The findings of the re-licensure survey, conducted 11/01/21 through 11/03/21, 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 and OARs 411 Division 004 for Home and Community Based Services Regulations.

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 revisit to the re-licensure survey of 11/3/21, conducted 1/10/22 through 1/11/22, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 2 of 2 sampled residents (#s 1 and 5), whose records were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 09/2021.

Resident 1's move-in evaluation failed to address the following required elements:

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

* Recent losses.

The facility's failure to complete all required elements for Resident 1's move-in evaluation was discussed with Staff 1 (Executive Director) and Staff 2 (Regional Director of Operations) on 11/02/21. They acknowledged the findings.

2. Resident 5 was admitted to the facility in 10/2021.

Resident 5's move-in evaluation failed to address the following required elements:

* Interests, hobbies, social, leisure activities;

* Spiritual, cultural preferences and traditions;

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

* Nutrition habits, fluid preferences and weight if indicated;

* Recent losses;

* Unsuccessful prior placements; and

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

The evaluation was inaccurate in the following areas:

* Skin condition; and

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

On 11/02/21, the need to ensure move-in evaluations were accurate and addressed all required elements was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations). They acknowledged the findings.

Required elements for preadmission evaluation was not fulfilled prior to move in. We have in serviced staff on move in checklist, and the importance of all the elements needed prior to move in.

Every new inquiry move in will have a checklist reviewed at stand up daily with DSO, ED, and Clinical team with RN and RCC to ensure all elements are received prior to admission date.

The ED will overview all preadmission paperwork with every new inquiry/move in and will be signing the paperwork as it is approved with all preadmission checklists.

The ED & DSO are responsible for maintaining this system.

3. Resident 5 was admitted to the facility in 10/2021 with a diagnoses including diabetes.

Observations of Resident 5 during the survey, interviews with staff, and review of the service plan, dated 10/19/21, and the medical record revealed the service plan was not reflective and/or followed in the following areas:

* Side rails on the bed;

* Preference to sleep in recliner;

* Trash removal instructions;

* Wheelchair use;

* Pressure-relieving cushion in wheelchair;

* Use of a urinal;

* Outside provider services;

* Edema to lower extremities; and

* Resistance to assistance with toileting and showers when offered.

The need to ensure service plans were reflective and were followed was discussed with Staff 1 (ED), Staff 2 (Regional Director of Operations) and Staff 3 (Regional Nurse Consultant) on 11/02/21.  They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure resident service plans were reflective of residents' current status and were followed for 3 of 5 sampled residents (#s 3, 4, and 5). Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 10/2020 with diagnoses including history of stroke and hemiplegia and hemiparesis of the right side.

The resident's 10/13/21 service plan was reviewed during survey. Interviews with staff and the resident revealed the service plan was not reflective of the resident's current status and care needs in the following areas:

* Home health services; and

* Transfer status.

The need for service plans to accurately reflect residents needs and status was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations) on 11/02/21. They acknowledged the findings.

2. Resident 4 was admitted to the facility in 01/2020 with diagnoses including diabetes.

The resident's 10/21/21 service plan was reviewed. Interviews with the resident and staff revealed the service plan was not reflective of the resident's current status and needs in the following areas:

* Wound care;

* Checking CBGs as needed;

* Foot care; and

* PRN medications.

The facility's failure to ensure the service plan was reflective was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations) on 11/02/21. They acknowledged the findings.

Service plans have been reviewed for current needs, followed up on POC needs to ensure documentation of needs being meet.

To prevent recurrence the RCC will follow up on PCC of what needs were not marked done as complete or have been marked as done. This will be reviewed every morning at clinical daily stand up with the executive director and RN.

The system will be reviewed during our CQI meetings monthly to ensure clinical team is able to ensure our residents are receiving the care that is needed.

The RN and RCC are responsible to maintain this system.

2. Resident 1 was admitted to the facility in 09/2021 with diagnoses including anxiety and chronic obstructive pulmonary disease.

