Print Inspection: WLNI

The findings of the re-licensure survey, conducted 08/22/23 through 08/25/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 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 first re-visit to the re-licensure survey of 08/25/23, conducted 11/15/23, 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 and OARs 411 Division 004 Home and Community Based Services Regulations.

Based on observation and interview, it was determined the facility failed to ensure residents were provided a safe and homelike environment. Findings include, but are not limited to:

The facility environment was toured on 08/22/23. The residents' dining room was observed to have approximately one quarter of the space dedicated to storage of boxes containing disposable single use items from the facility kitchen. The boxes were stored on carts, racks and tables, with some boxes open and their contents spilled out onto tables and floors.

In an 08/23/23 interview, Staff 13 (Food Services Coordinator) reported the facility had been storing the items in the dining room as a convenience to the staff to prevent staff from having to travel to the fourth floor of the facility to retrieve the items from storage. Staff 13 stated the facility had been storing items in the dining room for at least two years.

The need to ensure residents were provided a safe and homelike environment was discussed with Staff 1 (Administrator) on 08/23/23. He acknowledged the findings.

1. Administrator will ensure that items listed, but not limited to, survey regarding our Dining Room environment are removed and/or repaired to restore a home-like environment as dictated by policy.

2. Administrator will perform weekly checks of building interior to ensure that spaces are clean, free of clutter, offer safe access pathways and repaired when showing signs of wear.

3. Monthly by Administrator.

4. Administrator.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (#5). Findings include, but are not limited to:

Resident 5 was admitted to the facility in 05/2023 with diagnoses including depression, anxiety, and muscle spasms. Review of the resident's intake forms dated 04/28/23 and move-in evaluation dated 05/05/23 revealed a lack of the following required elements:

* Customary routines, including eating;

* Effective non-drug interventions for mental health issues;

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

* How a person expresses pain or discomfort; and

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

The need to ensure new move-in evaluations addressed all required elements was discussed with Staff 1 (Administrator) on 08/25/23. He acknowledged the findings.

1. Resident Service Navigator will ensure that all new residents' new move-in evaluations include, but not limited to, those items listing in the Survey.  

2. Administrator and Resident Care Supervisor will reviewall new resident move-in documentation together  for thoroughness and allignment with the regulation.   

3. Administrator will audit all new move-in templates in QuickMar monthly

4. Administrator

Based on observation, interview, and record review, it was determined the facility failed to ensure significant changes of condition were assessed and the service plan was updated by an RN for 1 of 1 sampled resident (#2) reviewed for significant changes of condition. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 04/2022 with diagnoses including a history of falls.

Progress notes dated 06/05/23 through 08/21/23, the service plan dated 07/12/23, an incident report dated 07/13/23 were reviewed and staff and the resident were interviewed and revealed the following:

The 07/12/23 service plan indicated the resident was independent with bathing, dressing, and toileting, and slept in a regular bed. A 07/13/23 progress note indicated the resident fell and was sent to the hospital for left wrist pain and was subsequently diagnosed with a fractured wrist. Upon return from the hospital, subsequent progress notes indicated the resident had a cast and sling for the fracture, required assistance with bathing, dressing, and toileting, and was using a hospital bed with side rails.

The wrist fracture and change in ADL assistance constituted a significant change of condition and required an RN assessment and service plan update. During an interview on 08/23/23 at 11:00 am, Staff 2 (Housing RN) confirmed no assessment or service plan update had been completed for the change of condition.

The need to ensure all significant changes of condition were assessed by an RN and the licensed nurse participated on the service planning team or reviewed the service plan with date and signature within 48 hours was discussed with Staff 1 (Administrator) and Staff 2 on 08/25/23. They acknowledged the findings.

1. Housing Leadership will review the Change of Condition regulations and practices with our RN, RCS and all Med Aides at shift meeting.  RN will document all changes of condition as required.

2. Housing Leadership will review residents with potential changes or condition or need for increased monitoring weekly with RN. RN will be responsible for documentation, Administrator or delegate will audit. Lastly, Leadership will designate a back-up RN designee when RN is on PTO for more than 48 hours.

