The findings of the re-licensure survey, conducted 12/12/22 through 12/16/22, 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.

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 12/16/22, conducted 06/20/23 through 06/21/23, are documented in this report. The survey was conducted to determine 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 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 second revisit to the re-licensure survey of 12/16/22, conducted 08/23/23, 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, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Based on interview and record review, it was determined the facility failed to ensure incidents of abuse, suspected abuse, and injuries of unknown cause were promptly investigated, reported to the local Senior Services and Disability (SPD) if abuse was not reasonable ruled out, and necessary measures taken to protect residents and prevent the reoccurrence of abuse for 1 of 2 sampled resident (#6). Findings include, but are not limited to:

Resident 6 was admitted to the facility in 10/2022 with diagnoses including Lewy Body Dementia.

Review of the resident's current service plan, 10/18/22 through 12/14/22, temporary service plans, progress notes, hospice visit summaries, and faxes to hospice/physician revealed the following:

* On 10/28/22, a progress note and temporary service plan noted the resident had sustained a wound on his/her left leg. There was no documented evidence the facility had investigated the injury of unknown cause to rule out abuse or report to the local SPD.

* On 11/11/22, the facility RN faxed hospice noting the resident "is getting into other people's beds several times a day, disrobing frequently." There was no documented investigation related to the incidents to rule out abuse, nor were they reported to the local SPD.

* On 12/01/22, a fax to hospice titled "Physician Fall Notification" indicated Resident 6 was found in an unidentified resident's bathroom, "standing over other resident holding their hands appearing to try and help them up. Unsure if resident fell or was just helping." There was no documented investigation related to the incident to rule out abuse, nor was the incident reported to the local SPD.

* On 12/04/22, a resident to resident altercation was documented, investigated and reported to the local SPD. In a fax sent to hospice to inform them of the altercation, the facility stated, "This is a regular occurrence for this resident to pull sleeping people from their beds." There was no documentation of the other occurrences in the resident's clinical record.

* In a progress note dated 12/10/22, staff wrote Resident 6 went into another resident's room, and "then undressed and got into the bed with [the other resident]." There was no documented evidence the facility investigated the incident or reported the incident to the local SPD.

The need to ensure incidents of abuse, suspected abuse, and injuries of unknown cause were promptly investigated, reported to the local SPD if abuse was not reasonable ruled out, and necessary measures taken to protect residents and prevent the reoccurrence of abuse was discussed with Staff 1 (Operations Support Specialist) and Staff 2 (RN) on 12/16/22. They acknowledged the findings.

The facility was instructed to report the above incidents and references to incidents to the local SPD. Fax confirmations of the reports were provided to the survey team prior to exit.

Hopice was contacted and resident move to a hospice house in Eugene on 12/17/2022. She died there on 12/27/2022

Administrator/RCM will review all new incident reports and progress notes at daily clinical meeting to investigate and report incidents per the Oregon Abuse and investigation Guide

Daily or within 48 hours on the weekend

Administrator and RCM if Administrator is absent for meetings

Based on interview and record review, it was determined the facility failed to ensure initial move-in evaluations addressed and contained all the required elements for 2 of 2 sampled residents (#s 2 and 6) whose move-in evaluations were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to facility in 10/2022.  

Resident 2's new move-in evaluation, dated 10/25/22 did not address or was missing the required elements:

* Mental Health issues;

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

* History of dehydration; and

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

2. Resident 6 was admitted to the facility in 10/2022.

Resident 6's new move-in evaluation, dated 10/17/22 did not address or was missing the required elements:

* Visits to health practitioner (s), ER, hospital or nursing facility;

* Mental Health issues;

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

* Ability to be understood;

* History of dehydration;

* Recent losses;

* Alcohol and drug use; and

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

On 12/16/22, the need to ensure residents' initial move-in evaluations addressed and contained all the required elements was reviewed and discussed with Staff 1 (Operations Support Specialist) and Staff 2 (RN).

Resident 2 will be reassessed for missing elements and if service is needed it will be added to the service plan.

Evaluation was found to to include two of the cited elements but the other two elements were added to the evaluation. All residents will be evaluated on their upcoming scheduled review with new evaluation tool.

