The findings of the re-licensure survey, conducted 11/15/21 through 11/17/21, 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, Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.

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 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

MCCMemory 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 11/17/21, conducted 02/14/22 through 02/15/22, 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 and OARS 411 Division 004 for Home and Community Based Regulations.

Based on interview and record review, it was determined the facility failed to ensure falls with injury and resident to resident altercations were promptly investigated to rule out abuse and reported to the local SPD office as required for 2 of 3 sampled residents (#s 1 and 2) whose incidents were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in July 2021 with diagnoses including dementia.  

The resident's service plan dated 09/17/21 and interviews with care staff between 11/15/21 and 11/17/21 indicated the resident could ambulate on his/her own and utilized a walker. The resident was unable to consistently direct his/her own care and had a history of falls.

Review of incident investigations and progress notes from 08/27/21 through 11/15/21 showed the following:

* A progress note dated 08/27/21 indicated the resident was found on the floor with a large football size bruise to the middle of his/her back. No investigation of the incident was completed.  

* A progress note dated 10/01/21 indicted the resident was found on the floor in front of his/her room. The resident complained of shoulder pain and was sent to the emergency room for evaluation. No injuries were found. No investigation of the incident was completed.

The need to ensure resident incidents were promptly investigated to rule out abuse and neglect was discussed with Staff 1 (MC Administrator), Staff 2 (Regional Director of Operations) and Staff 3 (Chief Operating Officer) on 11/16/21. The staff acknowledged the findings.

The facility reported the incidents to the local SPD office on 11/17/21. Confirmation of the reports were provided prior to survey exit.

2. Resident 1 was admitted to the facility in September 2017 with diagnoses including dementia.  

The resident's service plan dated 10/18/21 and interviews with care staff between 11/15/21 and 11/17/21 indicated the resident was dependent on staff for care, had a recent neck fracture in September and had frequent falls. The resident was unable to consistently direct his/her own care and had a history of falls.

Review of incident investigations and progress notes from 08/27/21 through 11/15/21 showed the following:

* A progress note dated 10/15/21 indicated the resident was shoved by another resident. There were no injuries noted. The incident was not reported to the local SPD office.

* A progress note dated 11/08/21 indicted the resident had a non-injury fall. A large rug burn to the back was found on the resident later the same day. No investigation of the incident was completed.

The need to ensure resident incidents were promptly investigated to rule out abuse and neglect and reported to the local SPD office as needed, was discussed with Staff 1 (MC Administrator), Staff 2 (Regional Director of Operations) and Staff 3 (Chief Operating Officer) on 11/16/21. The staff acknowledged the findings.

The facility reported the resident to resident altercation to the local SPD office on 11/17/21. Confirmation of the reports were provided prior to survey exit.

1)  Resident #1-two noted incidents were investigated and reported as of 11/17/21.  A review of resident falls and/or altercations in the prior 30 days were reviewed to assure investigations were completed and reporting done in accordance with regulations.

2) Re-education was provided to the MCD regarding incident investigations and reporting requirements to assure understanding.  Occurrence reports and associated documentation will be reviewed routinely to assure completed invetigations and reporting is conducted as applicable.

3) Daily

4) MCD and ED

Based on observation and interview, it was determined the facility failed to ensure the kitchen was kept clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:

1. On 11/15/21 at 9:30 am, the facility's main kitchen was observed to need cleaning or repair in the following areas:

* Floors throughout the kitchen, including dry storage, walk-in refrigerator, freezer and underneath the beverage station had black matter buildup and food debris in corners, around perimeter edges, under equipment, inside floor drains, and in between tile grout;

* The juice dispenser had a metal shelf with chipped paint, and rust had developed around the rim where the shelf attached to the machine;

* Shelving throughout the kitchen, including the walk-in refrigerator and freezer, and shelving in the dry storage had food spills, splatters, dirt, dust, and debris;

* Pipes behind multiple appliances had grease, dirt, and debris on them;

* Caulking around the stainless-steel edge of the dishwashing area was black;

* Ceiling vents had an accumulation of lint and dust on the grates; and

* Chipped paint and black smears on the kitchen doors and frames.

