Print Inspection: B32Z

The findings of the initial survey conducted 06/27/22 through 06/29/22 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, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.

Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

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 re-licensure survey of 06/29/22, conducted 10/04/22 and 10/05/22, are documented in this report. It was determined the facility was in compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.

Based on interview and record review, it was determined the facility failed to thoroughly investigate incidents to rule out suspected abuse or neglect for 1 of  2 sampled residents (# 2) who experienced falls. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 06/2022 with diagnoses including dementia.

Progress notes dated 06/01/22 through 06/27/22, an Incident Reporting Form dated 06/15/22 and 05/27/22 move-in evaluation and service plan were reviewed and revealed the resident experienced a fall on 06/15/22.

The resident's move-in evaluation and service plan noted s/he should be checked for safety and location in an attempt to prevent falls and unmet needs.

On 06/15/22 facility staff charted "At around 6:00 this MT found resident lying on the ground" and "...this MT observed resident and noticed an open gash on resident's left side elbow..."

The facility lacked documented evidence of a thorough investigation to rule out abuse and neglect as a cause of the resident's injury.

The need to thoroughly investigate Resident 2's injuries to rule about abuse and neglect was discussed with Staff 1 (Executive Director) and Staff 2 (RN) on 06/29/22. They acknowledged the findings.

1.  The RN added additional information to the sample resident's chart to clarify that she had no reason to suspect abuse and her rationale for that opinion.  

2.  The RN, Administrator, or designee will investigate all injuries of unknown cause in a timely fashion.  Documentation of the investigation will include: time, date, place, individuals present, description of the event as reported, response of staff at the time of the event, follow up actions, if and how abuse is ruled out, and Adminstrator's follow-up.  If abuse is not ruled out, the incident will be reported to SPD, AAA, or law enforcement agency.   

3.  The Administrator will ensure compliance to the POC as he/she processes and reviews incident reports in each resident's records.        

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required components for 1 of 2 sampled residents (#1) who were recently admitted to the facility. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 05/2022. The move in evaluation was reviewed and failed to address the following components:

* Spiritual preferences;

* Cognition including confusion;

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

* Complex medication regimen; and

* Recent losses.

The need to ensure move in evaluations included all required components was discussed with Staff 1 (ED) on 06/29/22. She acknowledged the findings.

1.  The community has added spiritual preferences, cognition including confusion, personality including how the person copes with change or challenging situations, complex medication regimen, and recent losses to the sampled resident's evaluation.

2.  The community has updated the Resident Evaluation tool to prompt the person documenting the evaluation to include all elements required in the rule.  

3.  Upon consideration for admission, all potential residents will be evaluated, the required information will be added to the evaluation software which will generate the Individualized Service Plan

4.  Existing residents' evaluation tools will be converted to the updated version, with their quarterly Service Plan, and as needed in the case of changes.  

5.  The Administrator will ensure compliance with each Service Plan Review.

Based on interview and record review, it was determined the facility failed to ensure changes of condition were evaluated and referred to the RN when necessary, for 1 of 3 sampled residents (#2), who experienced a change of condition. Resident 2 experienced a fall which resulted in fracture of the left elbow. The resident continued to experience pain and loss of function for several days before being sent to the emergency room. Findings include, but

are not limited to:

Resident 2 was admitted to the MCC in 06/2022 with diagnoses including dementia. The resident's progress notes, incident reports and interim service plans (ISP's) were reviewed and revealed the following:

* A 06/15/22 progress note and Incident Reporting Form indicated the resident experienced an unwitnessed fall on the same date resulting in a "open gash on resident's left elbow."

* 06/15/22 The resident was placed on alert for the fall and injury to the left elbow, staff were informed via ISP to notify the RN and Med Tech if the resident was not using the left arm and had increased pain or swelling;

* Daily documentation between 06/15/22 and 06/20/22, the resident was noted to experience pain or discomfort while completing ADL's;

* 06/20/22 An RN assessment was completed and the resident was removed from alert for the injury to the left elbow;

* 06/22/22 An RN assessment was completed and the resident was placed on alert due to increased edema and swelling in the left hand;

* 06/23/20 A progress note transcription from the resident's Physical Therapist noted " ...unable to use the left arm to assist due to pain and swelling of this arm after fall ..." after consultation with the residents PCP, the resident was referred to be seen at an urgent care facility; and

* 06/24/22 The resident was seen at the emergency department and diagnosed with a fracture to the left elbow.  The facility failed to evaluate and refer the resident's increased pain during ADL's to the RN for assessment. As a result, the resident continued to experience pain.