With each new service plan creation and or their scheduled review using updated Service Planning Tool

Administrator and RCM

Based on interview and record review, it was determined the facility failed to ensure all required elements were addressed for 2 of 2 sampled residents (#s 7 and 8) whose move-in evaluations were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 7 was admitted to facility in 05/2023 with diagnoses including dementia and insomnia.  

Resident 7's new move-in evaluation, dated 05/03/23 did not address the following required elements:

* Interests, hobbies, social, leisure activities;

* Spiritual and cultural preferences and traditions;

* Cognition, including orientation and decision making;

* Skin condition;

* List of treatments: type, frequency and level of assistance needed;

* Fall risk or history;

* Complex medication regimen;

* History of dehydration;

* Elopement risk or history; and

* Alcohol and drug use.

The facility's failure to ensure all required elements were addressed on new move-in evaluations was reviewed with Staff 1 (Corporate Administrator), Staff 14 (Executive Director) and Staff 15 (RCC/LPN) on 06/21/23. They acknowledged the findings.

2. Resident 8 was admitted to facility in 05/2023.  

Resident 8's move-in evaluation, dated 05/19/23 did not address or was missing the following required elements:

* Interests, hobbies, social, leisure activities;

* Spiritual, cultural preferences and traditions;

* Visits to health practitioner(s), ER, hospital or NF in the past year;

* Effective non-drug interventions for behaviors;

* Confusion and decision making abilities;

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

* History of dehydration or unexplained weight loss or gain;

* Recent losses; and

* Alcohol and drug use.

On 06/21/23 the need to ensure initial move-in evaluations addressed all required elements was discussed with Staff 1 (Corporate Administrator), Staff 14 (Executive Director), and Staff 15 (RCC/LPN). They acknowledged the findings.

Res #7 is deceased.  Res #8 evaluation dated 5/19/23 has been updated to include elements not addressed.

All evaluations will be checked by the Administrator to ensure they are complete.

Each new move-in will be reviewed to assure all area's of evaluations are addressed.

Administrator will review all new assessments for completion.

3. Resident 6 was admitted to the facility in 10/2022 with diagnoses of Lewy Body Dementia.

Review of the Resident's current service plan, 10/18/22 through 12/14/22 progress notes, interviews with staff and observations of the resident revealed the resident's service plan was not reflective or was not followed in the following areas:

a. Communication: The service plan indicated Resident 6 was "Able to verbalize [his/her] needs and wants."

In a progress note dated 11/01/22, the RN stated the resident "answered 'yes' and 'no' questions at times".

In an interview on 12/16/22, Staff 6 (CG) indicated the resident was only intermittently able to answer yes or no questions.
 

b. Vision: The service plan instructed staff to assist the resident with putting on and taking off his/her glasses in the morning and at bed time and indicated Resident 6 had "severely impaired corrective lens [sic]."

During an interview on 12/16/22, Staff 6 (CG) reported she had never seen the resident's glasses.

The resident was observed to bump into a hand sanitizer dispenser while walking in the hallway on 12/14/22. S/he was not wearing glasses.

The need to ensure the service plan was reflective of the resident's current status, care needs, and was followed was discussed with Staff 1 (Operations Support Specialist) and Staff 2 (RN) on 12/16/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current status and care needs and provided clear direction to staff for 3 of 5 sampled residents (#s 1, 3 and 6) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the memory care community in 03/2021 with diagnoses including Alzheimer's disease.

Resident 1 was identified during the acuity interview on 12/12/22 as being resistive to care and to have behaviors including resident-to-resident altercations.

A review of the resident's clinical record, including progress notes, temporary service plans (TSPs) from 09/02/22 through 11/20/22, staff interviews and observations identified:

Resident 1 experienced four resident-to-resident altercations, had increased aggression and agitation towards staff and other residents between 09/12/22 and 11/20/22. The resident's current 11/21/22 service plan was not reflective of the resident-to-resident altercations or interventions and did not provide clear instructions to staff on interventions to help reduce negative behaviors for the resident.   

The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (Operations Support Specialist) and Staff 2 (RN) on 12/16/22. They acknowledged the findings.

