Print Inspection: RGYK

The findings of the Change of Owner survey, conducted 10/09/23 through 10/10/23, 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, 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 first re-visit to the re-licensure survey of 10/10/23, conducted 12/26/23 through 12/27/23, 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 57 for Memory Care Communities.

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

cc:cubic centimeter

CG:caregiver

cm:centimeter

F:Fahrenheit

HH:Home Health

HS or hs:hour of sleep

LPN:Licensed Practical Nurse

MA:Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

O2 sats:oxygen saturation in the

blood

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

RN:Registered Nurse

SP:service plan

TAR:Treatment Administration

Record

tid:three times a day

The findings of the second revisit to the change of ownership survey of 10/10/23, conducted on 03/20/24, 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, Division 57 for Memory Care Communities, and Division 004 for Home and Community Based Services.

Based on observation, interview, and record review, it was determined the facility failed to ensure injuries of unknown cause and other incidents were promptly investigated to rule out abuse and/or neglect and reported to the local SPD office when required, for 2 of 2 sampled residents (#s 1 and 2) reviewed with incidents. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 07/2023 with diagnoses including dementia.

Observations of the resident, interviews with staff, review of the resident's 09/22/23 service plan, 07/21/23 through 10/09/23 temporary service plans, progress notes, physician communications, and incident investigations were completed.

The resident could direct portions of his/her own care, was very forgetful and his/her feelings were easily hurt. The resident was independent with most of his/her ADLs and ambulated around the facility without assistance. The resident was additionally identified as having extremely fragile skin.

Review of the resident's records showed the following:

* A facility investigation dated 08/12/23 indicated the resident was found with a skin tear on the right elbow. The resident could not say what had occurred. The injury of unknown cause was not reported to the local SPD office.

The facility reported the incident to the local SPD office at the time of survey on 10/09/23. A confirmation of the report was provided to the survey team prior to exit.

The need to ensure injuries of unknown cause were investigated and reported to the local SPD office was discussed with Staff 1 (Administrator), Staff 2 (RCC) and Staff 3 (RN) on 10/10/23. The staff acknowledged the findings.

2. Resident 2 was admitted to the facility in 02/2017 with diagnoses including dementia and stroke.

Observations of the resident, interviews with staff, review of the resident's 09/25/23 service plan, 06/01/23 through 10/09/23 temporary service plans, progress notes, physician communications, and incident investigations were completed.

The resident was noted to require full assistance from staff for all care. The resident required two staff assistance for bed mobility, incontinent care and transfers due to paralysis. Staff used a sit to stand lift to transfer the resident to and from the bed/wheelchair. The resident required meal assistance from staff and was often fed by staff. The resident had mechanical soft foods, thickened liquids and extra gravies ordered to keep foods moist. Speech therapy and occupational therapy instructions for the resident's meals included small bites, clearing of his/her mouth, drinks between bites and positioned at a 90-degree angle for meals.

Review of the resident's records showed the following:

* A progress note dated 07/19/23 indicated the resident had a "small choking incident that was resolved." No other information was documented about the incident.

There was no investigation documented to show that service planned swallowing and safety interventions were implemented by staff when assisting the resident with his/her meal to rule out abuse and neglect.

* A progress note dated 07/27/23 indicated the resident choked at lunch and abdominal thrusts were used to assist the resident. No other information was documented about the incident.

There was no investigation documented to show that service planned swallowing and safety interventions were implemented by staff when assisting the resident with his/her meal to rule out abuse and neglect.

* A progress note dated 09/07/23 indicated the resident was coughing and choking on soup and threw up. No other information was documented about the incident.

There was no investigation documented to show that service planned swallowing and safety interventions were implemented by staff when assisting the resident with his/her meal to rule out abuse and neglect.

* A progress note dated 09/27/23 indicated the resident was found to have a light bruise to the left lower leg. Staff noted the area looked as if it may have been caused by the resident's footrest on the wheelchair.  

Observations of the resident during two different transfers, showed a long metal bar protruding out from the right side of the residents bed. The placement of the bar was at the same approximate height of the bruised area on the residents leg. A large yellow bruise was observed on the back of the resident's left lower leg.

There was no investigation documented related to the bruise.

The facility reported the choking incident in which staff documented abdominal thrust was used as well as the bruise to the resident's lower leg, to the local SPD office at the time of survey on 10/09/23 and 10/10/23. A confirmation of the report was provided to the survey team prior to exit.

