The findings of the re-licensure survey, conducted 07/10/23 through 07/13/23, 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 re-visit to the re-licensure survey of 09/07/23, conducted 01/31/24 through 02/01/24, 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 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. Tag numbers beginning with the letter H refer to the Home & 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

The findings of the second revisit to the re-licensure survey of 07/13/24 conducted 05/22/24 through 05/23/24, 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, OARs 411 Division 57 for Memory Care Communities

Based on interview and record review, it was determined the facility failed failed to promptly investigate all reports of suspected abuse and immediately investigate an injury of unknown cause (IUC) and reasonably conclude and document the injury was not the result of abuse or report the IUC to the local APD (Aging and People with Disabilities) office, for 3 of 3 sampled residents (#s 1, 2 and 4) who had documented injuries. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 11/2021 with diagnoses including Alzheimer's disease, depression and gastroesophageal reflux disease (GERD).

The resident's current service plan, dated 03/08/23, indicated the resident required two-person assistance for all transfers. An interview with Staff 8 (CG) on 07/13/23 confirmed the resident still required two staff to assist with transfers.

On 06/10/23, a staff person documented in the "Resident Progress Notes": "While transferring [Resident 1] to [his/her] wheel chair, [his/her] elbow hit the side arm and broke open." The resident was subsequently placed on "Alert Charting" for a "skin tear to left elbow."

As the documentation failed to indicate whether two staff were assisting with the transfer when the resident sustained the injury, this represented an instance of suspected abuse for which an investigation was required.

There was no documented evidence the facility promptly investigated the incident in order to determine if measures needed to be taken to prevent the reoccurrence of injuries.

The need to promptly investigate any incident of suspected abuse was reviewed with Staff 1 (Regional Director of Nursing) and Staff 2 (Administrator) on 07/13/23. They acknowledged the facility had not investigated the incident to ensure staff transferred the resident properly.

The surveyor directed the facility to report the incident to the local APD office. Confirmation the incident was reported was obtained on 07/13/23.

2. Resident 2 was admitted to the facility in 06/2023 with diagnoses including dementia, anxiety and acute cystitis.

Review of "Resident Progress Notes" indicated Resident 2 was identified with the following injuries:

* 06/26/23: skin tear to right forearm; and

* 07/03/23: an abrasion to the top of the right thigh.

As there was no explanation of how these injuries occurred, they would be considered injuries of unknown cause. Per rule, the facility was required to report the injuries to the local APD office unless it conducted an immediate investigation which reasonably concluded and documented the injuries were not the result of abuse or neglect.

There was no documented evidence the facility conducted an immediate investigation of the injuries to rule out abuse or reported the injuries to the local APD office.

The process for investigating or reporting injuries of unknown cause was reviewed with Staff 1 (Regional Director of Nursing) and Staff 2 (Administrator) on 07/11/23.

The surveyor directed the facility to report the incidents to the local APD office. Confirmation the incidents were reported was obtained on 07/11/23.

3. Resident 4 was admitted to the facility in 06/2023 with diagnoses including mixed Alzheimer's and vascular dementia.

Review of "Resident Progress Notes" indicated Resident 4 was identified with a bruise on the forehead on 07/09/23.

As there was no explanation of how this injury occurred, it would be considered an injury of unknown cause. Per rule, the facility was required to report the injury to the local APD office unless it conducted an immediate investigation which reasonably concluded and documented the injury was not the result of abuse or neglect.

There was no documented evidence the facility conducted an immediate investigation of the injury to rule out abuse or reported the injuries to the local APD office.

The process for investigating or reporting injuries of unknown cause was reviewed with Staff 1 (Regional Director of Nursing) and Staff 2 (Administrator) on 07/11/23.

The surveyor directed the facility to report the incidents to the local APD office. Confirmation the incidents were reported was obtained on 07/11/23.

1. Incidents in question were reported to APS.  Community completed investigations and implemented interventions to residents service plans.  APS was on site on 8/1/23 and completed a training during the Staff Devleopment meeting.

2. All staff to receive re-training on current Policy & Procedure on investigating incidents timely, implementing interventions and reporting abuse as applicable.