Review of Resident 1's physician orders, 10/01/2021 through 10/31/21 MAR, and progress notes dated 9/13/21 through 11/01/21, the following short-term changes of condition were identified:

* 09/30/21: orders were received to discontinue Simvastatin (for cholesterol) and Aspirin. Orders were received to start Urea packets (supplement) daily and to obtain daily weights;

* 10/04/21: orders were received for Xanax (psychotropic) to be taken every six hours as needed for anxiety; and

* 10/22/21: the resident had a fall and sustained two skin tears to the left arm and a bruise to the forehead.

There was no documented evidence evaluations were completed, interventions were developed and communicated to staff, or of weekly monitoring to resolution for the medication changes, daily weights, fall, or skin injuries.

The need to ensure changes of condition were evaluated, interventions were developed and communicated to staff on all shifts, and were monitored weekly to resolution was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations) on 11/02/21. They acknowledged the findings.

3. Resident 5 was admitted to the facility in 10/2021 with diagnoses including diabetes.

Review of the resident's progress notes, 10/01/21 through 10/31/21 MAR, outside provider notes, and the transfer/discharge summary from Resident 5's previous residence revealed a left great toe deep tissue injury and a wound to the resident's right buttocks.  

There was no documented evidence an evaluation was completed, that interventions were developed and communicated to staff, or of weekly monitoring of the skin injury and wound to resolution.

The need to ensure short-term changes of condition were evaluated, interventions were developed and communicated to staff on all shifts, and were monitored weekly to resolution was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations). They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure resident changes of condition were evaluated and referred to the facility RN as indicated, resident-specific actions/interventions were determined, documented and communicated to staff on all shifts, and weekly progress was monitored through condition resolution for 4 of 5 sampled residents (#'s 1, 2, 3, and 5) who experienced changes of condition. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 03/2020 with diagnoses including multiple sclerosis and hypothyroidism.

Interviews with staff and review of Resident 2's clinical records (including the current service plan, weight records (05/01/21 - 10/31/21), progress notes, current physician orders, assessments, and evaluations) indicated Resident 2 began experiencing weight fluctuations in 05/2021:

* Between 05/07/21 and 06/11/21, Resident 2 experienced a severe weight loss of nine pounds, which constituted 8.25% loss in total body weight over one month. There was no documented evidence the facility evaluated and referred the resident to the facility RN for further assessment, determined what actions or interventions were necessary for the resident, and there was no documented evidence the weight loss was monitored on a weekly basis.

* On 07/22/21, the facility RN completed an assessment related to significant weight loss. Interventions included instructions for the facility to provide a nutritional supplement drink three times a day and fortified foods with each meal. A progress note dated 09/01/21, written by the RN, stated the resident lost 12.6 pounds from two weeks prior and stated the resident should be re-weighed for verification. The resident's recorded weights on 09/03/21 and 09/10/21 continued to show a significant weight loss of six pounds which constituted a 5.45% loss in total body weight over one month.

There was no documented evidence the facility evaluated and referred the resident to the facility RN, determined what actions or interventions were necessary for the resident, and there was no documented evidence the resident's weight status was monitored after 09/01/21.

The need to ensure resident changes of condition were evaluated and referred to the facility RN as indicated, resident-specific actions/interventions were determined and documented, and weekly progress was monitored through condition resolution was discussed with Staff 1 (ED) on 11/03/21. She acknowledged the findings.

4. Resident 3 was admitted to the facility in 10/2020 with diagnoses including history of stroke with hemiplegia and hemiparesis of the right side.

Progress notes for the resident, dated 08/04/21 through 10/28/21, 01/17/21 through 10/29/21 weight records, and physician correspondence were reviewed during survey, and interviews were conducted with staff and the resident.

