The findings of the re-licensure survey, conducted 08/15/22 through 08/16/22, 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, Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.

Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.

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 08/16/22, conducted 01/30/23 through 02/01/23, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 57 for Memory Care Communities.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the second re-visit to the re-licensure survey of 08/16/22, conducted 05/03/23 through 05/04/23, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 57 for Memory Care Communities.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCCMemory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the third re-visit to the re-licensure survey of 08/16/22, conducted on 07/18/23, 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, Home and Community Based Services Regulations OARs 411 Division 004 and Division 57 for Memory Care Communities.

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

1. Observations of the memory care kitchenettes between 08/15/22 and 08/16/22 revealed the following:

Kitchenette  #1:

* The convection oven had food debris and splatter on the inside and outside surfaces of the unit;  

* The cupboards had residue around the handles and pealing laminate on multiple shelves;

* The carts holding clean dishes had debris on the sides and legs of cart;

* The drawers had food debris, spills and stains on the front surfaces and within the drawers;

* The glass back splash was missing a tile and had food splatter in multiple areas;

* Food splatter was noted on the ceiling above refrigerator number one, the bar area and steamtable;

* The steam table was missing the right control on the control panel;

* The seals on refrigerator number two and three had food debris;

* The cabinet walls underneath the bar area had food spills and debris;

* The microwave had food debris on inside sides and ceiling.

* Dirty and clean dishes were stored next to each other prior to food service.

Kitchenette #2:

* The steamtable had food debris in the water and brown markings in the wells;

* The cupboards had residue around the handles;

* The drawers had food debris, spills and stains on the front surfaces and within the drawers;

* The carts holding clean dishes had debris on the sides and legs of the cart;

* The bottom of the cabinet under the steamtable was broken;

* The tile back splash had flood splatters;

* The convection oven front and dials had food splatters;

* The freezer bottom had red, pink and brown spills; and

* A black cart had a broken middle shelf.

2. Observations of meal service on 08/15/22 and 08/16/22 showed:

* Multiple staff did not wash hands and/or change gloves between clean and dirty tasks including dirty dish removal, meal placement, moving chairs, unlocking cabinets and opening doors;

* Staff 12 did not change gloves and clean hands after escorting a resident to the dining room and to sit at a table. The staff assisted with opening a straw and placed in the resident's drink.

* Multiple food items were transported from one kitchenette to the other without any cover in place on the foods;

The areas in need of cleaning and repair and the need to ensure safe food handling practices was discussed with Staff 1 (MC Administrator) and Staff 3 (Corporate) on 08/16/22. They acknowledged the findings.

1. Kitchenette #1 convection oven has been cleaned, cupboard laminate had been repaired and residue on handles have been cleaned, dish carts have been cleaned, drawers have been cleaned on front surfaces and within, glass backsplash tile has been replaced and cleaned. Ceiling has been cleaned, steam table right control has been repaired, seals on refridgerator #2 and 3 have been cleaned, cabinet walls under bar area have been cleaned, dirty and clean dishes are no longer being stored next to each other.  Kitchenette #2 steam table has been cleaned, cupboards have been cleaned around handles, drawers have been cleaned on front surfaces and within, cart holding clean dishes has been cleaned, bottom of cabinet under steam has been repaired, tile backsplash has been cleaned, outside of convection oven has been cleaned, freezer bottom has been cleaned, black cart has been removed.  Staff have been educated on proper hand washing and glove usage, food is now covered during transport.

2. An environment and sanitation audit will be completed weekly by Memory Care Administrator and reported to Administrator

3. Audit will be completed weekly. These audits will be presented at quarterly QA meetings

4. Memory Care administrator to ensure compliance.  

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

1. Kitchenette one was toured on 01/30/23 at 10:29 am.

a. Observation revealed an accumulation of grease, food spills, splatters, loose food debris, dirt and/or dust on or underneath the following:

* Door jamb and door leading to dining room;

* Microwave;

* Backsplash tiles;

* Drawers;

* Cabinets;

* Shelving in cabinets;

* Convection oven;  

* Refrigerator one;

* Step stool;

* Wall and flooring near refrigerator two;

* Wheels, castors and shelving of carts; and

* Steam table.

b. The following kitchenette one items needed repair:

* Cabinet handle under steam table; and

* Shelving of cabinets had lifted laminate exposing bare wood.

