The findings of the initial licensure survey, conducted 03/14/22 through 03/16/22, 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 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

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 first re-visit to the re-licensure survey of 03/16/22, conducted 07/13/22 through 07/14/22, are documented in this report. It was determined the facility was in compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004.

2. Resident 3 was admitted to the facility in 02/2022.

a. Review of  Resident 3's new move in evaluation dated 02/09/21 revealed the following elements were not addressed:  

* Social interests;

* List of current Diagnosis;

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

* Decision making abilities;

* Pain: Pharmaceutical and non-pharmaceutical interventions, including how the person expresses pain or discomfort;

* Nutrition habits, fluid preferences and weight if indicated;

* Indicators of nursing needs including potential for delegated nursing tasks;

* Fall risk or history;

* Complex medication regimen;

* Recent losses;

* Elopement risk or history; and

* Smoking, ability to smoke safely.

b. Resident 3's move-in evaluation failed to include the following elements:

* Environmental factors that impact a resident's behavior; and

* Personality, including how the person copes with change and changing situations.

The need to ensure new move-in evaluations contained all required elements was discussed with Staff 1 (Administrator) on 03/15/22. She acknowledged the findings.

3. Resident 4 was admitted to the facility in 03/2021 with diagnoses including Alzheimer's and arteriosclerosis.

Review of Resident 4's most recent quarterly evaluation, dated 10/25/21 indicated the document was not updated timely (within three months).

On 03/16/22 the need to complete timely updates of quarterly evaluations was discussed with Staff 1 (Administrator). She acknowledged the findings.

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 3 and 5) and failed to complete quarterly evaluations for 1 of 1 sampled resident (#4). Findings include, but are not limited to:

1. Resident 5 was admitted to the facility in 02/2022 with diagnosis including Alzheimer's disease and hypertension.

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

* Cultural traditions and preferences;

* Vital signs;

* Cognition, including: orientation, confusion and decision making abilities;

* Ability to use the call system;

* Housekeeping and laundry;

* Transportation;

* Nutrition habits; fluid preferences and weight if indicated;

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

* Nursing needs, including potential for delegated nursing tasks;

* Emergency evacuation ability;

* Complex medication regimen; and

* Unsuccessful prior placements.

b. Resident 5's move-in evaluation failed to include the following elements:

* Environmental factors that impact a resident's behavior; and

* Personality, including how the person copes with change and changing situations.

The failure to include all required elements and to address all required elements in the move-in evaluation was discussed with Staff 1 (Administrator) on 03/15/22. She acknowledged the findings.  

1. Administrator and RN,RCM now have in place a Evaluation check off list and the updated Oregon Evalution. .  New format for move-ins will be the responsibility of the Administator and RN, RCM to check the evalutions for all new move-ins, before resident is admitted..

2. All Evaluations for move-ins will be in place before resident move-in with the team to ensure it is complete, Adminiistrator/ RN/RCM, to check the Oregon Evaluation.   

3.Administrator will check every move-in and final check will be the RN signing off and reviewing the evaluations that are complete. Oversight by Administrator will be continued as a move-in pending weekly or monthly.

4.Administrator will oversee the move-in process and evalutions will be  double checked before move-in happens.  RN and RCM will check evalutions and sign off that the  resident is ready for move-in for the final check. This will include Activity Evaluations, and all medical information is completed. Activity evaluations are also in place, with training on the evalution process with activity director.

Based on interview and record review, it was determined the facility failed to create a service plan for 2 of 2 sampled residents (#s 3 and 5) who recently moved into the facility and update the service plan quarterly for 1 of 1 sampled resident (# 4) whose service plan was reviewed. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 02/2022 with a diagnosis of dementia.

During an interview with Staff 1 (Administrator) on 03/14/22, she stated service plans for new residents were not created until the resident had been in the facility for 30 days. The survey team reviewed the OAR with Staff 1 and she acknowledged the facility was not in compliance during this review.

The need to ensure service plans were created before residents moved into the facility was discussed with Staff 1 on 03/14/22. She acknowledged the findings.