3. Will be monitored routinely between the Administrator, RCC and nurse.

4. Administrator, RCC, Nurse

Based on observation, interviews and record review, it was determined the facility failed to ensure the kitchen was clean and in good repair in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to:

Observations of the kitchen on 07/10/23 through 07/13/23 identified the following:

* Cabinetry throughout the kitchen had chips, dings, and gouges exposing bare particle board underneath;

* Cutting boards were observed with deep scoring and staining;

* A floor drain below the three compartment sink had buildup of food debris;

* Cookware including pots and pans, were scorched, tarnished, and heavily scratched;

* Interior of the oven was coated with black, burnt food matter and grease buildup; and

* The ceiling around the stove exhaust hood was cracked and peeling.

During the survey, the kitchen's back door was open to help with the heat and ventilation. There was a magnetic mesh screen attached around the perimeter of the door frame. The screen failed to properly seal around the edges, causing gaps and openings where insects, pests, and other containments could enter the kitchen.

Caregiving staff assisting with meal service were observed to not consistently sanitize hands after touching contaminated surfaces.  

On 07/13/23, the need to ensure the kitchen was kept clean and in good repair and staff utilized hand hygiene practices was discussed with Staff 1 (Regional Director of Nursing) and Staff 2 (Administrator). They acknowledged the findings.  

1. Kitchen Cabinetry and ceiling above stove exhaust: Maintenance to repair.

Cookware and cutting boards: will be replaced.

Floor drain cleanliness- dietary aid to clean.

Caregiver and hygiene: re-eduate on infection control.

Magnetic door screen: maintenance to add more magnets to properly seal around edges.

2. Dietary cook and Dietary Aide to audit cleanliness of floor drains daily and to monitor magnetic mesh around door to ensure proper seal.

Dietary cook and Dietary Aide to observe caregivers entering kitchen for proper hand hygiene.

3. Weekly

4. Dietary Manager and Administrator  

Based on interview and record review, it was determined the facility failed to ensure the initial evaluation addressed all the 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 MCC in 06/2023 with diagnoses including dementia, anxiety and depression.

The resident's move-in evaluation failed to adequately address the following required elements:

* Mental health issues including history of treatment;

* Cognition, including decision making capabilities;

* Activities of daily living including dental status;

* Pain, pharmaceutical and non-pharmaceutical interventions; and

* History of unexplained weight loss or gain.

The need to address all required elements on the initial evaluation was reviewed with Staff 1 (Regional Director of Nursing) and Staff 2 (Administrator) on 07/13/23. They acknowledged the information that was not included in the evaluation.

1. The evaluation will be updated to reflect the deficiencies noted.  Existing Pre-Admission Evaluation requirements will be reviewed.

2.  Administrator, RCC, Nurse will collaborate to ensure the move in admission evaluation is complete and reflects the required elements.

3.  Evaluated prior to each admission.

4.  Administrator, RCC, Nurse  

Based on interview and record review, it was determined the facility failed to ensure documentation of staff instructions or interventions were resident-specific, weekly progress was noted until the condition resolved, and each resident was monitored consistent with his or her evaluated needs and service plan, for 3 of 4 sampled residents (#s 1, 2 and 4) with short-term changes of condition. Findings include, but are not limited to:

1. In response to a change of condition, the facility used the "Resident Alerts" form to inform staff of the condition and instruct staff to monitor a resident. The monitoring instructions were generated by the computer software system based on the type of condition identified. The monitoring instructions were not resident-specific as required by the rule.

In an interview on 07/13/23, Staff 1 (Regional Director of Nursing) acknowledged the monitoring instructions were not specific to a resident or the condition and said the facility was preparing to address this issue with an updated process.

The need to ensure actions or interventions needed for a resident following a short term change of condition were resident-specific was reviewed with Staff 1 and Staff 2 (Administrator) on 07/13/23. They acknowledged the findings.

2. Resident 1 was admitted to the facility in 11/2021 with diagnoses including Alzheimer's disease, depression and gastroesophageal reflux disease (GERD).

