Print Inspection: OV1K

The findings of the re-licensure survey conducted, 02/07/22 through 02/09/22 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 re-visit to the re-licensure survey of 02/09/22, conducted 04/28/22, 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. The facility was found to be in substantial compliance with the 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 (#1) whose move-in evaluation was reviewed. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 01/2022. The move-in evaluation was reviewed, and the following areas were identified as not being addressed:

* Customary routines: sleeping, eating, bathing;

* Interests, hobbies, social, leisure activities;

* Spiritual, cultural preferences and traditions;

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

* Ability to use call system;

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

* Skin condition;

* List of treatments: type, frequency, and level of assistance needed;

* Fall risk or history;

* Complex medication regimen;

* History of dehydration or unexplained weight loss or gain;

* Recent losses;

* Unsuccessful prior placements;

* Elopement risk or history;

* Alcohol and drug use not prescribed by a physician; and

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

The need to address all required elements on the move-in evaluation was discussed with Staff 2 (Administrative Assistant) on 02/09/22. She acknowledged the findings.

Initial Evaluation for Resident #1 reviewed and all missing items updated.

Our policies and our tools to complete move-in evaluations are in accordance with the regulations and do not need updating at this time.

However, we have re-educated our staff on the importance of completing these accurately and comprehensively prior to Resident move-in. We have also performed an audit of other Residents who have recently moved in to determine missing items that require updating.

The Administrative Assistant will review each move-in evalaution to ensure it is completed in accordance with policies and requirements.

This plan will be re-evaluated on a quarterly basis.

The Administrative Assistant is responsible for this plan of correction.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a service planning team that 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 2 and 4) whose service plans were reviewed. Findings include, but are not limited to:

The most recent service plans for Residents 2 and 4 were reviewed during the survey. The records lacked documented evidence that the service plans were developed by a service planning team.

On 02/08/22 the need to ensure service plans were developed by a service planning team was discussed with Staff 1 (Administrator) and Staff 2 (Administrative Assistant). They acknowledged the findings.

This Facility had scheduled meetings to discuss Care Plan with Resident and/or Resident's Representative for Resident #2 and 4, in the past, but since meetings were done virtually, signatures haven't been colected.

This Facility scheduled new meetings to discuss Care Plan with Resident and/or Representative for Resident #2 and 4, and will document collaboration/collect signatures from appropriate parties and all members involved, such as Facility RN, Caregiver(s), Resident and/or Resident's Representative, Administrator.

Our policies and our tools to complete Care Plans as compared to their last evaluations in collaboration with the Resident and/or Resident's Representative, Facility RN and Caregiver(s) are in accordance with the regulations and do not need updating at this time.

However, we have reviewed all Residents' care plans to identify other Residents that may need updates in this area and others.

These areas will be re-evaluated on a quarterly basis.

The Administrative Assistant is responsible for this plan of correction.    

2. Resident 4 was admitted to the facility in 10/2016 with diagnoses including hypertension, heart disease, dementia with behavioral disturbance, syncope, and chronic reflux esophagitis.

Review of Resident 4's progress notes, dated 10/13/21 to 02/07/22, service plan, dated 12/08/21, and incident reports indicated the resident had experienced multiple short-term changes of condition.

The resident experience the following changes of condition:

* On 12/17/21 Resident 4 was admitted to hospice. On that date, multiple medication changes were ordered. Records showed no documented evidence the resident was monitored for possible adverse effects or that staff were instructed on specific signs/symptoms to observe, or when to notify the RN.

* Progress notes, dated 01/21/22 revealed the resident had a  "yellow bruising to lower extremities". There was no documented evidence of ongoing monitoring of the bruising, at least weekly, to resolution.

Resident 4's records lacked documented evidence that changes of condition were evaluated, interventions determined and communicated to staff, and the conditions were monitored to resolution.

On 02/09/22 the need to evaluate short-term changes of condition, determine interventions needed, provide detailed instructions to staff and monitor the conditions to resolution was discussed with Staff 2 (Administrative Assistant). She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure short-term changes of condition were evaluated, referred to the RN when needed, and monitored through resolution, with at least weekly documentation, for 2 of 2 sampled residents (#s 2 and 4) who experienced short-term changes of condition. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 07/2021 with diagnoses including intestinal obstruction with an ostomy.

Resident 2's clinical chart, including the service plan, progress notes, temporary service plans, dated 09/10/21 through 02/01/22, and MARs dated 01/01/22 through 02/07/22. The resident and staff were interviewed.