2. Kitchenette two was toured on 01/30/23 at 10:40 am.

Observation revealed an accumulation of grease, food spills, splatters, loose food debris, dirt and/or dust on or underneath the following:

* Wall near entrance to kitchenette;

* Steam table;

* Convection oven;

* Shelving near convection oven;

* Drawers;

* Shelving in cabinets;

* Flooring throughout kitchenette; and

* Wheels, castors and shelving of cart.

The areas in need of cleaning and repair were discussed with Staff 16 (Memory Care Administrator) on 01/31/23 at 2:30 pm. She acknowledged the findings.

1. Kitchenette #1 *Door jam and door leading to dining room cleaned, *Microwave cleaned. *Backsplash tiles cleaned, *Drawers cleaned, *cabinets cleaned, *Shelving in cabinets cleaned, *Convection oven cleaned, *Refrigerator one cleaned, items labeled.  *Step stool cleaned, *Wall and flooring near refrigerator #2 cleaned, *Wheels, castors, and shelving of carts cleaned, *Steam table cleaned.

Kitchenette #2 *Wall near entrance to Kitchenette cleaned, *Steam table cleaned, *Convection oven cleaned, *Shelving in cabinets cleaned, *Flooring throughout kitchenette cleaned, *Wheels, castors, and shelving of cart cleaned.  

2. An environment and sanitation audit will be completed weekly by Memory Care Administrator and reported to Administrator

3. Audit will be completed weekly. These audits will be presented at quarterly QA meetings

4. Memory Care administrator to ensure compliance.  

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

1. Resident 1 was admitted to the facility in May 2021 with diagnoses including Alzheimer's disease.

Observations of the resident, interviews with staff, and review of the resident's service plan dated 05/06/22 and progress notes dated 05/01/22 to 08/15/22 showed the service plan was not reflective, did not provide clear direction to staff and/or was not followed in the following areas:

* Hoyer lift vs. Sit to Stand lift use;

* Number of staff used with each lift type;

* Strap placement for lift safety and colostomy protection;

* Behaviors including hallucinations, striking out and agitation;

* Skin injury, scratching and picking at skin;

* Weekly weights;

* Edema and elevation of legs; and

* Refusal of care and repositioning.

The need to ensure resident service plans were reflective of current care needs, provided direction to staff and were consistently followed was discussed with Staff 1 (MC Administrator), Staff 3 (Corporate), Staff 4 (RN Consultant) and Staff 5 (RN Consultant) on 08/16/22. They acknowledged the findings.

2. Resident 2 was admitted to the facility in December 2021 with diagnoses including dementia.

Observations of the resident, interviews with staff, and review of the resident's service plan dated 07/18/22 and progress notes dated 05/01/22 to 08/15/22 showed the service plan was not reflective of the resident's current care needs, did not provide clear direction to staff and/or was not followed in the following areas:

* Puree vs Mechanical soft diet texture;

* Divided plate use;

* Choking and coughing with intake;

* Non-drug interventions for chronic pain;

* Fall risk, safety interventions and therapy instructions; and

* Toileting assistance.

The need to ensure resident service plans were reflective of current care needs, provided direction to staff and were consistently followed was discussed with Staff 1 (MC Administrator), Staff 3 (Corporate), Staff 4 (RN Consultant) and Staff 5 (RN Consultant) on 08/16/22. They acknowledged the findings.

1.Resident #1 service plan was reviewed and updated in the following areas. * Hoyer lift vs. Sit to Stand lift use; * Number of staff used with each lift type; * Strap placement for lift safety and colostomy protection; * Behaviors including hallucinations, striking out and agitation; * Skin injury, scratching and picking at skin; * Weekly weights; * Edema and elevation of legs; and * Refusal of care and repositioning. Resident #2 service plan was reviewed and updated in the following areas. * Puree vs Mechanical soft diet texture; * Divided plate use; * Choking and coughing with intake; * Non-drug interventions for chronic pain; * Fall risk, safety interventions and therapy instructions; and * Toileting assistance.

2.Service plan Audits will be completed by Memory Care Administrator quarterly and at all COC to ensure all components are included.

3.Audits will be completed and presented at quarterly QA meetings

4. Memory Care Administrator to ensure compliance.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction regarding the delivery of services and/or were followed by staff for 1 of 2 sampled residents (#5) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 5 was admitted to the MCC in 07/2020 with diagnoses including Parkinson's disease.