The need to ensure the kitchen was kept clean and in good repair was shown to and discussed with Staff 2 (Regional Director of Operations) and Staff 8 (ED) on 11/17/21. The findings were acknowledged.

2. Observations of the kitchenette located in the memory care unit on 11/15/21 revealed the following areas were in need of cleaning and repair:

* The drain underneath the sink had black/brown accumulation and debris and the pipe above the drain had brown matter around the edges of the pipe and hanging down over the drain;

* The stove had food debris in the burners, the oven had debris on the bottom of the oven and spills on the door;

* The walls in the kitchenette had multiple chips, dings, splatters and spills;

* The refrigerator and freezer unit had food debris, spills and splatters to the lower shelf and doors;

* The microwave had splatters and spills to the inside of the unit and on the door;

* The dry storage area had cobwebs along the corners, food debris under the shelving units, individual dead insects under the shelves and a large pile of dead insects at the inner corner near the door of the storage; and

* The wall near the refrigerator had a large hole, approximately 12 inches long and two inches wide with chunks of dry wall hanging within the hole.

The areas in need of cleaning and repair were discussed with and shown to Staff 1 (MC Administrator) on 11/15/21. Staff 1 acknowledged the findings and the dead insects were cleaned up right away.

1) Both the main kitchen and Memory Care kitchenette have been deep cleaned.  Inservicing conducted with kitchen and Memory Care staff to review cleaning schedule.  Repainting and repairs will be completed for items noted in the survey.

2) Routine walkthroughs of both the main kitchen and memory care kitchenette will be conducted to evaluate for effective cleaning and verify cleaning schedules are being followed

3) Daily for 30 days then resume weekly

4) MCD, ED and DSM

Based on observation, interview and record review, it was determined the facility failed to provide an activity program based on individual and group interests, physical, mental, and psychosocial needs, and opportunities for active participation in the community at large. Findings include, but are not limited to:

During the re-licensure survey conducted 11/15/21 through 11/17/21, there was a lack of scheduled and unscheduled activities provided for residents living in the memory care community.

On entrance to the memory care unit on 11/15/21 there was no monthly activity calendar posted and no daily lists indicating what activities were going to be offered throughout the day. A dry erase easel was located in the common area which indicated the date was 11/15/21 and it was health care month. The board remained unchanged for the entirety of the survey.

Multiple continuous observations of the memory care unit on day shift and swing shift between 11/15/21 and 11/17/21 showed a lack of group activities provided for the residents. Approximately 6-8 residents were gathered in the common area at one time throughout the day. The residents were observed sitting in the common area both awake and asleep, additional residents were observed wandering the halls back and forth with minimal interaction by staff and the remaining residents were in their apartments asleep in chairs/beds, watching TV or looking out the window. A movie or television show was running on the TV in the common area throughout the day.

Staff interviews conducted between 11/15/21 and 11/17/21 revealed the person assigned to activities was new to the position and was only able to work on activities a few days a week because she was frequently pulled to work the floor. The care staff were generally aware they should conduct activities with the residents but indicated there was not enough time and they were not sure what exactly to do.

In interview on 11/15/21 and 11/16/21 Staff 1 (MC Administrator) indicated the memory care unit did not have an activity calendar and there was nothing posted or provided to residents. Staff 1 stated the new activity staff worked as strictly activity staff about three days a week with the goal they would be five full days. The staff member was working as a medication technician frequently and Staff 1 was not able to get her full time to activities quite yet. Staff 1 further indicated they had a list of suggested activities to do with the residents, but not an actual plan/calendar in place.

The lack of an activity program and calendar was discussed with Staff 1 (MC Administrator), Staff 2 (Regional Director of Operations) and Staff 3 (Chief Operating Officer) on 11/16/21. Staff 3 indicated the memory care unit should have its own calendar and she would assist Staff 1 to get it in place. Staff 3 further stated the activity staff should not be pulled to work other positions and that would stop immediately. The staff acknowledged the findings.

