Print Inspection: IKBS

The findings of the re-licensure survey, conducted 08/22/22 through 08/24/22, 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, Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.

Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities 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 revisit to the re-licensure survey of 08/24/22, conducted 12/07/22 through 12/08/22, 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 57 for Memory Care Communities.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and in good repair, in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:

1. Observation of the kitchen on 08/22/22 revealed an accumulation of food spills, splatters, loose food debris, dirt and/or dust on or underneath the following:

* Dry food storage area;

* Hand washing sinks and towel dispensers;

* Surfaces and underneath storage shelves, cabinets, and drawers throughout the kitchen;

* The coffee and beverage countertop inside the kitchen;

* Walls throughout the kitchen;

* Floors and drains;

* Flooring inside the walk-in refrigerator and freezer;

* The dishwashing area walls, floors, and equipment;

* Behind and underneath appliances;

* Food delivery carts;

* Ceiling vents;

* Interior of the microwave;

* Ice machine vent had a buildup of dust;

* Janitor closet inside the kitchen area needed to be deep cleaned, sanitized, and properly organized;

* Doors and door frames throughout the kitchen had chipped paint, scuffs, gouges, and food stains;

* Food was stored on the floor of the freezer;

* Opened and leftover food items that were stored in the refrigerator were not consistently dated;

* Opened food items were observed in the dry food storage area; and

* Garbage cans in food preparation areas did not have lids when not in use.

2. The kitchenette in the MCC was toured on 08/23/22. The following areas were in need of cleaning and/or repair:

* Laminate countertop had chips in multiple areas, and edge of countertop next to the steam table was missing laminate;

* Cabinets under the kitchenette sink were chipped and splintered on the corners;

* The steam table had food debris in the water and brown markings in the wells;

* The drain underneath the steam table had thick black and brown matter; and

* Caregiving staff plating and serving food were not using aprons.

The areas that required cleaning and repair were observed and discussed with Staff 1 (ED) and Staff 5 (Executive Chef) on 08/24/22. They acknowledged the areas that needed cleaning and repair.

The following areas in  observation of the kitchen have been addressed as described below:

1. Accumulation of food spills, splatters, loose food  debris, dirt and/or dust on or underneath the following:

*Dry food storage area;

Area cleaned by 10/1/2022.

*Hand washing sinks and towel dispensers;

Sinks and towel dispensers cleaned by 10/1/2022

*Surfaces and underneath storage shelves, cabinets, and drawers throughout the kitchen;

Areas deep cleaned by 10/1/2022

*The coffee and beverage countertop inside the kitchen;

Area cleaned by 10/1/2022.

*Walls throughout the kitchen;

Areas cleaned by 10/1/2022.

*Floors and drains;

Areas cleaned by 10/1/2022.

*Flooring inside the walk-in refridgerator and freezer;

Flooring deep cleaned by 10/22/2022.

*The dishwashing area walls, floors, and equipment;

Dishwashing area deep cleaned by 10/22/2022.

* Behind and underneath appliances;

Areas cleaned by 10/1/2022

* Food delivery carts;

Carts cleaned by 10/1/2022.

* Ceiling vents;

Vents cleaned by 10/22/2022.

* Interior of the microwave;

Microwave cleaned by 10/1/2022.

* Ice machine vent had a buildup of dust;

Area cleaned by 10/1/2022.

* Janitor closet inside the kitchen area needed to be deep cleaned, sanitized, and properly organized;

Janitor closet will be deep cleaned, sanitized, and properly organized by 10/22/2022.

* Doors and door frames throughout the kitchen had chipped paint, scuffs, gouges, and food stains;

Doors and door frames throughout the kitchen cleaned, repaired, and repainted as needed by 10/22/2022

* Food was stored on the floor of the freezer;

Ordered storage bins will be in place by 10/1/2022.

