The findings of the re-licensure survey, conducted 10/04/21 through 10/06/21, 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, 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

Based on observation and interview, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents. Findings include, but are not limited to:

Observations were made during the survey to determine adherence to precautions for infection control.

1. On 10/5/21 at 3:10 pm, the surveyor observed Staff 6 (Care Partner) carry soiled linens out of a resident's room in her arms without a bag. During an interview with Staff 6, she stated the linens were soiled with urine. Staff 6 stated she was not trained regarding handling of soiled linens.

2. During the survey, conducted 10/4/21 through 10/6/21, Oregon Department of Human Services infection control guidelines, which were established to protect the facility staff and residents from the spread of COVID-19 and made available to all facilities, were not being followed by the facility including, but not limited to:

*Multiple staff were observed to wear face masks below their noses and/or wearing cloth masks in resident care areas.

During an interview with Staff 1 (Administrator) and Staff 2 (Admin Support) on 10/06/21, they acknowledged the incorrect use of personal protective equipment.

The need to ensure the facility implemented effective methods of infection control was discussed with Staff 1 and Staff 2 on 10/06/21. They acknowledged the findings.

1. The actions that will be taken to correct the rule violations include:

  a) The community will provide appropriate training to all staff which will focus on infection control education for all team members.

  b) The community will provide appropriate COVID 19 training on the proper way to wear PPE and provide infection control in order to limit the spread of COVID 19.

2. The system will be corrected to avoid future violations by:

  a) Moving forward, mandatory training will be provided for all new hired team members that will focus on infection control.  This training will be documented and placed in the team members personnel file.

   b) Moving forward, COVID 19 training on how to properly wear PPE and provide infection control in order to limit the spread of COVID 19 will be provided for all new hired team members.  This training will be documented and placed in the team members personnel file.

  c) Quarterly training will be conducted with all team members on infection control, which includes COVID 19 protocol, to ensure the community is exercising reasonable precautions against any condition that could threaten the health, safety, or welfare of the residents.

3. The area needing correction will be evaluated on a daily basis.

4. The Administrator and Licensed Nurse will be responsible for monitoring this.

Based on interview and record review, it was determined the facility failed to conduct an immediate investigation of an injury of unknown cause to rule-out abuse and neglect or report the injury as suspected abuse or neglect to the local Seniors and People with Disabilities (SPD) office, for 1 of 1 sampled resident (# 2). Findings include, but are not limited to:

Resident 2 was admitted to the facility with diagnoses including dementia and had multiple falls.

During an interview with Staff 4 (RN) s/he stated Resident 2 was dependent on staff for all ADL care.

Review of Resident 2's progress notes dated 07/12/21 through 10/04/21 revealed s/he had six unwitnessed falls from 08/20/21 through 10/01/21, two resulting in skin tears.  There was no documented evidence the two injuries of unknown cause had been investigated to reasonably rule out abuse nor had the injuries been reported to the local SPD.

During an interview with Staff 3 (Interim Administrator) on 10/05/21, she stated  she had not conducted an investigation on the two injuries of unknown cause.

The surveyor asked Staff 3 to report the incidents to the local SPD office. Confirmation of the self report to the local SPD office was received on 10/06/21.

The need to ensure resident incidents were investigated immediately to rule out abuse or reported to the local SPD office when abuse could not be ruled out was discussed with Staff 1 (Administrator) and Staff 2 (Admin Support) on 10/06/21. They acknowledged the findings.

1. The actions taken to correct the rule violations include: The six unwitnessed falls that occurred, including the two that resulted in resident injury, were reported to the local SPD office.

2. The system will be corrected so that the violation will not occur again by:

  a) When a resident incident occurs, an incident report will be created by the Med Tech, RCC, Licensed Nurse, or Administrator.  This incident report will include as much information that can be gathered including witness statements.

  b) Administrator or Licensed Nurse will immediately investigate to rule out abuse.  If the investigation cannot rule out abuse, the incident will be self-reported to the local SPD office.