The need to ensure injuries of unknown cause were investigated and reported to the local SPD office was discussed with Staff 1 (Administrator), Staff 2 (RCC) and Staff 3 (RN) on 10/10/23. The staff acknowledged the findings.

Both Incidents have been reported to local SPD Office to rule out potential abuse or neglect. Protruding metal bar has been removed.

All Resident Chart Notes will be audited to ensure no other incidents have occurred which require SPD Office reporting; any incidents discovered will be investigated and/or reported as required.

Training will be conducted for all staff whose duties include Incident Reporting and Chart Notes to ensure injuries of unknown origin are investigated and reported as required, and that Service Plan interventions are followed.

All resident use furniture and equipment have been inspected for issues which may compromise resident safety.

Resident Equipment Inspections will be added to routine Monthly Maintenance Rounds.

Audits of Incident Reports, Chart Notes, and Maintenance Inspections will be completed monthly and reviewed at Quarterly QAPI.

Administrator or Designee will be responsible to ensure compliance.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements prior to the resident being admitted to the facility for 1 of 1 sampled resident (#3) who recently move in. Findings include, but are not limited to:

Resident 3 was admitted to the facility on 08/16/23 with diagnoses including dementia.

The resident's new move in evaluation was completed on 08/10/23.  The following elements were not addressed or had conflicting information in the move-in evaluation:

* Visits to health practitioner(s), ER, Hospital or NF in the past year;

* Customary routines including eating, bathing;

* Spiritual, cultural preferences and traditions;

* Vital signs if indicated by diagnosis, health problems or medications;

* Hearing, vision and assistive devices;

* ADLs including bathing and personal hygiene;

* Nutrition habits, fluid preferences and weight if indicated;

* Presence of depression, thought disorders, behavioral or mood problems;

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

* Fall risk or history;

* Unsuccessful prior placements; and

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

The need to complete move-in evaluations prior to a resident being admitted to the facility and to address all required elements was discussed with Staff 1 (Administrator), Staff 2 (RCC) and Staff 3 (RN) on 10/10/23. The staff acknowledged the findings.

Resident's move in evaluation has been amended to include missing elements. These elements are included in the Resident's Service Plan.

Move-In Evaluations for all residents have been reviewed for completeness and accuracy and placed in plastic sheet protectors to ensure they remain in the on-site resident record.

All prospective residents will be screened prior to admission and the move in evaluation will contain all required elements. RCC will monitor with each admission and subsequent service plan revision that move in evaluations are complete and remain in resident chart.

Audits of Move in Evaluations will be added to QA Process.

Administrator and RCC will be responsible to ensure compliance.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction for staff and were consistently implemented by 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 1 was admitted to the facility in 07/2023 with diagnoses including dementia.

Observations of the resident, interviews with staff, and review of the resident's service plan dated 09/22/23 and progress notes dated 07/21/23 to 10/09/23 were completed. Staff indicated the resident had poor safety awareness, was able to transfer on his/her own and ambulated independently. The resident could make his/her needs known and was independent with the majority of his/her ADLs. The resident's service plan was not reflective and lacked resident specific direction for staff in the following areas:

* Cane vs. Walker use;

* Agitation; and

* Resident to resident altercations and interventions to utilize.

The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (Administrator), Staff 2 (RCC) and Staff 3 (RN) on 10/10/23. The staff acknowledged the findings.

2. Resident 2 was admitted to the facility in 02/2017 with diagnoses including dementia and hemiplegia.  

Observations of the resident, interviews with staff, and review of the resident's service plan dated 09/25/23 and progress notes dated 06/01/23 to 10/09/23 were completed. Staff indicated the resident required full assistance with all ADL care. The resident needed two staff assistance for care and the use of a sit to stand mechanical lift. The resident could make some needs known and frequently yelled out repetitively. The resident's service plan was not reflective, lacked resident specific direction for staff and/or was not consistently implemented by staff in the following areas:

* Fall mat, bed height and fall risk;

* Side rail use, position and air bed use;

* Two person transfers and use of the sit to stand lift;

* Positioning in bed, wheelchair and tilt in space wheelchair use;

* Incontinent care in bed, brief changes and centering in bed during care;

* Brace for the left hand and hand roll/wash cloth use;

* Dressing, grooming and hygiene assistance;

* Meal assistance, upright positioning, small bites, clearing mouth and drink protocols; and

* Smoking interventions, apron use and extender clip for cigarette.