2. Resident 3 was admitted to the memory care community in 09/2021 with diagnoses including dementia.

A review of the resident's clinical record, including progress notes, temporary service plans (TSPs) from 08/29/22 through 11/20/22, staff interviews and observations identified:

Resident 3 experienced three falls between 08/29/22 through 11/29/22. The resident's 12/09/22 service plan was not reflective of the resident's recent falls or risk, and did not provide clear instructions to staff on interventions to help reduce the risk of falls for the resident.

The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (Operations Support Specialist) and Staff 2 (RN) on 12/16/22. They acknowledged the findings.

Resident 1 will have the service plan for Behavior Management corrected and interventions added. Resident 3 will have fall risk service updated to reflect interventions that are working for fall reduction from TSP

TSP's were reviewed and section added prompting evaluation of current interventions and calling out clear next intervention/s. This was added to any TSP's that would benefit fromthis such as the one for Behavioral monitoring.

This will be evaluated at the DC of any TSP during the clinical meeting

Administrator and RCM

2. Resident 8 was admitted to the facility in 05/2023 with diagnoses including vascular dementia, Diabetes (type 2) and depression.

Review of Resident 8's service plan dated  05/23/23, progress notes dated 05/19/23 through 06/19/23, temporary service plans, incident reports and interviews with staff determined the service plan was not reflective, or did not provide clear instructions to staff in the following areas:

* Nutrition and hydration;

* Resistance to care;

* Combative/aggressive behaviors; and

* Inappropriate sexual behaviors

In an interview on 06/20/23, Staff 22 (Caregiver) stated Resident 8 had been the aggressor in resident to resident altercations, exhibited sexually inappropriate behavior with another resident, and was frequently resistant to care.

On 06/21/23 the need to ensure service plans were reflective of residents' current status and provided clear instructions to staff was discussed with Staff 1 (Corporate Administrator), Staff 14 (Executive Director), and Staff 15 (RCC/LPN). They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current status and care needs, and provided clear instruction to staff for 2 of 2 sampled memory care community residents (#s 7 and 8). This is a repeat citation. Findings include, but are not limited to:

1. Resident 7 was admitted to facility in 05/2023 with diagnoses including dementia and insomnia.

Observations of the resident, interviews with multiple caregivers, and review of the resident's clinical record including current service plan, progress notes, behavior monitoring records, and temporary service plans from 05/03/23 through 06/20/23 revealed the service plan was not reflective of the resident's current status, care needs and/or did not provide clear instruction to staff in the following areas:

a. Behaviors:

* Hitting his/her head on the wall;

* Disrobing in public;

* Sexual inappropriateness with male CG staff;

* Use of profanity;

* Verbalizations of staff wanting to cause him/her harm;

* Wandering; and

* Medication refusals.

b. Nutrition:

* Meal refusal;

* Frequent snacking throughout the day;

* Preferred snacks including granola bars; and

* Adaptive equipment used during meals including a no-spill cup with a straw.

c. Pain:

* Ability to verbalize pain;

* Location of pain including knee, leg, back and headache; and

* Non-drug interventions.

d. Grooming

e. Oral care

f. Dressing

The facility's failure to ensure resident service plans were reflective of current care needs and provided clear instruction to staff was discussed with Staff 1 (Corporate Administrator), Staff 14 (Executive Director) and Staff 15 (RCC/LPN) on 06/21/23. They acknowledged the findings.

Res #7 deceased. Res #8 had service plan updated with missing services.

We have immplemented a service planning tool form that will be completed by the RCM and/or Nurse who develops the service plan. They will check off that each of the required services are captured on the service plan and turn in the completed form to the Administrator demonstrating compliance. This will be done for all new service plan as well as required intervals.

Administrator will ensure that the service planning tool was used and all elements were checked off.

3. Resident 6 was admitted to the facility in 10/2022 with diagnoses including Lewy Body dementia.

Review of the resident's current service plan, 10/18/22 through 12/14/22 temporary service plans, and progress notes revealed the facility failed to ensure short-term changes of condition related to wounds on the resident's left leg and left great toe were monitored to resolution.

