Print Inspection: DER4

The findings of the initial survey, conducted 12/26/23 through 12/28/23, 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

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 revisit to the relicensure survey of 12/28/23, conducted 03/26/24, 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 OARs 411 Division 004 for Home and Community Based Services Regulations.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (#3) whose evaluation was reviewed. Findings include, but are not limited to:

Resident 3's move-in evaluation, dated 07/31/23, lacked information regarding the following required elements:

* Customary routines;

* Spiritual, cultural preferences & traditions;

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

* Complex medication regimen; and

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

The move-in evaluation and the required elements was reviewed with Staff 1 (Director of Health Services/Administrator) and Staff 2 (RN, Director of Nursing) on 12/28/23. They acknowledged the findings.

It was identified that 16 residents were not asked 6 required questions prior to move-in.  Those 6 questions are captured in the form "CBC Resident Review Questions Missing from Pre Screening Eval pre 12.28.23" (attached). All 16 residents will be asked those questions, and any pertinent information learned will be used to update the resident service plan by February 26, 2024.

For future move-ins, we will use form "CBC Resident Review Form" (attached) to do the preadmission screening to ensure all questions are identified and asked.  

The Resident Care Manager will be responsible for verifying that all required questions have been asked prior to move-in.

Because move-ins do not occur frequently, we will evaluate compliance with each move-in.

The Resident Care Manager will report on the completion of all pre-move-in questions at the 24-hour report meeting preceding the move-in. The Director of Nursing is responsible to monitor to ensure this occurs.

Based on interview and record review, it was determined the facility failed to ensure an RN significant change of condition assessment, including findings, resident status, and interventions made as a result of the assessment, was completed in a timely manner following severe weight fluctuations for 1 of 1 sampled resident (#2) who experienced weight changes. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 05/2023 with diagnoses including congestive heart failure and vascular dementia.

A review of Resident 2's clinical record, including the current service plan dated 12/17/23, progress notes dated 09/26/23 through 12/26/23, and weight records was completed and staff were interviewed. The following was identified:

* 06/26/23 - 194.6 pounds;

* 07/26/23 - 194.2 pounds;

* 08/26/23 - 206 pounds;

* 09/26/23 - 211 pounds;

* 10/26/23 - 213.2 pounds;

* 11/26/23 - 218.2 pounds;

* 12/27/23 - 219.8 pounds (obtained during survey).

From 07/26/23 to 08/26/23, Resident 2 gained 11.8 pounds, an increase of 6%. This constituted a severe weight gain.

In a Change of Condition note, completed 09/14/23, the RN documented the resident's weight gain with enough information to be considered a significant change of condition assessment. The assessment was completed nineteen days after the significant weight gain was documented.

Between 08/26/23 and 11/26/23, the resident displayed continued weight gain of 12.2 pounds. Resident 3 was weighed during survey on 12/27/23 and displayed an additional weight increase of 1.6 pounds.

During an interview on 12/27/23 at 1:30 pm, Staff 3 (RN, Resident Care Manager) confirmed the physician was informed of daily weights via fax from 05/26/23 until 11/14/23, when a physician's order requested weekly weights. She stated upon correspondence with the physician, Resident 2's weight gain was not due to edema fluctuations, but a steady gain over time. There was no documented evidence of the correspondence.

The need for a significant change of condition assessment, which included findings, resident status, and interventions made as a result of the assessment, to be completed by an RN in a timely manner was discussed with Staff 1 (Director of Health Services/Administrator), Staff 2 (RN, Director of Nursing Services), Staff 3, Staff 4 (LPN, Resident Care Manager Assistant), Staff 18 (Staffing Coordinator/CNA), Staff 19 (Activities Coordinator), Staff 20 (Director of Social Services), and Staff 21 (Director of Human Resources) on 12/28/23 at 11:35 am. They acknowledged the findings.

An RN will document via late entry into the resident record the findings of the RN assessment, resident status, interventions put into place, and review of the ABST for the affected resident's significant change of condition due to weight increases of 11.8 lbs / 6% for dates 07/26/23 - 08/26/23 and 12.2 lbs for dates 08/26/23 - 11/26/23. No adverse outcomes occurred for the resident due to the delayed documentation of RN assessment.

The RN Resident Care Manager will monitor the electronic health record for information that may indicate a change of condition. Larkspur staffs a licensed nurse 24 hours a day, and the licensed nurse is responsible for notifying the RN Resident Care Manager or in their absence the Director of Nursing of changes in resident status that may indicate a change of condition.

