Print Inspection: SMCO

The findings of the re-licensure survey, conducted 08/05/24 through 08/08/24, are documented in this report. The survey was conducted to determine 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.

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. Tag numbers beginning with the letter H refer to the Home and Community Based Services 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

Based on observation, interview, and record review, it was determined the facility failed to provide a daily program of social and recreational activities based upon individual and group interests, and physical, mental, and psychosocial needs. Findings include, but are not limited to:

Observations during the survey from 08/05/24 to 08/08/24, showed a lack of scheduled and unscheduled activities provided for residents living in the memory care community.

The Activity Calendar for August 2024 was provided and indicated scheduled activities for each day of the week. The activities scheduled according to the calendar for 08/06/24, 08/07/24, and 08/08/24 included the following:

08/06/24

* 10:00 am Reading with staff at 10 am; and

* 2:00 pm Afternoon walk in the courtyard.

Observations at 10:00 am and 2:00 pm were made and the activities did not take place.

08/07/24

* 10:00 am Stretch and breathe; and

* 2:00 pm Let's make snow cones.

Observations at 10:00 am and 2:00 pm were made and the activities did not take place.

08/08/24

* 10:00 am Glamour group;

* 2:00 pm Go fish; and

* 4:00 pm Crosswords.

Observations at 10:00 am, 2:00 pm, and 4:00 pm were made and the activities did not take place.

During the survey, multiple residents were observed throughout the day sitting at the dining room tables, asleep in the living room, or watching TV in the living room.

The need to ensure the facility provided a daily program of social and recreational activities that were based on individual and group interests, and physical, mental, and psychosocial needs was discussed with Staff 1 (Administrator) on 08/07/24 and 08/08/24. She acknowledged the findings.

Although we have both scheduled and unscheduled Activities that are documented in our individual Resident activity tracking forms, we have implemented a more thorough and personalized format for activities and will incorporate this into our printed Activity Calendar as well as the Service Plan

We have hired an additional staff member for facilitating the changes to our documentation and our Incoming Administrator will oversee staff participation and the Owner and our Administrator will monitor the documenting of personalized scheduled and unscheduled Activities on a weekly basis.  All staff will try to adhere to our schedules regardless of survey trends or Outside Service Provider visits.

Based on interview and record review, it was determined the facility failed to ensure initial move-in evaluations addressed all required elements for 1 of 1 sampled resident (#2) whose move-in evaluation was reviewed. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 06/2024 with diagnoses including a traumatic brain injury and frontotemporal dementia. The following required elements were not addressed in the initial evaluation:

* Mental Health: history of treatment, and effective non-drug interventions;

* 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;

* Fall risk or history;

* Emergency evacuation ability;

* History of dehydration and/or unexplained weight loss;

* Recent losses;

* Smoking;

* Alcohol and drug use; and

* Environmental factors that impact the resident's behavior including noise, lighting, and room temperature.

On 08/07/24 and 08/08/24, the need to ensure the initial move-in evaluation addressed all required elements was discussed with Staff 1 (Administrator). She acknowledged the findings.

During the survey, it was determined that for Resident #2 the following required elements were not addressed in the initial evaluation:

Mental Health: history of treatment, and effective non-drug interventions; 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; Fall risk or history;

Emergency evacuation ability;  History of dehydration and/or unexplained weight loss; Recent losses;

Smoking;  Alcohol and drug use; and Environmental factors that impact the resident's behavior including noise, lighting, and room temperature.

Although we have required elements and additional formats to our move in evaluations as well as re-evaluations, we are currently creating a more in depth evaluation tool that lists every component separately.  Our heathcare team for this will consist of our Registered Nurses, our Medication Aides and direct Caregivers so that we can collaborate on every level.

Staff members will take additional training as to how to correctly utilize and understand this document and all staff will sign an individualized document for each Resident.  We will also have an additional training on our Alert Charting system so that it is utilized for every new move in or change of condition.  Our Lead Medication Aide and the Owner and Registered Nurse will perform scheduled and random checks to make sure this system is effective and concise.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs and provided clear directions to staff regarding the delivery of services 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 moved into the facility in 01/2022 with diagnoses including Type 2 diabetes and congestive heart failure.

Observations of the resident, interviews with staff, and review of the resident's service plan, dated 05/22/24, and progress notes, dated 04/28/24 through 08/04/24, were completed. Staff indicated the resident was dependent on staff for ADL care and required two staff for transfers.