* Opened and leftover food items that were stored in the refrigerator were not consistently dated;

Opened and leftover food items will dated by 10/1/2022

* Opened food items were observed in the dry food storage area;

Ordered storage bins will be in place by 10/1/2022.

* Garbage cans in food preparation areas did not have lids when not in use

Ordered garbage can lids will be in place by 10/1/2022

All areas above added to preventative daily zone deep cleaning schedule.

Weekly audits on all food outlets will be completed by Executive Chef.

ED and Executive Chef to conduct routine community kitchen inspections  at least monthly to check for areas needing cleaned, repaired, or replaced.

2. The kitchenette in the MCC; the following areas were in need of cleaning and/or repair:

* Laminate countertop had chips in multiple areas, and edge of countertop next to the steam table was missing laminate;

Laminate countertop unrepairable so it will be replaced by 10/22/2022.

* Cabinets under the kitchenette sink were chipped and splintered on thecorners;

Cabinets unrepairable so it will be replaced by 10/22/2022.  

* The steam table had food debris in the water and brown markings in the wells;

Steam table deep cleaned by 10/1/2022

* The drain underneath the steam table had thick black and brown matter;

Drain deep cleaned by 10/22/2022

* Caregiving staff plating and serving food were not using aprons.

Disposable aprons ordered and in place by 10/1/2022.

All areas above added to preventative daily zone deep cleaning schedule.

Weekly audits on all food outlets will be completed by Executive Chef.

ED and Executive Chef to conduct routine community kitchen inspections  at least monthly to check for areas needing cleaned, repaired, or replaced.

Based on interview and record review, it was determined the facility failed to ensure evaluations were reviewed and updated quarterly and after significant changes of condition for 1 of 2 sampled residents (# 1). Findings include, but are not limited to:

Residents 1's evaluations were not completed quarterly as required.

Additionally, Resident 1 experienced several significant changes of condition  between June and August, 2022. There was no documented evidence the previous evaluation had been reviewed and updated.

The need to ensure resident evaluations were reviewed and updated at least quarterly and with significant changes of condition was discussed with Staff 1 (ED), Staff 2 (Memory Care Administrator) and Staff 3 (RN) on 08/24/22. The staff acknowledged the findings.

Residents 1's evaluations were not completed quarterly as required. Additionally, Resident 1 experienced several significant changes of condition between June and August, 2022. There was no documented evidence the previous evaluation had been reviewed, updated, and did not contain items listed in citation.

Resident 1 will have review of service plan and update to reflect current care needs (Sleeping area preference; Two person full assist with care; Bed mobility; Transfers; Dressing; Grooming; Hygiene; Bathing; Bowel and bladder continence; Rash; Meal assistance; Orientation; Ability to use call system; Psychotropic medications; Expressions of pain; Hospice Services; Ability to make self understood; Significant weight losses; and Risk for dehydration) and completed by 9/1/2022.All resident's service plans will be reviewed, with ISP or handwritten changes that are initial and dated implemented for any care needs not addressed in service plan by 10/22/2022. Changes to be fully incorporated into service plan with next comprehensive service plan (quarterly or change of condition).

ED, HSD, and MCD will be re-educated on completed timely and comprehensive evaluations by VPO or Nurse Consultant by 10/1/2022.

Random SP audits to be conducted by Health Services Department during QA process at least monthly.

Staff to be educated on reporting changes of condition to HSD and documenting on 24-hour report that will be reviewed daily by Health Services Department.

Weekly audit of Service Plan binder to ensure most accurate SP is available to staff.

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

1. Resident 2 was admitted to the facility in 05/2022 with diagnoses including dementia and depression.

Observations, interviews and review of the current service plan, dated 08/03/22, indicated the service plan failed to reflect the resident's current care needs and lacked clear direction to staff in the following areas:

* Recent hospital stay for a subarachnoid hemorrhage;

* Falls and interventions;

* Recent injuries sustained from falls;

* Toileting assistance during the night; and

* Ability to use the call system.