The resident experienced the following changes of condition:

* 08/05/21: the resident's transfer assistance needs changed from a one-person assist to a two-person assist;

* 08/29/21: weight records revealed a severe weight loss of 18 lbs. in one month (from 171 lbs. to 153 lbs.), a 10.52% loss of his/her total body weight;

* 08/17/21: weight records revealed a significant three month weight loss of 18.3 lbs., or 10.76% of his/her total body weight; and

* 10/17/21: a progress note indicates the resident complained of pain related to not having a bowel movement for three days, and staff discovered s/he had hemorrhoids.

There was no documented evidence those changes of condition were evaluated, interventions were developed or communicated to staff, a referral was made to the RN, or they were monitored with at least weekly documentation through resolution.

The need to evaluate changes of condition, develop actions or interventions and communicate them with staff when indicated, refer to the RN when necessary, and monitor through resolution was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations) on 11/02/21. They acknowledged the findings.

Scheduled a med tech meeting to go over the policy and procedure of any changes of conditions and monitoring.

To prevent recurrence the RCC and RN will follow up with alert charting at clinical daily stand up to ensure we are monitoring our changes of conditions to ensure any evaluations that will need to occur be done in a timely manner.

The system will be reviewed monthly at our Med Tech meetings to ensure our clinical team is staying on top of changes and monitoring

The RN and Executive Director are responsible to maintain this system

2. Resident 2 was admitted to the facility in 03/2020 with diagnoses including multiple sclerosis and hypothyroidism.

Interviews with staff and review of Resident 2's clinical records (including the current service plan, weight records (05/01/21 - 10/31/21), progress notes, current physician orders, assessments, and evaluations) indicated Resident 2 began experiencing the following significant weight fluctuations in 05/2021:

* Between 05/07/21 and 06/11/21, Resident 2 experienced a severe weight loss of nine (9) pounds, which constituted 8.25% loss in total body weight over one month. There was no documented evidence the facility's RN completed an assessment to address the resident's weight loss.

* Between 06/11/21 and 07/22/21, Resident 2's weight fluctuated with one (1) to 10 pound weight gains and losses. On 07/22/21, the facility RN completed an assessment related to significant weight fluctuations. Interventions included instructions for the facility to provide a nutritional supplement drink three times a day and fortified foods with each meal.

* Weekly RN progress notes dated 09/01/21 stated the resident lost 12.6 pounds from two weeks prior and stated the resident should be re-weighed for verification. The resident's recorded weights on 09/03/21 and 09/10/21 continued to show a significant weight loss of six pounds, which constituted a 5.45% loss in total body weight over one month. There was no documented evidence the facility's RN completed an assessment to address the resident's continued significant weight fluctuations.

*Resident 2's weight was obtained on 11/02/21, per the surveyor's request, and showed a significant weight gain of eight (8) pounds or 6.8%. Staff 3 (Regional Nurse Consultant) completed an assessment on 11/02/21 to address the resident's weight fluctuations.

The need to ensure an RN assessment was completed for all significant changes of condition was discussed with Staff 1(ED), Staff 2 (Regional Director of Operations), and Staff 3 on 11/03/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure an RN assessment was completed for a significant change of condition, including findings, resident status, and interventions made as a result of the assessment, in a timely manner for 2 of 2 sampled residents (#s 2 and 3) who experienced significant changes. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 10/2020 with diagnoses including history of stroke and hemiplegia and hemiparesis of the right side.

The resident's 10/13/21 service plan, 08/04/21 through 10/28/21 progress notes, and

01/17/21 through 10/22/21 weight records were reviewed during survey. Staff and the resident were interviewed. The following changes of condition were identified:

*07/23/21 - 171 pounds;

*08/29/21 - 153 pounds; and

*10/22/21 - 151.2 pounds.

The resident lost 18 pounds, or 10.52% of his/her total body weight, in one month (07/23/21 to 08/29/21), which constituted a severe weight loss.

The resident lost 19.8 pounds, or 11.58% of his/her total body weight, in three months (07/23/21 to 10/22/21), which constituted a significant weight loss.

In a progress note dated 09/08/21, the RN wrote it was "unlikely resident lost 18# in 1 mos [sic], will have staff recheck weight tomorrow." There was no documentation of the resident being weighed on 09/09/21, nor was there any additional documentation about the resident's weight loss by the RN.