3.  The area needing correction will be evaluated daily.

4.  The Administrator and Licensed Nurse will be responsible for monitoring this.

2. Resident 4 was identified as a smoker during the acuity interview on 10/04/21.

Interviews with caregivers on 10/05/21 confirmed Resident 4 smoked once or twice a day, supervised by a caregiver.

Although smoking was documented on the service plan, there was no documented evidence a smoking safety evaluation had been completed since the initial move in on 11/20/20.

The facility's failure to complete a quarterly smoking evaluation was discussed with Staff 1 (Administrator) on 10/06/21. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure a new move in evaluation contained all required elements for 1 of 1 newly admitted resident (# 2) and failed to ensure a quarterly evaluation was updated 1 of 1 sampled resident (# 4) whose evaluations were reviewed.  Findings include, but are not limited to:

1.  Review of Resident 2's new move-in evaluation, dated 07/12/21, lacked the following elements:

* History of mental health treatment;

* Effective non-drug interventions;

* Spiritual, cultural and preferences and traditions;

* Decision making abilities;

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

* Non-pharmaceutical interventions, including how the person expresses pain or discomfort;

* Nutrition habits;

* Emergency evacuation ability;

* Elopement risk or history;

*Smoking and ability to smoke safely;

* Alcohol and drug use; and

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

The need to ensure all required elements were included in the new move-in evaluation was discussed with Staff 1 (Administrator) and Staff 2 (Admin Support) on 10/06/21. They acknowledged the findings.

1. The actions taken to correct the rule violation include: Service plans for residents 2 and 4 were updated to reflect the resident's current physical and mental statuses, and to provide clear direction for team members to follow.

2. The system will be corrected so that the violation will not occur again by:

 a) Licensed Nurse will review all current resident files to ensure evaluations are descriptive of the residents current physical and mental status.  During this record review, the Licensed Nurse will also ensure the evaluations provide a clear description and direction of the resident care needs for the team members.

 b) Current resident records will be reviewed by a Licensed Nurse to ensure all sub assessments are up to date and reflects the current resident needs and reflected in the updated evaluation.

 c) Licensed Nurse will review all current resident records to ensure that all change of conditions are reflected in an updated evaluation.

 d) Moving forward, resident evaluations will be performed at the time of move in, 30 days after move in, with change of condition, and quarterly that accurately reflects the residents current physical and mental health status.

 e) Licensed Nurse will complete a sub-assessment at the time of move in, 30 days after move in, at change of condition, and quarterly evaluation.  The sub-assessments will reflect the residents current physcial and mental status.  This will then be updated in the evaluation and the service plan.

 f) To ensure team is aware of all evaluations and change of conditions, a clinical meeting will be held daily to discuss any evaluations due, changes of conditions, and new move in evaluations

3.  The area needing correction will be evaluated  by the Licensed Nurse daily by auditing all current resident evaluations and ensuring they reflect the current physical and mental needs of the resident.  They will also ensure all change of conditions and sub-assessments are complete and reflective in the evaluation and service plan. Moving forward, the Licensed Nurse will ensure that this occurs with all current and new residents.  2nd checks will be done by the Administrator and/or 2nd Licensed Nurse to ensure these are done correctly and reflect the residents current needs.  A clinical meeting will occur daily to ensure these tasks are completed in a timely manner.  

4. The Administrator and Licensed Nurse will be responsible for monitoring this.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs, included all required areas, and provided clear direction to staff regarding the delivery of services for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in September 2020 with diagnoses including dementia, and required colostomy and nephrostomy drainage bags.

During the acuity interview, Resident 1 was identified to require two people for transfer using a mechanical Hoyer lift.

Review of Resident 1's current service plan, dated 7/4/21, revealed the service plan did not include use of the Hoyer lift.

Interviews with caregivers and Staff 4 (RN) confirmed Resident 1 did require a Hoyer lift, however, they could not recall when Resident 1 started using the Hoyer lift for transfers.

The need to ensure the service plan was reflective of resident's current status and provided clear instructions to staff was discussed with Staff 1 (Administrator) and Staff 2 (Admin Support) on 10/05/21. They acknowledged the findings.  