1)  Monthly and daily activity calendars are posted.  Activity personell schedules have been reviewed to assure primary focus is on the activity program.  Inservicing conducted with all Memory Care staff to review the current activity schedule and their role in assisting with the daily activity program.

2) Monthly activity calendars will be completed and posted by the 1st of every month and daily activities will be posted daily for resident/staff awareness.  Daily routine for caregivers that allows for time to conduct activities will be in place.  

3)  MCD will review for daily activity posting daily and will check for monthly calendar at least weekly to assure they are present.   MCD will observe adherence to the activity calendar daily for 15 days then twice weekly to assure ongoing compliance.  

4) MCD/ED  

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction to staff and/or was consistently followed by staff for 1 of 2 sampled residents (#2) whose service plans were reviewed. Findings include, but are not limited to:

Resident 2 was admitted to the facility in September 2017 with diagnoses including dementia.

Observations of the resident and interviews with staff from 11/15/21 to 11/17/21 and review of the service plan dated 10/18/21, showed the service plan was not reflective of the resident's current care needs, was not consistently followed by staff and/or did not provide clear direction to staff in the following areas:

* Transfer assistance and the number of staff needed;

* Incontinence care and toileting;

* Neck brace application and showering and dressing needs related to the brace;

* Wheelchair use;

* Meal assistance, health shakes and diet texture;

* Behaviors related to resident to resident altercations;

* Falls and safety interventions including fall mat, scoop mattress, low bed and side rails; and

* Bowel tracking, snack tracking and health shakes.

The need to ensure resident service plans were reflective of current care needs, provided direction to staff and were followed was discussed with Staff 1 (MC Administrator) and Staff 2 (Regional Director of Operations) on 11/17/21. They acknowledged the findings.

1) Resident #1-service plan has been updated to reflect current care needs and provide clear direction to the staff.  Remaining resident's service plans will be reviewed to assure they are reflective of care needs and provide clear directions for staff.

2) ED has reviewed the use process for Temporary Care Plans and service plan content expectations with the Memory Care Director to assure understanding. Memory Care Director will routinely review resident related documentation to assure TCP/SPs are reflective of resident care needs/staff direction.  Memory Care Director will review/update service plans upon move in, 30 days then 90 days or with a change of condition to assure accuracey.

3) Daily review of resident care documentation & TCP's

SP review initially, 30 days and quarterly or change of condition

4) Memory Care Director

Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 1 of 1 sampled resident (#2) whose MARs and Controlled Substance Disposition logs were reviewed. Findings include, but are not limited to:

Resident 2 was admitted to the facility in September 2017 with diagnoses including dementia.

Observations of the resident, interviews with staff and record review were completed. The resident's signed physician orders dated 11/03/21 included the following orders:

* Oxycodone HCL 100 mg/5 ml (30 ml), give 0.25 ml (5 mg) by mouth twice a day; and

* Oxycodone HCL 100 mg/5 ml (30 ml), give 0.25 ml (5 mg) by mouth every 30 minutes as needed for pain or shortness of breath.

The resident's Controlled Substance Disposition logs and MARS, reviewed from 10/01/21 through 11/15/21 showed the following:

* On 10/15/21 three PRN doses of Oxycodone were recorded on the MAR but only two doses were documented on the disposition log;

* On 10/16/21 three PRN doses of Oxycodone were recorded on the MAR but only two doses were documented on the disposition log;

* On 10/24/21 the disposition log showed a PRN dose of Oxycodone was signed out at 6:30 pm, but the MAR did not reflect the dose as given until 8:22 pm;

* On 10/25/21 the disposition log showed a PRN dose of Oxycodone was signed out at 7:30 pm, but the MAR showed the dose was administered at 5:03 pm; and

* On 11/10/21 two PRN doses of Oxycodone were signed as given on the MAR, but only one dose was documented on the disposition log.

Comparison of the medication bottles to the disposition logs, showed the amount of medication left was reflected accurately on the log.  