Observations of the resident, interviews with staff and review of the resident's service plan, dated 01/26/23, revealed the service plan was not reflective, did not provide clear direction to staff and/or was not followed in the following areas:

* Heel protectors;

* Location of incontinent care;

* Straws;

* Adaptive equipment to minimize hand contractures;

* Mildly thick versus thin liquid consistency; and

* Health shakes.

The need to ensure resident service plans were reflective of current care needs, provided clear direction to staff and were consistently followed was discussed with Staff 16 (Memory Care Administrator) on 02/01/23 at 9:56 am. She acknowledged the findings.

Resident #5 service plan was reviewed and updated in the following areas *Heel protectors added to Service plan, * Location of incontinent care-instructions added to care plan, *Use of straws updated in Service plan, *Use of adaptive equipment for hand contractures updated in care plan, *Clear instructions for mildly thick versus thin consistency in care plan, * Health shakes instructions updated in care plan per.

2.Service plan Audits will be completed by Memory Care Administrator quarterly and at all COC to ensure all components are included.

3.Audits will be completed and presented at quarterly QA meetings

4. Memory Care Administrator to ensure compliance.

Based on interview and record review, it was determined the facility failed to ensure residents who had short term changes of condition were evaluated, resident-specific instructions or interventions were developed, the condition was monitored at least weekly to resolution and that interventions were re-evaluated to determine effectiveness for 2 of 2 sampled residents (#s 1 and 2) who experienced changes of condition.

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

Observations of the resident, interviews with staff, review of the service plan dated 05/06/22, temporary service plans, incident investigations and progress notes dated 05/01/22 through 08/15/22 were reviewed.

The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness and/or lacked resident-specific directions to staff in the following areas:

* Multiple medication order changes;

* Missed medications and refused medications;

* Behaviors, refusing care and aggressiveness;

* Skin injuries, edema and "purple feet;" and

* Antibiotic use and foot soaks.

The need to ensure short-term changes of condition had documentation to reflect monitoring at least weekly to resolution, provided clear, resident-specific directions to staff and that interventions were evaluated for effectiveness was discussed with Staff 1 (MC Administrator), Staff 3 (Corporate), Staff 4 (RN Consultant) and Staff 5 (RN Consultant) on 08/16/22. They acknowledged the findings.

2. Resident 2 was admitted to the facility in December 2021 with diagnoses including dementia.

Observations of the resident, interviews with staff, review of the service plan dated 07/18/22, temporary service plans, incident investigations and progress notes dated 05/01/22 through 08/15/22 were reviewed.

The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness and/or lacked resident-specific directions to staff in the following areas:

* Medication order changes;

* Missed medications;

* Urinalysis and potential UTI;

* Coughing up phlegm;

* Falls;

* Back and neck pain; and

* Skin injuries.

The need to ensure short-term changes of condition had documentation to reflect monitoring at least weekly to resolution, provided clear, resident-specific directions to staff and that interventions were evaluated for effectiveness was discussed with Staff 1 (MC Administrator), Staff 3 (Corporate), Staff 4 (RN Consultant) and Staff 5 (RN Consultant) on 08/16/22. They acknowledged the findings.

1.Resident #1 and #2 short term problems were assessed by the RN to ensure monitoring was no longer needed.

2.In-service to be completed with med-techs on how to document and evaluate residents who are on alert monitoring for short term problems/conditions and when to notify the RN.

RN or designee to review 24-hour report and complete the follow-up tool to ensure short term problems/concerns have been charted on appropriately and initiate final LN assessment for closure to problem.

3. Monthly audits will be completed by Director of nursing to ensure that monitoring of any new change of conditions have been completed and that all skin checks have been completed timely and interventions put in place and communicated to staff. Audit details to be reported at quarterly QA meeting.

4. Director of nursing to ensure compliance

Based on interview and record review, it was determined the facility failed to ensure residents who had short-term changes of condition were evaluated, resident-specific instructions or interventions were developed, the condition was monitored at least weekly to resolution and interventions were re-evaluated to determine effectiveness for 2 of 2 sampled residents (#s 4 and 5) who experienced short-term changes of condition. This is a repeat citation. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 03/2015 with diagnoses including dementia.