2.  Resident 4 was admitted to the facility in 6/2020 with diagnoses including dementia.

Review of Resident 4's most current service plan and evaluation, dated 9/13/21, did not include environmental factors that impact the resident's behavior including noise, lighting and room temperature and personality and how the resident copes with change or challenging situations.

The need to ensure the service plan was reflective of resident's current status and provided clear instructions to staff was discussed with Staff 1 (Administrator) and Staff 2 (Admin Support) on 10/06/21. They acknowledged the findings.

3. Resident 2 was admitted to the facility in July 2021 with diagnoses including Dementia.

During the acuity interview on 10/06/21, Resident 2 was identified to have edema and was at risk for falls.

Observations, interviews, and review of the current service plan dated 07/12/21, revealed the service plan was not reflective of the resident's current status or provided clear instructions to staff, in the following areas:

* Use of pressure pad alarm in his/her bed;

* Use of pull tab alarm while s/he was in recliner; and

* Use of fall mat on the floor while resident was in bed.

4. Resident 3 was admitted to the facility in December of 2018 with a diagnoses including Dementia.

Review of Resident 3's most current service plan and evaluation, dated 07/21/21,  did not include environmental factors that impact the resident's behavior including noise, lighting and room temperature and personality and how the resident copes with change or challenging situations.

The need to ensure the service plan was reflective of the resident's current status and provided clear instructions to staff was discussed with Staff 1 (Administrator) and Staff 2 (Admin Support) on 10/06/21. They acknowledged the findings.

1.  The actions taken to correct the rule violation inlcude: Service plans for residents 1, 2, 3, and 4 were updated to reflect their current status, provide clear instruction to team members, including interventions, and all significant changes of conditions.

2.  The system will be corrected so that the violation will not occur again by:

 a) Licensed Nurse will review all current resident files to ensure service plans are descriptive of the residents current physical and mental status.  During this record review, the Licensed Nurse will also ensure the service plans provide a clear description and direction of the resident care needs for the team members.

 b) All current resident records will be reviewed by a Licensed Nurse to ensure all sub-assessments are up to date and reflects the current resident needs and are reflected in the updated service plan.

 c) Licensed Nurse will review all current resident records to ensure that all change of conditions are reflected in an updated service plan.

 d) Moving forward, resident service plans will be completed at the time of move in, 30 days after move in, with change of condition, and quarterly that accurately reflects the residents current physical and mental health status.

 e) Licensed Nurse will complete a sub-assessment at the time of move in, 30 days after move in, at change of condition, and quarterly evaluation. The sub-assessments will reflect the residents current physcial and mental status.  This will then be updated in the service plan.

 f) To ensure team is aware of all service plans and change of conditions, a clinical meeting will be held daily to discuss any service plans due, changes of conditions, and new move in evaluations

3.  The area needing correction will be evaluated  by the Licensed Nurse daily by auditing all current resident service plans and ensuring they reflect the current physical and mental needs of the resident.  They will also ensure all change of conditions and sub-assessments are complete and reflective in the service plan. Moving forward, the Licensed Nurse will ensure that this occurs with all current and new residents.  2nd checks will be done by the Administrator and/or 2nd Licensed Nurse to ensure these are done correctly and reflect the residents current needs.  A clinical meeting will occur daily to ensure these tasks are completed in a timely manner.  

4. The Administrator and Licensed Nurse will be responsible for monitoring this.

Based on interview and record review, it was determined the facility failed to evaluate and monitor changes of conditions, determine and document actions or interventions and communicate those to staff for 1 of 2 sampled resident (#2) who experienced a change of condition. Findings include, but are not limited to:

Resident 2's progress notes dated 07/12/21 through 10/03/21 were reviewed and the following was noted:

a. On 08/18/21, Resident 2 was noted to have a fall resulting in a skin tear. There was no documented evidence actions or interventions were determined nor was the skin tear monitored through resolution.  During an interview with Staff 4 (RN) on 10/05/21 she acknowledged the findings.

b. Physician orders dated 08/27/21 revealed Resident 2 had a discontinuation of a psychotropic medication and there was no documented evidence the resident was monitored for side effects.

