The findings of the Change of Ownership Survey, conducted 04/11/22 through 04/12/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.

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

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first re-visit to the re-licensure survey of 04/12/22, conducted 07/06/22, 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 and OARs 411 Division 57 for Memory Care Communities.

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

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCCMemory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the second revisit to the re-licensure survey of 04/12/22 conducted 09/01/22 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 and OARs 411 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 in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:

During a tour of the main kitchen located in the north building, on 04/11/22 at 10:30 am, it was determined the following areas were in need of cleaning or repair:

* The flooring near the dishwashing area, food prep area, and around multiple floor drains was cracked or missing floor covering that exposed the subfloor underneath;

* Multiple areas of floor baseboards had pulled away from the wall and floor seams were separating where debris could accumulate;

* Multiple floor drains had an accumulation of black and brown matter;

* The metal grease trap door located on the floor (near the Hobart mixer) had a buildup of rust and was separating away from the floor, which rendered the floor in this area uncleanable;

* The walls and shelving in the dishwashing area, next to the grill and underneath the service counter had a buildup of food debris and splattered food matter;

* The wall behind the food prep table, wall mounted spice rack, and coffee cart had a buildup of brown matter and dust;

* The Hobart (industrial) mixer, Vitamix blender and multiple toasters had food particle buildup;

* The ice machine had a side vent that was covered with dust debris. The vent blew air directly on the Hobart mixer;

* The faucet for the hand washing sink (located near the walk-in refrigerator), had a hole caused by corrosion;

* The walk-in refrigerator vent had dust debris that blew directly on food storage areas;

* Meat and other food items were stored on trays or bins on the floor in the walk-in refrigerator;

* Various meat products were piled into one bin, each at varied stages of thaw. The meat products were resting in a bloody water substance and some products were not labeled, dated or shelved to allow air circulation;

* The walk-in freezer had food spillage buildup on the floor;

* A gray metal shelf that stored grains and dried goods had an accumulation of food matter buildup and rust, which rendered the surface uncleanable;

* The grease trap on the grill was not working properly and caused a large amount of grease accumulation inside the oven and down the right side of the oven door;

* The stove top, grill hood vents and wall behind the grill/stove had an accumulation of food and grease matter;

* The ceiling ventilation unit and surrounding ceiling above the steam table had an accumulation of dust and condensation that was dropping onto a stack of clean plates, plate warmer and the top of the steam table;

* Ceiling and ceiling vent above coffee cart had an accumulation of dust buildup and rust;

* Ceiling above ice machine had peeling paint and exposed sheet rock;

* Ceiling light fixture (above ice machine) had a missing light fixture cover;

* A stool in the kitchen had a ripped seat, rendering the surface uncleanable;

* Brooms, dust pans and a mop bucket were not stored properly in a janitor's closet; and

* The janitor's closet had black matter substance on the walls and was being used to store multiple empty boxes and milk jugs.

On 04/11/22, at 11:30 am, the kitchen was toured and findings were discussed with Staff 4 (Kitchen/Maintenance Manager) and Staff 2 (Executive Director). They acknowledged the findings.

Corrective Action: 1. Flooring; All flooring has been caulked, sealed and new trim added to areas that were pulling away or breaking down. 2. Cleaning, vents and surfaces; being added to a daily/weekly accountability sheet for cleaning and sign off. 3. Rust; any areas of rust have been painted over and sealed with polyurathane to create cleanable surface. 4. Grease; all equipment will be cleaned daily, after use, or weekly depending on product and job funtion. 5. Food Storage; adding an additional shelving so all product can be stored separeately. 6. Dripping Overhead; Plexi-glass added to sides of serving rack to protect servig area and sign to instruct where to serve, and what area to avoid. 7. Janitor Closet; bracket being added to hang mop and broom and sign being added for no additional product or equipment to be in this area. Future Violation Prevention; Accountability cleaning sheet added to daily and weekly routine with specified areas outlined. Continued Evalution; inspection area added to accountability sheets for Executive Director and Kitchen Manager to sign off. Responsible Party: Kitchen Staff, Kitchen Manager to inspect.  

