Print Inspection: KPHM

The findings of the Change of Owner survey, conducted 10/02/23 through 10/05/23, 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

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 10/05/23, conducted  01/29/24 through 01/30/2024, 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 Home and Community Based Services Regulations OARs 411 Division 004.

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 2nd revisit to the re-licensure survey of 10/05/23, conducted on 04/03/24 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.

Based on interview and record review, it was determined the facility failed to promptly investigate all incidents to rule out potential abuse and/or neglect and document the Administrator's review for 1 of 1 sampled resident (#3) who had incidents of falls and an injury of unknown cause. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 01/2023 with diagnoses including dementia and ocular degenerative disease.

Progress notes, dated 07/02/23 through 10/02/23, were reviewed and revealed the following:

* 07/02/23 - fall with head wound, the resident could not report what happened;

* 07/24/23 - found on floor, Resident 3 could not report what happened;

* 07/31/23 - found sitting on the floor, dressed without shoes or socks on and the alarm did not alert staff;

* 08/13/23 - fall from the resident's wheelchair;

* 08/21/23 - fall and Resident 3 did not know how s/he fell; and

* 09/13/23 - quarter sized bruise found on the resident's left upper arm, "resident unaware of how bruise happened."

There was no documented evidence of the facility promptly investigating the incidents to rule out abuse or neglect which included documentation of the Administrator's review. On 10/04/23, Staff 2 (Administrator) reported there was no documented evidence she had investigated the above incidents to rule out abuse and/or neglect.

The need to ensure incidents were promptly investigated to rule out abuse and/or neglect and included documentation of the Administrator's review was discussed with Staff 1 (Owner) and Staff 2 on 10/05/23 at 10:47 am. They acknowledged the findings.

Sea Aire will conduct an investigation to rule out abuse and neglect immediately following incident. Interventions will also be placed as needed. This will be the plan of correction for investigations where abuse and neglect needs to be ruled out.

System will be evaluated at each incident, where abuse and neglect is needing to be ruled out.

Responsible staff will be administrator and owner.

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 (#5) whose move-in evaluation was reviewed. Findings include, but are not limited to:

Resident 5 was admitted to the facility in 09/2023. The Initial Evaluation and Assessment, dated 09/07/23, was reviewed. The following elements were not addressed:

* Customary routines including bathing;

* Interests, hobbies, social, leisure activities;

* Spiritual, cultural preferences, and traditions;

* Physical health status including vital signs if indicated by diagnosis, health problems, or medications;

* Mental Health issues including presence of depression, thought disorders, or behavioral or mood problems;

* Cognition, including confusion and decision making abilities;

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

* Ability to understand and be understood;

* Assistance needed with toileting, bowel and bladder management;

* Assistance needed with dressing, grooming, bathing, and personal hygiene;

* Assistance needed with mobility, ambulation, and transfers;

* Pain including pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort;

* Nutrition habits and fluid preferences;

* Indicators of nursing needs including potential for delegated nursing tasks; and

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

On 10/04/23 at 2:47 pm, Staff 2 (Administrator) confirmed Resident 5's move-in evaluation was only the second one she had completed since she had taken over as the Administrator.

The need to ensure move-in evaluations addressed all required elements was discussed with Staff 1 (Owner) and Staff 2 on 10/05/23 at 10:47 am. They acknowledged the findings.

All pre move-in evals will be completed at time of initial visit. All blanks and required info will be completed.

This corrected system will take place at each pre move-in evaluation.

At each pre move-in visit and also at time of move in.

Administrator and owner will be responsible

Based on interview and record review, it was determined the facility failed to notify the physician or other practitioner when a resident refused consent to an order for 1 of 2 sampled residents (#3), who had documented medication refusals. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 01/2023 with diagnoses including dementia and ocular degenerative disease.

The resident's MARs dated 09/01/23 through 10/02/23, progress notes, dated 07/02/23 through 10/02/23, and physician's orders were reviewed and revealed the following:

* 07/07/23 - staff documented the resident refused some of his/her medications;

* 08/03/23 - staff documented, "resident didn't want to finish taking [his/her] medications";

* 09/06/23 - the MAR reflected refusals of atorvastatin (to lower cholesterol), B complex (supplement), cranberry capsule (for reducing bladder infections), lisinopril (for high blood pressure), and memantine (for dementia); and

* 09/25/23 - the MAR reflected the resident refused vitamin B-12 (supplement).

There was no documented evidence the physician was notified of the refusals. On 10/04/23, Staff 2 (Administrator) reported she thought the physician would only be notified when a resident refused to consent to orders three consecutive times.

The need to notify the physician when a resident refused consent to orders was discussed with Staff 1 (Owner) and Staff 2 on 10/06/23 at 10:47 am. They acknowledged the findings.