The need to ensure service plans were reflective of residents' current needs and provided clear direction to staff was discussed with Staff 1 (ED), Staff 2 (Memory Care Administrator) and Staff 3 (RN) on 08/24/22 . They acknowledged the findings.

2. Resident 1 was admitted to the facility in May 2019 with diagnoses including dementia and was receiving hospice services since 03/2022.

Observations of the resident, interviews with staff and review of the care plan dated 10/18/21, showed the care plan was not reflective of the resident's current care needs and/or did not provide clear direction to staff in the following areas:

* Sleeping area preference;

* Two person full assist with care;

* Bed mobility;

* Transfers;

* Dressing;

* Grooming;

* Hygiene;

* Bathing;

* Bowel and bladder continence;

* Rash;

* Meal assistance;

* Orientation;

* Ability to use call system;

* Psychotropic medications;

* Expressions of pain;

* Hospice Services;

* Ability to make self understood;

* Significant weight losses; and

* Risk for dehydration.

The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 3 (RN) on 08/23/22 and Staff 1 (ED), Staff 2 (Memory Care Administrator) and Staff 3 on 08/24/22. They acknowledged the findings.

1. Resident 2 Observations, interviews and review of the current service plan, indicated the service plan failed to reflect the resident's current care needs, lacked clear direction to staff and did not contain items listed in citation.

Resident 2 will have review of service plan and update to reflect current care needs (Recent hospital stay for a subarachnoid hemorrhage; Falls and interventions; Recent injuries sustained from falls; Toileting assistance during the night; and Ability to use the call system) and completed by 9/15/2022.

2. Resident 1 Observations of the resident, interviews with staff and review of the care plan, showed the care plan was not reflective of the resident's current care needs, did not provide clear direction to staff, and did not contain items listed in citation.

Resident 1 will have review of service plan and update to reflect current care needs (Sleeping area preference; Two person full assist with care; Bed mobility; Transfers; Dressing; Grooming; Hygiene; Bathing; Bowel and bladder continence; Rash; Meal assistance; Orientation; Ability to use call system; Psychotropic medications; Expressions of pain; Hospice Services; Ability to make self understood; Significant weight losses; and Risk for dehydration) and completed by 9/1/2022.

All resident's service plans will be reviewed, with ISP or handwritten changes that are initial and dated implemented for any care needs not addressed in service plan by 10/22/2022. Changes to be fully incorporated into service plan with next comprehensive service plan (quarterly or change of condition).

ED, HSD, and MCD will be re-educated on completed timely and comprehensive service plans by VPO or Nurse Consultant by 10/1/2022.

Staff to be educated on utilization of service plans for providing care by 10/1/2022.

ED and/or HSD to review service plans prior to locking to ensure they reflect the Resident current care needs on an ongoing basis.

Random SP audits to be conducted by Health Services Department during QA process at least monthly.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a service planning team which 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 2 of 2 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to:

The most recent service plans for Residents 1 and 2 were reviewed during the survey. The records lacked documented evidence the service plans were developed by a service planning team.

On 08/24/22, the need to ensure service plans were developed by a service planning team was discussed with Staff 1 (ED), Staff 2 (Memory Care Administrator) and Staff 3 (RN). They acknowledged the findings.

Resident 1 & 2 will have service plans reviewed by Service Plan Team that will consist of the following members at a minimum: Executive Director, Health Services Director, Memory Care Director, Lifestyle Director, Resident/Responsible Party will be invited to attend and participate as part of this team. Other team member will be included on a Resident-by-Resident basis to include: Caseworker, Hospice, and other Third-Party Providers as appropriate.

Executive Director and/or HSD will oversee compliance by reviewing Service Plans prior to locking.

Based on observation, interview and record review, it was determined the facility failed to ensure residents who had short term changes of condition were evaluated, resident-specific interventions were developed, and that interventions were re-evaluated to determine effectiveness for 1 of 1 sampled resident (#2) who experienced changes of condition related to multiple falls. Findings include, but are not limited to:                                                                                                              

Resident 2 was admitted to the facility in 05/2022 with diagnoses including dementia.

