Print Inspection: Q4DG

The findings of the re-licensure survey conducted 8/23/21 through 8/24/21 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, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.

Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living 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 first re-visit to the re-licensure survey of 8/24/21, conducted on 11/23/21, 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.

Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living 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 second re-visit to the re-licensure survey of 08/24/22, conducted on 01/26/22, 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, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (#4) whose move-in evaluation was reviewed. Findings include, but are not limited to:

Resident 4 was admitted to the facility in 6/2021 with diagnoses including dementia with behavioral disturbance.

The resident's move-in evaluation dated 6/7/21, lacked information regarding the following required elements:

* Ability to manage medications;

* Dental status;

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

* Environmental factors that may impact the resident's behavior.

The lack of addressing all required elements in the move-in evaluation was discussed with Staff 1 (MCC Administrator) and Staff 2 (MCC RN) on 8/24/21. They acknowledged the findings.

Res#4 Record will be updated to reflect the required information.

Addendum added to move-in evaluation and service plan is being used as of 9/2/21 to include the following required information:

Ability to manage medications  

Dental status

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

Environmental factors that may impact the resident's behavior.

Transition to new software system, Point Click Care, on or around 2/1/22 will enable collection of all required information and improve efficiency.

DHS will be responsible for completion and ongoing monitoring.  

2. Resident 4 was admitted to the facility in 6/2021 with diagnoses including edema of lower extremity and dementia with behavioral disturbance. Review of the resident's clinical records revealed the following:

a. In a 7/16/21 progress note, Resident 4 was noted to have experienced weeping of the lower left and lower right leg chronic lymphedema.

b. A 7/19/21 progress note identified the resident to have superficial open wounds to both shins.

There was no documented evidence the facility determined and documented what actions or intervention were needed for each of Resident 4's skin conditions, and

monitored and documented the progress of the conditions at least weekly until the conditions resolved.

In an 8/24/21 interview with Staff 2 (MCC RN), she stated monitoring of Resident 4's edema had been difficult due to the resident's resistive behaviors.

The need to ensure the facility determined and documented what actions or interventions were needed for Resident 4's skin conditions and documented on the progress of skin conditions at least weekly until resolution was discussed with Staff 1 (MCC Administrator) and Staff  2 on 8/24/21. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to monitor the resident's condition until resolution for 2 of 5 sampled residents (#s 1 and 4) who had skin conditions. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in April 2021 with diagnoses including dementia and had a history of being resistive to care.

A review of the resident's service plan, temporary service plans and progress notes, 5/23/21 through 8/24/21, indicated the following change of condition related to skin:

* 8/16/21: blisters observed to both lower legs and reported to staff. MD was notified and ordered oral antibiotics and a cream to be applied daily to the area.

During an interview on 8/24/21, Staff 2 (MCC RN) reported a skin monitoring log had not been initiated since the areas on the legs were not open wounds. There was no additional documentation on the status of the skin condition since starting the medication and treatment.

A temporary service plan was initiated on 8/16/21 instructing staff to "monitor for ...diarrhea, rash, drainage, odor, swelling, pain and warmth to the touch". Progress notes between 8/16/21 through 8/23/21 included information on the resident's refusals of medications and other behaviors but did not include information on the status of the leg blisters.

The need to ensure there was a system for documenting and monitoring changes of condition was discussed with Staff 1 (MCC Administrator) and Staff 2 (MCC RN) on 8/24/21. They acknowledged the findings.

New system will be put in place to track and monitor skin conditions until community transitions to new software system on or before 2/1/22.

Tracking of skin conditions will be incorporated into monthly CQI meeting to ensure ongoing monitoring.

DHS and MCC RN will be responsible for completion and ongoing monitoring.  

