Print Inspection: YL7D

The findings of the re-licensure survey, conducted 07/10/23 through 07/12/23, 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, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for 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 revisit to the re-licensure survey of 07/12/23, conducted 11/13/23 through 11/14/23, 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 57 for Memory Care Communities.

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

Resident 2 was admitted to the facility in 06/2023. The move-in evaluation, completed on 06/13/23, failed to address the following required elements:

* Spiritual, cultural preferences and traditions;

* Mental Health issues including: presence of depression, thought disorders or behavioral or mood problems; history of treatment; and effective non-drug interventions;

* Pain: non-pharmaceutical interventions;

* Complex medication regimen;

* History of dehydration; and

* Elopement risk or history.

The need to ensure all required elements were addressed in the move-in evaluation was discussed with Staff 1 (Administrator), Staff 2 (Wellness Coordinator/LPN), and Staff 13 (Regional RN) on 07/11/23. They acknowledged the findings.

1.) Each resident identified as being out of compliance has been brought in to compliance.

2.) Our move in assessment has been check over and meets all requirments of the OAR if filled in completely. At each move in assessment the nurse will ensure that all of the questions are fully answered by the resident or resident family. If resident is unwilling to answer any questions at assessment the nurse will follow up with the resident and family again prior to move in to ensure all resident specific information is entered.

3.) Move in assessment will be evaluated by clinical team prior to move in.

4.) Clinical team consisting of Admin, Wellness director and RCC will monitor

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and provided a written description of who shall provide the services and what, when, how, and how often the services shall be provided for 1 of 5 sampled residents (#5) whose service plans were reviewed. Findings include, but are not limited to:

Resident 5 was admitted to facility in 06/2022 with diagnoses including dementia and repeated falls.

The current service plan dated 05/14/23 and Interim Service Plans (ISP's) from 04/11/23 to 07/01/23 were reviewed. The service plan was not reflective of the resident's current status or did not provide clear direction to staff in the following areas:

* Level of assistance required for transfers and toileting;

* Modified diet requirements; and

* Use of side rails, including safety checks.

The need to ensure service plans were completed quarterly, were reflective of residents' current needs and included a written description of who shall provide the services and what, when, how, and how often the services shall be provided was discussed with Staff 1 (Administrator) and Staff 2 (Wellness Coordinator/LPN) on 07/11/23 at 2:05 pm. They acknowledged the findings.

1. All residents' care plans found out of compliance have been reviewed, and corrected by using the care planning team consists of wellness director, caregiver, RCC family, and resident as able.

2.) Care planning team will meet and discuss the next weeks care plans that will be due. Team will discuss the residents current care needs and the wellness director will take all TSPs and information gathered at the care planning meeting and make adjustments to  ensure that each area of the care plan will reflects the residents current care needs.

3.) Care plans will be evaluated at move in, 30 days and then quarterly.

4.) The Wellness director will ensure that all corrections are completed

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team which consisted of the resident, the resident's legal representative if applicable, any person of the residents choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services, for 5 of 5 sampled residents (#s 1, 2, 3, 4, and 5) whose service plans were reviewed.  Findings include, but are not limited to:

Resident 1, 2, 3, 4, and 5's most recent service plans lacked documentation that a Service Planning Team reviewed and participated in the development of the service plans.

On 07/12/23 the need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (Administrator), Staff 2 (Wellness Coordinator/ LPN), and Staff 13 (Regional RN). They acknowledged the findings.

1.)  All residents' found out of compliance have been reviewed and corrected, using the care plan team of Wellness director, Admin, RCC caregiver, family, and resident as able.  Signatures of the care planning team are documented.

2.)  Care plan meetings completed weekly for the next weeks care plans that are due. Care plan team will consist of the RN, Admin, direct care staff, family, and the resident, as able. Signatures of care plan team will be collected on the signature page.

3. Wellness Director or delegate will review evaluation schedule weekly, schedule care plan meetings, and enter information into the system. The system will be evaluated weekly to ensure within compliance.

4. Wellness Director/Delegate/Admin

2. Resident 5 was admitted to the facility in 06/2022 with diagnoses including dementia and repeated falls.

Observations of the resident, interviews with staff, and review of the resident's service plan dated 05/14/23, and progress notes dated 04/01/23 through 07/07/23 were completed.

