The findings of the relicensure survey, conducted 03/28/22 through 03/30/22, 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 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 03/30/22, conducted 06/21/22 through 06/22/22, 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

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 2nd revisit to the re-licensure survey of 03/30/22, conducted 08/17/22 are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care, Assisted Living Facilities and Division 57 for Memory Care Communities.

2. Resident 1 was admitted to the facility in April 2017 with diagnoses including dementia.

During the entrance conference interview on 03/28/22, Staff 5 (MCC Resident Services Coordinator) reported Resident 1 had fallen and sustained a fractured leg.

Review of the 10/27/21 progress notes indicated that staff found Resident 1 on the floor in the bathroom after having had a shower.

An investigation report dated 10/27/21 stated Resident 1 had "got feet tangled in towel after exiting shower." The documentation indicated the fall was unwitnessed and the resident was unable to describe what had occurred. The resident was hospitalized with a fracture of the left femur and left wrist. The incident report stated there was a CG present during the shower, but had left the bathroom to retrieve clothing at the time of the fall.

Interviews with Staff 4 (LPN) and Staff 20 (MT/CG) on 03/28/22 and 03/29/22 revealed that at the time of the incident, Resident 1 was independent with transfers, toileting and ambulation.

Resident 1 had an unwitnessed fall with injury. The facility failed to complete a thorough investigation to rule out abuse or neglect and did not report the incident to the local SPD office.

The need to report unwitnessed falls with injuries to the local SPD was discussed with Staff 3 (RN), Staff 4 and Staff 5 on 03/28/22. They acknowledged the findings.

The facility was requested to report the event to the local SPD office and provided confirmation the report was made prior to survey exit.

3. Resident 4 was admitted to the facility in February 2022 with diagnoses including dementia.

Review of the 02/08/22 through 02/28/22 progress notes identified that on 02/27/22 at 09:29 am, Resident 4 had woke up and began actively exit seeking throughout numerous areas of the memory care community. Resident 4 was then observed in the parking lot outside.

The facilities incident report investigation determined the resident had gone to another resident's room and removed the window lock, opened the window, removed the screen and climbed out of the window, eloping from the facility for a brief period of time. Staff were able to convince the resident to return to the facility, and the resident was unharmed.

The facility failed to report the elopement to the local SPD.

The need to ensure that incidents of elopement are reported to the local SPD was discussed with Staff 2 (Previous ED), Staff 3 (RN), Staff 4 (LPN) and Staff 5 (Resident Services Coordinator) on 03/29/22. They acknowledged the findings.

The facility was requested to report the elopement to the local SPD office and provided confirmation the report was made prior to survey exit.

Based on interview and record review, it was determined the facility failed to thoroughly investigate an unwitnessed fall with injury, elopement, and injuries of unknown cause to rule out abuse or neglect and report the incidents to the local Seniors and People with Disabilities (SPD) office, for 3 of 3 sampled residents (#s 1, 2 and 4). Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 10/2019 with diagnoses including Alzheimer's dementia.

The clinical record revealed the following:

* On 03/17/22 progress notes identified a skin tear to the right shin. An incident report documented the injury "might have been during transfers earlier during the day or possibly another res [resident] bumped into [him/her] by accident. Resident was unable to give description."  The skin tear represented an injury of unknown origin and was a reportable incident.

There was no documented evidence the facility ruled out abuse or neglect and did not report the injury to the local SPD office.

The need to ensure injuries of unknown origin were thoroughly investigated to rule out abuse or neglect and reported if necessary was discussed with Staff 2 (Previous Executive Director), Staff 3 (RN), Staff 4 (LPN) and Staff 5 (MCC Resident Services Coordinator) on 03/30/22. They acknowledged the findings.

Staff 5 provided verification the facility had reported the incident to the local SPD office during the survey.

Abuse reporting and investigation:

Facility has clear policies and procedures in place to assure prevention and appropriate response to any incident. Incidents are reviewed daily during Clincal meeting with Nurse, RSC and administrator and discussed to determine next steps including reporting. Notes are captured to ensure documentation of the incident and followup plan. Incidents are reviewed at Quality meeting to check on progress and assess what further followup if required. Incidents signed off by administrator. Nurse, RSC and administrator have reviewed these protocols together to ensure reporting guidelines and invetigative procedures are clear.

Elopement training at All Staff for entire team 4/22.

In regards to specific incidents noted at time of survey, items were reported 4/1 and APS visited on 4/4 to review with RSC. The RSC reviewed our protocols and procedures with them. They had no findings and case will be closed.     

