Print Inspection: GB2S

The findings of the re-licensure survey, conducted 10/24/22 through 10/27/22, 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 for Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first revisit to the re-licensure survey of 10/27/22, conducted 02/06/23 through 02/07/23, are documented in this report. It was determined the facility was in substantial compliance with 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 incidents of suspected abuse were reported to the local Seniors and People with Disability (SPD) office for 1 of 3 sampled residents (#3), reviewed with incidents of suspected abuse. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 06/2022 with diagnoses including chronic pain and was noted to self-administer his/her medications.

Progress notes and incident reports from 08/01/22 through 10/24/22 were reviewed and revealed the following:

On 08/02/22, Resident 3 reported to facility staff half a bottle of Norco (pain medication) was missing from his/her apartment.

Resident 3's report of missing medication constituted suspected abuse for which the facility had the responsibility to report to the local SPD office.

The facility completed an investigation regarding the report of missing medication. However, there was no documented evidence the facility notified the local SPD office of the incident.

The facility's failure to notify the local SPD office of an incident of suspected abuse was discussed with Staff 1 (ED) on 10/27/22. She acknowledged the findings. The facility was asked to report the incident to the local SPD office. Confirmation was obtained during the survey.

Upon finding a report wasn't submitted to SPD, the ED immediatley submitted report to SPD and gave evidence to survey team.

In order to prevent recurrence every Monday through Friday during Stand Up and 24 hour review Incident Reports will be audited and reviewed by RCC, ED, and DHSa. If report needs to be sent to SPD based on daily audits(Monday-Friday) it will be the ED top priortity after every stand up. Every Friday ED will audit the previous week incident reports to double check if a report needs to be sent to SPD.  In addition RCC was scheduled to attend RCC training through OHCA. Training to include how to do proper incident reports, and how to accurately gather information for investigation, and proper wording in the documentation.   

ED will maintain the Incident Report auditing system. ED, RCC, and DHSa will maintain the 24 hour system to help identify when we need to send a report to SPD.

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 (#4) whose evaluation was reviewed. Findings include, but are not limited to:

1. Resident 4's move-in evaluation, dated 08/26/22, lacked information regarding the following required elements:

* History of mental health treatments;

* Cognition including memory and confusion;

* Personality;

* Unsuccessful prior placements; and

* Environmental factors.

The move-in evaluation was reviewed with Staff 1 (ED) on 10/24/22. She acknowledged the findings.

Missing information in resident #4 move-in evaluation was corrected in the most current evaluation and added to their service plan.  

In order to prevent a recurrence, moving forward Resident Care Coordinator and Executive Director will ensure pre-admission and admission evaluations, as well as service planning are completed prior to resident moveing into the facility. The pre-admssion assessment has been revised to be sure all the components required by state policy are included. Resident Care Coordinator will be using ALF Resident Move-In Checklist to ensure evaluation screening, and pre-evaluation are completed and entered in PCC.

Executive Director will perform a move-in audit within 24 hours of move-in and 48 hours post-move in and at 30 days. The move-in checklist will be brought to daily stand-up meetings and will be reviewed by the team to ensure all items are completed by those responsible for tasks including the resident is added to the ABST. The move-in checklist will be filed behind the Admissions/move-in tab in the clinical record within 30 day of move-in.

2. Resident 5 was admitted to the facility in 12/2020 with diagnoses including bipolar disorder and chronic pain.

Interviews with staff, review of progress notes, dated 08/03/22 through 10/24/22, the MAR, dated 10/01/22 through 10/24/22, and the current service plan, dated 09/18/22, revealed the service plan was not reflective of the resident's needs nor provided clear instruction to staff in the following areas:

* How the resident demonstrated pain, location of pain or non-drug interventions used for pain;

* Behaviors including how the resident demonstrated depression and anxiety; and

* Diabetic status.

The need to ensure service plans were reflective of the current needs of the resident and provided clear direction to staff related to the provision of care was discussed with Staff 1 (ED), Staff 3 (Director of Health Services Assistant) and Staff 4 (RCC). Staff acknowledged the findings.