The need to monitor short-term changes of condition through resolution was discussed with Staff 1 (Operations Support Specialist) and Staff 2 (RN) on 12/16/22. 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 reviewed for effectiveness and the condition was monitored to resolution at least weekly for 3 of 5 sampled residents (#s 1, 3 and 6) who experienced changes of condition. Findings include, but are not limited to:

1. Resident 1 was admitted to the memory care community in 03/2021 with diagnoses including Alzheimer's disease.

A review of the resident's clinical record, including progress notes, temporary service plans (TSPs), incident reports from 08/02/22 through 11/17/22, and staff interviews identified the resident was involved in the following resident-to-resident altercations.

* On 10/20/22, Resident 1 was in a physical altercation with another resident in the dining room. A TSP written the same day instructed staff to chart on resident's aggression towards other residents and report to MT;

* On 11/06/22, Resident 1 swung his/her back scratcher at another resident in the hallway three times. A TSP written the same day instructed staff to "follow behavioral interventions on behavior monitor if there is one," "provide for behavioral interventions prior to giving prn psychoactive medication," "provide extra fluids and encourage resident to drink," "please call/report to nurse immediately if increasing behaviors not managed by interventions"; and

* On 11/17/22, Resident 1 was heard shouting "get out of my room"; when staff arrived at the resident's bedroom, there was another resident in the room with a red mark on his/her arm. Resident 1 stated s/he had grabbed at the other resident's arm to get him/her out. A TSP written the same day instructed staff to "report behaviors to med tech and please keep other residents from the resident's apartment if possible."

There was no documented evidence the facility consistently reviewed or monitored interventions following each resident-to-resident altercation to determine if they were being provided and were effective or whether additional interventions were needed.

The need to monitor the effectiveness of interventions for changes of condition was discussed with Staff 1 (Operations Support Specialist) and Staff 2 (RN) on 12/16/22. They acknowledged the findings.

2. Resident 3 was admitted to the memory care community in 09/2021 with diagnoses including dementia.

A review of the resident's clinical record, including progress notes, temporary service plans (TSPs), incident reports dated 08/29/22 through 11/29/22, and staff interviews indicated the resident had experienced three non-injury and injury falls from 08/29/22 through 11/29/22.   

* On 08/29/22, Resident 3 was found on the floor in the living room. Bruising and swelling was noted on the resident's index finger. The facility incident report instructed staff to ensure the resident's wheelchair was within arm's reach;

* On 11/11/22, Resident 3 was found on the floor sitting on top of his/her comforter next to his/her bed. The facility incident report documented the hospice RN would be getting the resident a hospital bed which could adjust to a better and safer height for the resident to transfer safely. A TSP written on 11/12/22 documented the resident had sustained a bruise to the left hip from the fall on 11/11/22 and instructed staff to chart "pain, any other injuries identified, overall resident ability to transfer, walk, use devices if using, resident mental status, and vital signs daily"; and

* On 11/29/22, Resident 3 was found on the floor in his/her bedroom. The facility incident report instructed staff to ensure the resident's bed was at the lowest position and sheets were not a tripping hazard.

There was no documented evidence the facility had monitored previous fall interventions for effectiveness, had thoroughly investigated if previous fall interventions were being implemented and followed after each new fall, or whether new or additional fall interventions needed to be developed.

The need to ensure resident fall interventions and monitoring the effectiveness of previous interventions for each subsequent fall a resident might have was discussed with Staff 1 (Operations Support Specialist) and Staff 2 (RN) on 12/16/22. They acknowledged the findings.

Resident 6 was moved out of the facility and did not return. Resident 1 has new interventions added to service plan. Resident 3 service plan will be updated to include fall interventions that are being tried or in place and are working.

The TSP for Falls and Behaviors has been ammended to include prompt to identify what interventions are in place and an evaluation as to if they are working. it also includes a prompt to include new intervention/s that are added with subsquent falls/behaviors. A prompt was addd to add interventions to service plan if no longer temporary

With any occurance of change of condition and TSP implementation

Administrator or RCM

Based on interview and record review, it was determined 3 of 3 sampled, newly hired direct care staff (#s 6, 9 and 11) 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 12/12/22 through 12/16/22 identified:

Staff 6 (CG), Staff 9 (CG) and Staff 11 (CG), hired 11/02/22, 10/19/22, and 09/14/22, respectively, did not have documentation of First aid and abdominal thrust training completion within the required 30 days of hire.