On 11/02/21 the surveyor requested a current weight for the resident. Staff 1 reported the resident weighed 168 pounds, which was three pounds less than the resident weighed on 07/23/21, and a gain of 16.8 pounds since 10/22/21.

The resident stated in an interview on 11/03/21 s/he was able to eat any time s/he wanted, s/he liked the food served by the facility, and s/he had plenty of snacks available in his/her room.

There was no documented evidence the RN had completed a significant change of condition assessment which included findings, resident status, and interventions made as a result of the assessment.

The need to ensure an RN assessment was completed, which documented findings, resident status, and interventions made as a result of the assessment, for all significant changes of condition was discussed with Staff 1 and Staff 2 (Regional Director of Operations) on 11/02/21. They acknowledged the findings.

Audit the needs of assessments, assessments were caught up and entered into service plans as needed.

To prevent recurrence the executive director will follow up at the beginning of the week on monday what assessments need to be done, will follow up again Wednesday to ensure no other needs to document, and at the end of the week  follow up with the licensed nurse prior to end of week for completions.

This system will be monitored 3 times a week by the executive director and licensed nurse.

The licensed nurse is responsible to maintain this system.

2. Resident 2 was admitted to the facility in 03/2020 with diagnoses including multiple sclerosis and hypothyroidism.

Interviews with staff and review of Resident 2's clinical records (including the current service plan, progress notes, current physician orders, the MAR for 10/2021, hospital emergency department visit records, assessments, and evaluations) indicated the following:

On 10/19/21, Resident 2 was sent to the emergency department for evaluation of oral swelling.  Resident 2 returned to the facility with instructions to continue taking  numerous medications, including Augmentin (an antibiotic) and hyrochlorothiazide (a blood pressure medication).

Review of Residents 2's 10/2021 MAR indicated the resident was not administered either of the medications. There was no documented evidence the facility clarified the medication instructions with the resident's physician.

On 11/02/21, Staff 1 (ED) stated the medications had previously been discontinued so it was unclear why the medications were included with the ER's visit summary instructions.

The need to ensure the facility coordinated care with outside providers in order to ensure continuity of care was discussed with Staff 1 (ED) on 11/03/21. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to coordinate care with outside providers in order to ensure the continuity of care for 2 of 2 sampled residents (#s 2 and 5) who received services from an outside provider. Findings include, but are not limited to:

1. Resident 5 was admitted to the facility in 10/2021 with diagnoses including diabetes.

The resident's 10/11/21 through 11/01/21 progress notes, MAR, and outside provider visit summaries were reviewed.

In a 10/18/21 visit summary, the instructions provided were for staff to "apply iodine to left big toe and cover with bandaid [sic] twice daily, as well as apply barrier cream to coccyx every morning and night."

There was no documented follow-up to the recommendation for the left great toe until it was added to the MAR on 10/28/21. There was no follow up documentation regarding the barrier cream to be applied morning and night.

The need to ensure the facility coordinated care with outside providers in order to ensure continuity of care was discussed with Staff 1 (ED), Staff 2 (Regional Director of Operations), and Staff 3 (Regional Nurse Consultant) on 11/03/21. They acknowledged the findings.

The immediate fix was to ensure we have created an evaluation plan to ensure the residents are evaluated properly and put on alert for any changes that the resident is in need of from outside providers

To prevent recurrence we will have outside providers fill out our form specifically for them at the front desk prior to leaving the community, and have information turned in to the med techs to start processing there suggestions with the three check system.

The system will be evaluated daily by the executive director, RCC, and RN to ensure residents are receiving the outside providers suggestions and orders in a timely manner.

The RN and Executive director are responsible for maintaining this system.

2. Resident 1 was admitted to the facility in 09/2021 with diagnoses including chronic obstructive pulmonary disease.

a. During the acuity interview on 11/01/21 it was reported the resident received continuous oxygen.