Review of "Resident Progress Notes" and "Resident Alerts" indicated Resident 1 experienced the following short-term changes of condition:

* 04/16/23: Redness to left ankle;

* 06/08/23: Non-injury fall in bedroom; and

* 06/10/23: Skin tear left elbow:

* Injury fall in TV room.

For each of these incidents, the facility failed to document when the condition was determined to be resolved.

The need to ensure weekly progress was noted until the condition resolved was reviewed with Staff 1 (Regional Director of Nursing) and Staff 2 (Administrator) on 07/13/23. They acknowledged the findings.

3. Resident 2 was admitted to the facility in 06/2023 with diagnoses including dementia, anxiety and acute cystitis.

Review of "Resident Progress Notes" and "Resident Alerts" indicated Resident 2 experienced the following short-term changes of condition:

* 06/23/23: Non-injury fall in bedroom;

* 07/04/23: Fell three times during the day and re-opened a previous skin tear; and

* 07/05/23: Non-injury fall in the activity room.

For each of these incidents, the facility failed to document when the condition was determined to be resolved.

The need to ensure weekly progress was noted until the condition resolved was reviewed with Staff 1 (Regional Director of Nursing) and Staff 2 (Administrator) on 07/13/23. They acknowledged the findings.

4. Resident 4 was admitted to the facility in 06/2023 with diagnoses including mixed Alzheimer's and vascular dementia.

Review of "Resident Progress Notes" and "Resident Alerts" indicated Resident 4 experienced the following short-term changes of condition:

a. Resident 4 physically assaulted two different peers. The following deficiencies were identified:

* 06/19/23: Resident 4 was found on top of another peer "scratching and swinging" at the peer. The facility failed to document when the condition was determined to be resolved.

* 07/09/23: Resident 4 and another peer were found fighting on the floor outside the peer's room. Instructions for staff were not resident-specific. Additionally, a new intervention was noted in the "Investigation" report: "If [Resident 4] seen walking the halls, engage in an activity to keep [him/her] busy." This intervention was not added to the resident's service plan and communicated to staff for implementation.

b. Resident 4 actively sought peers of the opposite sex for intimacy. After the first incident on 06/09/23, the facility directed staff to "Monitor [Resident 4] to prevent from entering [peer's room] or inviting [him/her] back into [his/her] room.

* Staff documented additional incidents where Resident 4 was found alone with other peers' in rooms on 06/14/23, 07/03/23, 07/08/23. The facility failed to monitor whether existing interventions (i.e., staff to monitor the resident) were being followed, were effective, and whether additional interventions needed to be developed to protect residents on the unit.

* Following the 07/03/23 incident, a new intervention was noted in the "Investigation" report: "Instead of saying, 'This isn't your apartment' tell [resident] you need [his/her] help or you want to show [him/her] something really cool." This intervention was not added to the resident's service plan and communicated to staff for implementation.

* Following the 07/08/23 incident, a new intervention was noted in the "Investigation" report: "If seen walking the halls, engage in an activity to keep [resident] busy." This intervention was not added to the resident's service plan and communicated to staff for implementation.

The need to ensure the facility had a process for monitoring whether service-planned interventions were being followed by staff, were effective, and new interventions were added to the service plan and communicated to staff was reviewed with Staff 1 (Regional Director of Nursing) and Staff 2 (Administrator) on 07/13/23. They acknowledged the findings.

1. Resident specific interventions were added to the residents service plans and communicated to staff.  Residents were monitored for effectiveness of interventions. If not effective, new interventions were added.  

2. Re-train nurse, RCC on Root Cause Analysis for resident specific interventions and the use of current investigation tool to document intervention effectiveness.  Additional training with Medication Aides to review existing Alert Charting policy and procedure on monitoring to resolution.

3. MA to review daily. RCC, Nurse and Administrator to review weekly.

4. Administrator, RCC

Based on interview and record review, it was determined the facility failed to ensure written, signed physician or other legally-recognized practitioner orders were documented in the resident's facility record for all treatments the facility was responsible to administer, for 1 of 3 sampled residents (#2) for whom the facility provided wound care. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 06/2023 with diagnoses including dementia, anxiety and acute cystitis.