Forms for med rejections will be made and put in med room. Med techs will place form in folder after each med rejection on their shift. Folder will be checked daily at stand up meeting. Mar will be checked weekly for efficiency backup.

The actions above will correct the system.

Correction will be evaluated 1X daily with new forms, at stand up meeting. Mar will be checked 1X weekly checking for med rejections.

RCM will be responsible for keeping track of med rejections and faxing physicians as needed.  

Based on interview and record review, it was determined the facility failed to ensure all residents were entered into the Acuity-Based Staffing Tool (ABST). Findings include, but are not limited to:

On 10/04/23 at 1:15 pm, the facility's ABST was reviewed with Staff 1 (Owner). She stated there was a resident who was no longer in the facility. When she attempted to delete the resident from the tool, it deleted an entire wing of residents. She had to reenter all the residents back into the ABST.

The tool was reviewed by the survey team at approximately 2:00 pm on 10/04/23. It was discovered there were three residents that were not entered into the tool and multiple other residents were in the tool twice causing the census to be inaccurate.

The findings were shared with Staff 1 and Staff 2 (Administrator) on 10/04/23. They acknowledged the findings and stated they would reach out to the State for guidance with deleting the duplicates and adding the missing residents.

New move-in's will be entered in ABST prior to move-in. It will be entered alongside with electronic careplan. This will ensure it will be complete and entered before move-in.

This will be the change to the system to achieve compliance.

RCM will evaluate system and efforts.

Administrator and owner will be responsible to ensure all corrections are monitored.

Based on interview and record review, it was determined the facility failed to document pre-service training had been completed for 2 of 3 newly-hired staff (#s 9 and 14) whose pre-service training records were reviewed. Findings include, but are not limited to:

Staff training records were reviewed on 010/04/23 and the following was identified:

a. Training records for Staff 9 (MT), hired on 02/28/23, lacked documented evidence of pre-service training prior to beginning job responsibilities in the following areas:

* Resident rights and values of CBC care;

* Abuse reporting requirements;

* Infectious Disease Prevention;

* Fire safety and emergency procedures;

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

* Techniques for understanding, communication and responses to distressful behavioral symptoms;

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

* Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food/fluids, preventing wandering, and the use of person-centered approach.

b. Training records for Staff 14 (MT), hired on 02/28/23, lacked documented evidence of pre-service training prior to beginning job responsibilities in the following areas:

* Infectious Disease Prevention;

* Fire safety and emergency procedures;

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

* Techniques for understanding, communication and responses to distressful behavioral symptoms;

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

* Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food/fluids, preventing wandering, and the use of person-centered approach.

The requirement to document completed pre-service training prior to providing care to residents was discussed with Staff 1 (Owner) and Staff 2 (Administrator) on 10/05/23. They acknowledged the findings.

All CEU requirements will now be completed before any activity or training with residents. All required CEU's for new staff for new staff will be scheduled, in house, for three, eight hour days to complete required units.

This will ensure system stays in compliance.

System will be updated monthly to ensure updates are in compliance.

Administrator and owner will be responsible for corrections being completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure 1 of 2 newly-hired staff (#11) completed pre-service orientation prior to beginning their job responsibilities and pre-service dementia training prior to providing care to residents. This is a repeat citation. Findings include, but are not limited to:

Staff training records were reviewed on 01/30/24.

a. There was no documented evidence Staff 11 (CG), hired 01/05/24, had completed the following pre-service orientation topics:

* Resident rights and values of CBC care;

* Abuse reporting requirements;

* Infectious Disease Prevention;

* Fire safety and emergency procedures;

* Written job description;

b. There was no documented evidence Staff 11 had completed the following pre-service dementia training:

* 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 and engaging them in meaningful activities; and

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

The need for newly hired staff to complete all pre-service training in a timely manner, and to retain documentation of the training was discussed with Staff 1 (Owner) and Staff 5 (Admin Asst) on 01/30/24. They acknowledged the findings.

New system will be discussed with management team.

Pre training will be more closely monitored and overseen. Area will be monitored with every new hire. Administrator will be responsible.

For citation 370, Staff #11. I addressed Staff #11, addressing the training education issue. I went over training courses with #11 and gave deadline for completion.

Based on interview and record review, it was determined the facility failed to ensure there was documentation 2 of 3 newly-hired direct care staff (#s 9 and 14) had demonstrated competency of skills in all assigned job duties within 30 days of hire. Findings include, but are not limited to:

Training records were reviewed on 10/04/23 and identified the following:

a. Training records for Staff 9 (MT), hired on 02/28/23, lacked documentation of demonstrated competency in the following areas:

* Role of service plans in providing individualized care;

* 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 and abdominal thrust.

b. Training records for Staff 14 (MT), hired on 02/28/23, lacked documentation of demonstrated competency in the following areas:

* Role of service plans in providing individualized care;

* Providing assistance with ADL's;

* 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 and abdominal thrust.