Based on interview and record review, it was determined the facility failed to ensure pre-service orientation and pre-service dementia care training had been completed prior to providing care to residents, for 3 of 3 newly-hired staff (#s 19, 20 and 21). Findings include, but are not limited to:

Staff training records were reviewed on 8/24/21 and revealed the following:

1. Staff 20 (CG), hired on 4/22/21, and Staff 21 (CG), hired on 5/17/21 did not have documented evidence the following training was completed prior to providing direct care to residents:

* Standard precautions for infection control; and

* Fire safety and emergency procedures.

2. Staff 19 (CG), hired on 3/12/21, Staff 20 and Staff 21 did not have documented evidence of their completion of pre-service dementia training prior to providing direct care to residents.

The need to ensure all pre-service training was completed prior to staff providing direct care to residents was discussed with Staff 3 (ALF RN) and Staff 4 (ALF LPN) on 8/24/21. They acknowledged the findings.

The creation and development of a Training Grid to include all initial, supplemental, and on-going training required of all staff.  The grid will be sorted by department and available to all department managers.

The training grid will be on an interactive platform and will be available to all department managers.  It will include all required training and the status of each of those elements. The Grid will be created and maintained by Human Resources.

Department managers will review Grid prior to starting new employees and will be reevaluated at least monthly for accuracy and status.

HR Manager and Department Managers.

Based on interview and record review, it was determined the facility failed to ensure 1 of 3 newly hired memory care staff (#16) had demonstrated competency in all required areas within 30 days of hire and 3 of 3 newly-hired staff (#s 19, 20 and 21) completed first aid and abdominal thrust training within 30 days of hire.  Findings include, but are not limited to:

Staff training records were reviewed on 8/24/21 and revealed the following:

1. Staff 16 (MCC CG), hired in memory care on 6/17/21, did not have documented evidence of demonstration of competency in the following areas:

* Role of service plans in providing individualized care;

* Providing assistance with ADLs;

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

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

Staff 16 lacked evidence of certification in First Aid within 30 days of hire.

2. Staff  17 (MCC CG), hired 6/24/21, lacked evidence of certification in First Aid within 30 days of hire.

3. Staff 19 (CG), hired on 3/12/21, Staff 20 (CG), hired on 4/22/21 and Staff 21 (CG), hired on 5/17/21 had no documented evidence of receiving abdominal thrust and first aid training within 30 days of hire.

The need to ensure all newly hired staff had documentation of demonstrated competency and completed first aid and abdominal thrust training within 30 days of hire was discussed with Staff 5 (Human Resources) on 8/24/21. She acknowledged the findings.

The creation and development of a Training Grid to include all initial, supplemental, and on-going training required of all staff.  The grid will be sorted by department and available to all department managers.

The training grid will be on an interactive platform and will be available to all department managers.  It will include all required training and the status of each of those elements. The Grid will be created and maintained by Human Resources.

Department managers will review Grid prior to starting new employees and will be reevaluated at least monthly for accuracy and status.

HR Manager and Department Managers.

Based on interview and record review, it was determined the facility failed to ensure 1 of 3 long term staff (#22) completed the minimum required 12 hours of annual in-service training on topics related to the provision of care for persons in a CBC setting including 6 hours of dementia training. Findings include, but are not limited to:

Staff training records were reviewed on 8/24/21 and revealed the following:

Staff 22 (CG), hired in 11/2007, did not have documented evidence of completing 12 hours of annual in-service training including six hours related to dementia care topics.

The need to ensure all long term staff complete 12 hours of annual in-service training was discussed with Staff 5 (Human Resources) on 8/24/21. She acknowledged the findings.

The creation and development of a Training Grid to include all initial, supplemental, and on-going training required of all staff.  The grid will be sorted by department and available to all department managers.

The training grid will be on an interactive platform and will be available to all department managers.  It will include all required training and the status of each of those elements. The Grid will be created and maintained by Human Resources.

Department managers will review grid prior to starting new employees and will be reevaluated at least monthly for accuracy and status.

HR Manager and Department Managers.