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

1. Resident 1 was admitted to the facility in April 2017 with diagnoses including dementia.

Observations of the resident, interviews with staff and review of the care plan dated 11/13/22, showed the care plan was not reflective of the resident's current care needs and/or did not provide clear direction to staff in the following areas:

* Sleeping and waking routine;

* Diet texture;

* Meal assistance;

* Two person transfers;

* Two person assist for dressing, grooming, hygiene and toileting;

* Mobility;

* Edema;

* Fall prevention interventions; and

* Geri chair use and instructions.

The need to ensure resident service plans were reflective of current care needs and provided direction to staff  was discussed with Staff 3 (RN), Staff 4 (LPN) and Staff 5 (MCC Resident Services Coordinator) on 03/29/22. They acknowledged the findings.

2. Resident 2 was admitted to the facility in 10/2019 with diagnoses including Alzheimer's dementia. During the acuity interview on 03/28/22, Resident 2 was identified with a pressure ulcer.

Observations of the resident, interviews with staff and review of the care plan dated 03/09/22, showed the care plan was not reflective of the resident's current care needs and/or did not provide clear direction to staff in the following areas:

* Skin integrity interventions, including the use of pressure alternating mattress and repositioning every two hours;

* Hospice providing bathing assistance;

* Two person incontinent care completed in bed; and

* Geri chair use and instructions.

The need to ensure resident service plans were reflective of current care needs and provided direction to staff  was discussed with Staff 3 (RN), Staff 4 (LPN) and Staff 5 (MCC Resident Services Coordinator) on 03/30/22. They acknowledged the findings.

Service Plans:

Detailed care are plans will include personalized and current plan for resident care needs including ADL's, sleep status, diet, meal assistance, transfer ability, mobility, and interventions as needed. TSP's and coordination with outside services (HH, hospice) to be include specific direction to care staff at time of condition change. Changes must be noted and updated.Clear and detailed notes of interventions tried with outcomes and followup notes from RSC or nurse depending on the area being addressed.

Nursing notes to be present  (ex: Geri chair ) by in house team in coordination with hospice to support their use.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current status and care needs and provided clear instruction to staff for 2 of 3 sampled residents (#s 5 and 7) whose service plans were reviewed.  This is a repeat citation. Findings include, but are not limited to:

1.  Resident 7 was admitted to the facility in 06/2021 with diagnoses including dementia and anxiety. The resident's 06/13/22 service plan and temporary service plans were reviewed and were not reflective of the resident's needs and lacked clear direction to staff in the following area:

* Behaviors including history of physical aggression towards roommate.

The need to ensure service plans were reflective of resident's needs and provided clear instruction to staff was discussed with Staff 1 (ED) and Staff 4 (LPN) on 06/22/21. They acknowledged the findings.

2. Resident 5 was admitted to the facility in 06/2016 with diagnoses including dementia.

Review of the most current service plan dated 06/13/22 and observations and interviews conducted on 06/21/22 revealed Resident 5's service plan was not reflective, did not provide clear instruction to staff and/or was not followed in the following areas:

* Communication / Pain;

* Cognition;

* Behavior / Mood;

* Fall Risk Status;

* Bed routine;

* Dressing / Grooming;

* Dining;

* Toileting; and

* Skin Monitoring.

The need to ensure service plans were reflective of the identified needs and preferences of the resident, provided clear direction to staff regarding delivery of services and were followed by staff was discussed with Staff 1 (ED), Staff 4 (LPN) and Staff 5 (MCC Resident Services Coordinator) on 06/22/22 at 8:51 am. They acknowledged the findings.

Service Plans:

1. Detailed care are plans will include personalized and current plan for resident care needs including ADL's, sleep status, diet, meal assistance, transfer ability,and mobility. It will also include identified needs and preferences of the resident and provide clear direction to staff regarding individualized care and services.

2. Health Service team, Care team and Administrator meet weekly to review current and upcoming plans. Both Clinical and Psycho-social needs and changes are evaluated, with Care Plans updated to capture current needs.

3. Initial evaluation is provided, with 30 day update, then quarterly re-assessment are completed.

4. The Resident Services Coordinator (RSC) together with Nurse and Administrator meet daily to capture immediate changes, and weekly to monitor and update all residents.

Based on interview and record review, it was determined the facility failed to ensure PRN psychotropic medications used to treat a resident's behavior had documented non-drug interventions attempted with ineffective results prior to administering the medication for 1 of 2 sampled residents (#3) who were prescribed PRN medication to address behaviors. Findings include, but are not limited to:

Resident 2 admitted to the memory care community in 09/2021 with diagnosis including anxiety. Resident 2 was prescribed Quetiapine 12.5 mg tablet (a psychotropic medication) as needed every day for anxiety.