Based on interview and record review, it was determined the facility failed to ensure resident evaluations addressed all required elements for 3 of 3 sampled residents (#s 1, 2 and 3) whose new move-in or quarterly evaluations were reviewed. Findings include, but are not limited to:

1. Resident 3 was admitted in 03/2022.

The new move-in evaluation failed to address the following areas:

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

* Environmental factors that impact the resident's behavior including noise, lighting and room temp.

The need to ensure move-in evaluations included all required components was discussed with Staff 1 (Administrator) on 04/12/22. She acknowledged the findings. No further information was provided.

2. Resident 1 was admitted to the facility in 2015 with diagnoses which included Alzheimer's dementia, diabetes and anxiety.

The most recent quarterly evaluation, dated 01/2022, did not address the required elements in the following areas:

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

On 04/12/22, the need to ensure Resident 1's quarterly evaluation addressed all required components was discussed with Staff 1 (Administrator). She acknowledged the findings. No other information was shared.

3. Resident 2 was admitted to the memory care facility in 04/2021 with a diagnosis of Alzheimer's disease.

The quarterly evaluation failed to address the following areas:

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

* Environmental factors that impact the resident's behavior including noise, lighting and room temp.

The need to ensure evaluations included all required elements was discussed with Staff 1 (Administrator) on 04/12/22. She acknowledged the findings. No further information was provided.

Corrective Action: Personality section and environmental section added to evalutiaon. Sections specify Personality and behaviors or mood changes associated with changes. As well as environmental stimuli affecting moods and behaviors, i.e., smell, visual, hearing, etc.

Future Violation Prevention: If all information isn't available during initial evaluation, area will be flagged, information requested, added, then flag removed after being complete.

Continued Evalutation: All necessary areas have been added to evalutation and areas will be flagged and completed before move-in.

Responsible Party: RCC, RN and Executive Director.

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

During the acuity interview on 04/11/22, Resident 1 was identified to be administered insulin injections by non-licensed staff.

Review of Resident 1's delegation documentation during the survey revealed the following:

a. Re-delegations for Staff 8 (MT) completed by Staff 10 (Nurse Practitioner/VP Clinical) on 12/13/21, lacked documentation in the following areas:

* Date when nursing assessment of the client was completed;  

* How frequently the resident should be reassessed by the RN, including rationale for the frequency based on the client's needs; and

* How frequently the unlicensed person should be supervised and re-evaluated, including rationale for the frequency based on the competency of the caregiver.

b. The initial delegation for Staff 9, completed by Staff 10 on 12/13/21, lacked documentation in the following areas:

* Date when nursing assessment of the client was completed;  

* How frequently the resident should be reassessed by the RN, including rationale for the frequency based on the client's needs; and

* Frequency and rationale for how often the unlicensed person(s) should be supervised and reevaluated based on the competency of the caregiver.

c. According to the OSBN Division 47 Delegation Rules, "if the delegating and supervising nurses are two different individuals, the following shall occur:

* The reasons for the separation of delegation and supervision shall be justified from the standpoint of delivering effective client care;

* The justification shall be documented in writing;

* The supervising nurse agrees, in writing, to perform the supervision; and

* The supervising nurse is either present during teaching and delegation or is fully informed of the instruction, approves of the plan for teaching and agrees that the unlicensed person is taught the task of nursing care is competent to perform the task."

During an interview with Staff 3 (RN) on 04/12/22 at 10:30 am, she stated Staff 10 delegated Staff 8 and 9, but she provided the supervision. Review of delegations for Staff 8 and 9 revealed no documentation regarding the separation of delegation and supervision. A copy of OSBN Division 47 was provided and reviewed with Staff 3. She acknowledged that documentation requirements for separation of delegation and supervision had not been completed.

The need to ensure staff who administered insulin injections were appropriately delegated in accordance with OSBN Division 47 Rules was discussed with Staff 1 (Administrator) on 04/12/22. She acknowledged the findings.

Corrective Action: RN actively in building and caring for residents will be transferring over all delegation related tasks.

Future Violation Prevention: Regional team made aware of all OSBN requirement for RN team and procedure moving forward for LTC. New auditing tool to catch incoming and out going nurse needs being implemented.

Continued Evaluation: Tool to be made available to all Executive Directors, Administrators and RCC's to keep community in compliance.

Responsible Party: Administrator and RN

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

During the acuity interview on 07/06/22, Resident 1 was identified to be administered insulin injections by non-licensed staff.