Observations of the resident, interviews with staff, review of the service plan dated 08/03/22, temporary service plans, incident investigations and charting notes dated 05/27/22 through 08/24/22 were reviewed.

Resident 2 experienced ten falls, some with injuries, between 05/29/22 and 08/22/22. The facility failed to complete investigations at the time of incident and determine if service-planned interventions were implemented, were effective or if new interventions were needed following each fall.

The need to ensure fall investigations were completed timely, and interventions were reviewed to determine if they were effective and appropriate was shared with Staff 1 (ED), Staff 2 (Memory Care Administrator) and Staff 3 (RN) on 08/24/22. They acknowledged the findings.

The community acknowledged incomplete investigations at the time of incident and determine if service-planned interventions were implemented, were effective or if new interventions were needed following each fall.

The health services department reviews high risk residents weekly, documentation will be updated to reflect if current interventions are effective and appropriate.

ED, HSD, and MCD will be re-educated on completed timely fall investigations and incident reports by VPO or Nurse Consultant by 10/1/2022.  

Based on observation, interview and record review, it was determined the facility failed to ensure RN significant change of condition assessments, including findings, resident status, and interventions made as a result of the assessments, were completed following severe, weight loss and decline in condition for 1 of 1 sampled resident (# 1). Findings include, but are not limited to:

Resident 1 was admitted to the facility in May 2019 with diagnoses including dementia.

a. The resident was observed during survey to be bed bound and required full assist with all cares.

Review of the resident's record revealed an RN assessment had been completed on March 31, 2022, after Resident 1 was admitted to hospice services for dementia,   with fluctuating weights and ongoing meal refusals, and noted continued weight loss was expected. The resident was started on protein shakes three times a day. Documentation showed refusal of meals continued, although Resident 1 continued to accept the protein drinks provided.

Staff interviewed during survey, reported Resident 1 had a decline in condition in June 2022, going from independent in mobility and all ADLs, to needing full assist from staff.

There was no RN assessment of the significant change of condition, nor was the service plan updated to reflect the resident's changes in care needs.

Observations of care and staff interviewed during survey found that the staff knew how to care for the resident, and s/he was observed to be receiving the level of care indicated.

b. A review of the resident's 05/05/22 through 08/22/22 progress notes, 03/2022 through 08/02/22 weight records, physician communications, and 08/01/22 through 08/22/22 MAR identified the following:

* Resident continued to drink 50% to 75% of the protein shakes provided.

* From 06/02/2022 to 07/02/22, Resident 1 lost 20 pounds, from 163.3 pounds to 143.3 pounds, a decrease of 13.9% of his/her total body weight. This constituted a severe weight loss.

* Between 07/02/22 and 08/02/22, the resident lost an additional 6.4 pounds, from 143.3 pounds to 136.9 pounds. This constituted another severe loss in one month, and combined weight loss of 19.2% of his/her total body weight in two months.

The resident was unable to be weighed during the time of the survey due to his/her further declines of condition.   

There was no documented RN significant change of condition assessment of the resident's severe weight losses, including findings, resident status, and interventions made as a result of the assessment.

Staff 3 (RN) reported on 08/23/22 that he was aware of the resident's declining condition and weight loss, but did not complete an RN assessment, as the declines were expected.

The need for significant change of condition assessments, which included findings, resident status, and interventions made as a result of the assessment, to be completed by an RN was discussed with Staff 1 (ED), Staff 2 (Memory Care Administrator) and Staff 3 (RN) on 08/24/22. They acknowledged the findings.

The RN completed a change of condition assessment and the service plan was updated to reflect the resident's current care and services indicated on 08/22/22.

Resident 1 The community acknowledged there was no documented RN significant change of condition assessment of the resident's severe weight losses, including findings, resident status, and interventions made as a result of the assessment.