4. Resident 2 was admitted to the facility in 06/2022 with diagnoses including chronic obstructive pulmonary disorder.

Review of the resident's service plan, dated 09/08/22, TAR, dated 10/01/22 through 10/24/22, physician's orders dated 09/15/22, and progress notes, dated 08/01/22 through 10/24/22, revealed the service plan was not reflective and lacked clear instruction to staff  in the following area:

* Oxygen use including the resident's habit and risks associated with adjusting the liter level to nine despite an order to titrate between one to three liters to keep the resident's oxygen saturation greater than 92%.

The need to ensure Resident 2's service plan was reflective of his/her needs and included clear instructions for staff was discussed with Staff 1 (ED), Staff 3 (Director of Health Services Assistant) and Staff 4 (RCC) on 10/26/22. They acknowledged the findings.

3. Resident 1 was admitted to the facility in 10/2016 with diagnoses including hypertension.

Observations were made, interviews with the resident and staff were conducted and the resident's current service plan, dated 10/21/22, was reviewed. The service plan was not reflective and/or did not provide clear direction to staff in the following areas:

* Dressing assistance;

* Continence status;

* Fingernail care assistance;

* Meal preferences including saving and warming up breakfast when s/he wakes up late;

* Access to fresh water at bedside; and

* Housekeeping preferences including making the bed daily.

The need to ensure service plans were reflective of the current needs and preferences of the resident and provided clear caregiving instruction to staff was discussed with Staff 1 (ED), Staff 3 (Director of Health Services Assistant) and Staff 4 (RCC) on 10/26/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current status, care needs and preferences and provided clear instruction to staff for 4 of 5 sampled residents (#s 1, 2, 5 and 6) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 6 was admitted to the facility in 03/2022 with diagnoses of spinal stenosis radiculopathy (narrowing of the spinal canal with a pinched nerve) and anxiety disorder.

Interviews with the staff and review of the resident's service plan, dated 09/19/22, showed the service plan was not reflective of the resident's current care needs and lacked clear direction to staff in the following areas:

* Bathing/showering needs;

* Depression/anxiety; and

* Dining escort.

The need to ensure service plans were reflective of the resident's current care needs and provided clear direction to staff was discussed with Staff 1 (ED), Staff 4 (Resident Care Coordinator) and Staff 3 (Director of Health Services Assistant) on 10/26/22. They acknowledged the findings.

The service plans of resident #1, 2, 5, and 6 were all updated upon findings to accuratley reflect the residents status, care needs, and preferences with clear instructions.

Resident Care Coordinator will complete a service plan audit weekly on five residents to ensure the service plan reflects the resident's needs as identified in the evaluation. In addition, a copy of the service plan will be placed in the Service Plan Binder at the nurse's station, to ensure it is available for staff to review. Each time there are changes to a resident's service plan and/or level of care evaluation a new copy will be updated in the binders for staff to review.

Executive Director, DHSa, and Resident Care Coordinator will be responsible for maintaining this system. ED will audit the audited service plans once a month to assure they accurately reflect the current needs, status, and preferences of the residents.  

Based on observation, interview and record review, it was determined the facility failed to determine and document what action or intervention was needed with weekly progress notes through resolution for 4 of 4 sampled residents (#s 1, 2, 3 and 5) who experienced changes of condition. Findings include, but are not limited to:

1. Resident 5 was admitted to the facility in 12/2020 with diagnoses including bipolar disorder and chronic pain.

Resident 5's current service plan, dated 09/18/22, noted the resident was independent with ADL care and was alert and oriented.

Review of the resident's progress notes, dated 07/31/22 through 10/24/22, noted the following changes of condition:

* On 08/03/22 Resident 5 returned to the facility from the hospital with diagnoses including abdominal pain and complaints of nausea and vomiting; and

* On 10/05/22 Resident 5 returned from the hospital after a fall with complaints of pain and polypharmacy.

There was no documented evidence the facility determined what actions or interventions were needed for the resident after returning from the hospital and there was no documented evidence the resident was monitored through resolution.

Changes of condition were reviewed and discussed with Staff 1 (ED), Staff 3 (Director of Health Services Assistant) and Staff 4 (RCC). Staff acknowledged the findings.

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

Review of the resident's 08/01/22 through 10/24/22 progress notes revealed the resident experienced the following short-term changes of condition:

* 08/01/22 Boil in groin area; and

* 10/11/22 Complaints of swelling to the right foot.