When a change of condition is identified, an RN assessment - to include findings, resident status, interventions put into place, and review of ABST - will occur within 48 hours.

Compliance will be monitored via twice weekly interdisciplinary team meetings, which include both the RN Resident Care Manager, and the Director of Nursing. The RN RCM will report on any changes of condition and the status of the RN assessment. The Director of Nursing is responsible to monitor to ensure this occurs.

Based on interview and record review, it was determined the facility failed to have a written policy describing how prescription drugs not prepared as unit dose or blister packs should be dispensed. Findings include, but are not limited to:

A copy of the facility's medication administration policy that addressed how prescription drugs that were not prepared as unit dose or blister packs were dispensed was requested during the entrance conference on 12/26/23. Staff 2 (RN, Director of Nursing Services) reported the facility did not have a written medications administration policy addressing medications not prepared in blister packs.

On 12/28/23, the need to ensure a written policy describing how prescription drugs that were not prepared as unit dose or blister packs should be dispensed was discussed with Staff 1 (Director of Health Services/Administrator), Staff 2, Staff 3 (RN, Resident Care Manager), Staff 4 (LPN, Resident Care Manager Assistant), Staff 18 (Staffing Coordinator/CNA), Staff 19 (Activities Coordinator), Staff 20 (Director of Social Services), and Staff 21 (Director of Human Resources). They acknowledged the findings.

No residents were impacted by this deficiency.

The attached Medications Packaging policy will be implemented, including education provided to all licensed nurses. Education will consist of all licensed nurses reviewing the policy and having the opportunity to ask questions.  

On a quarterly basis, the consultant nurse pharmacist will conduct an audit of medication administration procedures, and compliance with this policy will be added to their scope of work.  The Director of Nursing is responsible for reviewing the consultant nurse's report and ensuring corrective action is taken for any identified issues.

Based on interview and record review, it was determined the facility failed to ensure all pre-service orientation topics and pre-service dementia training had been completed, with certification, prior to staff providing direct care to residents for 3 of 3 newly hired staff (#s 6, 7, and 13). Findings include, but are not limited to:

The facility's training records were reviewed on 12/27/23 and revealed the following:

A. Staff 7 (Nursing Assistant), hired 11/14/23 and Staff 13 (CNA), hired 05/08/23, lacked documented evidence s/he had completed the following:

* Resident's rights and values of CBC care;

* Abuse reporting requirements;

* Infectious Disease Prevention (two hour course);

* Fire safety and emergency procedures;

* Dementia disease process including progression, memory loss, psychiatric and behavioral symptoms;

* Techniques for understanding, communicating and responding to behaviors: reducing use of antipsychotics;

* Strategies for addressing social needs & engaging them in meaningful activities; and

* Specific aspects of dementia including pain, proving food/fluids, preventing wandering, use of person-centered approach.

B. Staff 6 (CNA), hired 08/28/23,lacked the following documented evidence s/he had completed the following:

* Resident's rights and values of CBC care;

* Infectious Disease Prevention (two hour course);

* Fire safety and emergency procedures; and

* Techniques for understanding, communicating and responding to behaviors: reducing use of antipsychotics;

Requirements for pre-service training were reviewed with Staff 1 (Director of Health Services/Administrator) and Staff 2 (RN, Director of Nursing Services) on 12/28/23. They acknowledged the findings.

An audit will be conducted for all employees to create a comprehensive list of gaps in required preservice trainings.  Any missed trainings will be assigned to each person, and they will be scheduled for a time to complete the trainings by the date of allegation of compliance.

Preservice trainings for all employees will include Resident Rights and Values of CBC Care; Abuse Reporting Requirements; Standard Precautions for Infection Control; Fire Safety & Emergency Procedures; Food Handler's Certificate (if handling food); and a signed written job description. In addition, direct care staff will be required to complete 6 hours of training on dementia in accordance with 411-054-0070 (3) & (4).

At the time of hire, new employees will be given a written document that states the pre-service training requirements. For non-direct care staff, the Recruitment and On-boarding Specialist will be responsible for ensuring each new non-direct care staff member completes their required preservice training.  The Recruitment and On-boarding Specialist will notify the applicable manager when a new staff member has completed the requirements and is eligible to be scheduled for their first shift.  For direct care staff, the Staffing Coordinators will be responsible for scheduling the new staff member to complete their training, and the Staffing Coordinator will be responsible for verifying that all preservice training has been completed before scheduling the new employee for their first shift.