3. Adminstrator will audit 5% of charts monthly.

4. Administrator

2. Resident 3 was admitted to the facility in 05/2022 with diagnoses including chronic obstructive pulmonary disease.

The resident's TAR dated 08/01/23 - 08/21/23, current physician orders and ADL log dated 08/01/23 - 08/21/23 were reviewed and revealed the following:

* Resident 3 had a physician order dated 08/02/23 for two liters of oxygen to be applied continuously by nasal cannula and bleed-in with continuous positive airway pressure (CPAP); and

* The ADL log documented the resident refused use of his/her CPAP three times in 08/2023.

The resident was observed not using oxygen on 08/23/23 at 1:49 pm and on 08/24/23 at 1:00 pm. On 08/24/23, Resident 3 reported s/he only used oxygen at night. Staff 2 (Housing RN) confirmed Resident 3 frequently refused oxygen during the daytime, but it did not negatively affect his/her oxygen saturation levels.

There was no documented evidence the facility notified Resident 3's physician of the oxygen refusals.

On 08/25/23, the need to notify the physician or practitioner when a resident refused consent to an order was discussed with Staff 1 (Administrator) and Staff 2. They acknowledged the findings. No additional information was provided.

Based on observation, interview, and record review, it was determined the facility failed to notify the physician or other practitioner when a resident refused consent to an order for 2 of 5 sampled residents (#s 2 and 3), who had documented medication or treatment refusals. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 04/2022 with diagnoses including type 2 diabetes.

The resident's MAR dated 08/01/23 through 08/23/23 was reviewed and revealed facility staff documented Resident 2 refused the following orders:

The following refusals were identified:

* Arthritis Pain relief, 650 mg, on four occasions;

* Cetirizine HCL 10 mg tablet (allergy symptoms), on one occasion;

* Glimepiride 1 mg tablet (diabetes), on one occasion;

* Januvia 25 mg tablet (diabetes), on one occasion;

* Metformin HCL ER 750 mg tablet (diabetes), on one occasion;

* Oxycodone HCL 5 mg tablet (pain), on one occasion; and

* Vitamin D3 2000 unit softgel (supplement), on one occasion.

During an interview on 08/23/23 at 11:00 am, Staff 2 (Housing RN) confirmed the physician had not been notified of the above order refusals.

On 08/25/23, the need to notify the physician/practitioner when a resident refused consent to orders was discussed with Staff 1 (Administrator) and Staff 2. They acknowledged the findings.

1. Administrative Assistant or designee will run a medication refusal report and fax to the primary care provider.

2. A medication refusal report will be run at least monthly and will be kept for review.

3. Resident Care Supervisor will audit monthly.

4. Administrator will ensure the monthly audit is completed.

Based on interview and record review, it was determined the facility failed to update the acuity-based staffing tool (ABST) no less than quarterly for 2 of 6 sampled residents (#s 4 and 6) and multiple unsampled residents whose ABST was reviewed. Findings include, but are not limited to:

The facility's ABST was reviewed on 08/23/23 and revealed the following:

a. Resident 4 was admitted to the facility in 10/2019 and his/her ABST had not been reviewed and updated quarterly since 10/18/22.

b. Resident 6 was admitted to the facility in 05/2022 and his/her ABST had not been reviewed and updated quarterly since 10/18/22.

c. The ABST for multiple unsampled residents had not been reviewed or updated quarterly.

The need to ensure the facility's ABST was updated no less than quarterly was reviewed with Staff 1 (Administrator) on 08/25/23. He acknowledged the findings.

1. Resident Service Navigator will not only populate each new resident's ABST entry upon move-in-but also will review for possible changes each resident's current acuity in the ABST at the time of their Service Plan update.

2. Resident Service Navigator will be ensure that this ABST component is a part of her Service Plan review cycle.

3. Monthly

4. Administrator

Based on interview and record review, it was determined the facility failed to ensure pre-service dementia training had been completed for 1 of 2 newly-hired staff (# 9) whose pre-service training records were reviewed. Findings include, but are not limited to:

Staff training records were reviewed on 08/23/23 and the following was identified:

Training records for Staff 9 (Personal Care Attendant), hired on 02/27/23, lacked documented evidence of pre-service dementia training prior to beginning job responsibilities in the following areas:

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

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

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

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

The requirement to complete pre-service dementia training prior to providing care to residents was discussed with Staff 1 (Administrator) on 08/23/23. He acknowledged the findings.