The need to ensure the facility evaluated changes of conditions to determine if actions or interventions were needed and monitored those changes through resolution was discussed with Staff 1 (Administrator) and Staff 2 (Admin Support) on 10/06/21. They acknowledged the findings.

1.  The actions taken to correct the rule violation include: Service plan was updated for resident #2 to ensure the resident's needs are accurately reflected on the service plan.  All residents who exhibit a change of condition will be evaluated to determine if further action should occur.  The resident will then be monitored by the Licensed RN until the condition resolves.

2. The system will be corrected so that the violation will not occur again by:

 a) Licensed Nurse will review all current resident files to ensure service plans are descriptive of the residents current physical and mental status.  During this record review, the Licensed Nurse will also ensure the service plans provide a clear description and direction of the resident care needs for the team members.

 b) Licensed Nurse will review all current resident records to ensure that all change of conditions are reflected in an updated service plan.  Licensed nurse will document instructions and interventions that are specific to each resident.

 c) Licensed RN will monitor resident daily for any changes.  These changes will be documented and communicated to the staff daily.

 f) To ensure the entire team is aware of all resident  change of conditions, a clinical meeting will be held daily to discuss these changes and the determined intervention.

3.  The area needing correction will be evaluated  by the Licensed RN daily by monitoring residents for any changes.  Moving forward, the Licensed Nurse will ensure that this occurs with all current and new residents that have a change of condition and require monitoring.  2nd checks will be done by the Administrator and/or 2nd Licensed Nurse to ensure these are done correctly and reflect the residents current needs.  A clinical meeting will occur daily to ensure these tasks are completed in a timely manner.  

4. The Administrator and Licensed Nurse will be responsible for monitoring this.

Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules, for 1 of 1 sampled resident (# 1) who received insulin injections by unlicensed facility staff.  Findings include, but are not limited to:

During the acuity interview on 10/4/21, Resident 1 was identified to be administered insulin injections by non-licensed staff.

Review of Resident 1's delegation documentation during the survey revealed the RN delegation was missing the following components:

*CG taught task was client specific and not transferable;

*Transfer and acceptance, reason, effective date was signed by both RNs; and

*RN takes responsibility for delegating task and ensures supervision will occur for as long as RN was supervising performance.

The need to ensure delegation and supervision of special tasks of nursing care was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules was discussed with Staff 1 (Administrator), Staff 2 (Admin Support) and Staff 4 (RN) on 10/06/21. They acknowledged the findings.

1. The actions taken to correct the rule violation includes: Resident #1's delegation documentation was updated with the missing components.  

2. The system will be corrected so that the violation will not occur again by:

  a) The RN will review the records of all current residents who received delegated specific care needs to ensure the RN delegations are not missing any required components.

  b) Moving forward, the RN will ensure that all delegations and teachings will be client specific and not transferable.

  c) If a transfer delegation must occur between two Registered Nurses (RN), they will be sure to both sign the delegation documentation and include the effective date on that same delegation documentation.

  d) RN will take responsibility for delegating tasks and ensuring supervision will occur as along as RN is supervising performance.

3.  The area needing correction will be evaluated by the RN daily by monitoring the EMAR and delegation documentation.

4.  The Administrator and Licensed Nurse will be responsible for monitoring this.   

Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was kept of all medications administered by the facility, for 3 of 4 sampled residents (#s 1, 3 and 4) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 09/2020 with diagnoses including Type 2 diabetes mellitus and required blood sugar testing and insulin injections.

a.  Review of Resident 1's MAR dated 09/01/21 to 09/30/21 revealed missing documentation for the medications: nystatin ointment, fluticasone inhaler, ventolin inhaler, humalog insulin, fluticasone nasal spray, acetaminophen 500 mg, lidocaine 5% patch, and glargine insulin.

b.  On 09/16/21 and 09/18/21 Resident 1's blood sugar was checked and documented incorrectly on the MAR, as 19 instead of 119.  