The facility lacked documented evidence the conditions were monitored with progress noted at least weekly through resolution.

The need to ensure short term changes of condition were monitored with progress noted at least weekly through resolution was discussed with Staff 1 (ED), Staff 3 (Director of Health Services Assistant) and Staff 4 (RCC) on 10/27/22. They acknowledged the findings.  

4. Resident 3 was admitted to the facility in 06/2022 with diagnoses including diabetes and was noted to experience frequent falls.

The resident's 08/03/22 through 10/24/22 progress notes were reviewed and revealed the resident experienced the following short-term changes of condition:

* 08/08/22 Fall;

* 09/06/22 Swelling to the left leg;

* 09/12/22 Fall;

* 09/21/22 Fall;

* 10/08/22 Fall;

* 10/10/22 Bruising to the right hand and swelling to the left foot;

* 10/12/22 Fall; and

* 10/17/22 Fall.

The facility lacked documented evidence the skin conditions and falls were monitored with progress noted at least weekly through resolution.

The need to ensure short-term changes of condition were monitored with progress noted at least weekly through resolution was discussed with Staff 1 (ED), Staff 3 (Director of Health Services Assistant) and Staff 4 (RCC) on 10/27/22. They acknowledged the findings.

2. Resident 1 was admitted to the facility in 10/2016 with diagnoses including anxiety disorder.

Resident 1's progress and electronic MAR notes, dated 08/01/22 through 10/23/22, were reviewed and revealed the following short-term changes of condition:

* 08/01/22 - Celexa 40 mg (for depression) was not administered or available in the facility from 08/01/22 through 08/11/22;

* 08/16/22 - Resident 1 complained of genital pain and CGs documented concerns regarding a potential urinary tract infection; and

* 09/11/22 - CGs identified a rash on the resident's inner thighs with documented complaints of pain and itching.

There was no documented evidence the facility determined an action or intervention regarding the identified short-term changes of condition and there was no documentation the resident was monitored through resolution.

Changes of condition were reviewed and discussed with Staff 1 (ED), Staff 3 (Director of Health Services Assistant) and Staff 4 (RCC) on 10/26/22. Staff acknowledged the findings.

All findings related to change of condtion, monitoroing and follow up with residents 1, 2, 3, and 5 were immediatley addressed and corrected.

In order to prevent a recurrence, all staff will participate in the training on identifying Significant Changes of Condition as well as Acute Changes of Condition and reporting to DHSa. Staff will receive monthly trainings on putting resident on alert, entering ISP, new interventions as needed, and monitoring process.  Every day, Monday through Friday, ED, RCC, and DHSa will review 24/72-hour reports to ensure the change of condition process is followed, all Interim Servic Plans are completed, reviewed, and followed up on. Resident Care Coordinator completed three-day "Resident Care Coordinator" Training with OHCA the first week of November. The training reviewed the process around policy on Change of Condition and state requirements. DHSa will do change of conditions audits weekly to be sure all have been docuemented and followed up on.

DHSa, RCC, and ED will be responsible to ensure current staff and new hired staff receive appropriate training and understands reporting any Change of Condition. DHSa will maintain the change of condition audit system.  

2. Resident 2 was admitted to the facility in 06/2022 with diagnoses including diabetes. Physician's orders, dated 09/15/22, diabetic administration record, dated 10/01/22 through 10/24/22, revealed the following orders could not be confirmed as followed:

* CBG checks were not administered on four occasions; and

* Lantus SoloStar Solution Insulin (for diabetes) was not administered on four occasions.

On 10/24/22 at 1:43 pm, in an interview with Staff 4 (RCC), she was unable to confirm or verify if the above orders had been followed.

The need to ensure physician's orders were carried out as prescribed was discussed with Staff 1 (ED), Staff 3 (Director of Health Services Assistant) and Staff 4. They acknowledged the findings. No further information was provided.