Resident 1's MARs, reviewed from 06/01/22 through 07/06/22, revealed the following:

* The resident received Lantus (insulin to treat diabetes) once daily; and

* The insulin had been given by Staff 8 (MT), Staff 9 (MT) and Staff 11 (MT) on multiple occasions.

Review of Resident 1's delegation documentation during the survey revealed the following:

a. Initial delegation for Staff 8 and Staff 9 was completed by Staff 3 (RN) on 04/27/22. There was no documented evidence how frequently the resident should be reassessed by the RN; and

* Staff were to be scheduled for re-evaluation in 60 days which was approximately 06/26/22. There was no documented evidence the facility RN re-evaluated Staff 8 and 9's skills and ability as of 07/06/22.

b. Initial delegation for Staff 11 was completed by Staff 3 on 05/04/22. There was no documented evidence how frequently the resident should be reassessed by the RN; and

* Staff 11 was scheduled for re-evaluation in 60 days which was approximately 07/03/22. There was no documented evidence the facility RN re-evaluated Staff 11's skills and ability as of 07/06/22.

On 07/06/22, the need to ensure all staff who administered insulin injections were appropriately delegated and documented in accordance with OSBN Administrative Rules was discussed with Staff 1 (Administrator) and Staff 3. They acknowledged the findings.

1. All staff have been redelegated by new on coming RN and new RN has been trained on the importance of delegations being on time, and recorded what time frame redelegation will be held on. Sheets have been updated to reflect redelegation dates.

2. The RN has updated dates and created a spread sheet that is trackable for when redelegation is due.

3. Currently we are auditing weekly for the first 90 days, to ensure all residents have been delegated on, and staff that are able to administer are all within their delegation time period and can show competency.

4. Regional Director of Operations, Admin or designee, RN

2. Resident 1 was admitted in 2015 with diagnoses including Alzheimer's dementia.

Residents 1's physician orders and MARs were reviewed from 03/01/22 through 04/10/22 and the following was noted:

* The resident had orders for PRN Tylenol, PRN Tylenol suppository and PRN tramadol for pain. The MARs lacked resident-specific instructions for the multiple PRN pain medications, including sequential order of use.

The need to ensure there were clear parameters for staff when administering multiple PRN medications for the same condition was discussed with Staff 1 (Administrator) on 04/12/22 at 2:00 pm. No further information was provided.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included resident-specific parameters for PRN medications for 2 of 2 sampled residents (#s 1 and 2) whose medications were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the memory care facility in 04/2021 with a diagnosis of Alzheimer's disease.

Resident 2's 03/01/22 through 04/11/22 MARs were reviewed during the survey. The following PRN medications lacked clear parameters for administration:

* PRN Tylenol 300-30 mg, PRN biofreeze roll-on gel, PRN Ibuprofen 400 mg, and PRN tramadol 50 mg were all prescribed to treat pain and lacked clear parameters for the sequence of administration.

The need to ensure MARs included clear parameters for multiple PRN medication that were prescribed to treat the same condition was discussed with Staff 1 (Administrator) on 04/12/22. She acknowledged the findings.

Corrective Action: RN to review all PRN medication to specify order of use if "pain complaint" is generated so staff have clear written instructions on order of use.

Future Violation Prevention: RN will review all medications upon receiving for new orders and assign nursing note with insturctions of use. RCC when reviewing med orders will send a note to RN with notification review is needed and use newly created stamp that will alert the med-techs and staff RN must address and sign off on before filing.

Continued Evaluation: Alerting pharmacy consultants of audit needs, auditing meds during 180 orders review for RN to sign off that require use instructions.

Responsible Party: Administrator, RCC, RN

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included resident-specific parameters for PRN medications for 2 of 3 sampled residents (#s 1 and 2) whose MARs were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 1 was admitted in 2015 with diagnoses including dementia.

Residents 1's 06/01/22 through 07/06/22 MARs were reviewed and the following was noted:

* The MAR showed the resident had orders for PRN Tylenol and PRN tramadol for pain. The MARs lacked resident-specific instructions for the multiple PRN pain medications, including sequential order of use.