The resident's service plan was not reflective and lacked clear direction for staff, in the following areas:

* Transfer ability, including the use of a Hoyer lift and two staff;

* Use of side rails;

* Use of a tilt-in-space wheelchair;

* Hard of hearing and use of a pocket talker; and

* Current skin condition and treatment.

On 08/08/24, the need to ensure resident service plans reflected current care needs and provided clear direction to staff was discussed with Staff 1 (Administrator). She acknowledged the findings.

2. Resident 2 was admitted to the facility in 06/2024 with diagnoses including a traumatic brain injury and frontotemporal dementia.

Observations of the resident, interviews with staff, and review of the service plan, dated 07/20/24, revealed the service plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas:

* Increased episodes of anxiety and exit-seeking behaviors; and

* Outside service visits including frequency, responsibilities, and recommendations made by the agency.

On 08/08/24, the need to ensure resident service plans reflected current care needs and provided clear direction to staff was discussed with Staff 1 (Administrator). She acknowledged the findings.

During our Survey it was determined that resident #1 service plan was not reflective and lacked clear direction for staff, in the following areas:

Transfer ability, including the use of a Hoyer lift and two staff; Use of side rails; Use of a tilt-in-space wheelchair; Hard of hearing and use of a pocket talker; and current skin condition and treatment.  

In addition, it was noted during survey that the service plan was not reflective of the resident #2's current care needs and did not provide clear direction to staff in the following areas:

Increased episodes of anxiety and exit-seeking behaviors; and Outside service visits including frequency, responsibilities, and recommendations made by the agency.

I am setting up a mandatory training for the staff with regard to the importance of making sure any change of condition or added adaptive equipment be listed in the Service Plan immediately as well as the placement of a short term or long term alert that will be monitored by our facility Registered Nurse.  Resident #1 had just received her new titling chair from her Daughter and  our staff had started using a hoyer for transfers for under one week.  I was not aware that her family had just purchased the new chair or that staff members had just started using the hoyer for back safety and potential hesitency on Resident #1 during transfers.  Going forward, our Residents will be tracked at every shift change by our shift Supervisors as well as documented on their personal service plan and if necessary short or long term alerts put into place.  Our current Service Plans have been updated to outline a more specific section for anxiety, exit-seeking and behaviors that will have outlines for staff members.  Our Outside Service Providers have been asked to make sure to sign in and out so that staff are able to determine and document any requests made ny their agency.   These documents will assist with giving clear indication that any noted change, treatment or medication order or change of status request including notes to a PCP be shared with our healthcare team.  We will continue to have them sign in and out and if our new policy is not effective, we will meet with the management of the outside service providers to make sure that our community partners understand the importance of sharing our Residents healthcare needs collectively.  Our Shift Supervisors will utilize these documents and create an alert or narrative written in the new shift report of our Residents progress.

Based on interview and record review, it was determined the facility failed to evaluate changes of condition, refer a significant change of condition to the facility nurse, determine actions or resident-specific interventions, and document weekly progress noted until the condition resolved for 2 of 2 sampled residents (#s 1 and 2) who experienced changes of condition. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 01/2022 with diagnoses including Type 2 diabetes and congestive heart failure.

During the entrance conference on 08/05/24, Resident 1 was identified as needing a two-person assist with the Hoyer lift for transfers.

A review of the resident's progress notes, dated 04/28/24 through 08/04/24, service plan dated 05/22/24, and interviews with staff identified the following changes of condition:  

* On 05/22/24, staff noted the resident was having a more challenging time standing with his/her walker;

* On 06/10/24, staff noted the resident was having more difficulty standing with his/her walker to transfer; and  

* On 08/02/24, staff noted the resident needed the Hoyer lift to transfer, and s/he was unable to stand up with prompts.

Resident 1's 05/22/24 service plan indicated that the resident was a one person assist with transfers.

Staff interviewed during the survey reported that the resident had recently changed from a one-person assist to a two-person assist with using the Hoyer lift.

There was no documented evidence that the facility had evaluated the resident's change of condition, referred to the facility nurse, documented the change, or updated the service plan to reflect the resident's increased assistance with transfers.

The need to ensure residents with a change of condition were evaluated and referred to the RN if needed for a significant change of condition was discussed with Staff 1 ( Administrator) on 08/07/24. She acknowledged the findings.

2. Resident 2 was admitted to the facility in 06/2024 with diagnoses including a traumatic brain injury and frontotemporal dementia.