3. Resident 4 was admitted to the facility in 03/2021 with diagnoses including Alzheimer's and arteriosclerosis.

Review of Resident 4's most recent quarterly service plan, dated 10/25/21 indicated the document was not updated timely (within three months).

On 03/16/22 the need to complete timely updates of quarterly service plans was discussed with Staff 1 (Administrator). She acknowledged the findings.

2. Resident 5 was admitted to the facility in 02/2022 with diagnosis including Alzheimer's disease and hypertension.

There was no documented evidence the facility completed an initial service plan prior to move-in.

On 02/21/22 the resident had an injury fall with fractured left hip. The resident returned to the facility on 03/04/22. The resident had a decline in ADL ability. This constituted a significant change of condition. The RN completed an assessment of the resident's condition and noted changes in ADL care.

There was no documented evidence a service plan was updated after the significant change of condition.

The need to ensure residents had an initial service plan developed that provided clear direction regarding the delivery of services, included a written description of who shall provide the services and what, when, how, and how often the services shall be provided, and was updated after the resident experienced a significant change of condition was discussed with Staff 1 (Administrator) and Staff 4 (RN) on 03/15/22. They acknowledged the findings.

1. Administrator and RCM will set up a system for tracking service plans to alert the clinical team, who is due for quarterly, and 30 day.  Administrator, and RCM/will notify RN of changes of condition.  RCM and Administrator will talk with med-techs to review the information for the change of condition, When RN is notified RN will note in service plan the change.

2.Administrator and RCM with clinical team input will use the tracking system, keep updated on all service plans quartely, 30 day and change of conditions

3. Administrator and RCM, will check weekly for any service plans that may need TSP, and changed.. This will ensure the service plans are timely.

4. Administrator per regulation and oversite including RCM will be responsible for oversight of the service plans and review the weekly service plan audit to keep service plans up to date.

Administrator and RCM/RN during the weekly clinical meetings will review service plans and residents needing updates..

2. Resident 1 was admitted to the facility in 03/2020 with diagnoses including dementia.

Review of facility charting notes indicated Resident 1 returned from a hospital stay on 12/17/21 with "...a large spot of caked on blood on [his/her] right cheek." On 12/18/21 following a shower it was noted "Cleaned wound and placed a small band aid on [his/her] cheek."

There was no documented evidence the injury had been monitored until resolved.

The need to monitor changes of condition to resolution was discussed with Staff 1 (Administrator), Staff 4 (RN), and Staff 3 (Resident Care Manager) on 03/15/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to monitor and document weekly progress of short-term changes of condition until the condition resolved for 2 of 5 sampled residents (#s 1 and 5) whose records were reviewed. Findings include, but are not limited to:

1. Resident 5 was admitted to the facility in 02/2022 with diagnoses including Alzheimer's disease.

A review of the resident's charting notes and MARs dated 02/14/22 through 03/14/22 indicated the following short term changes of condition:

* New move-in on 02/14/22;

* New medication (Seroquel) on 02/15/22;

* New medication (Depakote) on 02/16/22;

* Behaviors on 02/15/22;

* Injury fall resulting in fractured left hip on 02/21/22; and

* Non-injury fall on 03/06/22.

There was no documented evidence the facility determined and documented what action or intervention was needed for the changes of condition, communicated the interventions to staff and documented staff instructions or interventions were not made part of the resident record with weekly progress noted until the condition resolved.

The need to ensure short term changes of condition were monitored, weekly progress noted, and interventions were developed and reviewed for effectiveness was discussed with Staff 1 (Administrator) on 03/15/22. She acknowledged the findings.

1.Administrator during the Clinical meetings which are daily  will meet with RCM/RN to review each resident for any changed health issues. This meeting will be done to ensure residents change whether short term or Long term.  Weekly meeting will enhance the wellness of residents change of condition. RN/RCM will use white board to help RN to see how the residents are doing and to track residents on-going.