Based on interview and record review, it was determined the facility failed to ensure fire and life safety instruction to staff was provided on alternate months of fire drills. Findings include, but are not limited to:

Fire and life safety records were reviewed from February 2021 to August 2021 and revealed the facility lacked documented evidence it was providing fire and life safety instruction to staff on alternating months.

The requirements regarding fire and life safety instruction for staff was reviewed with Staff 1 (MCC Administrator) and Staff 8 (Facility Director) on 8/24/21. They acknowledged the findings.

Fire and life safety drills and Instruction will be provided to all staff.  Given the most recent fire drill on July 30 2021 the next fire drills will be conducted in the month of September.  Education will be provided through Relias on alternating months beginning October 2021.

Additionally, we are installing and implementing a new Facility Maintenance software call TELS.  Once installed, this will be added to the routine inspection items.

This will be added to the monthly schedule of inspection items.

Fire and life safety will be reviewed during the monthly CQI meeting.

Facility Maintenance Director will be responsible for ongoing monitoring.

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements were being met. Findings include, but are not limited to:

Fire and life safety records from February 2021 to August 2021 revealed the facility lacked documented evidence of the following:

* Fire and life safety training for residents at least annually that included general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire; and

* A written record of fire safety training, including content of the training sessions and the residents attending.

The need to ensure fire and life safety instruction was provided to residents at least annually was discussed during interviews on 8/24/21 with Staff 1 (MCC Administrator) and Staff 5 (Facility Director). They acknowledged the findings.

Facility Maintenance Director will implement fire life training program for residents.

Recorded resident specific training in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This will be added to the TELLS building maintenance system.

Program will be offered twice yearly in January and June.

Facility Maintenance Director will be responsible for ongoing monitoring.

Based on interview, it was determined the facility failed to ensure their relicensure survey plan of correction was implemented and satisfied the Division. Findings include, but are not limited to:

Refer to C 555.

We have an approved extention for a single correction.  The exception is based on unavailability of the needed electronic components.  Components are to be delivered and installed by 12/31/21

Based on observation and interview, it was determined the facility failed to ensure operable windows were designed to prevent accidental falls when sill heights were lower than 36 inches and above the first floor. Findings include, but are not limited to:

The facility was toured on 8/24/21. Resident unit windows on the second and third floors opened vertically, and windowsills were lower than 36 inches. The windows lacked a system which limited how much the window could be opened to prevent accidental falls.

The lack of a mechanism to prevent accidental falls was discussed with Staff 1 (MCC Administrator) and Staff 8 (Facility Director) on 8/24/21 at 2:30 pm. They acknowledged the findings.

Adjustable, limiting devices have been ordered for all resident windows above the first floor.  

These devices will not be able to be adjusted or removed by residents but are adjustable by maintenance personnel.

The devices will be monitored for security and possible adjustments/tightening on a semi-annual basis by the maintenance personnel and will be added to the TELS management system.

Facility Maintenance Director will be responsible for ongoing monitoring.

Based on observation and interview, it was determined the facility failed to ensure covers, grates, or screens of wall heaters and associated heating elements did not exceed 120 degrees Fahrenheit (F) when they were installed in locations that were subject to incidental contact by individuals. Findings include, but are not limited to:

The facility was toured on 8/24/21. Room 2011, a one-bedroom unit, had a wall heater in the bedroom located under the window where a resident could come into accidental contact with it. When the heater was turned on and the temperature of the surface of the metal grill was measured using the surveyor's digital thermometer, the temperature exceeded 150 degrees F.

On 8/24/21 at 2:30 pm, the surveyor informed Staff 1 (MCC Administrator) and Staff 8 (Facility Director) of the temperature of the heater grill. Staff and the surveyor checked a two-bedroom unit, which had a similar wall heater in each bedroom. The temperature of the grills of each heater also exceeded 150 degrees F. The facility reported there were 46 one-bedroom and 23 two-bedroom units which had similar wall heaters.

Staff 1 and Staff 8 acknowledged the surface of the wall heater grills exceeded the 120 degrees F specified in the rule.