Resident 1 The RN completed a change of condition assessment and the service plan was updated to reflect the resident's current care and services indicated on 08/22/22.

The health services department reviews high risk residents weekly, hospice residents will be added to this weekly meeting to discuss current health status.

ED, HSD, and MCD will be re-educated on the need for a change of condition assessment by VPO or Nurse Consultant by 10/1/2022.  

Staff to be educated on reporting changes of condition to HSD and documenting on 24-hour report that will be reviewed daily by Health Services Department.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included resident specific parameters for PRN medications for 2 of 2 sampled residents (#s 1 and 2) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in May 2019 with diagnoses including dementia, anxiety and agitated depression. Resident 1 was receiving hospice services.

Review of the resident's 08/01/22 through 08/22/22 MAR and 07/25/22 physician orders were reviewed and showed the following:

* The MAR included orders for PRN Morphine Sulfate to be administered every two hours as needed for pain or shortness of breath, and Lorazepam every four hours as needed for anxiety and agitation.  The nurse instructions for administration directed staff to administer the Morphine first to rule out pain as a source of anxiety. Lorazepam was to be given if the morphine was not effective after 30 minutes.  

On four occasions between 08/01/22 and 08/22/22 the Lorazepam was administered first, instead of the Morphine, and on one occasion both medications were administered at the same time.  

* The MAR included multiple PRN psychotropic medications for  anxiety, agitation, delirium and "behaviors".  The MAR did not contain resident specific instructions for staff describing how the resident expressed anxiety, agitation, delirium and "behaviors".

The need to ensure MARs were accurate, included resident specific instructions, and the instructions were followed was discussed on 08/24/22 with Staff 1 (ED ), Staff 2 (Memory Care Administrator) and Staff 3 (RN). The staff acknowledged the findings.

2. Resident 2 was admitted to the facility in 05/2022 with diagnoses including dementia and hypertension.

Review of the resident's 08/01/22 through 08/22/22 MAR identified the following:

* Multiple PRN bowel care medications lacked specific parameters and instructions to staff regarding administration.

The need to ensure PRN medications included resident specific parameters and instructions for staff was discussed with Staff 1 (ED), Staff 2 (Memory Care Administrator) and Staff 3 (RN) on 08/24/22. They acknowledged the findings.

Resident 1 & 2 MAR will be updated to ensure PRN medications included resident specific parameters and instructions for staff prior to administartion of PRN medication.

All residents PRN medications will be reviewed to ensure their MAR reflects resident specific parameters and instructions for staff prior to administartion by 10/22/2022.

Med Techs will be re-educated on PRN medications; the need to ensure MARs are accurate, resident specific parameters and instructions, that the MAR is followed and documentation.

HSD/Memory Care Director to oversee the compliance with MAR accuracy and documentation.

HSD or Designee to oversee compliance with QMAR audits quarterly.

Based on observation, interview and record review, it was determined the facility failed to ensure a thorough assessment had been completed by an RN, PT or OT, and caregivers had been instructed on the correct use and precautions related to the use of the device for 1 of 1 sampled resident (# 1) who used siderails. Findings include, but are not limited to:

Resident 1 was admitted to the facility in May 2019 with diagnoses including dementia.

Observations on 08/22/22 revealed two quarter length side rails in the up position on the resident's bed.

Staff interviewed during survey reported the side rails had been on the bed for a few weeks.

There was no RN, PT or OT assessment for use of the side rails including:

*The resident specifically requested or approved of the device;

*The facility had informed the individual of the risks and benefits associated with the device;

* The facility had documented other less restrictive alternatives evaluated prior to the use of the device; and

*Instructed caregivers on the correct use and precautions related to use of the device.

The need to complete all required elements related to use of an assistive device with restraining qualities was discussed with Staff 1 (ED), Staff 2 (Memory Care Administrator) and Staff 3 (RN) on 08/24/22. They acknowledged the findings.