Observations of the resident, interviews with staff, review of the service plan dated 01/25/23, temporary service plans, incident investigations and progress notes dated 10/2022 through 01/2023 were reviewed.

The resident experienced multiple short-term changes of condition without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness and some lacked resident-specific directions to staff in the following areas:

* Multiple medication order changes;

* Missed medication; and

* Skin injuries and edema.

The need to ensure short-term changes of condition had documentation to reflect monitoring at least weekly to resolution, provided clear, resident-specific directions to staff, and interventions were evaluated for effectiveness was discussed with Staff 16 (Memory Care Administrator) on 02/01/23. She acknowledged the findings.

2. Resident 5 was admitted to the MCC in 07/2020 with diagnoses including Parkinson's disease.

Observations of the resident, interviews with staff, review of the resident's service plan dated 01/26/23, temporary service plans, incident investigations and progress notes dated 10/2022 through 01/2023 were reviewed.

The following short-term changes of condition lacked documentation of monitoring, at least weekly, through resolution:

* 10/28/22 - Tramadol changes;

* 11/03/22 - Flu and COVID vaccines;

* 11/15/22 - Increased restlessness with attempts to get out of bed;

* 11/26/22 - Quetiapine changes;

* 12/09/22 - Fall;

* 01/10/23 - Initiating docusate sodium; and

* 01/17/23 - Initiating polyethylene glycol.

The need to ensure short-term changes of condition had documentation to reflect monitoring at least weekly to resolution was discussed with Staff 16 (Memory Care Administrator) on 02/01/23. She acknowledged the findings.

Resident #4 and #2 short term problems were assessed by the RN to ensure monitoring was no longer needed.

2.In-service to be completed with med-techs on how to document and evaluate residents who are on alert monitoring for short term problems/conditions and when to notify the RN. Example charting posted in Med Room for reference.

RN or designee to review 24-hour report and complete the follow-up tool to ensure short term problems/concerns have been charted on appropriately and initiate final LN assessment for closure to problem. RN to complete Role of the RN education.

3. Weekly check ins done with Administrator and RN to ensure all documentation is completed. Monthly audits will be completed by Director of nursing to ensure that monitoring of any new change of conditions have been completed and that all skin checks have been completed timely and interventions put in place and communicated to staff. Audit details to be reported at quarterly QA meeting.

4. Director of nursing to ensure compliance

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 sampled newly hired, direct care staff (#s 10, 13 and 14) completed abdominal thrust and First Aid training within the required 30 days of hire. Findings include, but are not limited to:

Training records were reviewed on 08/16/22 revealing the following:

1. Staff 10 (CG) hired 06/01/22 and Staff 14 (MT) hired 07/05/22, lacked documented evidence of First Aid and abdominal thrust training.

2. Staff 13 (MT) hired 06/27/22 lacked documented evidence of First Aid training.

The need to ensure newly-hired direct care staff completed abdominal thrust and First aid training within 30 days of hire was reviewed with Staff 1 (MC Administrator) and Staff 3 (Corporate) on 08/16/22. They acknowledged the findings.

1. Staff #10 and #14 will complete first aide and abdominal thrust training. Staff# 13 will complete first aide training.

2. A training program and audit tool has been created utilizing a separate training binder and spread sheet to ensure all trainings and certificates are recieved and filed away in the employees training folder.

3. A training binder audit will be completed monthly with finding being reported to the administrator and staffing coordinator.  These finding will also be reported on Quarterly QA meetings.

4. The human resource director in collaboration with the staffing coordinator will be reposnsible to ensure that all trainings are completed timely or staff member will be removed from the schedule until such trainings have been completed.              

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 sampled newly-hired direct care staff (#s 17 and 18) completed abdominal thrust and First Aid training within the first 30 days of hire. This is a repeat citation. Findings include, but are not limited to:

Training records were reviewed on 01/31/23 and revealed the following:

There was no documented evidence Staff 17 (CG), hired 10/27/22, and Staff 18 (CG), hired 10/11/22, completed First Aid and abdominal thrust training within the first 30 days of hire.

The need to ensure newly-hired direct care staff completed abdominal thrust and First aid training within 30 days of hire was reviewed with Staff 16 (Memory Care Administrator) on 02/01/23. She acknowledged the findings.

Staff #17 and #18 will complete first aide and abdominal thrust training.

2. A training program and audit tool has been created utilizing a separate training binder and spread sheet to ensure all trainings and certificates are recieved and filed away in the employees training folder.