2. Daily and weekly updates on residents will be done  during clinical meetings when reviewing each resident from QuickMar.  RN/RCM/Administator will be responsible for the oversight of meetings, and new change conditions of the residents.

3. At the end of each week RN/RCM/RCC will  review any changes in condition when discussing residents to RCM/Med-techs, to meetng their care needs.

4. Administrator and the RN/RCM will discuss in daily clinicals which residents need addressed and or how they are doing.   

Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 1 of 5 sampled residents (#5) whose orders were reviewed. Findings include, but are not limited to:

Resident 5 moved into the facility in 02/2022 with diagnoses which included hypertension and Alzheimer's disease.

a. Resident 5's MARS, reviewed from 02/14/22 (move-in) through 02/21/22 (day resident left facility) and admission orders dated 02/11/22 revealed the following medications were not administered as prescribed:

* Gabapentin 100 mg, give daily at night was administered at 8:00 am;

* Lidocaine Patch every 12 hours was not administered; and

* Melatonin 3 mg daily was not administered.

On 03/15/22, Staff 11 (MT), reviewed the MARs and confirmed the resident had not received Melatonin or Lidocaine patches.

From 02/14/22 through 02/21/22 there was no documented evidence the Melatonin and Lidocaine patches were administered as prescribed and there were no other signed physician orders for discontinuation of these orders.

b. On 03/03/22 the facility received electronically signed hospital discharge orders. The resident returned to the community on 03/04/22. The following prescribed medications were not administered as ordered:

* From 03/04/22-03/14/22, Gabapentin 100 mg, give daily at night was administered at 8:00 am;

* Docusate/Senna 50 mg twice daily, was not administered until 03/08/22;

* Levothyroxine 137 mcg daily, was not administered until 03/08/22;

* Melatonin 6 mg daily, was not administered until 03/09/22; and

* Quetiapine 25 mg daily, was not administered until 03/07/22.

MAR exception notes indicated "waiting on delivery" and "order not approved".

During an interview with Staff 4 (RN) and Staff 3 on 03/15/22 they acknowledged the facility did not have an effective system to ensure physician orders were signed, medications were obtained in a timely manner and administered as prescribed.

1. Administrator will meet with RCM/RN, to set up training with Med-techs om orders including what to do if orders are not complete RCM/RCC will assist in training med-techs along with Administrator reviewing the training and RN oversight with medication  training on Orders, MARS, Faxing.

2.RCM will do weekly audits on MARS and check orders coming in.  Orders will have 3 way checks for review to ensure signed Orders or changes.  this will include RN.RCM/Administator/ Med-tech.

3. Clinical orders will be reviewed daily for completed physicians orders, Med-techs to notify RN/RCM/Administrator for any issues with orders so they can be completed correctly.

4. Administrator RCM/RN will be respsonsible for all physcians orders and correct orders,including physician signature and any descrepancies that may occur will be corrected through physicians or Pharmacy.   

Based on interview and record review, it was determined the facility failed to ensure residents' MARs provided clear medication specific instruction and resident specific 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's February 1st through March 14th 2022 MARs were reviewed.

Resident 1 had orders for:

*Enema as needed for constipation; and

*Polyethylene Glycol 3350 powder as needed for constipation.

There were no resident specific parameters or instructions directing non-licensed staff when to use which PRN medication and in which order.

The need to ensure MARs were accurate and included clear directions for as needed medications to direct non-licensed staff was reviewed with Staff 1 (Administrator), Staff 4 (RN), and Staff 3 (Resident Care Manager) on 03/15/22. They acknowledged the findings.

2. Resident 5 was admitted to the facility in 02/2022 with diagnosis including Alzheimer's disease.

Resident 5's February 1st through March 14th 2022 MARs identified the following PRN medications lacked resident specific parameters and instructions for non-licensed staff on when to use the medication and lacked the order of administration for multiple PRN medications used to treat the same condition.

* PRN Mylanta and PRN Pepto Bismol for upset stomach;

* PRN Tylenol and PRN hydrocodone for pain; and

* PRN olanzapine for agitation.