The resident experienced several short-term changes of condition, including:

* A 10/19/21 progress note referenced an "order from PCP instructing staff to collect UA [urinalysis] sample." There was no further documentation related to the outcome of the UA or antibiotics being prescribed for a urinary tract infection (UTI) or of any monitoring.

* On 11/22/21 staff documented a suspected UTI because the resident complained of burning with urination, a sample was taken and sent to the lab, and the primary care physician faxed an order for an antibiotic for seven days. There was no documentation of monitoring, no temporary service plan, and no alert charting of the resident's condition.

A temporary service plan was signed by Staff 2 (Administrative Assistant) on 02/01/22 related to a UTI; there was a physician order for an antibiotic dated 02/03/22. There was no documented monitoring of the resident's condition.

The RN was not available for an interview. Staff 2 stated all monitoring had been done verbally between staff for the last few months.

The need to document monitoring of all short-term changes of condition at least weekly through resolution was discussed with Staff 2 on 02/09/22. She acknowledged the findings.

Our policies and tools in place, to ensure short-term changes in condition are monitored, are in accordance  with the regulations and do not need updating at this time.

1. We have reviewed Resident #2 Care Plan and Progress Notes and we have re-educated our staff on the importance of following the steps in our 24 hour Report Book and our Temporary Service Plans accurately and that every report communicated verbally, even when there is no changes, needs to be documented in writing, at least weekly and as needed if any changes, through resolution. Also we re-educated staff to follow steps in our Temporary Service Plans reflecting short-term changes in condition regarding when to nofity the facility RN or Administrator/Administrative Assistant.

We have reviewed all Resident's charts to identify any missing documentation regarding short term change in condition.

These short-term changes areas will be reviewed on a weekly basis.

The Administrative Assistant is responsible for this plan of correction.

2. Resident #4 was evaluated by Hospice and admitted on 12/17/21. No changes to her care, several supplements were discontinued and "Comfort Kit" medications ordered, per Hospice protocol. All medications in the "Comfort Kit" are PRN medications and written parameters are in place, completed by Hospice RN, that include instructions for staff with possible adverse reactions to look for and when to notify RN. None of the medications in Resident's "Comfort Kit" have been administered to the Resident yet.

Our RN and Administrative Assistant have been reeducated concerning significant change of status and their roles and responsibilities and our RN completed an evaluation regarding changes in Resident's status and changes in medication.

Our policies and tools for documenting and monitoring any skin issues as well as when to complete an Incident Report are in accordance with the regulations and no changes needed at this time.

We have reeducated our staff regarding documentation and monitoring of any skin issue in our CBC and Skin Integrity Chart as well as when to complete and Incident Report, signs to look for and when to notify RN and Administrator and/or Admnistrative Assistant.

Hospice RN wrote a progress note on 1/21/22, stating the Resident had "yellow bruising to lower extremities".

Meeting set up with Hospice RN and staff to investigate this matter. During this visit, Hospice RN is stating she discovered 2 yellow spots, of approximately 0.8 and 1.2 cm diameter, at Resident's Right knee area. While evaluating Resident's skin during this meeting, RN was showing us the exact area at around her Right knee where she previously saw those spots. At this time, Resident is crossing her legs, touching her knees together. RN evaluates the way Resident is laying and concludes these small yellow spots may be caused by bone pressing on bone when she's crossing her legs and touching her knees. Staff also reports no purple bruises observed before at this area, but sometimes these very small yellow bruising/spots apear and dissapear, when Resident crossing her legs. Resident has history of bruising easily. Educated staff to place small pillow in between Resident's knees, to prevent yellow bruising/spots from forming when her knees are touching and Resident's care plan has been updated.

***Resident has been observed not keeping small pillow in place in between her knees, she is removing it shortly after staff place it.

We have reviewed all our Residents' care plans to identify other Residents that may require updates in this area and others.

Staff will perform a full skin check for Resident twice a week, during bed bath.

The Administrative Assistant is responsible for this plan of correction.

Based on interview and record review, it was determined the facility failed to ensure recommendations made by outside service providers were included in the resident ' s service plan for 1 of 1 sampled resident (#2) who received outside services. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 07/2021 with diagnoses including muscle weakness and an intestinal obstruction with ostomy.