"Resident Alerts" notes indicated staff discovered a skin tear on the resident's right forearm on 06/26/23. Multiple notes between 06/26/23 and 06/28/23 indicated staff were administering repeated wound care, including dressing the wound.

There was no written, signed prescriber's order for the wound care in Resident 2's facility record.

The need to ensure the facility obtained written signed orders for any treatments it provided was reviewed with Staff 1 (Regional Director of Nursing), Staff 2 (Administrator) and Staff 5 (LPN) on 07/13/23. They acknowledged the lack of an order for wound care.

1. PCP faxed for signed treatment order.

2. Standard treatment orders to be added to admission orders.

3. Prior to move in and as needed after move in.

4. Admin, RCC, Nurse.  

Based on interview and record review, it was determined the facility failed to maintain an accurate treatment administration record (TAR) for all treatments administered by the facility, for 2 of 3 sampled residents (#s 1 and 2) who were administered wound care by the facility. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 11/2021 with diagnoses including Alzheimer's disease, depression and gastroesophageal reflux disease (GERD).

a. "Resident Alerts" notes indicated staff discovered a pressure sore on the resident's coccyx on 05/07/23. In an interview on 08/13/23, Staff 1 (Regional Director of Nursing) stated she instructed staff to apply Calmoseptine ointment to the wound daily with each brief change.

b. "Resident Alerts" notes indicated Resident 1 sustained a skin tear to the left forearm following a fall on 06/11/23. Several notes between 06/11/23 and 06/13/23 indicated staff were administering repeated wound care, including dressing the wound.

There facility failed to document the administration of the wound care for the pressure sore and skin tear on Resident 1's TAR.

The need to ensure the facility documented all treatments administered on the resident's TAR was discussed with Staff 1 (Regional Director of Nursing) and Staff 2 (Administrator) on 07/13/23. They acknowledged the lack of documentation on the TAR.

2. Resident 2 was admitted to the facility in 06/2023 with diagnoses including dementia, anxiety and acute cystitis.

"Resident Alerts" notes indicated staff discovered a skin tear on the resident's right forearm on 06/26/23. Multiple notes between 06/26/23 and 06/28/23 indicated staff were administering repeated wound care, including dressing the wound.

The facility failed to document the administration of the wound care on Resident 2's TAR.

The need to ensure the facility documented all treatments administered on the resident's TAR was discussed with Staff 1 (Regional Director of Nursing) and Staff 2 (Administrator) on 07/13/23. They acknowledged the lack of documentation on the TAR.

1. Treatment was added to the resident MAR.

2. Re-training with nurse, RCC and Medication Aides on current procedure that requires all treatments to be manually added to the MAR to document administration.

3. Medication Aides to review daily with each new treatment order. RCC/Nurse to review weekly.

4. Admin, RCC, Nurse

Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) that met the regulation. Findings include, but are not limited to:

The facility was unable to provide documented evidence it was using an ABST to determine appropriate staffing levels for the facility.

The requirements of the ABST were discussed with Staff 1 (Regional Director of Nursing) and Staff 2 (Administrator) on 07/13/23. They acknowledged the findings.

1. Currently working with Acuity-Based Staffing Corrective Action Coordinator. Trial run on ABST tool is currenty being tested.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 direct care staff (#s 14 and 15) had documented evidence of completion of First Aid certification and abdominal thrust training within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed on 07/12/23 and revealed Staff 14 (CG), hired 04/26/23, and Staff 15 (CG), hired 04/28/23, lacked documented evidence they had completed First Aid certification and abdominal thrust training within 30 days of hire.

The need for staff to complete all required training in the specified time frames was discussed with Staff 1 (Regional Director of Nursing), and Staff 2 (Administrator) on 07/13/23. They acknowledged the findings.

1. The staff have completed the missing trainings for the First Aid and abdominal thrust.

2. New hire documents to be reviewed prior to 30 days of hire for compliance.

3. With each new hire and annually.

4. Office Manager, Administrator  

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted according to the Oregon Fire Code (OFC) and that the facility met the applicable evacuation level. Findings include, but are not limited to:

During the relicensure survey, 07/10/23 through 07/13/23, the survey team identified the following concerns:

The MCC was home to 34 residents, including two requiring two-person assist for transfers and 14 residents with high care needs.