On a monthly basis, the Recruitment and On-boarding Specialist and the Staffing Coordinators will report to the Administrator on the number of staff members hired in the preceding month and the status of timely completion of preservice trainings.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 sampled staff (#s 8, 11, and 15) completed 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care setting, including six hours on dementia care. Findings include, but are not limited to:

Staff training records were reviewed on 12/27/23 and revealed the following:

* Staff 8 (CNA), hired 11/26/21, Staff 11 (CNA), hired 12/18/19, and Staff 15 (CNA), hired 10/13/14, did not have documented evidence of completing the required 12 hours of annual in-service training.

In an interview with Staff 2 (RN, Director of Nursing Services) on 12/27/23, he acknowledged that the annual staff training was incomplete.

The need to ensure all direct care staff completed 12 hours of annual required training including six hours on dementia care was discussed with Staff 1 (Director of Health Services/Administrator) and Staff 2 on 12/28/23. They acknowledged the findings.

An audit will be conducted for all direct care employees to create a comprehensive list of gaps in required annual trainings.  Any missed trainings will be assigned to each person, and they will be scheduled for a time to complete the trainings by the date of allegation of compliance.

Annual trainings for direct care employees will include 6 hours of dementia training and 6 additional hours of training related to provision of care for persons in a community-based care setting.

At the time of hire, direct care staff members will be given a written document that states the annual training requirements, including the time frame in which they are expected to complete that training.

Each month, Staffing Coordinators will review the status of annual training for all staff members whose hire date falls within the following 2 months.  Staffing Coordinators are responsible for contacting the employee about any outstanding trainings and making a plan with the staff member for completing the trainings.  If a staff member fails to complete their required annual trainings by the anniversary date of their hire, they will be removed from the schedule until they do so.

On a monthly basis, the Staffing Coordinators will report to the Administrator on the number of staff members who are reaching the anniversary date of their hire within the following 2 months and the status of completion of their required annual trainings.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted according to 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:

On 12/26/23, review of facility fire drill and fire and life safety instruction records, from 06/2023 through 12/2023, and interviews with staff indicated the facility was not documenting:

* The escape route used; and

* Problems encountered and comments related to residents who resisted or failed to participate in the drills.

There was no documented evidence the facility provided fire and life safety instruction to staff every other month as required.

On 12/26/23, the need to ensure fire and life safety instruction was provided to staff on alternate months and all areas of fire drills were documented was discussed with Staff 1 (Director of Health Services/Administrator) and Staff 2 (RN, Director of Nursing Services). They acknowledged the findings.

The Administrator will conduct a broad-based fire life safety training with Larkspur staff that will include the fire drill procedure (RACER and exit pathways), fire prevention (potential ignition sources and actions to take), earthquake response, use of lockdown buttons in an active shooter situation on campus, location of emergency food and water supplies, and emergency phone tree.

On even numbered months, the Administrator or their designee will conduct fire life safety instruction with Larkspur staff.  Content of each training will be documented and a signature collected for each staff member who participated in the trainings. Training records will be collected in a 3-ring binder with fire safety inspection records.

Each quarter, the Administrator will review all fire drill and training records for compliance in partnership with the Facility Services Manager.

Based on interview and record review, it was determined the facility failed to provide Fire and Life Safety instruction to residents annually. Findings include, but are not limited to:

Fire drill records, from 06/2023 through 11/2023, were reviewed on 12/26/23 and revealed the following:  

Staff 2 (RN, Director of Nursing Services) stated the facility was not providing or documenting annual instruction for residents in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire.

The requirements for Fire and Life Safety instruction for residents were reviewed with Staff 1 (Director of Health Services/Administrator) and Staff 2 on 12/28/23. They acknowledged the findings.

Each resident will be assessed for cognitive capacity for retaining and following fire safety and evacuation instructions. For residents who do not have the cognitive capacity to retain and follow such instructions, this will be documented in the resident record.  All residents who are cognitively able to retain and follow fire safety and evacuation instructions will receive such instruction by February 26, 2024, including evacuation methods, responsibilities during fire drills, and designated safe meeting spaces. In addition, written information will be provided to resident representatives (friends or family) via email.

Education will be provided to residents (with cognitive capacity for retaining and following the instructions) or their representatives within 24-hour of admission, at their first quarterly care confernece, and then annually at care conferences occurring in the 1st quarter of each calendar year. Education will include evacuation methods, responsibilities during fire drills, and designated safe meeting spaces. A training record will be maintained that states the content of the training, the date provided,  and the attendees.

This process will be managed by the Director of Social Services. At the end of the first quarter, the Director of Social Services will report to the Administrator on the completion of this training with each resident or representative.