The need to ensure narcotic disposition logs accurately reflected the medications administered and the time they were administered was discussed with Staff 1 (MC Administrator), Staff 2 (Regional Director of Operations) and Staff 3 (Chief Operating Officer) The staff acknowledged the findings.

1) Resident #1:  Records were updated to reflect all dosing for noted medication.  A review will be conducted of remaining residents on controlled substances to assure narcotic logs and MARs match for all doses given.

2) Re-education will be provided to all MT's regarding proper process for signing out controlled substances given to residents to assure timely and accurate documentation in both the narcotic log and MAR.

MCD & RN will conduct routine sample audits of controlled substance documentation to assure ongoing compliance.

3) audits will be conducted weekly

4) MCD and RN

Based on interview and record review, it was determined the facility failed to ensure physicians orders were available in the residents' records and were carried out as prescribed for 2 of 2 sampled residents (#s 1 and 2) whose orders were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in July 2021 with diagnoses including dementia.  

The resident's 7/28/21 signed physician orders and 10/01/21 to 11/15/21 MARs showed the following:

* An order for Eliquis (blood thinner) 5 mg tablet, take by mouth twice daily.

The medication was documented on the MARs. There was no indication the medication was being given and no discontinuation order was located in the resident's record.

The need to ensure orders were available in the resident's record for all prescribed medications and were administered as ordered by the prescriber was discussed with Staff 1 (MC Administrator), Staff 2 (Regional Director of Operations) and Staff 3 (Chief Operating Officer) on 11/16/21. The staff acknowledged the findings and indicated the physician would be contacted for clarification.

2. Resident 2 was admitted to the facility in September 2017 with diagnoses including dementia.

The resident's 11/03/21 signed physician orders and 10/01/21 to 11/15/21 MARs showed the following:

* An order for Oxycodone HCL 100 mg/5 ml (30 ml), give 0.25 ml (5 mg) by mouth twice a day. The order indicated it originated on 10/03/21.

The October 2021 MAR showed the medication was given only one time per day, at 1:00 am, until 10/30/21 when the order was changed to reflect an 8:00 am and 8:00 pm administration.

* An order for Tylenol 500 mg by mouth every four hours as needed for pain.

The Tylenol was not reflected on the 11/01/21 to 11/15/21 MAR.

The need to ensure orders were available in the resident's record for all prescribed medications and were administered as ordered by the prescriber was discussed with Staff 1 (MC Administrator), Staff 2 (Regional Director of Operations) and Staff 3 (Chief Operating Officer) on 11/16/21. The staff acknowledged the findings and indicated the physician would be contacted for clarification.

1) Resident #1-DC order for Eliquis was obtained and filed in residents record.  Resient #2:  Clarification on the Tylenol order obtained and records updated as applicable.  A review conducted of remaining residents orders to verify they are correct and being given per MD orders.  

2) Re-education provided to the MT's on the order review process.  MCD and RN have also reviewed the communities 3 check order review process to assure understanding.  

3) MCD/RN will review new/changed orders daily to assure they are accurate in the MAR.  MCD/RN will conduct routine MAR audits weekly to verify orders are being given per MD direction.  

4) MCD & RN   

Based on observation, interview and record review, it was determined the facility failed to ensure a thorough assessment, with all required components was completed by a PT, OT or RN for assistive devices with potentially restraining qualities for 1 of 1 sampled resident (#2) reviewed who had supportive devices. Findings include, but are not limited to:

Resident 2 was admitted to the facility in September 2017 with diagnoses including vascular dementia.

During the acuity interview on 11/15/21, Staff 15 (RN) identified the resident as having side rails on his/her bed.

The resident's most recent service plan dated 10/18/21 contained no information on the use of side rails.

An order from hospice dated 11/9/21 indicated the resident "may have side rails for stimulation enhancement (tactile) and (visual), ½ rails."

A temporary service plan dated 11/13/21 indicated the resident had an injury fall out of bed, and staff requested a hospital bed from hospice. The temporary service plan indicated the resident may have side rails for stimulation enhancement (tactile) and (visual).