3. A training binder audit will be completed monthly with finding being reported to the administrator and staffing coordinator.  These finding will also be reported on Quarterly QA meetings.

4. The human resource director in collaboration with the staffing coordinator will be reposnsible to ensure that all trainings are completed timely or staff member will be removed from the schedule until such trainings have been completed.              

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 sampled newly-hired direct care staff (#s 19 and 20) completed abdominal thrust and First Aid training within the first 30 days of hire. This is a repeat citation. Findings include, but are not limited to:

Training records were requested on 05/04/23 and identified the following:

There was no documented evidence Staff 19 (CG), hired 03/07/23, and Staff 20 (CG), hired 03/01/23, completed First Aid and abdominal thrust training within the first 30 days of hire.

The need to ensure newly-hired direct care staff completed abdominal thrust and First aid training within 30 days of hire was reviewed with Staff 3 (Administrator) and Staff 16 (MCC Administrator) on 05/04/23. They acknowledged the findings.

1.Direct Care staff #19 and 20 completed abdominal thrust and First Aide training.  

2. Bussiness office manager will review and complete checklist for all necessary trainings for all current and incoming staff in Memory care.  Any trainings not completed for MC staff will be completed and updated.

3. Bussiness office Manager will check on MC files weekly to ensure correct progress made to ensure all trainings completed within the first 30 days.

4. Bussiness office manager and Administrator will meet The 1st Tuesday of every week until charts up to date then will meet every month to check in on trainings to ensure all is up to date.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted every other month, included required components on fire drill records, and provided fire life safety instruction to staff on alternating months. Findings include, but are not limited to:

On 08/15/22, fire drill and fire/life safety training records for the previous six months were requested.

Review of the documentation provided identified the following:

* One fire drill had been completed during the six-month time frame reviewed;

* Fire drill records lacked the following components:

- Escape route used;

- Problems encountered, comments relating to residents who resisted or failed to participate in the drills;

- Evacuation time-period needed;

- Number of occupants evacuated; and

- Evidence alternate routes were used during fire drills.

* Fire and life safety instruction was not provided to staff on alternating months of fire drills.

The requirements regarding fire drills and fire and life safety instruction for staff were reviewed with Staff 1 (MC Administrator) and Staff 3 (Corporate) on 08/16/22. They acknowledged the findings.

1. A fire drill will be completed on a monthly basis moving forward. Fire drill records will include the following components moving forward: Escape route used, problems encountered (with comments relating to residents who resisted or failed to participate), the evacuation time period needed, the number of occupants evacuated if available, and evidence that alternative routes were used during drill.  Fire and life safety instruction will also be provided to staff.

2. Maintenance director and Administrator will execute monthly fire drills ensuring that all shifts are covered over a three month time period and that all components to the drill will be completed and documented. This will be recurring throughout the year.

3. Drill will be executed monthly. Findings will be reported at quarterly QA meeting

4. Maintenance director and Administrator will ensure compliance

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted every other month and fire and life safety instruction was provided to staff on alternating months. This is a repeat citation. Findings include, but are not limited to:

On 01/31/23, fire drill and fire and life safety training records since 10/15/22 were requested.

Review of the documentation provided identified the following:

* No fire drills had been completed on the memory care during the time frame reviewed; and

* Fire and life safety instruction was not provided to staff on alternating months of fire drills.

The requirements regarding fire drills and fire and life safety instruction for staff were reviewed with Staff 16 (Memory Care Administrator) on 02/01/23. She acknowledged the findings.

A fire drill training/drill will be completed on a monthly basis moving forward. Alternating months between education and active practice drills. Fire drill records will include the following components moving forward: Escape route used, problems encountered (with comments relating to residents who resisted or failed to participate), the evacuation time period needed, the number of occupants evacuated if available, and evidence that alternative routes were used during drill.  Fire and life safety instruction will also be provided to staff.

2. Maintenance director and Administrator will execute monthly fire education/drills ensuring that all shifts are covered over a three month time period and that all components to the drill will be completed and documented. This will be recurring throughout the year.

3. Drill will be executed bi monthly with training education alternating months from active drills. Findings will be reported at quarterly QA meeting

4. Maintenance director and Administrator will ensure compliance

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

Refer to C 240, C 260, C 270, C 372, C 420, C 513, Z 142 and Z 162.