3. Resident 1 was admitted to the facility in 10/2016 with diagnoses including anxiety disorder and heart failure.

Resident 1's complete MAR, dated 10/01/22 through 10/24/22, partial MAR, dated 07/01/22 through 08/31/22, and corresponding progress notes were reviewed and revealed the following:

The following medications were documented as not administered on the following occasions because the medication was not in the facility, or the MAR was blank:

* Celexa 40 mg (for depression) was not administered on 13 occasions;

* Fluticasone Propionate Nasal Suspension 50 mcg/ACT (for asthma) was not administered on nine occasions;

* Prevident 5000 (for sensitive teeth) was not administered on six occasions;

* Metoprolol Tartrate Tablet 25 mg (for high blood pressure) was not administered on one occasion;

* Calcium Carbonate 500 mg (supplement) was not administered on 15 occasions; and

* Acetaminophen ER Tablet 650 mg (for pain) was not administered on two occasions.

On 10/24/22 at 2:06 pm, the surveyor and Staff 16 (MT) observed and checked the MARs and medication supply. Staff 21 was unable to verify if the above orders had been followed.

The need to ensure medications were carried out as prescribed was discussed with Staff 1 (ED), Staff 3 (Director of Health Services Assistant) and Staff 4 (RCC) on 10/26/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure physician's orders were carried out as prescribed for 3 of 4 sampled residents (#s 1, 2 and 6) whose orders were reviewed. Findings include, but are not limited to:

1. Resident 6 was admitted to the facility in 03/2022 with diagnoses including spinal stenosis radiculopathy (narrowing of the spinal canal with a pinched nerve) and anxiety disorder.

Review of the MAR, dated 10/01/22 through 10/23/22, and current physician's orders, dated 09/04/22, noted the following:

* Lidocaine patch 4% was to be applied to the right upper thigh topically every 12 hours for pain.

During an interview on 10/26/22 at 12:30 pm, Staff 4 (RCC) and Staff 14 (MT) confirmed the Lidocaine patch had not been applied to the resident between 10/01/22 until the time of survey's entrance on 10/24/22.

The need to ensure that physician's orders were carried out as prescribed was discussed with Staff 1 (ED), Staff 3 (Director of Health Services Assistant) and Staff 4. They acknowledged the findings.

Missed documentation was corrected immediately and staff were educated on the need to be sure they have completed all documentation, and to ensure the orders they have entered match physician orders. HCCs have been educated on how to read orders and parameters and entering accurately in the PCC.

In order to prevent recurrence, Resident Care Coordinator and all HCCs will be in-serviced on the processing of new orders, medications/treatments, and triple check process to ensure accurate transcription of medication or treatment orders, timely processing of new or changed orders, and medications and treatments are reconciled and stored appropriately.

On a quarterly basis, Resident Care Coordinator will double check and DHSa will tripple check the physician orders, verifying through the hard chart that every order in the hard chart matches exactly the order on the POs. If there is something new the RCC will be sure it gets added to they EHR, MAR, TAR, and DAR. On a daily basis RCC will audit MAR, TAR, and DAR. RCC will issue Audit write ups to HCC's to correct the documentation immediatley.

DHSa will audit MAR, TAR, DAR for unavailable medications three times weekly, and coordinate with ED to obtain medications. If unable to obtain med DHSa will notify MD and request alternative. HCC will be in-serviced to notify RCC, DHSa if medications are not received from pharmacy or medications that have ran out and RCC will follow up with pharmacy.

Resident Care Coordinator and DHSa will be responsible for maintaining this system to ensure that all orders were reconciled and transcribed correctly into EHR. RCC, DHSa, and ED will maintain the auditing system for charting.

Based on observation, interview and record review, it was determined the facility failed to obtain a physician's order for resident's self-administered medications and evaluate a resident's ability to safely self-administer medications for 1 of 4 sampled residents (#2) who self-administered some of their medications. Findings include, but are not limited to:

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

The TAR, dated 10/01/22 through 10/24/22, and physician's orders, dated 09/15/21, indicated the resident was prescribed the following medications:

* Albuterol nebulizer treatments for chronic obstructive pulmonary disease; and

* Combivent Respimat inhaler for chronic obstructive pulmonary disease.

Observations and an interview conducted on 10/24/22 confirmed the resident self- administered the Albuterol nebulizer and Combivent Respimat inhaler treatments.

There was no documented evidence of physician's orders for the resident to self-administer the Albuterol nebulizer treatments or the Combivent Respimat inhaler or a facility evaluation of Resident 4's ability to safely self-administer the medications.