An unsigned, supporting device evaluation dated 11/15/21, indicated the reason for use was for stimulation enhancement (tactile and visual). The resident's cognitive awareness of the device and functional ability to use the device stated "stimulation enhancement." Under the section titled Less Restrictive Alternatives Considered, it was documented "Hospice order."

Observations of the resident's room on 11/15/21 and of the resident while in bed on 11/16/21, showed two half side rails were attached to the top of the resident's bed. The side rail located on the right side was loose when pulled on and had a small 1-2 inch gap between the rail and mattress.

Interviews with staff between 11/15/21 and 11/17/21 showed inconsistent knowledge around the use of the side rails and what staff were to watch for. The staff indicated the side rails were new for the resident and were in place for less than a week, but they were unaware of an exact date.

Interviews with Staff 1 (MC Administrator), Staff 2 (Regional Director of Operations) and Staff 3 (Chief Operating Officer) were conducted on 11/16/21. Staff 1 indicated the side rails had been in place for a short time. They were unaware of the reason for use listed by hospice and listed on the evaluation of "stimulation enhancement." Staff 3 indicated they would take a further look at the hospice order and intent of the side rails. Staff 1 indicated the resident would sometimes yank/pull on the rails and shake them which loosened them. Staff 1 stated she would have maintenance take a look at the rails.

The need to complete a thorough assessment of supportive devices with restraining qualities and their appropriateness for use was discussed with Staff 1 (MC Administrator), Staff 2 (Regional Director of Operations) and Staff 3 (Chief Operating Officer) on 11/16/21. The staff acknowledged the findings.

1) Resident #1-resident and support devices have been re-evaluated and documents placed in the residents chart.   Maintenance was called to assure devices were functioning properly.  A review of all remaining residents with suuportive/restraint devices was conducted to assure devices were functional, assessments completed and signed and in residents record.

2) Re-education provided to all MT and CG staff regarding supportive/restraint devices and what to observe/report related to the functionality of the device.  RN has reviewed the community policy and associated rules relate to the content and completion of initial and ongoing evaluations of supportive/restraint devices to assure understanding.   Resident records will be reviewed upon new orders for support/restraint devices and at least quartelry therafter to verify completion of required evaluations.

3) Upon initial use and at least quarterly

4) RN & MCD

Based on interview and record review, it was determined 2 of 3 sampled, newly hired direct care staff (#s 4 and 5) failed to complete First Aid and abdominal thrust training within 30 days of hire. Findings include, but are not limited to:

A review of the facility's training records on 11/16/21 and again on 11/17/21 revealed:

Staff 4 (CG) hired on 09/24/21, and Staff 5 (MT/CG) hired on 09/05/21 did not have documentation of first aid and abdominal thrust training completion within the required 30 days of hire.

On 11/17/21, the need to ensure First Aid and abdominal thrust training was completed within the required timeframe was discussed with Staff 2 (Regional Director of Operations), Staff 8 (ED) and Staff 15 (RN). They acknowledged the findings.

1) Staff 4&5:  First Aid/CPR training conducted late.  A review of remaining applicable employees conducted to verify presence of active first aid/CPR certification.  

2)  ED and MCD have reviewed training requirements to assure understanding.  Employee training files will be routinely audited intiial and ongoing to assure current certificaton is completed timely and ongoing.

3) Employee training will be audited upon completion of the new hire training process and monthly thereafter to maintain ongoing compliance.

4) ED/Assistanct ED

Based on interview and record review, it was determined the facility failed to ensure fire and life safety documentation reflected all required fire drill components. Findings include, but are not limited to:

Fire drill records were reviewed from April 2021 to October 2021.

The following deficiencies were identified:

* There was no documented evidence the facility was conducting fire drills every other month on alternating shifts for the memory care community; and

* The evacuation/drill documentation did not contain information on the escape route used, problems encountered, evacuation time period needed, staff members on duty and participating in the memory care and the number of occupants evacuated.