A review of the resident's clinical record, including progress notes dated 06/03/24 through 08/05/24, service plan dated 07/20/24, and staff interviews identified the following changes of condition:  

* On 06/01/24, the resident moved into the facility;

* On 06/17/24, staff noted the resident had a rough night and was up all night and was acting upset and exit-seeking;

* On 06/18/24, staff noted the resident was still feeling anxious and was exiting seeking around dinner;

* On 06/19/24, staff noted the resident was accusing the staff of kidnapping him and doing something with his wife, and the resident called 911;

* On 06/21/24, staff noted the resident was still exit-seeking a lot; and

* On 06/24/24, staff noted the resident was exit-seeking after dinner.

The above short-term changes of condition lacked documentation the facility determined what resident-specific action or intervention was needed for the resident, communicated the determined action or intervention to staff, or documented weekly progress until the condition resolved.

On 08/08/24, the need to ensure the facility determined what resident-specific action or intervention was needed for the resident following a short-term change of condition, communicated the determined action or intervention to staff, and documented progress until the condition resolved was discussed with Staff 1 (Administrator). She acknowledged the findings.

During our servey, it was determined that the facility had not correctly identified and evaluated and documented Resident #1 and Resident #2 changes of condition and did not immediately notify the facility Registered Nurse of these recent changes.

Our community does have policies in place for changes of condition of our Residents.  Given that we did not have the follow up from a recent change of conditon from a Resident, I am instituting a new written requirement that at every shift change, our Supervisors will give a report on any Resident with a change of status and document these changes to their personal service plans and if necessary and short or long term alert.  In addition, staff will make sure to notify our facility Registered Nurse immediately should any change of status be noted.  These documents will determine what resident-specific actions or interventions are needed for the resident, are communicated and that the determined actions or interventions by staff are documented in a weekly progress note until the condition is resolved. Alerts will be included for all new move-ins and all staff will be made aware.  This report will be kept near our current Medication Administration Records and will be monitored weekly by Management staff that includes the RN, the Administrator and the Owner.  In addition, all staff will be re-trained on the established protocol for our documentation.   

Based on interview and record review, it was determined the facility failed to ensure physician or other legally recognized practitioner orders were carried out as prescribed for 1 of 2 sampled resident (#1) whose orders were reviewed. Findings include, but are not limited to:

Resident 1 moved into the facility in 01/2022 with diagnoses including Type 2 diabetes and congestive heart failure.

Review of Resident 1's progress notes dated 04/28/24 through 08/04/24, current physician orders and MARs from 07/01/24 through 08/05/24 identified the following:

A progress note dated 06/27/24 indicated the resident had gone out to a diabetic foot appointment. A corresponding signed Physician order dated 06/27/24 instructed the facility as follows:  

"Betadine daily Right 2nd toe daily";

"Adaptic paper tape";

"Can shower then replace dressing";

"Wear off loading shoe";

"Wear loose fitting sock - diabetic socks";

"Foot cradle, no blanket touching toe, no pressure"; and

"Stop lotion between toes";

The order was not transcribed on the MAR or current service plan. There was no documented evidence the order was being carried out as prescribed.

In an interview with Staff 1 (Administrator) on 08/07/24, she acknowledged the order should have been transcribed on the MAR for staff to follow.

The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1  on 08/08/24. She acknowledged the findings.

We are creating an additional policy and document for all outside service providers that encourages them to sign.  This document should assist with giving clear indication that any noted change, treatment or medication order or change of status request including notes to a PCP be shared with our healthcare team.  We will continue to have them sign in and out and if our new policy is not effective, we will meet with the management of the outside service providers to make sure that our community partners understand the importance of sharing our Residents healthcare needs collectively.  Our Shift Supervisors will utilize these documents and create an alert or narrative written in the new shift report of our Residents progress.

Based on observation, interview, and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities was assessed by an RN, PT or OT, less restrictive alternatives prior to use were documented, instruction was provided to caregivers on the correct use of and precautions for the device, and use of the device was documented in the resident's service plan for 1 of 1 sampled resident (#1) who used potentially restraining devices. Findings include, but are not limited to:

Resident 1 moved into the facility in 01/2022 with diagnoses including Type 2 diabetes and congestive heart failure.

Resident 1 was observed during the survey to have a quarter length side rail on both sides of his/her bed in the up position and used a tilt-in-space wheelchair. Both devices had potentially restraining qualities.

A review of the resident's clinical record revealed the following were lacking from the record:

* Thorough assessment by an RN, PT, or OT;

* Documentation of less restrictive alternatives evaluated prior to use of the devices;

* Instruction provided to staff on the correct use and precautions related to the devices; and

* Documentation of the side rails and the tilt-in-space wheelchair in the resident's service plan.