2. Resident 4 was admitted to the facility in 06/2020 with diagnoses including dementia.

A progress note dated 09/28/21 documented "had a prn for anxiety", however, the MAR dated 09/01/21 to 9/30/21 did not record the medication administration.

The need to ensure resident MARs were accurate was reviewed with Staff 1 (Administrator) and Staff 4 (RN). They acknowledged the findings.

3. Review of Resident 3's MAR dated 9/1/21 through 9/30/21 revealed the MAR was missing documentation of medication administration for Clinpro 5000 1.1% toothpaste and act mint .05% solution.

The need to ensure resident MARs were accurate was reviewed with Staff 1 (Administrator) and Staff 4 (RN) on 10/06/21. They acknowledged the findings.

1. The following actions that will be taken to correct the rule violation include: The EMAR for residents 1, 3, and 4 were reviewed and updated with accurate medications and documentation in place.

2.  The system will be corrected so that the violation will not occur again by:

  a) Licensed Nurse will review all current resident EMAR's to ensure accuracy of all medications administered or not administered and are documented correctly in the EMAR.

  b) Moving forward, all team members that administer medications to residents will receive the required training to ensure accurate documentation of medication administration in the EMAR.

  c) Ongoing monthly training will be provided to all team members who administer medications to ensure continuous accuracy of resident medication administration.

3.  The area needing correction will be evaluated by the Licensed Nurse daily.

4.  The Administrator and Licensed Nurse will be responsible for monitoring this.

3. Resident 4 had a physician's order for PRN Lorazepam 0.5 mg for anxiety.

Review of Resident 2's MAR dated 09/01/21 through 09/30/21 revealed s/he received PRN Lorazepam on 09/27/21 and lacked documented evidence any non-drug interventions were attempted before administering the medication.

The need to ensure PRN medications used to treat a resident's behavior had written, resident-specific parameters and non-drug interventions for staff to attempt prior to administering a PRN psychotropic medication was discussed with Staff 1 (Administrator) and Staff 2 (Admin Support) on 10/06/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure PRN medications used to treat a resident's behavior had written, resident-specific parameters and non-drug interventions for staff to attempt prior to administering a PRN psychotropic medication for 3 of 3 sampled residents (#s 2, 3 and 4) who received psychotropic medications. Findings include, but are not limited to:

1. Resident 2 had a physicians order for PRN Lorazepam 0.5 mg for anxiety.

Review of Resident 2's MAR dated 9/01/21 through 09/30/21 revealed s/he received PRN Lorazepam on 09/25/21 and lacked resident specific parameters when to administer PRN Lorazepam and documented evidence non-drug interventions were attempted and documented as ineffective before administering the medication.

2. Resident 3 had a physician's order for PRN Haloperidol 5mg for aggressive behavior.

Review of Resident 3's MAR dated 09/01/21 through 09/30/21 revealed s/he received PRN Haloperidol on 09/02/21, 09/03/21, 09/05/21 and 09/19/21 and lacked resident specific parameters when to administer PRN Haloperidol and lacked documented evidence non-drug interventions were attempted and ineffective before administering the medication.

The need to ensure PRN medications used to treat a resident's behavior had written, resident-specific parameters and non-drug interventions for staff to attempt prior to administering a PRN psychotropic medication was discussed with Staff 1 (Administrator) and Staff 2 (Admin Support) on 10/06/21. They acknowledged the findings.

1. The actions that will be taken to correct the rule violation include: The EMAR's for residents 2, 3, and 4 were updated to ensure PRN medications used to treat a residents behavior had written resident specific parameters on when to administer the PRN medication.  Each EMAR for residents 2, 3, and 4 was also updated with resident specific non drug interventions to be attempted before administering the PRN medications.

2. The system will be corrected so that the violation will not occur again by:

  a) Licensed Nurse will review all current resident EMAR's that receive PRN medications to ensure that each medication has written resident specific parameters as well as resident specific non drug interventions that should be attempted before administering the PRN medication.

  b) All care team members that administer medications will receive training prior to administering medications on PRN medications, resident specific parameters, non drug interventions, and how to document the evidence that these non drug interventions occurred before giving the PRN medication.

  c) The community will provide monthly refresher training on PRN medications, resident specific parameters, non drug interventions, and how to document the evidence that these non drug interventions occurred before giving the PRN medication.