The need to ensure MARs included clear directions and parameters for non-licensed staff was reviewed with Staff 1 (Administrator) and Staff 4 (RN) on 03/15/22. They acknowledged the findings.

Administrator and RCM/RCC will check orders on quickmar to review the medications are given  correctly and, training will be through RCC/RCM. RN is working on PRN parameters and Med-techs will be trained to report to RCM/RCC and Administrator any missed meds. Clinical meetings daily through Emar will be reviewed to see if meds are missing. RCM to run medication exception for all residents daily.This will ensure orders, treatments, and any medications that have not been given or on wait list, can be addressed immediately,to prevent harm.

2. Medication audit Administrato will meet daily with RCC.RCM oversight for quality assurance, Any missed medications notify Administrator, and RN, to review.

3. Daily evalutations will be reviewed  for orders, and any unusal  medications that need a RN to oversee and verify. Administrator will be notified and RCM/RCC.

4. RCC oversees the medication room with RCM and RN oversight, Administrator will review any medications that need attention with clinical team for resolutions.

Based on observation and interview, it was determined the facility failed to ensure covers, grates, or screens of wall heaters and associated heating elements did not exceed 120 degrees Fahrenheit (F) when they were installed in locations that were subject to incidental contact by individuals. Findings include, but are not limited to:

The interior of the RCF was toured on 03/14/22 at approximately 1:30 pm. The surveyor observed a fireplace in the common area living room where a resident could come in incidental contact with it. The fireplace was on and felt hot to the touch. The surface temperature of the heater was in excess of 160 degrees F when measured with the surveyor's digital thermometer. There were similar fireplaces installed in each separate cottage.

The surveyor asked Staff 1 (Administrator) on 03/14/22 to turn off the fireplace and ensure it was deactivated. The fireplace was off for the remainder of the survey.

The fireplaces were discussed with Staff 1 (Administrator) on 03/14/22. She acknowledged the need to address the risks associated with the fireplaces.

Maintenance is covering the fireplaces with screens, This action will keep residents  from getting close when fireplace is to hot.  Maintenance will report to Administrator if the fireplaces seem hotter than the temperature 120.Maintenance will check temperatures 2x's weekly to ensure the correct temperatures.

2. Maintenance will continue to monitor all 3 fieplaces and keep tracking the system to ensure safety of residents who like to get close to the fireplaces.

3. Weekly checks and documentation to show temperatues to maintan the fireplaces for resident safety. Maintenace will report any issues to Administrator.

4.Maintenance will be responsible to report temperatures. This can be done at daily stand-up what the temperatures  are by the fireplaces, Action will be taken if temperture are higher than 120, Administrator will contact the appropriate vendor to assist in the temperatures

.

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

On 03/14/22, it was observed the exit doors that residents used to access an interior outdoor courtyard for each cottage had exit door alarms but were not activated to alert the staff when the doors were opened. In Oak Cottage, the door alarm would sound if the door was held open for five second. In Pine Cottage, the door alarm would activate if the door was open for 15 seconds and Maple Cottage door alarm would activate if the door was open for 30 seconds.

In an interview on 03/14/21, Staff 1 (Administrator) confirmed the doors to the courtyard did not have an alarm that alerted staff when a resident went outdoors.

The need to ensure the facility had an exit door alarm or other acceptable system for security purposes or to alert staff when residents exited the facility was discussed with Staff 1 on 03/14/22. She acknowledged the findings.

1.Administrator has taken action with maintenance for the exit doors alarms to be within the 3 second for possible alarm exiting. Sentinel alarm company has been informed to come evaluate the issue and fix.

2.Maintenance and Administrator will test the doors weekly to check alarms and make sure they are within the parameters for exit timing. Maintenance will oversee with Administrator to get the  appropriate company to look at the alarms.

3. Maintenance to test doors weekly for appropriate time for the alarm to go off.  Maintenance will document days tested and report to Administrator.

4. Maintenance, Administrator, to follow-through on timing of door alarms.  Maintenance will call for company to repair when needed, and report issue to Administator.  If Alarm is not working staff will need to watch doors, for any risks.   