1. Resident Care Supervisor will perform an audit of all pre-service orientation requirements and will ensure that all new caregivers complete all orientation components, including but not limited to pre-service IP and Dementia modules.

2. Resident Care Supervisor will develop an orientation checklist and sign off on completion prior to caregiver starting work. RCS will provide a checklist to the Administrator for review.

3. Will be reviewed prior to caregiver work start date.

4. Administrator will review for completion of orientation.  

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 sampled newly-hired direct care staff (#s 4 and 9) demonstrated competencies in all required training within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed on 08/23/23 and the following was revealed:

Staff 4 (Personal Care Attendant), hired on 08/29/22, and Staff 9 (Personal Care Attendant-Lead), hired on 02/27/23, failed to have documented evidence of competency demonstrated in all assigned job duties prior to working independently with residents in the following areas:

* Role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Identification, documentation and reporting of changes of condition;

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

* General food safety, serving and sanitation; and

* First aid and abdominal thrust training.

The need to ensure newly hired direct care staff had documented evidence of demonstrated competency in all assigned job duties prior to working independently with residents was reviewed with Staff 1 (Administrator) on 08/23/23. He acknowledged the findings.

1. Resident Care Supervisor will perform an audit of all competency requirements and will ensure that all competencies are completed.

2. Resident Care Supervisor will utilize a competency checklist and sign off on completion prior to caregiver starting work. RCS will provide a checklist to the Administrator for review.

3. Will be reviewed prior to caregiver work start date.

4. Administrator will review for completion of competencies.

Based on interview and record review, it was determined the facility failed to ensure documented evidence of the required 12 hours of annual in-service training, including six hours of dementia care training, was completed for 3 of 3 long term staff (#s 6, 7 and 8) whose training records were reviewed. Findings include, but are not limited to:

Annual in-service training records were reviewed with Staff 1 (Administrator) on 08/23/23. Staff 6 (Personal Care Attendant), hired on 08/11/09, Staff 7 (Personal Care Attendant), hired on 02/27/22 and Staff 8 (Personal Care Attendant-Lead), hired on 04/01/05, lacked documented evidence of a minimum of 12 hours of in-service training annually, based on their hire dates, on topics related to the provision of care for persons in a community-based care setting, including training on chronic diseases in the facility population, and at least six hours of dementia care training,

The need to ensure long-term staff completed 12 hours of annual in-service training, including six hours of dementia care training was discussed with Staff 1 on 08/23/23. He acknowledged the findings.

1. Resident Care Supervisor will perform an audit of all annual training requirements and will ensure that all training is completed.

2. Resident Care Supervisor will develop an annual training checklist and sign off on completion. RCS will provide checklist to Administrator for review.

3. Will be reviewed monthly based on date of hire.

4. Administrator will review monthly.

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

The facility was toured on 08/22/23 at 09:45 am. The following areas were observed to need cleaning and/or repair:

* First floor laundry room floor had black and brown marks and was worn in several areas making the surface uncleanable;

* Exterior brick wall outside of first floor laundry room had gray lint and debris coming out of the vents and covering the surface;

* Walls in first and fourth floor laundry rooms had gouges and chipped paint;

* Wall between the exit door and staff break room was missing its baseboard molding;

* Electrical outlet in first floor public restroom was not secured to the wall;

* Entrance door and doorframe to the kitchen had chipped paint;

* Ceiling vents in the dining room were coated with black and brown dust and debris;

* Door, doorframe and furniture on the second floor patio had cobwebs and black and brown debris on the surfaces;

* Carpet outside of the second floor elevators and staff laundry room and third floor medication room had black stains;

* Corridor near unit 326 had an unpleasant pervasive odor throughout the survey; and

* Table and windowsill near the fourth floor stairwell had dead plant matter and spillage on both surfaces.

The surveyor toured the environment with Staff 1 (Administrator) on 02/23/23. He acknowledged the findings.

1. Administrator will ensure that items, included but not limited to those listed in survey are remediated and/or repaired.

2. Administrator will perform monthly checks of building exterior to ensure grounds are clear of litter, refuse and ensure that pathways are accessible. Administrator will perform monthly checks to ensure the facility is free from pervasive unpleasant odors.

3. Monthly by Administrator.

4. Administrator.