The need to ensure there were clear parameters for staff when administering multiple PRN medications for the same condition was discussed with Staff 1 (Administrator) on 07/06/22 at 2:40 pm. No further information was provided.

2. Resident 2 was admitted to the memory care facility in 04/2021 with a diagnosis of Alzheimer's disease.

a. Resident 2's 06/01/22 through 07/06/22 MARs were reviewed and revealed the following:

* PRN Tylenol/Codeine 300-30 mg, PRN biofreeze roll-on gel, PRN Tylenol 650 mg, PRN Ibuprofen 400 mg, and PRN tramadol 50 mg were all directed to treat pain. The MARs lacked resident-specific instructions for the multiple PRN pain medications, including sequential order of use.

b. Resident 2's 06/01/22 through 07/06/22 MARs were reviewed and revealed the following:

* PRN Hydroxyzine 25 mg and PRN Perphenazine 2 mg were directed to administer for anxiety or for schizoaffective.

* The MARs lacked resident-specific instructions for the multiple PRN psychoactive medications, including sequential order of use.

The need to ensure MARs included clear parameters for multiple PRN medication that were prescribed to treat the same condition was discussed with Staff 1 (Administrator) on 07/06/22. She acknowledged the findings.

1. Admin and RN have ran a report for all pain and psychotropic medications per resident. We are listing each medication by resident specific sequence, to give instructions to non-licensed staff.

2. Our Regional nurse will be auditing monthly for the first 90 days, and then will be audited every 90 days when physician orders are sent out to the physician to include instructions.

3. Every 90 days it will be evaluated during our 90 day physician orders being sent out.

4. RCC, RN, Admin and/or designee

Based on interview and record review, it was determined the facility failed to ensure that staff documented non-pharmacological interventions had been attempted with ineffective results prior to administering PRN psychotropic medications for 1 of 2 sampled residents (#2) who were prescribed PRN psychotropic medications. Findings include, but are not limited to:

Resident 2 was admitted to the memory care facility in 04/2021 with diagnoses including Alzheimer's disease and bipolar type schizoaffective disorder.

Resident 2 was prescribed PRN hydroxyzine to treat symptoms of anxiety.

The 04/01/22 through 04/10/22 MAR indicated the resident was administered the medication on six occasions. Prior to each administration, the facility failed to document non-pharmacological interventions were attempted with ineffective results before administering the psychotropic medication.

The need to ensure staff attempted and documented non-pharmacological interventions were ineffective prior to administering PRN psychotropic medications was discussed with Staff 1 (Administrator) on 04/12/22. She acknowledged the findings.

Corrective Action: RN to review all psychoactive and pain medications to specify intervention needed and order of use requirments.

Future Violation Prevention: A stamp will be created to use on all psychoactive medication and pain medication that will alert the RN for review and intervtion addition to chart. Can not be cleared from RN section until signed by RN.

Continued Evaluation: RN will review medication orders for RN review stamp trigger and do an in-service for all staff to train on the usage and the importance of the procedure follow through.

Responsible Party: RN, RCC, Admin and Med-techs.

Based on interview and record review, it was determined the facility failed to ensure PRN psychoactive medications were given only for specific medical symptoms and only after non-drug interventions had been attempted and were ineffective, for 2 of 2 sampled residents (#s 1 and 2) who were administered PRN psychoactive medications. This is a repeat citation. Findings include, but are not limited to:

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

Resident 1's 06/01/22 through 07/06/22 MAR was reviewed during the survey and revealed the following:

* The resident had an order for PRN Ativan for "anxiety and agitation";

* The PRN Ativan was administered on three occasions; and

* The MAR lacked clear instructions to non-licensed staff regarding how the resident demonstrated signs and symptoms of agitation or anxiety.

On 07/06/22 Resident 1's record was reviewed with Staff 1 (Administrator) who acknowledged the findings.

2. Resident 2 was admitted to the memory care facility in 2021 with diagnoses including Alzheimer's disease and bipolar type Schizoaffective disorder.

Resident 2's 06/01/22 through 07/06/22 MAR was reviewed during the survey and revealed the following:

* The resident had an order for PRN Hydroxyzine for "anxiety";

* The PRN Hydroxyzine was administered on six occasions;

* The MAR lacked clear instructions to non-licensed staff regarding how the resident demonstrated signs and symptoms of agitation or anxiety; and

* No documented evidence non-drug interventions had been attempted with ineffective results prior to administering the medication.