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for non-healthcare areas for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to C 540 and C 555.

1.Per Oregon State reulations under Administrative responsibilbities, The Administrator must follow both the licensing rules for the facility and these rules, as outlined in the memory care regulations and assisted living regulations.Administrator has been consulted, and assistiing in learning how the regulations and licensing are implemented.

2.  Administrator training has been completed in the process of Memory Care licensure and regulations for Assisted Living..

3. Administrator will audit weekly through clinical area's and  RCM to ensure the complinance in all departments.

4. Administrator will be oversight in the area's and meet with staff to assist in any questions, and or area's of concern. . Administrator will check clincials area's for completeness.  

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to C 252, C 260, C 270, C 303 and C 310.

1. Administrator and RCM have set up times for Hydration at snack times and with meals,for hydration. Water with the meals and will be  available at all times. Residents will be offered water and juices with snacks and also at all 3 meals.

2. Caregivers will be trained on hydration changes with residents through RCM and Administrator to offer water at snack times and meals. RCM will montior the caregivers on hydration measures.

3.RCM will do daily walkthrough to see how the hydration program is going to ensure the residents are getting fluids appropriately and offered daily.

4. . Administrator will work with RCM for compliance with hydrations and water with juices offered at meal times.Administrator will do daily rounds to monitor the hydration for residents.  RCM will report if hydration is not getting met, through staff daily .

Based on interview and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan for each resident was developed and included in residents' service plans for 2 of 5 sampled residents (#s 3 and 5) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in February of 2022 with a diagnosis including dementia.

The facility failed to create a nutrition and hydration plan for Resident 3. There was no documented evidence the facility provided staff instructions related to individualized nutrition and hydration status and needs.

In an interview with Staff 1 (Administrator) on 03/15/22, she revealed the nutrition and hydration plan was created when the first service plan was completed after the first 30 days of move in.   

The need to develop individualized nutrition and hydration plans as part of the initial service plan was discussed with Staff 1 on 03/15/22. She acknowledged the findings.

2. Resident 5 was admitted to the facility in February 2022 with a diagnosis including Alzheimer's disease. Failure to thrive was noted on the resident's new move-in evaluation.  

There was no documented evidence the facility provided staff instructions related to individualized nutrition and hydration status and needs.

On 03/14/22, Staff 1 (Administrator) reported the facility does not create an initial service plan until the resident had been in the community for 30 days. The nutrition and hydration plan was part of the service plan that was created on the resident's 30th day of residing in the community.

The need to develop individualized nutrition and hydration plans as part of the initial service plan was discussed with Staff 1 and Staff 3 (Resident Care Manager) on 03/14/22. They acknowledged the findings.

1, Administrator will work with RCM/RCC/RN for updated information on service plans regarding Hydration, including nutrition. All service plans will be reviewed for hydration and nutrition for service plan compliance. Each service plan is individulized for nutrition, hydration, along with  nursing services.

2. RCM and Administrator will review service plans to assess any changes in hydration and nutrition.  Monthly audit on all service plans for completeness, and as they arise.

3. Clinical team will review on the 30 day service plan and 90 day service plans, as condition changes for resident

4. RCM/RCC/RN with Administrator will oversee the information regarding nutrition, and hydration for the new move-in and quarterly service plans..

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 2 of 5 sampled residents (#s 3 and 5) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 02/2022 with a diagnosis including dementia.

Resident 3's life history evaluation offered some information about the resident's interests, but 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 residents 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) on 03/15/22. She acknowledged the findings.

2. Resident 5 was admitted to the facility in 02/2022 with a diagnosis including Alzheimer's disease.

A document titled "Life Story" offered some information about the resident's past and current interests, however 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;

* Activities that could be used as behavioral interventions, and

* There was no initial service plan or activity plan created for the resident that documented the resident's activities of preference.

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 6 (Activities Director) on 03/15/22. They acknowledged the findings.