The following short-term changes of condition lacked documentation of actions or interventions needed for the resident and communication of the determined actions or interventions to staff on all shifts:

* 04/11/23 - Fall out of bed with head injury;

* 06/17/23 - Fall out of wheelchair; and

* 06/27/23 - Dietary change to pureed diet.

The need to ensure short-term changes of condition had actions or interventions determined documented in the resident record and were communicated to staff on all shifts was discussed with Staff 1 (Administrator) and Staff 2 (Wellness Coordinator/LPN) on 07/11/23. They acknowledged the findings, and no additional documentation was provided.

Based on observation, interview, and record review, it was determined the facility failed to determine, document, and communicate resident-specific actions or interventions needed for 2 of 5 sampled residents (#s 2 and 5) who experienced changes of condition. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 06/2023 with diagnoses including Alzheimer's disease.

During the acuity interview on 07/10/23, Resident 2 was identified as having recently experienced a "rapid decline." Staff 3 (Resident Care Coordinator) and Staff 11 (Med Tech MC) both reported s/he was able to walk independently, feed him/herself, and interact with staff when s/he was admitted to the facility, and in a short period of time s/he became bedbound, non-responsive, and unable to eat.

The resident's clinical record was reviewed, staff were interviewed, and observations were made.

Interviews with Staff 8 (Care Partner MC), Staff 17 (Care Partner MC), and Staff 11 (Med Tech MC) on 07/10/23, 07/11/23, and 07/12/23 confirmed the information about Resident 2 presented in the acuity interview.

Between 07/10/23 and 07/12/23 the resident was observed to be in bed during the entire survey. Staff were observed attempting to feed him/her on 07/11/23, but s/he was not responsive and did not eat anything.

There was no documented evidence in the resident's clinical record of his/her recent decline or instructions to staff about changes in his/her ADL care needs.

The need for actions or interventions to be determined, documented, and communicated with all staff was discussed with Staff 1 (Administrator), Staff 2 (Wellness Coordinator/LPN), and Staff 13 (Regional RN) on 07/11/23 and 07/12/23. They acknowledged the findings.

1.)  Residents identified as being out of compliance having due to having change of condition have been assessed by the RN. Needed interventions put in place. Changes of conditions communicated to the resident's physician and staff.

2.)  All Staff have been trained on how to identify changes of condition (COC) and reporting expectations. Staff were aslo trained on documentation expectations. Nursing will assess the reported changes, iniciate a new (COC) assesment and careplan that reflects new care needs. Staff will review and sign the new care plan acknoledging the changes. Nursing will monitor change in conditions and review interventions for effectiveness.

3.) Clinical team will monitor daily the resident chart notes, incident reports and weights to identify possible changes in condition. The new implemented Significant Change form are reviewed daily with follow up evaluation. Weekly written chart note of the progress of implemented interventions.

4. Wellness Director/Delegtate/Admin

Based on interview and record review, it was determined the facility failed to ensure significant changes of condition were assessed by an RN in a timely manner for 2 of 3 sampled residents (#s 1 and 2) who experienced significant changes. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 06/2023, already on hospice, with diagnoses including Alzheimer's disease.

During the acuity interview on 07/10/23, Resident 2 was identified as having recently experienced a rapid decline.

A review of the resident's clinical record and interviews with staff identified the following:

* When the resident was admitted to the facility in 06/2023, s/he was ambulating and eating independently and spent time each day walking around the unit.

* The resident experienced a fall on 06/27/23.

* Staff reported after the fall the resident stopped ambulating, was unable to feed him/herself, and became bedbound and "mostly" non-responsive.

* Hospice indicated to staff the resident was in a "pre-transition" phase.

There was no documented evidence the RN had completed a significant change of condition assessment which documented findings, resident status, and interventions made as a result of the assessment, and the service plan was not updated.

The RN was unavailable for interview during the survey.

The need to ensure a significant change of condition assessment was completed by an RN within 48 hours was discussed with Staff 1 (Administrator), Staff 2 (Wellness Coordinator/LPN), and Staff 13 (Regional RN). They acknowledged the findings.