The 03/01/22 through 03/27/22 MAR was reviewed and noted the following:

* Quetiapine was administered on six occasions when no documented behavior was observed; and

* On four occasions there was no documented intervention attempted with ineffective results prior to administering the PRN medication to the resident.

The need to ensure non-drug interventions for staff to attempt prior to the administration of psychotropic medications was reviewed with Staff 2 (Previous ED), Staff 3 (RN), Staff 4 (LPN) and Staff 5 (MCC Resident Services Coordinator) on 03/30/22. They acknowledged the findings.

Nurse to review each resident to ensure eMAR includes personalized interventions including  written resident specific parameters including order and duration of interventions recommended for PRN psychtropic meds.

Documentation of intervention attempted with ineffective results must occur prior to giving the resident PRN. Orders to be reviewed as changes occur and updated interventions, orders, duration for each.

All direct care staff retrained to ensure knowledge of non-pharmocological intervientions.

All orders reviewed during weekly Quality (acuity) meeting by nurse to ensure eMAR is updated and personalized for each resident to meet their needs. Standing topic at Med Tech bi monthly meeting to discuss PRN protocols and intervention practices.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted in accordance with the Oregon Fire Code. Findings include, but are not limited to:

Fire and life safety records for October 2021 through March 2022 were reviewed with Staff 8 (Plant Operations Director) on 03/29/22. Staff 8 revealed the facility did not relocate or evacuate the residents during the fire drills. Therefore, documentation was lacking regarding the escape route used, residents who resisted or failed to participate in the drills, evacuation time period needed, and number of occupants evacuated.

The need to evacuate residents during fire drills unless there was documented evidence an alternative fire drill plan had been developed with the Oregon Fire Authority and documentation of the fire drills included all necessary components was discussed with Staff 1 (Executive Director), Staff 2 (Previous Executive Director) and Staff 8 on 03/29/22. They acknowledged the findings.

Unannounced Fire drills will be completed every other month at different times of the day, evening and night. A written fire drill record is kept in a red beinder in the training office. It will include the following:

date and time of drill, location of fire origin, escape route used, evacuation time needed and # of staff and residents evacuated.

It will also include any problems encountered, and comments related to residents who resist or fail to participate in the drill.

The Plant Operations manager will ensure the correct documents are placed in the red binder after each drill. The Administrator will review the binder for accuracy monthly

Based on interview and record review, it was determined the facility failed to ensure a written fire drill record was maintained and included all components in accordance to the Oregon Fire Code (OFC). This is a repeat citation. Findings include, but are not limited to:

Fire drill records for 06/2022, were requested during survey.

The facility failed to document completed fire drills and to relocate or evacuate residents during fire drills. Therefore, documentation was lacking in the following areas:

* Date and time of the fire drill;

* Location of simulated fire origin;

* The escape route used;

* Problems encountered and comments relating to residents who resisted or failed to participate in the drills;

* Evacuation time period needed;

* Staff members on duty and participating; and

* Number of occupants evacuated.

During an interview with Staff 1 (ED) and Staff 8 (Plant Operations Director) on 06/21/22 at 2:09 pm, they confirmed that drills were completed in the MCC in 06/2022. However, during the drill, no residents were evacuated or relocated and no documentation was completed.

The need to ensure a written fire drill record was maintained and included all components in accordance to the Oregon Fire Code (OFC) was discussed with Staff 1 and Staff 8 on 06/21/22. They acknowledged the findings.

Fire Drills:

1. Unannounced Fire drills will be completed every other month in Memory Care at different times of the day, evening and night.

2. A written fire drill record is kept in a red beinder in the training office. It will include the following:

date and time of drill, location of fire origin, escape route used, evacuation time needed and # of staff and residents evacuated.It will also include any problems encountered, and comments related to residents who resist or fail to participate in the drill.

3. Administrator and Plant Operations manager meet weekly, and will review an issues that arise during drills.

4. The Plant Operations manager will ensure the correct documents are placed in the red binder after each drill. The Administrator will review the binder for accuracy monthly.

Based on observation and interview, it was determined the facility failed to ensure all chemicals and toxic materials were maintained in a locked storage unit and all exterior pathways and accesses to the facility's common use areas were maintained in good repair. Findings include, but are not limited to:

The interior and exterior of the building was toured on 03/29/22. The following issues were noted:

1. On 03/29/22, multiple observations were made throughout the day of a restroom with the door propped open. The restroom was in a hallway near resident rooms and the dining room. Inside the restroom there were unlocked cupboards with cleaning chemicals, air freshener and bathing supplies accessible to the residents.