The need to ensure First Aid and abdominal thrust training was completed within 30 days of hire was discussed with Staff 1 (Operations Support Specialist) and Staff 2 (RN) on 12/16/22. They acknowledged the findings.

All staff charts will be audited to determine if any others are missing abdominal thrust and/or first aide training. The employees will be assigned the training video that have been added to the 30 day training. RN will verify with return demonstration for all employees and document it.

Administrator and BOM will audit new hire charts for compliance at the end of each month

Monthly

BOM and Administrator

Based on interview and record review, it was determined the facility failed to provide fire and life safety instruction to staff on alternating months from fire drills and did not address all of the required elements on the fire drill records. Findings include, but are not limited to:

Fire and Life Safety records for the previous six months were reviewed on 12/12/22, and identified the following:

a. There was no documented evidence fire and life safety instruction was provided to staff on alternate months from fire drills.

b. Fire drill records did not address the following required elements:

* The escape route used;

* Problems encountered and comments relating to residents who resisted or failed to participate in the drills;

* Evacuation time period needed;

* Staff members on duty and participating; and

* Number of occupants evacuated.

In an interview on 12/12/22, Staff 5 (Maintenance Director) indicated the facility had not evacuated residents during fire drills.

The requirements regarding fire and life safety instruction for staff and fire drill record components were reviewed with Staff 1 (Operations Support Specialist) and Staff 5 on 12/13/22. They acknowledged the findings.

A Task was created in TELS to require completion of the training on alternate months and upload the documentation on the TELS system

The administrator will check monthly that the fire drills and fire and life safety tasks have been completed per TELS

Monthly by the Administrator

Administrator and Maintenance person

Based on interview and record review, it was determined the facility failed to ensure residents who can follow instructions received instruction at admission and re-instruction in fire and life safety training, at least annually after admission. Findings include, but are not limited to:

Fire and life safety records were requested during the survey. The following deficiencies were identified:

There was no documentation that residents who were able to follow instructions were provided with fire and life safety training at admission, or fire and life safety training at least annually following admission.

The need to ensure residents who could understand instructions receive fire and life safety instructions at admission, and annual re-instruction was discussed with Staff 1 (Operations Support Specialist) and Staff 5 (Maintenance Director) on 12/12/22. They acknowledged the findings.

All RCF and MC residents will be given a safety orientation the next resident meeting for RCF and one on one for memory care residents. Ability or inability to evacuate without assistance be added to the service plan. It will describe the assistance needed to evacuate if resident is unable to retain information on evacuation.

New resident check list was updated to prompt the administrator to assure the new residents fire and life safety orientation will be completed timely.

Monthly by administrator

Administrator and Maintenance person

Based on observation, interview and record review, it was determined the facility failed to ensure its relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:

Refer to C 252, C 260, and Z 162.

We submitted this Plan of Correction in accordance with OAR 411-054-0105.

Administrator

Based on observation and interview, it was determined the facility failed to maintain all exterior pathways to the common-use areas in good repair. Findings include, but are not limited to:

The exterior walkways of the building was toured on 12/12/22. There were multiple areas of deterioration of the concrete up to two inches deep and four inches wide between concrete sections along the exterior walkways. Those areas represented tripping/fall risks for residents.

The walkways were reviewed  with Staff 1 (Operations Support Specialist) and Staff 5 (Maintenance Director) on 12/12/22. They acknowledged the findings.

Replacement of the cement sidewalk will be scheduled and completed as soon as weahter allows.

Bid was obtained and accepted and the work will be completed when the weather allows the pouring of concrete

The administrator will monitor this monthly until complete

Adminstrator and Maintenance person

Based on observation and interview, it was determined the facility failed to ensure all exit doors were equipped with an alarming device or other acceptable system to provide security and to alert staff when residents exited the building. Findings include, but are not limited to:

Observations during the survey revealed the facility's main entrance door and the exit door near the kitchen did not have an operational alarm or other acceptable system to alert staff when residents exited.