1. Activities has a new evaluation assessment for residents with person centered activites and emotional well-being.  Assessment will be completed on each resident. The evaluation/assessment will inlcude spirtual, cultural sensory, physicial activites and level of participation, life history, likes and dislikes,.

2. Administrator will oversee activites, and audit the new format to assure the activities director understands how  to use the evaluation and  capture the residents activity levels.

3. Activites will be notified when resident has a change of condition and re-assess the level of participation as of change of condition. Administrator will meet with activites and notify activites of the change.

4. Administrator will review activities. assessment/evalution upon new move-ins and resident changes in level of care.  .

2. Resident 3 was admitted to the facility in 02/2022 with a diagnosis including dementia.

Resident 3's record had documented behaviors including yelling, hitting staff and aggression towards staff.

Resident 3 did not have a service plan and there was no additional documentation which addressed the behaviors and there were no individualized interventions to assist staff in minimizing the negative impact of the behaviors.  

On 03/15/22 the need to develop individualized behavior plans for residents with behaviors was discussed with Staff 1 (Administrator). She acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to evaluate behavioral symptoms which negatively impacted the resident and others in the community and include information and instructions for staff on the service plan, for 2 of 2 sampled residents (#s 3 and 5) who had documented behaviors. Findings include, but are not limited to:

1. Resident 5 was admitted to the facility in 02/2022 with a diagnosis including Alzheimer's disease.

Resident 5's charting notes documented behaviors including exit seeking, wandering in other resident rooms and refusing to leave, crying, disorientation and agitation.

On 03/15/22, Resident 5 was observed upset and becoming agitated when Staff 19 (CG) intervened with reassurance and redirection. Staff 19 was observed spending a significant amount of time with the resident until s/he was calmed.

On 03/15/22, Staff 19 reported s/he was a new employee, didn't know the resident very well, there wasn't much information regarding the resident and s/he was just doing the best s/he could with the resident.

Resident 5 did not have an initial service plan and there were no temporary service plans that documented additional information and resident specific interventions to assist staff in minimizing the negative impact of the behaviors.  

On 03/15/22 the need to develop individualized behavior plans for residents with documented behaviors was discussed with Staff 1 (Administrator). She acknowledged the findings.

1. Administrator to work with RCM/RCC to assist staff in behavioral measures for resident. RCM will be contacting a outside behavior specialist for memory care to come and  in-service the staff. Staff will be showen on how to walk away and come back later when resident is upset and threatening. Service Plans will be addressed for behavior and interventions

2. In-service training from a behavioral specialist and complete service plans with addressing behaviors for staff.  Staff then will read service-plan for clarity for how to handle behaivors. Administrator to assist RCM in getting staff behavior training.

3.  Administrtator and clinical team will meet to discuss residents with behavior in the meeting daily. RCM/RCC and assitance from RN, will discuss the evaluation for residents with behaviors.

4. Administrator, clinical team RCC/RCM/RN, will complete service plans are updated with behaviors when needed, during there daily clinical meetings. .

Based on observation and interview, it was determined the facility failed to ensure furniture in the outdoor recreation areas was of sufficient weight and design to not aid in elopement. Findings include, but are not limited to:

On 03/14/22, a tour of the facility courtyard revealed round metal patio tables and chairs which were easily moveable and not of sufficient weight or design to prevent elopement.

On 03/15/22, the need to ensure furniture in the outdoor recreation areas was of sufficient weight and design to not aid in elopement was discussed with Staff 1 (Administrator) and Staff 6 (Maintenance Director). They acknowledged the findings.

1. Administrator and Maintenance are in contact with the Owner/Operator to get patio furniture non-removable. The facility fence is 8 feet,which is elevated more than the required 6 feet. Administrator and Maintenance will get professional assistance for evaluation of the patio furniture.

2. Maintenance will report to Administrator if any furniture has issues with repositioning on patio.

3. Once the furniture has been evaluated by a professional and owner/operator  Maintenance can report any deficiencies with the furniture to Administartor, if there is a failure.  

4. Maintenance will oversee the furniture of the community and report any issues to the Administrator who will contact the Owner/Operator.