The need to ensure Resident 2's change of condition was evaluated and referred to the RN was discussed with Staff 1 (Executive Director) and Staff 2 (RN) on 06/29/22. They acknowledged the findings.

1.  The RN added documentation to the sampled resident's record to confirm that she had evaluated the resident several times and did not suspect a fracture. The resident was sent to urgent care when his/her condition changed.   

2.  All changes of condition will be referred to the RN for review, documentation, and any necessary directions to staff for management.

3.  The RN, Administrator, and RCC will review compliance with change of condition monitoring with Service Plan Reviews.   

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

The first and second floors were toured on 06/27/22. There were multiple dark stains on the carpet throughout the first floor.

On 06/29/22, the need to ensure all materials and surfaces were clean and in good repair was discussed with Staff 1 (ED). She acknowledged the findings.

1.  The carpet will be cleaned in the common areas.

2.  The carpet has been added to a routine cleaning schedule for ongoing maintenance.

3.  Stains will be reported to houskeeping for remedy as noted in between routine carpet cleaning appointments.  

4.  The Administrator will monitor.  

Based on observation and interview, it was determined the facility failed to ensure all exit doors were equipped with an alarming device or other acceptable system to alert staff when residents exited the building. Findings include, but are not limited to:

Observations during the survey revealed exit doors, including the doors to the enclosed courtyard, had no alarm or other acceptable system to alert staff when residents entered or exited.

The failure to ensure doors were equipped with an alarming device or other acceptable system was discussed with Staff 1 (ED) on 06/29/22. She acknowledged the findings.

1.  The facility has ordered chimes that will alert the staff through the call system if residents should use a courtyard door.

2.  Once received, the chimes will be added to the call system

3.  The Administrator will check the chimes, at least, annually for continued efficacy.           

Based on interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to C 231, C 513 and C 555.

Please refer to C231, C512, and C55

Based on interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to C 252, and C 270.

Please refer to C231, C512, and C55

Based on observation, interview and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan was developed and included in the service plan for 1 of 3 sampled residents (#2) whose service plans was reviewed. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 06/2022 with diagnoses including dementia.

The resident's 05/27/22 move-in evaluation and service plan were reviewed.  The evaluation noted the resident was at risk for dehydration and fluids should be offered with and between meals to promote good hydration.

The service plan lacked staff instructions related to the resident's individual nutritional and hydration status and needs.

The facility failed to create an individualized nutrition and hydration plan based on the resident's preferences and needs and failed to document the plan in the resident's service plan.

The need to ensure individualized nutrition and hydration plans were developed, followed and included in the service plan was discussed with Staff 1 (Executive Director) and Staff 2 (RN) on 06/29/22. They acknowledged the findings.

1.  The sampled resident's nutrition and hydration status and needs were evaluated and made accessible to staff

2.  The facility evaluation software has been updated to include the required elements so that the person entering the informatin will be prompted to consider each item. Upon admission, as needed, and with each Service Plan Review, nutrition and hydration status and preferences will be reviewed and updated.

3.  Compliance will be reviewed by the Administrator with each Service Plan Review.  

Based on observation, interview and record review, it was determined the facility failed to ensure an individualized activity plan was developed for each resident based on their activity evaluation and failed to consistently provide meaningful activities for all residents that promoted or helped sustain physical and emotional well-being, for 3 of 3 sampled residents (#s 1, 2 and 3) whose service plans were reviewed. Findings include, but are not limited to:

Resident 1, 2 and 3's service plans offered some information about the residents' interests, however, the facility had not fully evaluated the residents':

* Current abilities and skills;

* Emotional and social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for the resident to participate; and

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

There were no specific activity plans developed from the evaluations that detailed what, when, how and how often staff should offer and assist the resident with individualized activities.

Observations and interviews indicated the residents were dependent on staff to initiate activities.

On 06/29/22 the need to ensure the facility provided meaningful activities based on a thorough evaluation and individualized activity plan for each resident was discussed with Staff 1 (ED), who acknowledged the findings.

1.  The sampled residents' Service Plan were updated to include specific activity plans.  

2.  The facility evaluation software has been updated to include the required elements so that the person entering it will be prompted to consider each item.  Each resident will be evaluated upon admission and quarterly with Service Plan Reviews for updates and modifications to that Service Plan to reflect the individualized activity plan for each resident.

3.  Compliance will be reviewed quarterly by the Administrator with Service Plan Reviews.