On 07/06/22 Resident 2's record was reviewed with Staff 1 (Administrator) who acknowledged the findings.

1. Admin and/or designee along with the RN are adding new "Purpose of giving" options that will allow the staff to choose resident specific reason it is being given. Staff will record all ineffective non-drug interventions that were tried previous to the administration of medication.

2. An in-service and MAR training will be held with all med-techs to show proper recording instructions that will meet all required documentation.

3. Weekly audits for the first 60 days of all med variances, to ensure documentation is correct.

4. Admin and/or designee, RCC

Based on interview and record review, it was determined the facility failed to ensure 1 of 1 direct care staff (# 12) had documented evidence of completion of First Aid certification and training in abdominal thrust within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed on 07/06/22 and revealed Staff 12 (CG), hired on 06/01/22, lacked documented evidence of First Aid certification and abdominal thrust training within 30 days of hire.

The need for staff to complete all required training in the specified time frames was discussed with Staff 1 (Administrator) and Staff 5 (Human Resources) on 07/06/22. They acknowledged the findings.

1. HR and the regional director have created a training spread sheet to show all state required training for RCF's that will allow us to have better record keeping and to determine when trainings are due and take immediate action.

2. We will be doing weekly audits for the first 60 days to have all staff scheduled for trainings correctly, and catch any that are due. If trainings are not done in a timely manner, the staff will not be scheduled until required trainings have been completed.

3. Weekly audits for first 60 days, monthly and there after.

4. HR, Staffing/Training Coordinator/Admin and/or designee

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

Refer to C282, C310, C330, Z155 and Z164.

1. Regional director and admin revised new policies to address identified areas of need, monthly environmental walk throughs. Also, please see stated tags to identify acceptable areas of improvement plan requested for approval.

C282, C310, C330, Z155 and Z164

2. Admin and regional director will review policies annually to ensure compliance.

3. Annual Review.

4. Admin and/or designee and regional director.

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

During a walk-through of the facility on 04/11/22 at 10:15 am, exit doors to the courtyard were found to have no working audible alarm or system in place to alert staff when a resident exited the building.

The need to ensure all exit doors were equipped with an acceptable system to alert staff when a resident exited was discussed with Staff 1 (Administrator) on 04/11/22 at 11:00 am. She acknowledged the findings.

Corrective Action: Door alarm purchased to add to door with magnetic trigger. Alarm will be on when doors are unlocked.

Future Violation Prevention: Door will be checked for functioning alarm periodically during walk through.

Continued Evaluation: Door will be checked by maintenance quarterly to ensure battery is functioning and alarm is in place.

Responsible Party: Maintenance, RCC, Caregivers.

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

Refer to C240 and C555.

Please refer to corrective action for C240 and C 555 on pages 1 and 6 of the CBC plan of correction.

Based on interview and record review, it was determined the facility failed to ensure all pre-service dementia training was completed prior to providing care and service independently, and competency was demonstrated within 30 days of hire for 1 of 1 newly hired direct care staff (#6). Findings include, but are not limited to:

On 04/12/22, training records were reviewed with Staff 5 (Human Resources).

a. Staff 6 (CG) was hired on 11/16/21. Staff 6 did not complete the following pre-service training topics before providing care and services independently:

* Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain;

* How to recognize behaviors that indicate a change in the resident's condition and report behaviors that require on-going assessment; and

* How to provide personal care to a resident with dementia, including an orientation to the resident's service plan.

b. Staff 6 did not complete the following required competency training within 30 days of hire:

* Role of the service plan in providing individualize care;

* Providing assistance with ADL's;

* Changes associated with normal aging;

* Identification, documentation and reporting changes of condition; and

* Conditions that require an assessment, treatment, observations and reporting.

The need to ensure all newly hired staff completed pre-service dementia training and 30-day competency training was discussed with Staff 1 (Administrator) and Staff 5 (HR) on 04/12/22. They acknowledged the findings.

Corrective Action: All required documentation will be provided upon job changes or additional training, a copy will be provided to trainee and trainor.

Future Violation Prevention: Any job changes will be approved by HR and Executive Director and then followed up on for proper paper work and additional training provided.

