Ivy Court Senior Living

The findings of the re-licensure survey conducted 09/11/23 through 09/14/23 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 Home and Community Based Services Regulations. Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day
The findings of the first revisit to the re-licensure survey of 09/14/23, conducted on 11/30/23, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

Based on interview and record review, it was determined the facility failed to investigate incidents or injuries of unknown cause to rule-out abuse, document all required areas of an investigation and report to the local SPD office, if abuse or neglect could not be ruled out, for 1 of 2 sampled residents (#1) with incidents or injuries of unknown cause. Findings include, but are not limited to:Resident 1 was admitted to the facility in 11/2021 with diagnoses including pain in right hip joint. Observations of the resident, interviews with staff, review of the resident's service plan, 06/11/23 through 09/11/23 temporary service plans and progress notes and incident investigations were reviewed, and the following was identified:* 06/28/23 injury of unknown cause, right hip; * 07/09/23 injury of unknown cause, "severe cut"; and * 07/24/23 injury of unknown cause, "open skin on bottom". There was no documented evidence the occurrences had been investigated at the time of occurrence and the investigations included all required components, or the occurrences reported to the local APS office, if abuse and/or neglect could not be ruled out.At the request of the survey team, all incidents above were reported to APS. The need to ensure injuries of unknown cause were immediately investigated, contained all required areas of documentation, including if abuse and neglect could be ruled out and if not, the injuries were reported to the local APS office, was discussed with Staff 1 (Administrator) and Staff 10 (RN) on 09/14/23. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents who had short-term changes of condition were evaluated, resident-specific instructions or interventions were developed and progress was documented weekly until resolution for 1 of 3 sampled residents (#1). Findings include, but are not limited to:Resident 1 was admitted to the facility in 11/2021 with diagnoses including right hip pain.Observations of the resident, interviews with staff, and review of the resident's service plan, 06/11/23 through 09/11/23 temporary service plans and progress notes, physician communications, and incident investigations were completed. The following short-term changes of condition lacked documentation of actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, and/or progress noted at least weekly through resolution:* Multiple skin changes;* Multiple medication changes; and* New behaviors. The need to ensure actions or interventions for short-term changes of condition were documented, communicated to staff on each shift, and the changes of condition were monitored through resolution was discussed with Staff 1 (Administrator) and Staff 10 (RN) on 09/14/23. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure devices with restraining qualities were assessed by an RN, PT, or OT prior to use and evaluated quarterly, and instruction was provided to staff on the correct use and precautions related to the devices, for 1 of 1 sampled resident (#1) who had devices with potentially restraining qualities. Findings include, but are not limited to:Observation of Resident 1's room 09/11/23 through 09/14/23, revealed there were bilateral half-length side rails in the raised position on the bed and a tilt-in-space wheelchair. Resident 1 required a hoyer lift for transfers and had cognitive impairment which rendered him/her unable to adjust the position of the wheelchair independently, and therefore required an assessment. Review of the resident's clinical record revealed the following:There was no documented evidence the following required elements were completed for the side rails:* Quarterly evaluation; and * Instruction provided to staff on the correct use and precautions related to the device. There was no documented evidence the following required elements were completed for the tilt-in-space wheelchair:* Assessment by an RN, PT or OT; * Documentation of less restrictive alternatives evaluated prior to use of the device; * Instruction provided to staff on the correct use and precautions related to the device; and* Documentation of a tilt-in-space wheelchair in the resident's service plan.The need to ensure devices with restraining qualities were assessed by an RN, PT, or OT prior to use and evaluated quarterly, and instruction was provided to caregivers on precautions and correct use of the devices, was discussed with Staff 1 (Administrator) and Staff 10 (RN) on 09/14/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 1 of 2 newly hired direct care staff (# 5) demonstrated competency of skills in all assigned job duties within 30 days of hire. Findings include, but are not limited to:Training records were reviewed on 09/13/23 and 09/14/23 and identified the following:Staff 5 (CG) hired on 07/11/23, lacked documentation of demonstrated competency in the following areas:* Providing assistance with ADL's;* Changes associated with normal aging; * Identification, documentation and reporting of changes of condition; * Conditions that require assessment, treatment, observation and reporting; and* First Aid and abdominal thrust.The need to ensure staff demonstrated competency in all assigned job duties within 30 days of hire was discussed with Staff 1 (Administrator) on 09/14/23. She acknowledged the findings.