The need to ensure documentation of staff demonstrated competency in all assigned job duties within 30 days of hire was discussed with Staff 1 (Owner) and Staff 2 (Administrator) on 10/05/23. They acknowledged the findings.

All CEU requirements will now be completed before any activity or training with residents. All required CEU's for new staff will be scheduled, in house, for three, eight hour days to complete required units.

This will ensure system stays in compliance.

System will be updated monthly to ensure updates are in compliance.

Administrator and owner will be responsible for corrections being completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly-hired staff (#s 18, 19, and 21) demonstrated satisfactory performance in any duty they were assigned. This is a repeat citation. Findings include, but are not limited to:

Staff training records were reviewed on 01/30/24.

There was no documented evidence Staff 18 (CG), Staff 19 (MA), or Staff 21 (MA), hired 11/06/23, 12/01/23, and 12/17/23, respectively, had demonstrated competency in one or more of the following areas:

* 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;

* Other duties as applicable (Med pass, treatments); and

* First Aid/Abdominal Thrust.

Staff 1 (Owner) reported there was no documentation MAs had demonstrated competency related to medication pass. Survey requested the facility observe and document medication pass competency for the MA on shift, prior to the next med pass, as well as for the MA on the next shift. Confirmations of these observations were received.

The need to ensure new staff demonstrate satisfactory performance in all assigned duties within 30 days of hire was discussed with Staff 1 (Owner) and Staff 5 (Admin Asst) on 01/30/24. They acknowledged the findings.

new system will be put in place by management team.there will be a closer view of new employee training before floor training. The system will be evaluated with each new hire. Administrator will be responsible.

Citation 372, Staff #18, 19, 21. Discussed  the within 30 day training courses with staff and explained the requirements. Staff received review of training and a deadline for completion

Based on observation, interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:

Refer to C 370 and C 372.    

Referral, see report

Based on observation and interview, it was determined the facility failed to ensure all exterior pathways and accesses were maintained in good repair. Findings include, but are not limited to:

The facility was toured on 10/04/23. The following issues were identified as needing repair:

* Exterior sidewalks around the facility had multiple drop-offs up to 4 inches, measured from the concrete to the ground. These drop-offs created potential hazards for residents.

* The courtyard had a brick walkway which was uneven in places, creating a potential tripping hazard.

On 10/05/23, the areas were discussed with Staff 1 (Owner) and Staff 2 (Administrator). They acknowledged the findings.

Drop off's will be built up with sand, fill dirt, and garden stepping bricks. The sand and brick will keep brick from moving. Brick will be layed to be flush with sidewalk and surrounding lawn.

Bricks on walkway will be removed, repacked, and releveled and put back in place.

Monthly quality checks will include outside environment, courtyard, and sidewalks surrounding the building.

Maintenance manager-Avan

Final check for compliance-Robin Allen

Based on observation and interview, it was determined the facility failed to ensure pathways and courtyard surfaces were level and did not create a tripping hazard for residents. Findings include, but are not limited to:

The facility was previously cited on 10/05/23 related to uneven surfaces in the resident courtyard. The facility requested and was granted an extension for completion of this repair. The resident courtyard was not looked at during the revisit to the relicensure survey conducted on 01/30/24 as the facility's correction period had not ended for the courtyard repair.

Original plan of correction...Drop off's will be built up with sand, fill dirt, and garden stepping bricks. The sand and brick will keep brick from moving. Brick will be layed to be flush with sidewalk and surrounding lawn.

Bricks on walkway will be removed, repacked, and releveled and put back in place. Monthly quality checks will include outside environment, courtyard, and sidewalks surrounding the building.

Maintenance manager

Final check for compliance-Administrator

Extension approved until 3/2/24 related to soggy ground and standing water making repairs impossible. Per Administrator on 3/8/24 the ground continues to be extremely soggy but plan is to attempt the leveling in current condition. Plan using sand and foot stones. The ground will be leveled next to sidewalk edges. The sand, then stones will be placed and be flush with edges of sidewalk. Administrator plans to have this completed by current compliance date of 3/15/24

Emailed Administrator Robin Allen and asked for additional information for staff training tags. Information was emailed back to me and added to the citations within the POC with Robins permission. Discussion with Robin via phone on 3/7/24 and email on 3/8/24 were had, previous POC and update sent via email placed in the POC related to the environment. Spoke with supervisor Jeanne Bristol regarding use of the newest AOC date for the environment and the current revisit items which she approved.