Continued Evaluation: HR to audit training files according to job descriptions and assign proper training courses on going and ensure descriptions and training time have been met.

Responsible Party: Administrator and HR

Based on interview and record review, it was determined the facility failed to ensure all pre-service training was completed prior to providing care for 1 of 1 newly hired direct care staff (# 12). This is a repeat citation. Findings include, but are not limited to:

On 07/06/22, training records were reviewed with Staff 5 (Human Resources).

Staff 12 (CG) was hired on 06/01/22. Staff 12 did not complete the following pre-service training topics before providing care and services to residents independently:

* Infection Disease Prevention; and

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

The need to ensure all newly hired staff completed pre-service training was discussed with Staff 1 (Administrator) and Staff 5 on 07/06/22. They acknowledged the findings.

1. All staff during the hiring process will not be added to the schedule until all required training documents have been proven and provided for file.

2. A new training spread sheet has been created to track all required training and documentation needed before being added to the schedule.

3. Will be verified before starting a scheduled floor training and reaudited within 30 days of hire.

4. HR/Admin and/or designee.

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

Refer to C252, C282, C310 and C330.

Please refer to corrective action for C252, C282, C310 and C330 on pages 2, 3, 4 and 5 of CBC plan of correction.

Based on 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 C282, C310 and C330.

1 Please see tag correction for C282, C310 and C330 for complaince date and action to be taken.

Based on interview and record review, it was determined the facility failed to evaluate and develop individualized activity plans for 3 of 3 sampled residents (#s 1, 2 and 3) whose activity plans were reviewed. Findings include, but are not limited to:

Resident 1, 2 and 3's records were reviewed during the survey. There was no documented evidence an activity evaluation had been completed and that service plans had been individualized to reflect the following:

* Current abilities and skills;

* Emotional/social needs and patterns;

* Adaptations needed to participate;

* Identification of activities for behavioral interventions; and

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

On 04/12/22, the lack of an activity evaluation and individualized activity plan was discussed with Staff 1 (Administrator). She acknowledged the findings.

Corrective Action: Adding resident ability to perform current level of activities and past activities of interest and ability to still perform them. Including modivications if necessary to still perform activitiy. Being added to resident activity profile and biography page.

Future Violation Prevention: All forms will be updated and used for all future move-ins. Ability for current residents will be added to their current forms and profiles.

Continued Evalution: Abilities will be updated during quarterly evaluations.

Responsible Party: Activities Director and RCC

Based on interview and record review, it was determined the facility failed to evaluate and develop individualized activity plans for 3 of 3 sampled residents (#s 1, 2 and 4) whose activity plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 1, 2 and 4's records were reviewed during the survey. There was no documented evidence an activity evaluation had been completed and that service plans had been individualized to reflect the following:

* Current abilities and skills;

* Emotional/social needs and patterns;

* Identification of activities for behavioral interventions; and

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

On 07/06/22, the lack of an activity evaluation and individualized activity plan was discussed with Staff 1 (Administrator). She acknowledged the findings.

1 Admin and Regional director have developed new History/Biography's and Activity plan from a state compliant sister community that we will be redoing all plans for the current residents.

2. New bio/history and Activity plan to be given to potential residents before move-in to be in place upon arrival. Plan was previously approved at a sister community and hits all state regulated memory care OAR needs.

3. Upon all move-ins and adaptions and behaviors to be evaluated every 3 months for updates.

4. Activities Director and Admin and/or designee.

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

On 04/11/22, a tour of the facility's outdoor area revealed the following:

* The secured courtyard had several chairs which were easily moveable and not of sufficient weight and design to prevent injury and not aid in elopement.

During a walk-through of the facility at 11:00 am the same day, Staff 1 (Administrator) was shown the concern. She acknowledged the findings.

Corrective Action: All outside furniture will be weighted down with sandbags to prevent the ability to move them. Chairs will have a short plastic covered wire to connect them to tables and prevent them from being moved. Wires will be in a position to not cause trip hazard and still allow resident to pull chair out and sit.

Future Violation Prevention: All furniture will be tested for weight and adjusted according to product.

Continued Evaluation: Replace weighted device if warn and necessary, quarterly walk-throughs.

Responsible Party: Maintenance