The need to complete all required elements related to supportive devices with potentially restraining qualities was discussed with Staff 1 (Administrator) on 08/08/24. She acknowledged the findings.

This tag is interconnected to the prior issues regarding the addition of a tilting wheelchair and recent change of condition to a Residents ability to transfer with minimal assistance as well as the bedrail.  We have established protocol and documents that are very specific for equipment that had restraining qualities that require  licensed providers to initially evaluate and re-evaluate at least quarterly or for any change of condition to how the Resident can utilize the device to increase independence.  In addition, all equipment with these components will have a current signed Physicians order in their chart.  A Touch of Grace prides itself on being a restraint free community but it is clear that we will now add this concern to our daily shift report document to prevent any future documents being missed.  We currently have training materials that show alternatives tried prior to the use of additional equipment with retraining qualiuties. Instruction will be provided to staff on the correct use and precautions related to the devices; and we will make sure that

Documentation of the side rails and the tilt-in-space wheelchair are added to the resident's service plan.  The Administrator and the RN will monitor this area weekly to make sure that the documents are in place in our shift report as well as the Residents chart..

Based on interview and record review, it was determined the Administrator failed to show documented evidence of a current Residential Care Facility Administrator license. Findings include, but are not limited to:

On 08/05/24, the facility was asked to provide documentation of the Residential Care Facility Administrator license.

There was no documented evidence Staff 1 (Administrator) had a Residential Care Facility Administrator license that met the department's requirements.  

The need to ensure the facility's administrator had a licensed Residential Care Facility Administrator was discussed with Staff 1 on 08/08/24. She acknowledged the findings.

This area has proven to be one of the most difficult areas for us.  I have personally paid for the complete training and wages for seven Administrators (four for the last two years), only to have them complete the training and leave to work at another community.  We are a smaller community and this is not an issue that I have taken lightly and it has had the additional burden of being very expensive.  I communicated with our Policy Analyst and she was able to share some very useful data with regard to writing a contract prior to placing another canidate through the training, which I have done.  Our new Administrator has been employed by our organization and is very adept at her job and is very enthusiastic with expanding her duties.  We have all the components of her licensing packet (pending approval from DHS) that will be sent in immediately, as well as her contract and we look forward to going forward with her in the intricate lead position.

Based on interview and record review, it was determined the facility failed to have a sufficient number of direct care staff to meet the 24-hour scheduled and unscheduled needs of each resident and to meet the fire safety evacuation standards during the night shift. Findings include, but are not limited to the following:

During the entrance conference on 08/05/24 at 1:00 pm with Staff 3 (MT/CG) the following was identified:

* The memory care community was home to eight residents at the time of the re-licensure  survey;

* One resident required a two-person assist with the use of the Hoyer lift; and

* Four other residents were reported to require high levels of caregiving assistance due to cognitive decline and need for one-person transfer assistance.

The facility's posted staffing plan and the staffing schedule from 08/01/24 through 08/31/24 were reviewed. The facility's posted staffing plan indicated one shift supervisor was scheduled to work 11:00 pm to 7:30 am shift daily. This was confirmed in an interview with Staff 1 (Administrator) on 08/07/24.

The facility lacked a sufficient number of overnight staff to meet the scheduled and unscheduled needs and fire evacuation standards of the resident who required the assist of two care staff for transfers.

The need to have a sufficient number of staff  to meet all scheduled and unscheduled needs of residents on the overnight shift was discussed with Staff 1 on 08/08/24. She acknowledged the findings.

Per our Acuity Based Staffing Model, we have continued to have staffing hours per Resident ratio above the stipulated amount and degree of acuity.  Unfortunately, we had one Resident that had a very new change of condition and after a diologue with our Surveyor, it was brought to my attention that we would need an additional staff member added to our night shift.  Although our Resident count at the time of survey was pretty low for our bed count, I immediately placed employment ads for this position and staffed it with existing staff members (which created over-time for our current employees).  Although this area of concern is still pending for the permanent hire of an amployee with the skill sets that would be an attribute to our community, this area has been resolved.

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 242, C 355, and C 360.

Refer to C 242 -We have implemented a more thorough and personalized format for activities and will incorporate this into our printed Activity Calendar as well as the Service Plan.  We have hired an additional staff member for facilitating the changes to our documentation and our Incoming Administrator will oversee staff participation and the Owner and our Incoming Administrator will monitor the documenting of personalized scheduled and unscheduled Activities on a weekly basis.

Refer to C 355 - Our new Administrator has been employed by our organization and is very adept at her job and is very enthusiastic with expanding her duties.  We have all the components of her licensing packet (pending approval from DHS) that will be sent in immediately, as well as her contract and we look forward to going forward with her in the intricate lead position.  