Resident 1 was observed with oxygen being administered via nasal cannula on 11/01/21 and 11/02/21.

Resident 1's physician orders and 10/2021 MARs were reviewed. The records failed to include signed orders for oxygen administration.

On 11/02/21 Staff 1 (ED) reported there was no signed order for oxygen administration.

b. Resident 1's progress notes, physicians orders, and 10/01/21 through 10/31/21 MAR were reviewed and revealed orders dated 09/30/21 for daily weights.

There were no weights documented on seven occasions in October 2021, which indicated the weight was not obtained daily as ordered.

The need to ensure signed physician orders were documented in the resident's facility record for all medications the facility was to administer and that orders were followed was reviewed with Staff 1 and Staff 2 (Regional Director of Operations) on 11/02/21. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure signed physician orders were documented in the resident's facility record for all medications and treatments administered by the facility and medication and treatment orders were carried out as prescribed for 2 of 4 sampled residents (#s 1 and 2) whose physician orders were reviewed. Findings include, but are not limited to:

1.  Resident 2 was admitted to the facility in 03/2020 with diagnoses including multiple sclerosis and multiple mental health diagnoses.

Review of Resident 2's current physician orders and 10/01/21 through 11/01/21 MARs indicated the following:

An order for Trazodone (for insomnia) 1 tablet at bedtime and 0.5 tablet at midnight was not administered to the resident on 14 occasions in October 2021.

On 11/03/21, Staff 1 (ED) stated issues with the pharmacy was the reason the medication was not administered.  

The need to ensure medication orders were carried out as prescribed was discussed with Staff 1 on 11/03/21. She acknowledged the findings.

A training with med techs will be held about following physician orders and the 1st and 2nd check process, when orders do not line up with what we have on the MAR we need to clarify the order with the physician to ensure we are following correct orders.

To prevent recurrence staff will continue our process of 1st, 2nd, and 3rd checks that will be reviewed daily in clinical stand up with the Executive Director, RN, and RCC to ensure all physician orders are being followed properly and follow up with staff to correct as needed.

The system will be evaluated by clinical team monthly as a part of the Med room audit that is to be done as part of our CQI process.

The Executive Director and RN are responsible for maintaining this system.

Based on interview and record review, it was determined the facility failed to ensure residents' MARs provided clear instruction and parameters for administration of PRN medications for 2 of 5 sampled residents (#s 1 and 5) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 09/2021 with diagnoses including chronic obstructive pulmonary disease.

Resident 1's 10/1/21 through 10/31/21 MAR was reviewed and noted the following respiratory and anti-anxiety medications:

* Albuterol Sulfate HFA inhaler, two puffs every four hours as needed for wheezing;

* Ventolin HFA inhaler, two puffs every four hours as needed for wheezing;

* Alprazolam (psychotropic) 0.25 mg up to two times a day as needed for anxiety; and

* Lorazepam (psychotropic) 1 mg every six hours as needed for anxiety.

The MAR lacked clear instruction and parameters for administration of the PRN respiratory and anxiety medications.

The need to ensure MARs included clear parameters and instructions to staff for medication administration was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations) on 11/02/21. They acknowledged the findings

2. Resident 5 was admitted to the facility in 10/2021 with a diagnosis of diabetes.

Resident 5's 10/11/21 through 10/31/21 MAR was reviewed and noted the following pain and bowel care medications:

* Acetaminophen 650 mg every four hours as needed for pain or fever greater than 100 degrees F;

* Acetaminophen 650 mg every six hours as needed for pain or fever greater than 100 degrees F; and

* Tramadol HCL 50 mg every 12 hours as needed for pain.

* Bisacodyl Laxative Suppository 10 mg as needed for no bowel movement four hours after Milk of Magnesia. (There was no order for Milk of Magnesia on the MAR.); and

* Sennosides-Docusate Sodium tablet, one as needed for constipation.

The MAR lacked clear parameters and instructions for administration of the PRN pain and bowel care medications.

The need to ensure MARs were accurate and included clear parameters and direction to staff for medication administration was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations) on 11/02/21. They acknowledged the findings.