The need to ensure resident service plans were reflective of current care needs, provided clear direction to staff and were consistently implemented by staff was discussed with Staff 1 (Administrator), Staff 2 (RCC) and Staff 3 (RN) on 10/10/23. The staff acknowledged the findings.

Resident 1's Service Plan has been updated to provide specific direction for staff related to walker/cane use, agitation, and interventions to help prevent resident to resident altercations. Resident 2's Service Plan has been revised to reflect current care needs, including ADL cares, transfer status, mechanical lift use, fall risks, positioning, equipment use, meal assistance, and smoking.

All resident Service Plans have been reviewed to ensure they accurately reflect resident health status and provide clear direction to staff.

RCC will collaborate with RN and direct care staff with each service plan update to ensure accuracy no less than quarterly. New and Updated Service Plans will be reviewed and signed by all staff providing care. Intermittent direct observation of care will be performed by Administrator/RCC/RN to ensure Service Plans are followed.

Administrator or Designee will be responsible to ensure compliance.

Based on observation, interview and record review it was determined the facility failed to ensure short term changes of condition were monitored with documented progress at least weekly to resolution, current interventions were evaluated for effectiveness, additional interventions were implemented as indicated and resident specific instructions were communicated to staff for 2 of 2 sampled residents (#s 1 and 2). Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 07/2023 with diagnoses including dementia.

Observations of the resident, interviews with staff, and review of the resident's service plan dated 09/22/23 and progress notes dated 07/21/23 to 10/9/23 were completed.

The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, and/or lacked resident-specific directions to staff in the following areas:

* Increased agitation, hallucinations and confusion;

* Medication changes;

* Fall; and

* Hospital stay and emergency room visit.

The need to ensure short-term changes of condition had documentation to reflect monitoring at least weekly to resolution and provided clear, resident-specific directions to staff was discussed with Staff 1 (Administrator), Staff 2 (RCC) and Staff 3 (RN) on 10/10/23. They acknowledged the findings.  

2. Resident 2 was admitted to the facility in 02/2017 with diagnoses including dementia and stroke.

Observations of the resident, interviews with staff, and review of the resident's service plan dated 09/25/23 and progress notes dated 06/01/23 to 10/9/23 were completed.

The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness and/or lacked resident-specific directions to staff in the following areas:

* Choking episodes with and without abdominal thrusts;

* Increased behaviors with agitated responses from other residents;

* Yellowing of skin/eyes;

* Rashes, scratches and open sores to multiple parts of the resident's body; and

* Hospital return and shoulder fracture.

The need to ensure short-term changes of condition had documentation of progress at least weekly to resolution, interventions were not reviewed for effectiveness and/or failed to provided clear, resident-specific directions to staff was discussed with Staff 1 (Administrator), Staff 2 (RCC) and Staff 3 (RN) on 10/10/23. They acknowledged the findings.  

Resident 1 and 2 have been reviewed for short term change of condition and found to be currently at baseline.

All resident chart notes have been reviewed to identify short term changes of condition, and if found, placed on alert and weekly monitoring until resolved. Training will be provided to all staff whose job duties include documenting and reporting short term change of condition. Residents with short term changes of condition will be communicated through the ISP process, placed on alert, and monitored to resolution.  Any needed additional interventions will be communicated through the 24 hour system and ISP.

Weekly audits of chart notes, 24 hour communications, ISP's, and alert will be conducted and brought to QAPI.

Administrator, RCC, or Designee will be responsible to ensure compliance.

Based on interview and record review, it was determined the facility failed to ensure short-term changes of condition had determined actions or interventions needed, communicated those to staff, and/or monitored interventions for effectiveness for 1 of 2 sampled residents (#5) who experienced short-term changes. This is a repeat citation. Findings include, but are not limited to:

Resident 5 was admitted to the MCC in 11/2023, with diagnoses including dementia, hypertension, and epilepsy.

Review of Resident 5's service plan, dated 11/17/23, progress notes, dated 12/09/23 through 12/26/23, interim service plans, and incident reports indicated the resident had experienced six falls over the previous seventeen days.