The resident's 12/13/21 service plan and progress notes dated 09/10/21 through 01/31/22 were reviewed, and staff and the resident were interviewed. The resident received home health services from an outside provider for PT and skilled nursing.

The following was identified:

* On 01/05/22, the PT recommended the resident use his/her four-wheeled walker to move from his/her recliner to the bathroom two to four times per day with stand-by assistance.

* A 01/31/22 progress note about the resident's admission to home health skilled nursing stated "try putting pt on toileting schedule every two hours change incontinent briefs change ostomy pouch when 1/3 or ½ full."

There was no documented evidence those recommendations had been added to the resident's service plan.

In an interview, Staff 2 (Administrative Assistant) stated the recommendations were verbally communicated to staff and were implemented.

The need to ensure recommendations from outside providers were added to resident service plans was discussed with Staff 2 on 02/09/22. She acknowledged the findings.

Our policies and tools we have in place to ensure recommendations made by outside service providers are included in Resident's care plan are in accordance with the regulatioons and no updates or changes are needed at this time.

On 1/5/22 the HHPT recommended the Resident use her walker to move from her recliner to the bathroom two to four times a day with stand-by assistance.

Staff in collaboration with Resident made a schedule and posted it in Resident's bathroom where it was documented on this schedule every time this was accomplished.

On 1/31/22 HHRN recommended to "try putting PT on toileting schedule every two hours change incontinent briefs change ostomy pouch when 1/3 or 1/2 full.  

Staff in collaboration with Resident made a schedule and posted it in Resident's bathroom and it was documented on this schedule every time this task was performed.

However, we have reeducated our staff about documenting in Resident's care plan any recommendations made by outside providers.

We have reviewed all other Residents' care plans to identify any changes needed to be made in this area and others.

These areas will be reviewed on a quarterly basis.

The Administrative Assistant is responsible for this plan of correction.  

Based on observation and interview, it was determined the facility failed to ensure the general exterior of the building was maintained in good repair and the outdoor perimeter fencing was not secured to prevent exit. Findings include, but are not limited to:

The courtyard was toured on 02/07/22, and the following was identified:

* Multiple two- to three-inch drop-offs on pathway edges, which created a potential safety hazard for residents;

* Multiple pieces of broken or damaged equipment including, but not limited to, a manual Hoyer lift and sling; a bed frame, headboard, and footboard, and mattress springs were all  in the courtyard next to the storage shed;

* An indoor freezer and refrigerator used by the kitchen were stored on the outside patio;

* Glass vases filled with rainwater were piled in the corner of the courtyard;

* There were unsecured covers on two patio drains;

* Garden chemicals and yard tools were lying on the ground;

* Two rodent bait trays were on the rock bed next to the pathway;

* A storage shed containing equipment and yard supplies was unlocked;

* Access to the courtyard was not available to all residents. The two doors exiting to the courtyard were locked. One door was located in the back hallway required a code to exit, and the code was not posted. The other exit was a sliding glass door located in the living room had a wooden dowel on the door track which prevented the door from opening; and

* The courtyard perimeter fencing had three gates with electronic keypads, and no codes were posted.

In an interview on 02/07/22, Staff 1 (Administrator) stated she had not received approval from the Department to keep the gates locked.

The courtyard was toured with Staff 1 on 02/08/22 and deficiencies were reviewed. She acknowledged the findings. She stated, she would post the codes to the electronic keypads so residents could exit the courtyard.

All pathway edges have been leveled and will be kept in good maintanance.

All equipment found outdoor has been disposed.

The refrigerator has been disposed and the freezer moved indoors.

All the vases and rodent bait trays have been disposed.

The two unsecured patio drains covers have been secured in place.

All garden chemicals and yard tools moved and kept in the locked outdoor storage.

The Code for the back hallway has been posted, the sliding door for the courtyard access kept free of blockage, allowing access at all times.

One of the gates is not an exit and willl be permanently locked. Code has been posted on the other two gates.

These areas will be reviewed on a quarterly basis.

The Administrator is responsible for this correction.  

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

During a tour of the facility on 02/07/22, the following was observed:

* An exit door to the courtyard located in the back hallway had broken, split pieces of wood on  the interior and exterior of the door frame.  

The environment was toured with Staff 1 (Administrator) on 02/08/22. She acknowledged the findings. She further stated, the door would be replaced.

The exit door will be replaced completely.

This area will be reviewed on a quarterly basis.

Administrator is responsible for this correction.