Community acknowledges incomplete required elements related to use of an assistive device with restraining qualities for Resident 1 and there was no RN, PT or OT assessment completed.

The RN completed a change of condition assessment and the service plan was updated to reflect the resident's current care and services indicated on 08/22/22, which included the use of an assistive device with restraining qualities.

ED, HSD, and MCD will be re-educated on all required elements related to use of an assistive device with restraining qualities by VPO or Nurse Consultant by 10/1/2022.

Health Services Team will complete monthly audit for QA purposes on all residents that utilize assistive devices with restraining qualities to ensure all required elements are in place and the resident is still needing and able to use the device appropriately.  

High Risk Board in HSD office will now list residents that use Supportive Devices with restraining qualities

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted in accordance with the Oregon Fire Code. Findings include, but are not limited to:

Fire and life safety records for February 2022 through July 2022 were reviewed with Staff 1 (ED) on 08/24/22 . Staff 1 revealed the facility did not relocate or evacuate the residents during their monthly fire drills. Therefore, documented evidence was lacking regarding the escape route used, residents who resisted or failed to participate in the drills, evacuation time period needed, and number of occupants evacuated.

The need to provide evacuation assistance to residents from the building to a designated "point of safety" during fire drills was discussed with Staff 1 on 08/24/22. She acknowledged the findings.

Community acknowledged fire and life safety records were lacking documentation regarding the escape route used, residents who resisted or failed to participate in the drills, evacuation time period needed, and number of occupants evacuated. The need to provide evacuation assistance to residents from the building to a designated "point of safety" during fire drills.

ED and ESD re-educated on fully completed fire drill logs and all required information by VPO by 10/1/2022

ED and ESD to oversee the compliance with fire and life safety with monthly QA audits to review documentation.

Fire drill log document will be updated to list residents that participated in drill.

Based on observation, 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 240 and C 420.  

Refer to POC for C 240 and C 420

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 newly hired staff (#s 7 and 13) completed all required pre-service orientation prior to performing any job duties and 1 of 2 newly hired staff (# 13) demonstrated competency in all assigned job duties within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed on 08/23/22 with Staff 1 (ED).

1. There was no documented evidence Staff 7 (CG), hired 07/01/22, and Staff 13 (CG), hired 02/17/22 had completed the required pre-service orientation topic related to Infectious Disease Prevention prior to performing any job duties.

2. There was no documented evidence Staff 13 (CG), hired 02/17/22 demonstrated competency in all assigned job duties within 30 days of hire in the following areas:

* Providing assistance with ADLs;

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

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

The need to ensure staff completed all required training within the specified time frames was discussed with Staff 1 (ED), Staff 2 (Memory Care Administrator) and Staff 3 (RN) on 08/24/22. They acknowledged the findings.

Community acknowledges incomplete staff training records for 2 of 2 newly hired staff.

1. There was no documented evidence Staff 7 (CG), hired 07/01/22, and Staff 13 (CG), hired 02/17/22 had completed the required pre-service orientation topic related to Infectious Disease Prevention prior to performing any job duties.

The  pre-service infection prevention and control for community-based care will be completed by 10/1/2022.

2. There was no documented evidence Staff 13 (CG), hired 02/17/22 demonstrated competency in all assigned job duties within 30 days of hire in the following areas: * Providing assistance with ADLs; * Identification, documentation and reporting of changes of condition; and * Conditions that require assessment, treatment, observation and reporting.

Skills checklist was completed and provided prior to survey exit on 8/24/2022.

Monthly Sample of 5-10% employee records will be audited by BOM for QA purposes.

All re-education and missing staff training records to be completed by 10/15/2022.  

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities.  Findings include, but are not limited to:

Refer to C 252, C 260, C 262, C 270, C 280, C 310 and C 340.