The current service plan noted the resident was at risk for falls and identified the following fall interventions:

* "attempt to assist with walking"; and

* "encourage to use walker".

There was no documented evidence actions or interventions were developed and communicated to staff, nor were the identified fall interventions monitored for effectiveness following the series of repeated falls.

On 12/27/23, determining actions or interventions needed, communicating to staff on all shifts and reviewing interventions to determine effectiveness was discussed with Staff 2 (Administrator), Staff 3 (RN), and Staff 12 (RCC). They acknowledged the findings.

Resident 5 has been reviewed for short term change of condition and found to be at baseline.

All residents chart notes have been reviewed to identify short term changes of condition, and if found, placed on alert and weekly monitoring until resolved. Training will be provided to all staff whose job duties include documenting and reporting short term change of condition. Residents with short term changes of condition will be communicated through the ISP process, placed on alert and monitored to resolution. Any needed additional interventions will be communicated through the 24 hour system and ISP.

Weekly audits of chart notes, 24 hours communications, ISP's and alerts will be conducted and brought to QAPI.

Administrator, RCC or Designee will be responsible to ensure compliance.   

Based on interview and record review, it was determined 3 of 3 sampled, newly hired direct care staff (#s 5, 10 and 11) failed to complete First Aid and abdominal thrust training within 30 days of hire. Findings include, but are not limited to:

A review of the facility's training records on 10/09/23 and again on 10/10/23 revealed:

Staff 5 (CG/MT), Staff 10 (CG) and Staff 11 (CG), hired 06/09/23, 07/10/23, and 09/06/23, respectively, did not have documentation of first aid and abdominal thrust training completion within the required 30 days of hire.

The need to ensure First Aid and abdominal thrust training was completed within 30 days of hire was discussed with Staff 1 (Administrator) and Staff 3 (RN) on 10/10/23. The staff acknowledged the findings.

Staff 5, 10, and 11 have received training in first aid and abdominal thrust.

Staff Training files audited to ensure all other direct care staff have training in First Aid and Abdominal Thrust. Additional Abdominal Thrust training provided to staff by RN to reinforce competencies.

Training spreadsheet created with applicable expiration dates. All newly hired staff will be entered into this spreadsheet upon hire. RCC will monitor spreadsheet weekly and inform staff of upcoming training deadlines.

Administrator or Designee will be responsible to ensure compliance.

Based on 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 C270.

Refer to C270

Based on observation and interview, it was determined the facility failed to ensure courtyard surfaces did not contain drop-offs and were maintained in good repair. Findings include, but are not limited to:

Observations of the three secured courtyards on 10/09/23 and 10/10/23 showed the following:

* Multiple drop-offs of two to four inches were noted along pathway edges near the covered area and within the grassy area.

The need to ensure pathways in the resident courtyard did not have potential tripping hazards was discussed with Staff 1 (Administrator) on 10/10/23. She acknowledged the findings.

Drop-off edges along pathway near the covered area and within the grassy area have been leveled.

Maintenance Director has inspected all areas of pathways to determine and eliminate any other substandard drop offs.

Exterior Grounds and Pathways has been added to Routine Maintenance Inspection Checklist. Staff education provided regarding the importance of escorting residents to courtyard areas.

Administrator or Designee will be responsible for compliance.

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:

Observations of the facility on 10/09/23 and 10/10/23 showed the following areas in need of cleaning or repair:

* Flooring in the common area bathrooms and laundry room  had dings, gouges and scrapes. The floor was pulling apart at the seams which created gaps of various sizes;

* Eroded caulking was noted along the shower in the common bathroom near the dining room, molding was cracked and separating along edges of the shower area; and

* Significant stains/discoloration, encompassing several feet of the carpet in room 102 (unoccupied) and room 109 (occupied).

The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (Administrator) on 10/10/23. She acknowledged the findings.

Flooring in Shower Rooms and Laundry Room will be replaced. New molding and caulking will be included with the installation of new flooring. Carpets in Apartment 102 and 109 have been cleaned.

All flooring will be inspected and repaired and/or replaced as required.

Inspections of all flooring, including carpets, will be added to monthly Rountine Maintenance Checklists.

Administrator and Maintenance Director will be responsible to ensure compliance.

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 231, C 372, C 510 and C 513.