The requirements regarding fire drills and fire and life safety instruction for staff were reviewed with Staff 1 (MC Administrator), Staff 2 (Regional Director of Operations), Staff 3 (Chief Operating Officer) and Staff 13 (Maintenance) on 11/16/21. The staff acknowledged the findings.

1) Fire Drill schedule has been reviewed to assure it is scheduled every other month and on alternating shifts.   ED and Maintenance Dir have reviewed the requirements for what is required documentation for fire drills.

2) Fire drills will be reviewed for completion routinely to assure shifts are rotated and forms are filled out completely for each drill

3) Monthly

4) ED/Maintenance Dir

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements were being met. Findings include, but are not limited to:

Fire and life safety records, reviewed between April 2021 through October 2021, revealed the facility lacked documented evidence of the following:

* Alternate exit routes were used during fire drills; and

* Staff interviewed were not aware of the designated point of safety.

The need to ensure alternate exit routes were used during fire drills and all staff were aware of the designated point of safety was discussed with Staff 1 (MC Administrator), Staff 2 (Regional Director), Staff 3 (Chief Operating Officer) and Staff 13 (Maintenance) on 11/16/21. The staff acknowledged the findings.

1) Fire Drill form has been reviewed to assure it contains the required elements.  ED and Maintenance Dir have reviewd the community policy and associated rules for Fire Drills and documentation.

2)  Re-education will be provided to all staff to review alternative routes and points of safety.  Fire Drill documentation will be reviewed routinely to assure required elements are addressed/documented.  

3)  Re-education will be provided to staff monthly for 3 months then as per normal routine.  Review of fire drill documentation will be reviewed monthly.

4) ED and Maintenance Dir.

Based on observation and interview, it was determined the facility failed to ensure courtyard surfaces were maintained in good repair. Findings include, but are not limited to:

Observations of the secure outdoor area on 11/15/21, revealed there were multiple drop-offs of 2-4 inches along pathway edges.

The need to ensure pathways were free of safety hazards was discussed with Staff 1 (MC Administrator), Staff 2 (Regional Director of Operations) and Staff 3 (Chief Operating Officer)  on 11/15/21 and 11/16/21. They acknowledged the findings.

1) Bark mulch installed along drop offs 11/20/2021

2) ED and Maintenance Dir have reviewed environmental requirements specific to drop offs along pathway edges to assure understanding.  Routine retirement perfected audits will be conducted to identify and resolve any environmental issues.

3) Daily retirement perfected audits and daily review of outstanding maintenance requests to assure resolution is timely

4) ED and Maintenance Dir.

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

Observations of the facility on 11/15/21 and 11/16/21 showed the following areas in need of cleaning or repair:

* Multiple walls, doors and door frames in the dining room and hallways had, scrapes, splatters/drips and chips;

* Multiple chairs in the dining room and common area had scrapes, chips and dings to the arms and lower legs and one bench seat had a large tear on the seat;

* Window sills in the dining room had large pieces of food debris, dead insects, cobwebs and spills;

* The dining room floor had numerous long black streaks, scratches and gouges ranging from a few inches to a few feet in length;

* The common area bathroom had a brown substance on the toilet bowel, missing sections of the caulking around the base of the toilet and caulking that was in place was dark brown in color;

* Multiple handrails had spills and/or debris inside the ravine between the rail and the wall; and

* Two sections of handrail had a brown substance on the top and inner side of the rail.

The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (MC Administrator) on 11/15/21 and 11/16/21. She acknowledged the findings.

1) The following corrections were made:

-Walls/doors and door frames and hallways have been cleaned and repaired

-Damanged chairs have been removed from the dining room

-Window sills in the dining room were cleaned

-Dining room floor has been cleaned

-Common area bathroom was cleaned

-Handrails have been cleaned

Cleaning schedules have been reviewed to assure all noted areas were on a routine.  Cleaning schedules have been reviewed with housekeeping.

Routine retirement perfected walkthroughs will be conducted to assure cleaning is occurring per the schedule.  Cleaning schedules will be reviewed routinely to assure documentation is present.