The need to ensure exit doors were equipped with an alarming device or other acceptable system was discussed with Staff 1 (Operations Support Specialist) and Staff 5 (Maintenance Director) on 12/13/22. They acknowledged the findings.

The alarms were ordered for the door while survey was still in the building

The alarms arrived on 12/26/2022 at the community and were installed and tested on the IAlert system on 12/29/2022

This will be evaluated yearly to assure they are in operation

Administrator and Maintenance

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, C372, C420, C422, C510 and C555.

Tag Z 142 references tag C231,C372, C420, C422, C510, and C555. The actions taken to address each of those tags, as set out in the POC, will be taken to address the concerns se out in Tag Z142

The action taken to address Tags C231, C372, C420, C422,C510 and C555 as set out in this POC, will be taken to address the concerns set out in Tag Z142

The same schedule as set out in POC re. Tags C231, C372, C420, C422, C510 and C555

The same person identified in POC Tags C231, C372, C420, C422, C510 and C555

Based on interview and record review, it was determined the facility failed to ensure 1 of 3 sampled newly-hired direct care staff (#9) completed competency training within 30 days of hire. Findings include, but are not limited to:

A review of the facility's training records on 12/12/22 through 12/16/22 identified:

There was no documented evidence that Staff 9 hired 10/19/22 demonstrated competency in job duties within 30 days of hire in the following areas:

* The role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Changes associated with normal aging;

* Identification, documentation and reporting of changes of condition; and

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

The need to ensure all required training was completed within the specified time frame was discussed with Staff 1 (Operations Support Specialist) and Staff 2 (RN) on 12/16/22. They acknowledged the findings.

The employee that was missing the training will be assigned the correct training and will complete within 30 days.

BOM will do a monthly audit of the employee files for new employees to assure compliance. Any staff not completing training will be removed from regular schedule the day normally scheduled will be to complete training on site.

Monthly by BOM and administrator

BOM and admininstrator

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 and C270.

Tag Z162 references Tags C252, C260 and C270.

The actions taken to address each of these tags, as set out in this POC, will be taken to address the concerns set in Tag Z162

The actions taken to address tags C252, C260, and C270 as set out in this POC, will be taken to adress the concerns set out in Tag Z162

The same schedule set out in this POC re. Tags C252,C260, and C270

The same persons identified in this POC re. C252, C260 and C270

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. This is a repeat citation. Findings include, but are not limited to:

Refer to C 252 and C 260.

This is a referral tag

Based on interview and record review, it was determined the facility failed to evaluate residents for activities, to develop individualized activity plans from the evaluation, and ensure a selection of daily structured and non-structured activities were provided and included on the resident's activity service or care plan as appropriate based on residents' evaluations for 2 of 2 sampled residents (#s 7 and 8) whose service plans were reviewed. Findings include, but are not limited to:

A review of service plans for Residents 7 and 8, and an interview with Staff 15 (RCC/LPN) and Staff 7 (MT) on 06/21/23 revealed the following:

1. The facility had not completed activity evaluations which addressed the following:

* Past and current interests;

* Current abilities and skills;

* Emotional and social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for the resident to participate; and

* Identification of activities for behavioral interventions.

2. There was no documented evidence an individualized activity plan had been developed for Residents 7 and 8 based on their activity evaluation that was reflective of the resident's activity preferences and needs.

3. There was no documented evidence a selection of daily structured and non-structured activities were provided and included on the resident's activity service or care plan as appropriate and based on the resident's evaluation.

The need to ensure the facility completed an activity evaluation addressing the required elements, developed an individualized activity plan based on the evaluation for each resident, and provided daily structured and non-structured activities based on the evaluation was discussed with Staff 1 (Corporate Administrator), Staff 14 (Executive Director), and Staff 15 on 06/21/23. They acknowledged the findings.

Res #7 is deceased. Res #8 had service plan updated with missing services.

We have immplemented a Life History/Activity Assessment form as well as the Engagement Participation List that will be completed by the Life Enrichment Director who develops this portion of resident service plan. LED will use these forms to ensure that emotional, social needs, and physical abilities/limitations are addressed as well as individualized activity plan are developed.This will be done for all new service plan as well as required intervals.

Administrator will ensure the Life History/Activity Assessment form was used and all required elements were addressed.