Refer to POC C 252, C 260, C 262, C 270, C 280, C 310, and C 340

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

Residents 1 and 2's current service plans were reviewed during survey. The service plans lacked information and staff instructions related to individualized nutrition and hydration status and needs.

During the survey, it was observed that snacks and hydration were not consistently offered to residents throughout the day.

The need to develop individualized service plans addressing residents' nutrition and hydration needs was discussed with Staff 1 (ED), Staff 2 (Memory Care Administrator) and Staff 3 (RN) on 08/24/22. They acknowledged the findings.

Resident 1 & 2 will have service plans updated to reflect hydration needs.

Resident with specialized hydration needs will have service plans reviewed, with ISP or handwritten changes that are initial and dated implemented for any hydration needs not addressed in service plan by 10/22/2022. Changes to be fully incorporated into service plan with next comprehensive service plan (quarterly or change in condition).

Staff to be educated on hydration and inclusionof specialized hydration needs in service plans by 10/15/2022.

ED and/or HSD to review service plans prior to locking to ensure they reflect the Specialized Hydration needs (as needed) on an ongoing basis.

Random SP audits to be conducted by Health Service Department during QA process at least monthly.

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 2 of 2 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to:

Residents 1 and 2's service plans offered some information about the residents' historical and current 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 and scheduled activities were not consistently offered.  

On 08/24/22, the need to ensure the facility provided meaningful activities based on a thorough evaluation and individualized activity plans for each resident was discussed with Staff 1 (ED), Staff 2 (Memory Care Administrator) and Staff 3 (RN). They acknowledged the findings.

Resident #1 & #2 will have service plans updated to reflect individualized activity plans.

Residents will have the following areas evaluated with each comprehensive evaluation: 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. Individulaized Activity Plans to be developed in the Service Plan for each resident. Current residents will be reviewed and an ISP or handwritten changes that are initial and dated implemented for individualized activity plans not addressed in service plan by 10/22/2022. Changes to be fully incorporated into service plan with next comprehensive service plan (quarterly or change in condition).

Staff to be educated on individualized activity plans and utilization of these plans by 10/15/2022.

ED and/or HSD to review service plans prior to locking to ensure they reflect the individualized activity plan on an ongoing basis.

Random SP audits to be conducted by Lifestyles Director for QA process at least monthly.

Based on interview and record review, it was determined the facility failed to provide an individualized service plan for behavioral symptoms that negatively impacted the resident or others in the community for 1 of 1 sampled resident (# 1) with documented behaviors. Findings include, but are not limited to:

Resident 1 was admitted to the facility in May 2019 with diagnoses including dementia, anxiety and agitated depression.

Resident 1's August MAR revealed multiple psychotropic medications both scheduled and as needed for agitation, anxiety, delirium and delusions. The MAR did not include descriptions of how the resident would exhibit the behaviors.

Staff interviewed during survey reported the resident would yell out, start "sobbing" for unknown reasons, shake and at times refused medication and cares.

The resident's service plan, dated 10/18/21, did not address the behaviors and lacked individualized interventions to assist staff in minimizing the negative impact of the behaviors.  

On 08/24/22 the need to develop individualized behavior plans for residents with behavioral symptoms was discussed with Staff 1 (ED), Staff 2 (Memory Care Administrator) and Staff 3 (RN). The staff acknowledged the findings.

Resident 1 Service Plan will be updated to reflect behaviors to include the resident yelling out, start "sobbing" for unknown reasons, shake, at times refused medication and cares and indiviualized interventions to minimize or mitigate the potiential negative outcome from these behaviors by 9/15/2022.

Other Residents with known behaviors will have service plans reviewed and updated as needed to reflect behaviors and individualized interventions to minimize or mitigate the potential negative outcome from these behaviors by 10/22/2022.

ED and.or HSD to review service plans prior to locking to ensure they reflect the individualized intervention for behaviors on an ongoing basis.

Random SP audits to be conducted by Health Services Team for QA process at least monthly.