Daily walk throughs and weekly review of cleaning schedules

ED  Maintenance Dir

Based on observation and interview, the facility failed to ensure residents who lived in the facility had a key to their units per evaluated need. Findings include, but are not limited to:

Observations of the memory care unit on 11/15/21 showed 16 of the 22 resident rooms did not have locking door knobs on their apartments.

In an interview on 11/15/21 Staff 1 (MC Administrator) indicated the only rooms with locking door knobs were those residents who could manage a key and could unlock the door on their own. Staff 1 indicated in some cases family may request a lock to help keep other residents out of the room. She was unaware all rooms should have the ability to lock.

The need to ensure all resident apartments had locking door knobs, residents were evaluated for their ability to use a key and to ensure a key was provided for those residents who could operate the door lock was discussed with Staff 1, Staff 2 (Regional Director of Operations) and Staff 3 (Chief Operating Officer) on 11/16/21. They acknowledged the findings.

1) Door knobs have been replaced for all apt doors in the Memory Care unit.  Service plans have been reviewed to assure clarity for those who can utilize their keys to lock their doors.  

2)  MCD and ED have reviewed rules to assure understanding. Doors and locking knobs will be audited routinely to assure they are present and fucntional.  Residents will be routinely evaluated for ability to use their apt door keys and service plans reviewed for accuracy.  

3) Audit of door locks will be done weekly.  Resident evaluations will be done quarterly or with a change of condition.  

4) MCD/ED

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 C231, C240, C372, C420, C422, C510, C513 and H1518.

Refer to individual citations for C231, 240, 372, 420, 422, 510, 513 & H1518

Based on interview and record review, it was determined the facility failed to ensure 1 of 3 sampled newly hired staff (#5) completed all required pre-service and competency training prior to providing care and services independently and 1 of 1 sampled direct care staff (#7) completed a total of 16 hours of in-service training annually, including 10 hours related to provisions of care in CBC. Findings include, but are not limited to:

Review of the facility's training records on 11/16/21 and 11/17/21 revealed:

a. Staff 5 (MT/CG) hired on 09/05/21, lacked documented evidence training and demonstrated competency had been completed for all required components within the first 30 days of hire or before independently providing care and services, for topics including:

*  Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms;

* Techniques for understanding, communicating, and responding to distressful behavioral symptoms; including but not limited to, reducing the use of antipsychotic medications for non-standard uses when responding to distressful behavioral symptoms;

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

* Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: identify and address pain; provide food and fluid; prevent wandering and elopement; and use a person-centered approach;

* Environmental factors that are important to residents well-being (e.g., noise, staff interactions, lighting, room temperature, etc.);

* Family support and the role the family may have in the care of the resident;

* How to recognize behaviors that indicate a change in the resident's condition and report behaviors that require on-going assessment;

* How to provide personal care to a resident with dementia, including an orientation to the resident and the resident's service plan; and

* The use of supportive devices with restraining qualities in memory care communities.

b. Staff 7 (MT) was hired on 2/13/19. Review of the facility training records revealed Staff 7 did not complete the 10 hours of annual training related to provision of care in CBC.

The need to ensure newly hired staff completed all required pre-service and competency training prior to providing care and services independently and veteran staff completed a total of 16 hours of in-service training annually, including 10 hours related to provision of care in CBC was discussed with Staff 2 (Regional Director of Operations), Staff 8 (ED) and Staff 15 (RN) on 11/17/21. They acknowledged the findings.

1) Staff #5:  Missing training has been provided and documentation placed in employee training records.  Staff #7:  Missing annual training has been completed.  An audit of all remaining staff was conducted to verify compliace with intial and annual training requirements.

2)  Employee training files will be routinely audited upon completion of the new hire training process and ongoing to assure ongoing compliance.

3) Employee training records will be audited upon completion of the new hire training process and at least monthly thereafter

4) ED & Designee and MCD

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 C242, C260, C302, C303 and C340.

Refer to individual citations for C242, 260, 302, 303 & 340