3.  The area needing correction will be evaluated for accuracy by the Licensed Nurse daily.  This will be completed by the auditing of each resident EMAR that receives PRN medications.

4.  The Administrator and Licensed Nurse will be responsible for monitoring this.      

Based on interview and record review, it was determined the facility failed to provide documentation that fire drills included all required components and fire life safety training was conducted on alternating months. Findings include, but are not limited to:

Fire and life safety records for March 2021 through September 2021 were reviewed and lacked the following components:

* Escape route used; and

* There was no documented evidence fire drills or fire life safety training were conducted on alternating months of fire and life safety training.

The need to ensure the facility was in compliance with all required fire drill components and fire and life safety instruction was discussed with Staff 1 (Administrator), Staff 2 (Admin Support) on 10/06/21. They acknowledged the findings.

1.  The following actions that will be taken to correct the rule violations includes:

  a) Community will provide appropriate fire/life safety training to all team members on alternating months and will document evidence of this training.

  b) The community will document all escape routes used during the fire drills as well as document the number of occupants that are evacuated.  The community has implemented the use of a new Fire Drill Record document to ensure the rule is met (see attached).

2.  The system will be corrected to avoid future violations by:

  a) On alternating months the community will provide appropriate fire/life safety training to all team members as well as docmenting that the training has occurred.

  b) Ensuring that escape routes used during fire dirlls are documented.  As well, the community will also document the number of occupants evacuated during the drill.  Community will utilize the new Fire Drill Record document.

3.  The area needing correction will be evaluated on a monthly basis to ensure compliance.

4.  The Administrator and Maintenance Director will be responsible for monitoring this.  

Based on observation and interview, it was determined the facility failed to ensure  pathway edges did not drop off to prevent tripping hazards for residents. Findings include, but are not limited to:

Observations of the exterior of the facility on 10/4/21 showed:

* The side yard pathway edges revealed drop offs in excess of two inches in multiple areas;

* The courtyard pathways revealed drop offs in excess of two inches in multiple areas; and

* The courtyard pathway between the Town Center and Seacoast unit dropped off abruptly down to a storm drain.

The need to ensure pathways in the resident courtyard did not have potential tripping hazards was discussed with Staff 1 (Administrator) and Staff 15 (Maintenance Director). They acknowledged the findings.

1.  The following actions that will be taken to correct the rule violation include: Exterior pathways with drop offs will be filled-in and/or grinded down in order to provide a more level edge.

2.  The system will be corrected to avoid future violations by conducting monthly, exterior walk-throughs utilizing the Exterior Community Checklist to ensure that the pavement is not uneven or cracked, and to assure all other items in the regulation are met.

3.  The area needing correction will be evaluated on a monthly basis.

4.  The Administrator and Maintenance Director will be responsible for monitoring this.

Based on observation and interview, it was determined the facility failed to provide an exit door alarm or other acceptable system to alert staff when residents exited outside to the courtyards. Findings include, but are not limited to:

The memory care unit was toured on 10/04/21. Doors leading to the outside courtyards did not have a functioning alarm system that alerted staff when someone exited.

The need to ensure exit doors had some type of alarm to alert staff when a resident exited into the courtyard was discussed with Staff 1 (Administrator) and with Staff 15(Maintenance Director) on 10/05/21. They acknowledged the findings.

1. The actions taken to correct the rule violation include: The doors leading to the outside courtyards had functioning alarm systems installed so that the staff is alerted when a resident goes out to the courtyard.

2. The system will be corrected so that the violation will not occur again by ensuring all doors that exit the memory care unit have a functioning alarm system so that the staff are alerted when a resident exits the community.

3. The area needing correction will be evaluated daily by the Maintenance Director and Administrator to ensure the alarm systems are functioning properly.