2. Resident 1 was admitted to the facility in 11/2022 with diagnoses including Alzheimer's disease.

A review of the resident's record identified the following weights:

* 04/01/23:  181.8 lbs.;

* 06/01/23:  176 lbs.; and

* 07/01/23:  165 lbs.

Between 04/01/23 and 07/01/23 the resident lost 16.8 lbs., or 9.24% of his/her total body weight, in three months. This was a severe weight loss and constituted a significant change of condition.

Between 06/01/23 and 07/01/23 the resident lost 11 lbs., or 6.25% of his/her body weight, in one month. This was a severe weight loss and constituted a significant change of condition.

A review of the resident's progress notes revealed a significant change of condition assessment was completed by the RN on 07/07/23, over a week after the weight loss was triggered.

The facility's RN was unavailable for interview during survey.

The need to ensure significant change assessments were completed by the RN in a timely manner was discussed with Staff 1 (Administrator), Staff 2 (Wellness Coordinator/LPN), and Staff 13 (Regional RN) on 07/12/23. They acknowledged the findings.

1.)  Residents identified as being out of compliance having due to having change of condition have been assessed by the RN. Needed interventions added .

2.) Clinical team will meet daily and review all notes from the prior day as well as incidnet reports and new weights as to identify changes in condition. RN will iniciate an COC assessment for any new changes of condition found. If RN is not present LPN will iniciate COC by adding a chart note and notifying the RN. Staff training on how to identify COC and requirements for reporting COC's to the licsensed nurses have been held.

3. Chart notes and incident reports will be reviewed daily at our clinical meeting.

4. Wellness Director/Delegate/Admin

Based on interview and record review, it was determined the facility failed to coordinate care with outside providers, ensure staff were informed of new interventions, adjust the service plan if necessary, and ensure reporting protocols were in place for 1 of 3 sampled residents (# 2) who received outside services. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 06/2023 with a diagnoses of Alzheimer's Disease with behavioral disturbances.

Resident 2's outside provider notes, dated 06/14/23 through 07/10/23, were reviewed, and the following changes in pain and new skin concerns were identified:

* 06/22/23 Certified Nurses Aide (CNA): "lethargy, lower ability to ambulate, new behavior/grabbing";

* 06/28/23 CNA: "agitated during cares. Sm red area on bottom, two small red areas on L forearm, R knee-small";

* 06/29/23 CNA: "Ribcage looks swollen - R side more swollen than Left. [Resident 2] stated nothing was painful. Eyes-skin near inner R eye red - and L outer red";

* 06/30/23 CNA: "Declined taking off shirt and asked this CNA to stop when this CNA was washing stomach-chest. Patient was guarding [his/her] chest. Ribcage on both sides - swollen and painful. Discharge out of eyes - painful when gently wiping eyes - asked to "Not do that";

* 6/30/23 RN: "orders for eye cream to follow and schedule tylenol";

* 07/03/23 CNA: "declined a new shirt guarding chest and pulled shirt down. Feet cold and toes look purple. Lips look blue. Eyes - skin - red and painful when wiping. Painful when R arm touched. Seeing things and talking about tweezers that [s/he] needs to take to the cows. Lower ribcage swollen";

* 07/05/23 CNA: "new-Red area on R elbow and slightly swollen. Ribcage swollen. Toes appear slightly purple and lips appear blue. Painful when dressing and rolling";

* 07/06/23 CNA: "redness on R elbow - R elbow painful to touch. Skin around eyes - red"; and

* 07/07/23 RN: "painful to right elbow when touched, some swelling noted. Fidgeting with eyes closed."

There was no documented evidence staff were informed of new interventions and the service plan was adjusted to ensure continuity of care.

The need to coordinate care with outside providers, inform staff of new interventions, adjust the service plan when needed, and have reporting protocols in place was discussed with Staff 1 (Administrator), Staff 2 (Wellness Coordinator/LPN), and Staff 13 (Regional RN) on 07/12/23. They acknowledged the findings.

1. All residents' found out of compliance have been reviewed and corrected. Each residents Outside provider notes have been rechecked to ensure that all information was followed up on.

2.) Our Three check system has been re evaluated with the RCC doing first checks, LPN doing second checks and RN doing the third and final checks to ensure that all outside provider care is coordinated appropriately.