Refer to  C 360 - I have immediately added the additional staff member to the night shift to accommodate the recent change of condition so that in the event of an emergency or potential evacuation, two people will be available.

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

Refer to C 252, C 260, C 270, C 303, and C 340.

Refer to C 252 -We are currently creating a more in depth evaluation tool that lists every component separately.  Our heathcare team for this will consist of two Registered Nurses, our Medication Aides and direct Caregivers so that we can collaborate on every level.

Staff members will take additional training as to how to correctly utilize and understand this document and all staff will sign an individualized document for each Resident.  We will also have an additional training on our Alert Charting system so that it is utilized for every new move in or change of condition.  Our Lead Medication Aide and the Owner and Registered Nurse will perform scheduled and random checks to make sure this system is effective and concise.

Refer to C 260 - I am setting up a mandatory training for the staff with regard to the importance of making sure any change of condition or added adaptive equipment be listed in the Service Plan immediately as well as the placement of a short term or long term alert that will be monitored by our facility Registered Nurse.  This particular Resident had just received her new titling chair and recently became a two person or hoyer transfer and I was not aware that her family had just purchased the new chair.  Going forward, our Residents will be tracked at every shift change by our shift Supervisors as well as documented on their personal service plan and if necessary short or long term alerts put into place  .

Refer to C 270- I am instituting a new written requirement that at every shift change, our Supervisors will give a report on every Resident and document and changes to their personal service plans and if necessary and short or long term alert.  Alerts will be included for all new move-ins and all staff will be made aware.  This report will be kept near our current Medication Administration Records and will be monitored weekly by Management staff that includes the RN, the Administrator and the Owner. In addition, all staff will be re-trained on the established protocol for our documentation.

Refer to C 303 - We are creating an additional policy and document for all outside service providers that encourages them to sign.  This document should assist with giving clear indication that any noted change, treatment or medication order or change of status request including notes to a PCP be shared with our healthcare team.  We will continue to have them sign in and out and if our new policy is not effective, we will meet with the management of the outside service providers to make sure that our community partners understand the importance of sharing our Residents healthcare needs collectively.  Our Shift Supervisors will utilize these documents and create an alert or narrative written in the new shift report of our Residents progress.

Refer to C 340 - This tag is interconnected to the prior issues regarding the addition of a tilting wheelchair and recent change of condition to a Residents ability to transfer with minimal assistance as well as the bedrail.  We have established protocol and documents that are very specific for equipment that had restraining qualities that require  licensed providers to initially evaluate and re-evaluate at least quarterly or for any change of condition to how the Resident can utilize the device to increase independence.  In addition, all equipment with these components will have a current signed  Physicians order in their chart.  A Touch of Grace prides itself on being a restraint free community but it is clear that we will now add this concern to our daily shift report document to prevent any future documents being missed.  We currently have training materials that show alternatives tried prior to the use of additional equipment with retraining qualiuties.  The Administrator and the RN will monitor this area weekly to make sure that the documents are in place in our shift report as well as the Residents chart..

Based on interview and record review, it was determined the facility failed to ensure an individualized activity plan was developed for each resident, based on an activity evaluation, for 2 of 2 sampled residents (#s 1 and 2) whose records were reviewed. Findings include, but are not limited to:

Resident service plans and activity evaluations were reviewed. There was no documented evidence the facility had fully evaluated and developed individualized plans based on the residents':

* Current abilities and skills;

* Emotional and social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for the resident to participate; and

* Identification of activities for behavioral interventions, if necessary.

On 08/08/24, the need to ensure residents had individualized activity plans developed based on their activity evaluations, was discussed with Staff 1 (Administrator). She acknowledged the findings.

During our survey it was determined that the facility had documented evidence fully evaluated and developed individualized plans based on the residents Current abilities and skills; emotional and social needs and patterns; physical abilities and limitations;

adaptations necessary for the resident to participate; and identification of activities for behavioral interventions, if necessary.  Although we have both scheduled and unscheduled Activities that are documented in our individual Resident activity tracking forms, we have implemented a more thorough and personalized format for activities and will incorporate this into our printed Activity Calendar as well as the Service Plan

We have hired an additional staff member for facilitating the changes to our documentation and our Incoming Administrator will oversee staff participation and the Owner and our new upcoming Administrator will monitor the documenting of personalized scheduled and unscheduled Activities on a weekly basis.  All staff will try to adhere to our schedules regardless of survey trends or Outside Service Provider visits.