;

* Evacuation time period needed; and

* Number of occupants evacuated.

2. There was no documented evidence the facility provided fire and life safety instruction to staff on alternating months from fire drills.

The need to ensure documentation of all required components of fire drills and provide fire and life safety instruction to on alternate months was discussed with Staff 7 (Facilities Director) and Staff 2 (Administrator 2) on 11/09/22. They acknowledged the findings.

#1 - On 12/2/2022, the Director of Facilities conducted a fire drill for Assisted Living meeting the required components of documentation and participation.  Assisted Living associates who particpated in the fire drill signed that they participated in the fire drills.

#2 Executive Director re-educated the Director of Facilities on the required components and documentation for fire drills in Assisted Living.  The Director of Facilities will conduct fire drills, complete required documentation and maintain documentation of fire drills performed in the community every other month at different times of day, evening and night shifts.  

#3 & #4 - The Executive Director or Designee will conduct audits of fire drill documentaton quarterly for 6 months to verify compliance will performance of fire drills every other month on alternating shifts and documentation.  The Director of Facilities or Designee will report the results of fire drills and documentation to the Quality Improvement Committee at the Quarterly Meeting to evaluate compliance and determine if additional auditing is necessary.

Based on interview and record review, it was determined the facility failed to provide fire safety instruction to residents at least annually, in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to:

Review of facility records on 11/08/22 and an interview with Staff 2 (Administrator 2) and Staff 7 (Facilities Management Director) identified the following deficiencies:

There was no documented evidence training on fire safety was provided to residents at least annually.

On 11/09/22 the need to provide and document fire safety instruction to residents at least annually, in accordance with the OFC, was discussed with Staff 2 and Staff 7. They acknowledged the findings.

#1 - The Director of Facilities or designee will attend upcoming resident council meeting to review fire and life safety procedures with residents.

#2 - The Director of Facilities or designee will attend monthy Assisted Living Resident Council Meeting to review fire and life safety procedures with residents.

#3 & #4 - ED or designee will audit assisted living resident council meeting minutes monthly for 6 months to verify compliance. The Executive Director or Designee will report the results of the audit to the Quality Improvement Committee at the Quarterly Meeting to evaluate compliance and determine if additional auditing is necessary.

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 260, C 270, C 290, C 305 and C 325.

Immediate action:

C260, C270, C290, C303,C205, C325 and C455 will be in compliance as of 3/31/2023.

System to be put in place:

The Health and Wellness Director, Health and Wellness Coordinator and Med Techs will be re-educated on the six citation areas listed above.

The re-visit survey will be entered into our Quality Improvement Program to evaluate compliance and determine if additional auditing is necessary.

Based on observation and interview, it was determined the facility failed to ensure operable windows were designed to prevent accidental falls when sill heights were lower than 36 inches and above the first floor, and to provide keys to locked storage to residents. Findings include, but are not limited to:

1. The facility was toured on 11/07/22 and was observed to have windows with sills lower than 36 inches in at least one resident unit (Room M27) and common areas on the third floor.

2. During a group interview on 11/08/22, several residents stated they did not possess keys to the lockable storage units in their apartments.

In an interview on 11/09/22 with Staff 2 (Administrator 2), the "Resident Handbook" was reviewed. In reference to resident keys, the manual stated:  "The marketing staff will give you keys on or before your move-in day. A full set of keys includes a key for your home (One per resident) and a key for your mailbox (One per household)."

Staff 2 acknowledged the storage unit keys were neither addressed in the handbook nor consistently issued to residents.

On 11/08/22 at 9:45 am, the facility was toured with Staff 2 (Administrator 2) and Staff 7 (Facilities Management Director). They acknowledged the windows on the third floor were not designed to prevent accidental falls and the need to ensure residents have a lockable storage space with a key.

#1 - On 11/11/2022, the Director of Facilities or designee completed an audit of windows in Assisted Living to determine which windows required a locking mechanism.  On 11/11/22 the Facility Director ordered locking mechanisms which were delivered on 12/6/2022.  Installation of the locking mechanisms will be completed by 12/9/2022.  On 11/11/2022 the Director of Facilities conducted an audit of assisted living apartments to determine residents needing a key to locked storage.  The Director of Facilities or Designee will order and distribute storage keys to current residents by 12/23/2022

#2 - Director of Assisted Living or Designee will inspect assisted living windows after 12/9/2022 to verify installation of locking mechanisms on required windows.  No further intervention required regarding window locking mechanisms. Director of Assisted Living or Designee will interview current residents after 12/23/22 to verify receipt of storage key.  The Director of Assisted Living will re educate  Sales and Marketing Director on distributing storage keys to new residents upon move in and obtaining signature of receipt.  Sales and Marketing Director of Designee will distribute storage key to new residents upon move in and obtain signature verifying receipt.   

#3 and #4 The Director of Facilities will report confirmation of the installation of window locking mechanisms to the Quality Improvement Committee at the Quarterly Meeting to evaluate compliance.  The Director of Assisted Living or designee will audit key receipt form of new residents monthly for 3 months to verify compliance. The Diretor of Assisted Living or Designee will report the results of the audit to the Quality Improvement Committee at the Quarterly Meeting to evaluate compliance and determine if additional auditing is necessary.