Audit of MARs for resident was done for  antianxiety, bowel meds, pain meds to ensure we have non-pharmacy interventions and signs or symptoms that the resident may have.

To prevent the recurrence RN and RCC when conducting the 2nd and 3rd check that we have interventions and signs, and symptoms are added to the MAR per order that is given for PRN needs.

The system will be reviewed monthly with our CQI process to ensure our medications have non pharmacy interventions and signs and symptoms.

The RN and executive director are responsible to maintain this system.

Based on interview and record review, it was determined the facility failed to ensure PRN psychotropic medications used to treat a resident's behaviors had written, resident-specific symptoms for how the resident expressed anxiety and non-drug interventions for staff to attempt prior to administering the medications for 1 of 2 sampled residents (# 1) who was prescribed PRN psychotropic medications for anxiety. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 09/2021 with diagnoses including anxiety.

Review of the resident's 10/01/21 through 10/31/21 MAR and current physician orders showed the following psychotropic medications:

* Lorazepam 1 mg every six hours as needed for anxiety; and

* Alprazolam 0.25 mg up to two times a day as needed for anxiety.

The facility administered the Alprazolam on 49 occasions between 10/04/21 and 10/31/21.

The MAR stated the medications were for "anxiety" and did not include resident-specific symptoms of anxiety. Additionally, there was no documentation of what non-drug interventions to attempt prior to administration of the medications.

The need to ensure there were resident-specific symptoms of how anxiety was expressed and non-drug interventions were available, attempted, and documented as ineffective prior to administration of the PRN psychotropic medication was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations) on 11/02/21. The staff acknowledged the findings.

Audit of  psychotropic medication given PRN with non-pharmacy interventions and what signs we should be looking for when giving the medication.

To prevent recurrence the company will have training with Med techs with a list of psychotropic medications that should have interventions prior to giving medications and what the residents sign and symptoms are.

Psychotropic medication will be reviewed in our monthly CQI process to ensure our medications have non pharmacy interventions and signs of need.

The RN and executive director are responsible to maintain this system.

Based on observation, interview, and record review, it was determined the facility failed to ensure an RN, PT, or OT completed a thorough assessment of a supportive device with potentially restraining qualities prior to use, document other less restrictive alternatives prior to use of the device, and provide instruction to caregivers on the correct use of and precautions for the device for 1 of 2 sampled residents (#5) who had side rails on their bed. Findings include, but are not limited to:

Resident 5 was admitted to the facility in 10/2021.

On 11/01/21, Resident 5's bed was observed to have two half length side rails in the up position.

There was no documented evidence the device with restraining qualities had been assessed by an RN, PT, or OT, including documentation of less restrictive alternatives prior to use, nor was there evidence the service plan had identified the use of and precautions related to the device.

The lack of assessment and instructions provided for use of supportive devices with potentially restraining qualities was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations) on 11/02/21. They acknowledged the findings.

Went to residents' rooms to ensure any supportive devices in the resident's room and whether it has had an assessment finished.

To prevent recurrence any new move in that moves belongings in the RN and executive director will visit to ensure the resident either has a supportive device or is in need of one.

Supportive devices will be reviewed with our monthly CQI process to ensure our supportive devices have had assessments done quarterly and in a timely manner.

The RN and Executive Director are responsible to maintain this system.

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 newly hired staff (#s 11 and 15) completed required pre-service orientation and dementia training prior to beginning their job responsibilities and providing care for residents. Findings include, but are not limited to:

Staff training records were reviewed on 11/03/21 and revealed the following:

a. There was no documented evidence Staff 11 (MT), hired 9/11/21, completed orientation to fire safety and emergency procedures.

b. There was no documented evidence Staff 11 or Staff 15 (CGs), hired 7/11/21, completed the required pre-service dementia training prior to providing care to residents.