On 07/10/23, the weekly staffing schedule for the month was requested.

The 06/04/23 through 07/15/23 staffing schedule was received, and it identified there were three to four direct care staff on the day (6:00 am - 2:00 pm) and evening (2:00 pm - 10:00 pm) shifts, and one to two direct care staff for the night (10:00 pm - 6:00 am) shifts. There were 19 night shifts where one care staff was scheduled for the MCC.

On 07/12/23, fire and life safety records for 01/26/23 through 06/27/23 were reviewed with Staff 4 (Maintenance Supervisor). The record indicated that during a fire drill conducted at 8:20 pm on 04/21/23, the three care staff working could not secure the three exits and evacuate residents effectively. Staff 4 further stated that he tried to conduct fire drills every shift, and there were not enough staff scheduled on the evening and night shifts to evacuate residents safely.

An interview later that day with Staff 8 (CG) confirmed the evening and night shifts were unable to successfully evacuate residents during fire drills due to not having enough staff.

The need to ensure the facility met the applicable evacuation level and staff provided fire evacuation assistance to residents from the building to a designated point of safety was discussed with Staff 1 (Regional Director of Nursing) and Staff 2 (Administrator) on 07/13/23. They acknowledged the findings.  

1. At no time was one staff person scheduled for night shift.  Staff have been instruced to only use Paylocity scheduling system to accurately depict the staff scheudle of the community.  Prior RCC was using an excel spreadsheet along with Paylocity creating a misrespresentation of our staff schedule. This spreadsheet was not given to surveyors at time of survey to accurately reflect staffing.

2. During evacuation drills, Maintenance supervisor to review findings with RCC and Administrator. Staff to be retrained on how to evacuate residents.

3. Monthly after each drill and as needed after non-scheduled evacuations.

4. Maintenance supervisor, RCC, Administrator

Based on interview and record review, it was determined the facility failed to ensure the facility met the applicable evacuation level according to the Oregon Fire Code (OFC). This is a repeat citation. Findings include, but are not limited to:

During the revisit to the re-licensure survey, conducted 01/31/24 through 02/01/24, the survey team identified the following concerns:

The MCC was home to 31 residents, including two requiring two-person assist for transfers and intermittent care while in bed and 10 residents identified with higher care needs related to falls, behaviors, and/or weakness.

On 01/31/24, the weekly staffing schedule for the month was requested.

The 01/01/24 through 01/30/24 staffing schedule and posted staffing plan identified there were four direct care staff and one medication aide on the day shift (6:00 am - 2:00 pm), three direct care staff and one medication aide on the evening shift (2:00 pm - 10:00 pm), and one direct care staff and one medication aide on the night shift (10:00 pm - 6:00 am).

Payroll records were reviewed between 01/16/24 and 01/31/24 and confirmed the number of staff indicated in the staffing plan were present on each shift.

On 01/31/24, fire and life safety records for 11/14/23 through 01/19/24 were reviewed with Staff 4 (Maintenance Supervisor). No additional drills had been completed for the night shift yet. Staff 4 indicated the night shift did not have enough staff to evacuate residents safely. He was unable to determine an effective safety plan for the night shift related to previous concerns around insufficient staff to evacuate residents and secure exit doors.

In an interview on 01/31/24, Staff 2 (Administrator) and Staff 4 indicated no plan was put in place after the previous concern regarding night shift evacuations was cited on the re-licensure survey. Staff 2 and Staff 4 both acknowledged the two staff present on the floor for night shift was not sufficient to secure all exit doors, move residents to safety, and watch residents who were moved out of the building during an evacuation. Staff 2 and Staff 4 indicated additional staff was needed related to the evacuation needs. Staff 2 indicated she would immediately work on a plan for a third staff in place on night shift.

On 02/01/24, Staff 1 (Regional Director of Nursing) and Staff 4 provided a written plan for night shift to have three staff and a specific plan for what to do when evacuating residents during a drill or real fire. Staff 4 indicated he reviewed the information with the additional staff that was added for night shift on 01/31/24 and was planning to conduct a drill and education with the remaining night shift staff in the next few days. Additionally, the information would be posted for staff reference.