On 10/27/22, Staff 3 (Health Services Director Assistant) confirmed there was no evaluation related to the self-administration of Albuterol nebulizer treatments or the Combivent Respimat inhaler for Resident 2.

The requirement for the facility to obtain a physician's order for resident self-administered medications and evaluate a resident's ability to safely self-administer medications was discussed with Staff 1 (ED), Staff 3, and Staff 4 (RCC). They  acknowledged the findings.

Corrections were made to clarify resident #2's orders for self-adminstration of specific medications with their PCP, and corrections were then made on the EHR and service plan.

Going forward during quarterly care conferences with all residents, especially those who self administer medications and/or treatments, RCC and ED will ask residents if they have any medications in their apartment that they self administer. If there is a new/different medication that the resident doesn't have an order for, RCC will follow up with residents PCP to get an order for the resident to self adminster the medication. The DHSa will do quarterly assessments for all who self adminster. During assessments DHSa will also clarify what medications the resident is using. If there is anything there is not an order for DHSa will reach out to the residents PCP to get a signed order.

RCC, ED, and DHSa will be in charge of maintaining this system.   

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 11). Findings include, but are not limited to:

The facility's training records were reviewed on 10/25/22 and revealed the following:

1. Staff 6 (CG), hired 05/27/22, lacked documented evidence s/he had completed the following:

* Abuse reporting requirements;

* Standard precautions for infection control;

* Dementia disease process;

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

* Specific aspects of dementia.

2. Staff 7 (CG), hired 01/27/22, lacked documented evidence s/he had completed the following:

* Techniques for understanding, communicating and responding to behaviors; and

* Specific aspects of dementia.

3. Staff 11 (MT), hired 05/27/22, lacked documented evidence s/he had completed the following:

* Resident rights and values of CBC care;

* Abuse reporting requirements;

* Standard precautions for infection control;

* Fire safety and emergency procedures;

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

* Specific aspects of dementia.

Requirements for pre-service training were reviewed with Staff 1 (ED) on 10/25/22. She acknowledged the findings.

Current staff and all new hired staff will complete pre-service orientation and dementia training as well as all other required training to meet the OAR 411-054-0070 by November 30th or will be removed from the floor.

In order to prevent a recurrence, moving forward Executive Director along with Human Resources Manager will complete a full training audit by utilizing the company education tracking grid to track and ensure all staff completed training requirements. Any staff, that identified with incomplete pre-service or dementia training, will be removed from the floor until training is completed.

Executive Director is responsible for maintaining this system and will be reviewing the training grid once a week to ensure staff training is completed.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 6, 7 and 11) had documented demonstration of competency in all required areas within 30 days of hire. Findings include, but are not limited to:

Review of the facility's training records on 10/25/22 at 10:00 am revealed the following:

1. There was no documented evidence Staff 6 (CG), hired 05/27/22, and Staff 11 (MT), hired 04/07/22, had demonstrated competency in all required areas and within 30 days of hire including:

* Role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Changes associated with normal aging;

* Identification, documentation and reporting of changes of condition;

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

* General food safety, serving and sanitation; and

* First Aid certification and abdominal thrust training.

2. There was no documented evidence Staff 11 (MT), hired 04/07/22, had completed training in the administration of medications and treatments within 30 days of hire.

3. There was no documented evidence Staff 7 (CG), hired 01/27/22, had completed the following:

* Identification, documentation and reporting of changes of condition; and

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

The need to document demonstrated competency of job duties and complete First Aid certification and abdominal training within 30 days of hire was discussed with Staff 1 (ED) on 10/25/22. She acknowledged the lack of documented evidence the required training had been provided.

Staff identified were evaluated by RCC with the proper training checklist to show competency in their position.

Going forward every new employee will be given the competency checklist the first day they work the floor. The new employee and their mentor will complete the competencies by day thirty of employment and will turn competency form into the ED to file in the training binder. ED will audit new employee files on day thirty-one of employment to be sure that the competencies have been completed. If it hasn't been completed the employee will need to demonstrate any missing tasks on the training checklist to the RCC to prove competency.  ED will also audit current employees monthly to be sure they all have a thirty day competency checklist. If none is on file RCC will have the employee demonstrate competencies.

The ED will be responsible for maintaining this system.