The need for staff to complete all required pre-service orientation and dementia training before beginning their job responsibilities and providing care to residents was discussed with Staff 1 (ED), Staff 2 (Regional Director of Operations), and Staff 3 (Regional Nurse Consultant) on 11/03/21. They acknowledged the findings.

A complete audit will be done for staff training records. Staff trainings will be completed and up to date for current employees no later than January 2nd, 2022.

To prevent recurrence  staff will be required to complete the required pre-service training prior to working on the floor. In complete trainings will be reviewed five days a week as part of daily stand-up meetings to identify missing training components and to review the status of new hires and where they are at with their trainings to ensure all training is completed with in 30 days of hire. Pre-service training documents have been updated to ensure compliance with all required components.

The system will be evaluated monthly as a part of the facility CQI program and will include a review of all staff members and the status of their required trainings.

The Executive Director and Business office manager will be responsible for maintaining this system.

Based on interview and record review, it was determined the facility failed to verify 2 of 3 newly hired staff (#s 10 and 11) demonstrated satisfactory performance in all assigned job duties within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed on 11/03/21.

There was no documented evidence Staff 10 (MT/CG), hired 09/29/21, or Staff 11 (MT), hired 09/11/21, had demonstrated competency in one or more of the following required areas:

* 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;

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

* General food safety, serving, and sanitation; and

* First aid/abdominal thrust.

The facility's failure to ensure newly hired staff had demonstrated competency in all assigned duties within 30 days of hire was discussed with Staff 1 (ED), Staff 2 (Regional Director of Operations), and Staff 3 (Regional Nurse Consultant) on 11/03/21. They acknowledged the findings.

A complete audit will be done for staff training records. Staff trainings will be completed and up to date for current employees no later than January 2nd 2022.

To prevent recurrence for competency demonstration for 30-day demonstration will be signed and dated the day was shown to the trainer.

The form will be reviewed with the trainer and the business office manager prior to turning in the form and filed away.

The business office manager will be responsible for maintaining this system.

Based on interview and record review, it was determined the facility failed to ensure long-term staff completed the required minimum 12 hours of in-service training annually for 1 of 1 long-term staff (#5) whose training records were reviewed. Findings include, but are not limited to:

Staff training records were reviewed on 11/03/21.

There was no documented evidence Staff 5 (CG), hired 08/16/19, had completed a minimum of 12 hours of annual in-service training related to the provision of care, at least six of which needed to relate to dementia care.

The need to ensure all required in-service training hours were completed annually was reviewed with Staff 1 (ED), Staff 2 (Regional Director of Operations), and Staff 3 (Regional Nurse Consultant) on 11/03/21. They acknowledged the findings.

A complete audit will be done for staff training records. Staff  trainings will be completed and up to date for current employees no later than January 2nd, 2022.

To prevent recurrence all staff will be required to complete the annual training prior to the end of the month monthly and will be reviewed at daily stand ups of the status of employees that need to finish up the monthly training for their annual training upkeep.

The Executive Director and Business office manager will be responsible for maintaining this system.

Based on interview and record review, it was determined the facility failed to ensure fire drill records included documentation of all elements required by the Oregon Fire Code (OFC). Findings include, but are not limited to:

Fire drill records for 05/2021 through 10/2021 were reviewed on 11/02/21, and revealed documentation of fire drills did not include the following elements;

* Escape route used;

* Evacuation time period needed; and

* Number of occupants evacuated.

The need to ensure all elements required by the OFC were documented for fire drills was discussed with Staff 6 (Maintenance) on 11/02/21 and with Staff 1 (ED), Staff 2 (Regional Director of Operations), and Staff 3 (Regional Nurse Consultant) on 11/03/21. They acknowledged the findings.

Community completed a fire drill in November with all required components covered and staff to be re-educated at staff meeting on November 22nd, 2021, on the fire drill procedure.

To prevent reoccurrence company fire drill form has been updated to include all required components and computer program used to document fire drills.

Fire Drills will be reviewed monthly as a part of our CQI process to ensure compliance.

The Executive Director and Maintenance Director will be responsible for maintaining this system.