Refer to C 240, C 260, C 270, C 372, C 420, C 513, Z 142 and Z 162.

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

Refer to C372 and Z142.

Refer to C372 and Z142

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

Observations of the facility on 08/15/22 and 08/16/22 showed the following areas in need of cleaning or repair:

1. Kitchen #1

* The double door to the courtyard was scuffed exposing metal underneath, the kickplate on both doors had blue splatter;  

* Food debris on cabinet next to courtyard double door; and

* The back of coffee bar cabinet next to the public restroom was gouged exposing wood underneath.

2. Living room

* White spills down right cabinet in living room next to blue recliner;

* The right window seal had a gouge exposing metal material underneath;

* The blue recliner chair had white stains on the seat cushion and right arm rest;

* The two brown couches legs were gouged and in poor repair;  

* The black leather chair fabric was worn off on the arm rest, seat, and back cushion exposing different material underneath; and

* The red chair had stains on the arm rest and cushion.

3. Community areas

* The handrail next to room 346 was loose and detaching from wall;

* Room 346 plexiglass cover over the door was scratched and gouged causing a hole approximately one inch by one inch;

* The public restroom door was scuffed;

* The public restroom fan had dusty debris build up;

* The laundry room door was scuffed and gouged exposing wood underneath;

* The carpet had multiple white stains by rooms 332, 335 and the blue couch at the end of the hallway;

* Multiple ceiling tiles throughout the community had brown stains;

* The ceiling vent by blue couch had dust debris build up;

* The community had six brown pattern chairs with wood arms, arms were in poor condition exposing wood underneath; and

* Sit to stand machine had debris on foot well and blue tape wrapped around upper portion of the lift.

The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (MC Administrator) and Staff 3 (Corporate) on 08/16/22.  They acknowledged the findings.

1. Kitchenette #1 double door to the courtyard metal underneath was replaced, cabinet next to courtyard double door has been cleaned, back of coffee bar cabinet has been repaired, cabinet in living room has been cleaned, right window seal patched, Blue recliner chair will be removed and replaced, two brown couch legs will be resurfaced and repaird, black leather chair will be removed and replaced, red chair will be removed and replaced. Handrail next to room 346 has been repaired. 346 plexiglass cover over door has been replaced. Public restroom door has been repaired, public restroom fan has been cleaned, Carpet will be replaced, Ceiling Panels will be repainted, Ceiling vent by blue couch has been cleaned, Brown pattern chairs have been removed and replaced, Sit to Stand has been cleaned and tape has been removed.

2. Daily walk throughs will be preformed. An environment and sanitation audit will be completed weekly by Memory Care Administrator and reported to Administrator

3. Audit will be completed weekly. These audits will be presented at quarterly QA meetings

4. Memory Care administrator to ensure compliance.  

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

In an interview on 02/01/23, Staff 16 (Memory Care Administrator) acknowledged the findings and confirmed the facility had been granted an extension until 03/15/23 to complete maintenance and replacement of the facility carpet.

1. Kitchenette #1 double door to the courtyard metal underneath was replaced, cabinet next to courtyard double door has been cleaned, back of coffee bar cabinet has been repaired, cabinet in living room has been cleaned, right window seal patched, Blue recliner chair will be removed and replaced, two brown couch legs will be resurfaced and repaird, black leather chair will be removed and replaced, red chair will be removed and replaced. Handrail next to room 346 has been repaired. 346 plexiglass cover over door has been replaced. Public restroom door has been repaired, public restroom fan has been cleaned, Carpet will be replaced, Ceiling Panels will be repainted, Ceiling vent by blue couch has been cleaned, Brown pattern chairs have been removed and replaced, Sit to Stand has been cleaned and tape has been removed.

2. Daily walk throughs will be preformed. An environment and sanitation audit will be completed weekly by Memory Care Administrator and reported to Administrator

3. Audit will be completed weekly. These audits will be presented at quarterly QA meetings

4. Memory Care administrator to ensure compliance.  

Based on 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 C 240, C 372, C 420 and C 513.

Refer to POC for C240, C372, C420 and C513

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:

Refer to C 240, C 372, C 420 and C 513.

Refer to POC for C240, C372  C420 and C513

Based on interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:

Refer to C 372.