Circuit breakers to the existing wall heaters have been turned off to prevent any hazard. Replacement heating elements have been identified and were ordered from the manufacturer on 9/13/21.

The new elements will be set to not exceed 120 degrees.  The adjustments are made internally and cannot be changed by residents.

The heating temperatures will be tested annually at the beginning of cold weather season to ensure compliance.  This will be added to the TELS system.

Facility Maintenance Director will be responsible for ongoing monitoring.

Based on observation and interview, it was determined the facility failed to provide an exit door alarm or other acceptable system to alert staff when residents exited the RCF and MCC. Findings include, but are not limited to:

The facility consisted of an three-story residential unit building, referred to by the facility as the "Independent" area of the building, and a secured memory care unit. The first floor of the independent area included the main entrance, three additional doors by which residents could exit the building into the outdoor neighborhood and four doors which exited to an enclosed courtyard. The memory care unit included several doors by which residents could exit into two separate enclosed courtyards.

The facility was toured on 8/24/21. There was no system in place which alerted staff when a resident exited the RCF or MCC buildings.

The need to have a system which alerted staff when residents exited the RCF and MCC buildings was discussed with Staff 1 (MCC Administrator) and Staff 8 (Facility Director) on 8/24/21. They acknowledged there were no door alarms or other system in place to alert staff when a resident exited.

All exterior doors without notification devices have been identified and sensors have been ordered to add to our existing iAlert system.  Sensors are currently being programmed to our system.

This will allow exterior doors, when opened, to alert staff immediately.  The notification will include which door has been opened, and staff will investigate.

The monitors are self-testing and will alert staff if sensor cannot be detected or if sensor battery is low.

Facility Maintenance Director will be responsible for ongoing monitoring.

The facility was granted an extension until 12/31/21 to bring exit door alarms into compliance. The exit doors were not observed during the re-visit survey.

1. All exterior doors, without notification devices, have been identified and sensors have been ordered to add to our existing iAlert system.  Sensors are being programed to our system.

2. This will allow exterior doors, when opened, to alert staff immediately.  The notification will include which door has been opened, and staff will invistigate.

3.  The monitors are self-testing and will alert staff if senors cannot be detected or if battery is low.

4. Facility Maintenance Director.

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 370, C 372, C 374, C 420, C 422, C 515, C 540 and C 555.

Ref POC for C370, C372, C374, C420, C422, C515, C540 AND C555

Based on interview, 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 555.

1. All exterior doors, without notification devices, have been identified and sensors have been ordered to add to our existing iAlert system.  Sensors are being programed to our system.

2. This will allow exterior doors, when opened, to alert staff immediately.  The notification will include which door has been opened, and staff will invistigate.

3.  The monitors are self-testing and will alert staff if senors cannot be detected or if battery is low.

4. Facility Maintenance Director.

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 and C 270.

Ref - POC for C 252 AND C270

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, for 2 of 2 sampled residents (#s 1 and 4) whose records were reviewed. Findings include, but are not limited to:

Review of Resident's 1 and 4's Life Enrichment Plans found the facility had not fully evaluated the residents in the following areas:

* Emotional and social needs and patterns; and

* Activities that could be used as behavioral interventions, if needed.

There was no specific activity plan which detailed what, when and how often staff should offer and assist the residents with individualized activities.

The need to ensure each resident was evaluated and an individualized activity plan was developed from the evaluation was reviewed with Staff 1 (MCC Administrator) and Staff 25 (MCC Activities) on 8/24/21. They acknowledged the findings.

The Life Enrichment evlauation will be updated to include the following:

Emotional and social needs.

Patterns and activities that could be used as behavioral interventions.

When and how offten staff should offer and assist residents with individual activities.

The life enrichment evaluation will be completed upon move in and will be updated quarterly or if a resident has a change of condition.

The Life Enrichment Coordinator and MCC Administrator will be responsible for completing the corrections and monitoring.