The need to ensure the facility met the applicable evacuation level and staff provided fire evacuation assistance to residents from the building to a designated point of safety was discussed with Staff 1, Staff 2, and Staff 4 on 01/31/24 and 02/01/24. They acknowledged the findings.

1. Hire additional staff to meet deficencies due to location of exits

2. Schedule hired staff for night shift and train on current emergency fire drill/evacuation policy and procedure.

3. Monthly

4. Administrator and Maintenance Supervisor

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 C 420.

1. Current plan of correction has been implemented

2. Plan of correction will continue to be implemented

3. Routineily with monthly emergency drills

4. Administrator and Maintenance Director

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

Observations made on 07/13/23 revealed the following areas needed cleaning or repair:

* Two green striped chairs next to the mailboxes were stained and worn;

* A blue chair in the "Ladies Lounge" had a stain on the right arm;

* Two chairs in the hallway near Room 9 had stains on the seats;

* A chair at the table in the "Kitchen" area near Room 26 had a stain on the seat;

* A brown leather loveseat and chair in the "Man Cave" had stains; and

* There was an unpleasant odor in the common area near the entry to the unit that persisted throughout the survey.  

The environment was toured on 07/13/23 with Staff 1 (Regional Director of Nursing) and Staff 4 (Maintenance Supervisor). The need to ensure all interior surfaces were kept clean, in good repair, and free from unpleasant odors was discussed with Staff 1 and Staff 4. They acknowledged the findings.

1. Furniture and carept have been cleaned.

2. Maintenance supervisor and housekeeper to clean furniture and environment on a routine basis.

3. Environmental tour to be done monthly.

4. Maintenance, Administrator  

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 240, C 361, C 372, C 420 and C 513.

Refer to C231, C240, C361,C372, C420, C513.

Based on interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:

Refer to C 420.

1. See C420 Plan of Correction

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 270, C 303 and C 315.

Refer to C252, C270, C303, C315.

Based on observation, interview and record review, it was determined the facility failed to evaluate the resident for activities and develop an individualized activity plan for each resident based on their activity evaluation, for 3 of 4 sampled residents (#s 1, 2 and 4) whose activity plans were reviewed. Findings include, but are not limited to:

During the survey, many residents were observed needing assistance and encouragement from staff to initiate, attend and participate in activities. The facility offered group activities, which many residents attended. Some residents did not attend the activities and, instead, stayed in their rooms or walked around the facility. All residents were diagnosed with some type of dementia.

Resident 1 was receiving hospice services, was non-ambulatory, and spent most of his/her time during the survey in his/her apartment in bed. Resident 2 walked around the building almost constantly and staff reported they found it difficult to get Resident 2 to sit for any period of time, especially to participate in any activity. Resident 4 had a history of seeking peers of the opposite sex for intimacy and required extensive supervision by staff.

Resident 1, 2 and 4's service plan and "Life Enrichment Plan" documents were reviewed. Though the activities section of the service plan included some information about each resident's past and current interests, the facility had not fully evaluated the resident's:

* Current abilities and skills;

* Emotional and social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for participation; and

* Activities that could be used as behavioral interventions.

There was no specific activity plan which detailed what, when, how and how often staff should offer and assist the residents with more individualized activities.

The need to develop individualized activity plans which were based on a thorough evaluation of the resident's interests, abilities and needs was discussed with Staff 1 (Regional Director of Nursing) and Staff 2 (Administrator) on 07/13/23. They acknowledged the findings.

1. Resident's life enrichment and service plans to be updated to reflect the residents current and physical abilities, emotional and social needs, including activites that may be used for behavioral intervetions, and any adaptations that may be needed. They will also be updated with details for staff to know what, when and how often to assist the residents.

2. Per existing policy, Life Enrichment Plans and activity section of service plan to be reviewed prior to move in, quarterly and with each change of condition.

3. Life Enrichments Plans and activity section of service plan to be evaluated with each update.

4. Life Enrichment Coordinator, RCC, Administrator