3.) Wellness director and Admin will monitor system weekly to ensure compliance

4.) Wellness director and Admin

Based on interview and record review, it was determined the facility failed to ensure medications administered by the facility were set-up and documented by the same person who administered the medications for 1 of 5 sampled residents (#2). Findings include, but are not limited to:

Resident 2 was admitted to the facility in 06/2023 with diagnoses including Alzheimer's disease with behavioral disturbances.

The resident's clinical record was reviewed and the following was identified:

A progress note dated 06/15/23 stated: "[The resident] did not like me, and would not take the medicine from me. I got care partner to give it to [him/her]."

In an interview on 07/11/23, Staff 1 (Administrator) indicated she was "surprised" the med tech would have a care partner administer medication to a resident. She stated she would investigate and speak with the med tech.

The need for all medications to be administered by trained med techs and for medications to be administered and documented by the same person was discussed with Staff 1 (Administrator), Staff 2 (Wellness Coordinator/LPN), and Staff 13 (Regional RN). They acknowledged the findings.

1.) Med tech was counseled and med tech training was held on appropriate ways to handle medication refusals and the need for medications to be passed and documented by the same person.

2.) RCC will do quarterly audits of med passes with each med tech to ensure that all med techs are following policies and procedures.

3.) Quarterly audits will be held.

4.) RCC, Wellness director and Admin will follow

Based on interview and record review, it was determined the facility failed to ensure the ABST (Acuity Based Staffing Tool) was updated at least quarterly and following changes of condition, to determine appropriate staffing levels to address activities of daily living and other tasks related to care for 5 of 5 sampled residents (#s 1, 2, 3, 4, and 5). Findings include, but are not limited to:

Observations, interviews, and review of clinical records, including service plans for Residents 1, 2, 3, 4, and 5, revealed the facility's ABST tool was not updated quarterly and when there was a significant change of condition to reflect the residents' care needs, in order to ensure the ABST was accurately determining the needed staffing levels.

On 07/12/23 the need to ensure the ABST tool was updated to determine appropriate staffing levels to address activities of daily living and other tasks related to care was discussed with Staff 1 (Administrator), Staff 2 (Wellness Coordinator/ LPN), and Staff 13 (Regional RN). They acknowledged the findings.

1.) All care plans have been compared against the ABST and necessary adjustments have been made to ensure all resident cares are correct.

2. RCC will update the ABST when the Care plans are updated. Wellness director will give RCC a daily list of care plan updates at the daily clinical meeting.

3.) ABST will be updated for new move ins, 30 day eval, each quarterly eval and COC's. Residents will be removed once discharged.

Wellness director and Admin will do weekly checks for accuracy.

4.) RCC, Wellness director, Admin

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 361.

Plan of correction : Refer to C252, C260, C262, C270, C280, C290, C301, C361 and Z163

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 C252, C260, C 262, C270, C 280, C 290, and C 301.

Plan of correction : Refer to C252, C260, C262, C270, C280, C290, C301, C361 and Z163

Based on observation, interview, and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan for each resident was developed and included in the service plan for 5 of 5 sampled residents (#s 1, 2, 3, 4, and 5) whose service plans were reviewed. Findings include, but are not limited to:

Resident 1, 2, 3, 4, and 5's current service plans were reviewed during survey. Each service plan lacked information and staff instructions related to the individualized nutrition and hydration status and preferences and needs of the resident.  

The need to develop individualized service plans addressing residents' nutrition and hydration needs was discussed with Staff 1 (Administrator) and Staff 2 (Wellness Coordinator/LPN) on 07/11/23. They acknowledged the findings.

1.) Each care plan found to be missing individualized nutrition and hydration plan has been updated.

2.) At each move in assessment the nurse will ensure that questions are fully answered by the resident or resident family. If resident is unwilling to answer any questions at assesment the nurse will follow up with the resident and family again prior to move in to ensure all resident specific information is entered. Nurse will check in with caregivers periodically to gather information about the residents likes and dislikes to add to careplan as well.

3.) Move in assesment will be evaluated by clinical team prior to move in to ensure individualized information is present.

4.) Clinical team consisting of Admin, Wellness director and RCC will monitor