Refer to C231, C372, C510, and C513

Based on interview and record review, it was determined the facility failed to ensure 3 of 4 newly hired staff (#s 4, 5, and 11) completed all required pre-service orientation and dementia training topics prior to beginning job duties, and 1 of 3 new staff (# 11) demonstrated competency in all job duties within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed on 10/09/23 and 10/10/23.

a. There was no documented evidence Staff 4 (CG), Staff 5 (MT/CG) and Staff 11 (CG), hired 08/08/23, 06/09/23 and 09/06/23 respectively, completed one or more of the following pre-service orientation topics prior to beginning their job duties:

* Resident rights and values of CBC care;

* Abuse reporting requirements;

* Infectious Disease Prevention;

* Fire safety and emergency procedures;

* Food handler's certificate; and

* Written job description.

b. There was no documented evidence Staff 11 completed any of the required pre-service dementia care topics, prior to providing resident care and services independently.

c. There was no documented evidence Staff 11 demonstrated competency in one or more assigned duties within 30 days of hire, including:

* Role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Changes associated with normal aging;

* Identification, documentation, and reporting changes of condition;

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

* General food safety, serving, and sanitation.

The need to ensure all required staff trainings were completed in the required time frames was discussed with Staff 1 (Administrator) and Staff 3 (RN) on 10/10/23. They acknowledged the findings.

Staff 4, 5, and 11 have completed training on required Preservice training topics and demonstrated competency in assigned duties.

Audit completed on all direct care staff training. Spreadsheet created to track training and applicable expiration dates. Newly hired staff will not be permitted to work with residents until all preservice training is completed. Competency of staff will be verified through observation and return demonstration.

RCC will audit new employee files weekly and perform training audits of all staff monthly for three months and bring results of audits to QA.

Administrator will be responsible to ensure compliance.

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 252, C 260, and  C 270.  

Refer to C252, C260, and C270

Based on 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. This is a repeat citation. Findings include, but are not limited to:

Refer to C270.

Refer to C270

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

Service plans for Residents 1 and 2 were reviewed during survey. Each of the service plans included some food preferences, but lacked individualized hydration information and staff instructions related to meeting resident-specific nutrition and hydration needs.

The need to develop individualized service plans addressing residents' nutrition and hydration needs was discussed with Staff 1 (Administrator), Staff 2 (RCC), and Staff 3 (RN) on 10/10/23. They acknowledged the findings.

Individualized Nutrition and Hydration Plans are in place for Resident 1 and 2.

All residents reviewed for individual nutrition and hydration plans. Residents nutrition/hydration plans will be developed for all residents, including staff instructions for meeting resident-specific nutrition/hydration needs and will be incorporated into the Service Plan.

RCC will update service plans not less than quarterly and as nutrition/hydration needs may change. Comprehensiveness of Service Plans will be reviewed by Administrator and RN.

Administrator or Designee will be responsible for compliance.

Based on observation, interview, and record review, it was determined the facility failed to ensure activity evaluations and individualized activity plans were completed for 2 of 2 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to:

Resident 1 and 2's service plans offered some information about the residents' interests, but the facility had not fully evaluated the residents' activity needs in one or more of the following areas:

* Current abilities and skills;

* Emotional and social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for the resident to participate; and

* Activities which could be used as behavioral interventions, if necessary.

There were no resident-specific activity plans developed from activity evaluations which detailed what, when, how, and how often staff should offer and assist the resident with more individualized activities.

Observations between 10/09/23 and 10/10/23 showed multiple small group activities were being led by facility staff.

The need to ensure activity evaluations were completed for all residents, and individualized activity plans developed and implemented was discussed with Staff 1 (Administrator), Staff 2 (RCC), Staff 3 (RN) and Staff 4 (Life Enrichment Director) on 10/10/23. The staff acknowledged the findings.

Individual Activity Plans are in place for Resident 1 and Resident 2.

All residents reviewed for individualized activity plans. Resident Activity Plans will be developed for all residents including current abilities and skills, emotional and social needs and patterns, physical abilities and limitations, adaptations needed for the resident to participate, and activities which could be used as behavioral interventions if necessary.

Activity Director and RCC will coordinate service plan revisions not less than quarterly and as Activity Plans may change. Comprehensiveness of Service Plans will be reviewed by Administrator and RN.

Administrator or Designee will be responsible to ensure compliance.