4.  The Administrator and Maintenance Director will be responsible for monitoring this.

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: C160, C420, 510 and C555.  

Please refer to the POC for C160, C420, C510, C555

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 sampled newly-hired direct care staff (#s 9, 11 and 13) completed all required training and demonstration of competency, and 1 of 1 sampled long term direct care staff (# 7) completed a total of 16 hours of in-service training annually, including six hours of annual dementia care training. Findings include, but are not limited to:

Training records were reviewed with Staff 16 (Business Office Manager) and Staff 1 (Administrator) on 10/6/21. The following deficiencies were identified:

a. Staff 9 Care Partner (CP), was hired 8/16/21, Staff 11 (MT) was hired 1/15/21, and Staff 13 (CP) was hired on 6/30/21. There was no documented evidence Staff 9, 11, and 13 had completed pre-service training on the following topics:

* Environmental Factors that are Important to a resident's well-being and Use of supportive devices with restraining qualities in MCC's prior to working independently;

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

* How to recognize behaviors that indicate a change in the resident condition and report behaviors that require ongoing assessment.

There was no documented evidence that Staff 9 and Staff 13 had completed the required training in:

* Providing personal care to a resident with dementia;

* Use of supportive devices with restraining properties;

* The role of service plans;

* Changes associated with normal aging; and

* Changes of condition and changes that require reporting.

b. Staff 7 (MT) was hired 8/26/2010. For the annual period from 8/26/20 to 8/26/21 Staff 7 had documented only 7 of the required 16 hours of in-service training on topics related to dementia and provision of care.

The need to ensure newly-hired direct care staff completed all orientation training prior to beginning any job duties and pre-service training prior to working independently, and that long term direct care staff completed 16 hours of in-service training annually, including six hours of annual dementia care training, was reviewed with Staff 1 on 10/6/21. She acknowledged the findings.

1. The actions taken to correct the rule violation includes:  

  a) All required training and demonstration of competency by newly-hired direct care staff #9, 11, and 13 was completed.  

  b) Long term direct care staff (#7) completed the remaining 9 units in-service training on topics related to dementia and provision of care.

2. The system will be corrected so that the violation will not occur again by:

  a) Moving forward, all newly-hired direct care staff will complete all orienation training prior to beginning any job duties and pre-service training prior to working independently. This training will be documented and placed in the personnel file.

  b) The community will ensure that all long term direct care staff complete 16 hours of in-service training annually which includes six hours of annual dementia care training.The training will be documented and placed in the personnel file.

3. The area needing correction will be evaluated weekly.

4.  The Adminstrator, Licensed Nurse, and Business Office Manager will be responsible for monitoring this.

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 C231, C252, C260, C270, C282, C310 and C330.  

Please refer to C231, C252, C260, C270, C282, C310 and C330

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

Resident 1, 2, 3 and 4's service plans offered some information about the resident's 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 the resident to participate; and

* Activities that could be used as behavioral interventions, if necessary.

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

The need to ensure the facility provided meaningful activities based on a thorough evaluation and individualized activity plan for each resident was discussed with Staff 1(Administrator) and Staff 2 (Admin Support) on 10/06/21. They acknowledged the findings.

1. The actions taken to correct the rule violation include: Service plans were updated for residents 1, 2, 3, and 4 to reflect residents' current abilities and skills, emotional and social needs and patterns, physical abilities and limitations, adaptations necessary for the resident to participate, and activities that could be used as behavioral interventions.

2. The system will be corrected so that the violation will not occur again by ensuring that all residents are evaluated for activities and that the activities are person centered and available during residents' waking hours. This will be done at the time of move in as well as when a resident has a change of condition and will be in accordance with the licensing rules of the community. The evaluation will include input from the resident and the family members of the resident. The evaluation will be used by the community to provide meaningful activities based on a thorough evaluation and individualized activity plan.

3. The area needing correction will be evaluated at the time of a resident move in as well as monitored monthly to ensure the activity plan still meets the current needs of the resident.

4. The Life Enrichment Director, Administrator, and Licensed Nurse will be responsible for monitoring this.