Refer to C372

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired direct care staff (#s 10, 13 and 14) completed all required orientation, pre-service and competency training within required timelines, and 2 of 2 long term staff (#s 6 and 12) had 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 on 08/16/22. The following deficiencies were identified:

1. Staff 10 (CG), hired 06/01/22, Staff 13 (MT), hired 06/27/22, and Staff 14 (MT), hired 07/05/22, lacked documentation that all required pre-service orientation training was completed prior to staff working on the floor.

2. There was no documented evidence Staff #s 10, 13 and 14 demonstrated competency in their job duties within 30 days of hire in the following 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; and

* General food safety, serving and sanitation.

3. Staff 6 (CG), hired 03/24/21, and Staff 12 (CG), hired 05/18/17, lacked documented evidence of completing the required annual in-service training hours.  Additionally, Staff 12 failed to complete the required annual dementia training.

The need to ensure pre-service orientation, 30 day competencies and annual training requirements were completed in the required time frames was discussed with Staff 1 (MC Administrator) and Staff 3 (Corporate) on 08/16/22. They acknowledged the findings.

1.Staff #10 and #13 will complete required pre-service orientation training. Staff #10,#13 and #14 will complete documentation of job competency in all required areas. Staff # 6 and #12 will have documented evidence of completing the annual in-service training hours. Staff 12 will complete required annual dementia training.

2. A training program and audit tool has been created utilizing a separate training binder and spread sheet to ensure all trainings and certificates are recieved and filed away in the employees training folder.  

3. A training binder audit will be completed monthly with finding being reported to the administrator and staffing coordinator.  These finding will also be reported on Quarterly QA meetings.

4. The human resource director in collaboration with the memory care administrator will be reposnsible to ensure that all trainings are completed timely or staff member will be removed from the schedule until such trainings have been completed.                

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 260 and C 270.

Refer to POC for C260 and C270

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

Refer to C 260 and C 270.

Refer to POC for C260 and C270

Based on observation, interview and record review, it was determined the facility failed to consistently provide meaningful activities for all residents that promoted or helped sustain the physical and emotional well-being of the resident and failed to ensure an individualized activity plan was developed for each resident based on their activity evaluation, for 2 of 2 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to:

Resident 1 and 2's service plans 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 resident with more individualized activities.

Observations on 8/15/22 and 8/16/22 showed several small group activities being led by facility staff. Residents 1 and 2 were present at the activities but spent most of the time with their eyes closed or sleeping rather than engaged in the activity.  

The need to ensure all residents had individualized activity plans developed and implemented to engage them in meaningful activities was discussed with Staff 1 (MC Administrator), Staff 3 (Corporate), Staff 4 (RN Consultant) and Staff 5 (RN Consultant) on 08/16/22. The staff acknowledged the findings.

1. Resident 1 and 2's service plans have been updated to include * 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.

2.Individual activity plans and needs will be audited quartely during Service Plan audits as well as the Memory Care Activities Coordinator and Memory Care Administrator will meet monthly to discuss any changes in skills, ability, interest, behaviors, etc.

3. Audits will be preformed quarterly. Findings will be shared with the Administrator. These findings will be discussed at quarterly QA meeting.

4. Memory Care Administrator will ensure compliance.

Based on observation and interview, it was determined the facility failed to individually identify residents' rooms to assist residents in recognizing their room. Findings include, but are not limited to:

The memory care unit was toured on 08/15/22. Resident rooms 331A, 331B, 332A, 332B, 336A, 336B, 333B, 349, 348, 347, 344A, 344B, and 342B lacked individualized identification markers required to assist residents in recognizing their rooms.

The need to ensure each resident room was identified for the resident was reviewed with Staff 1 (MC Administrator) and Staff 3 (Corporate) on 08/16/22. They acknowledged the findings.

1. Individual identifiers will be added to shadow box in front of residents rooms 331A,331B,332A,332B,336A,336B,333B,349,348,347,344A,344B, and 342B.

2. Upon move-in. Residents will be interviewed and asked questions "about-me" to create a collage of pictures at move-in to place in residents shadow box. Family will be asked for pictures and/or recognizable items to add to box as well. Memory Care Administrator will complete a monthly walk through to ensure shadow boxes have individual identifiers as well as any updates are made that may need to be made.

3.Audits will be completed monthly during walk through. These findings will be reported discussed at quartely QA meetings.

4.Memory Care Administrator will ensure compliance.