2. The courtyard between Hampton Lane and Hampton Square was toured. The courtyard walkways had drop offs of up to approximately three inches, measured from the concrete to the planting bed surface. There were also two segments of the sidewalk near the door to Hampton Lane where the sidewalk had approximately an inch difference in height. These created a potential tripping and/or fall hazard for residents.

The need to ensure all toxic materials were maintained in locked storage and exterior resident pathways did not have potential tripping hazards was discussed with Staff 1 (Executive Director), Staff 2 (Previous Executive Director) and Staff 8 (Plant Operations Director) on 03/30/22. They acknowledged the findings.

General building:

cleaning supplies to be in locked closet (out of bathroom) at all times. RSC to conduct daily walk through to check that all cabinets remain locked when not in active use.

Landscape/Fill in drop offs in exterior courtyard that present a potential trip hazard to residents. Plant Operations manager to walk through regularly to determine and potential risk to residents in outdoor courtyard landscaping.

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

Observations of the facility on 03/29 - 03/30/22 revealed the following areas were in need of cleaning and/or repair:

* Multiple resident apartment doors throughout the facility had scrapes, missing paint and/or gouges;

* The walls throughout the facility were gouged exposing the sheet rock below and/or had drip marks and splatters;

* The handrails and baseboards throughout the facility had scrapes and gouges;

* The bathroom door in room 406 had a large hole in it and the bathroom faucet leaked water from around the handle when turned on;

* The shower room next to room 502 had dirt and food debris on the floor. The caulking around the base of the toilet was blackish-brown in color and the bathroom was in need of deep cleaning;

* The restroom next to room 504 had brown matter smeared on the toilet and a quarter size area of brown matter on the floor;

* Room 506 had food debris spilled on the floor in the doorway and something smeared on the flooring next to the bed;

* The restroom next to room 508 was in need of deep cleaning;

* There was a recliner next to room 509 that was worn through on the back and arms rendering it an uncleanable surface; and

* The kitchenette in Hampton Lane was missing some of the baseboards and there were places on the drawers and counter where the Formica was missing, exposing the wood below.

The environment was toured and the need to maintain interior surfaces clean and in good repair was discussed with Staff 1 (Executive Director), Staff 2 (Previous Executive Director) and Staff 8 (Plant Operations Director) on 03/30/22. They acknowledged the findings.

Interior Building:

Paint and sand wood railings in hallways; touch up paint of baseboards and resident doors in Hampton Lane hallway.

Ensure common restrooms are cleaned daily and odor free. RSC to walk area daily to ensure cleanliness. Plant Ops and Executive Director to conduct monthly walk through.

Kitchenette in HL needs formica repair. Plant operations manager to tour restrooms and MC areas daily to assess housekeeping and maintainance needs. Staff to list items in need of repair in TELS to ensure the work in noted and completed in a timely manner. RSC to share feedback with Plant Operations manager of any pressing issues.

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

On 03/29/22, it was observed the exit doors that residents used to access an outdoor courtyard did not have an alarm to alert the staff when the doors were opened.

In an interview on 03/30/21, Staff 2 (Previous Executive Director) 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 to alert staff when residents exited the facility was discussed with Staff 1 (Executive Director), Staff 2 and Staff 8 (Plant Operations Director) on 03/30/22. They acknowledged the findings.

Exit door alarms have been installed on each of the exits doors to the courtyard. These alarms are connected to the call system to alert staff to anyone exiting a door from the community.

Based on observation and interview, it was determined the facility failed to ensure the exit doors to the courtyard were equipped with an alarming device or other acceptable system to alert staff when residents exited the facility. This is a repeat citation. Findings include, but are not limited to:

Observations made on 06/21/22 revealed the alarm for the doors to the enclosed courtyard did not alert staff each time a resident exited the facility. The facility did not have another acceptable system in place.  

The requirement to ensure exit doors were equipped with an operable alarming device or other acceptable system to alert staff when residents exited the facility was discussed with Staff 1 (ED) and Staff 8 (Plant Operations Director) on 06/22/22. They acknowledged the findings.

Exit Door Alarms:

1. Exit door alarms have been installed on each of the exits doors to the property. These alarms will are now connected to the call system to alert staff to anyone exiting a door from the community. Door alarm times set from evening to morning in Assisted Living when the front desk is not staffed to ensure resident safety. Any doors leading in to or out of MC areas will be on alert 24/7. Staff will repond to all doors alarms to ensure resident safety and reset. No doors to be propped open causing alarms to become inactive.

2. open doors now sound a staff alert on devices and will be responded to in a timely manner.

3. RSC to continually monitor on device to ensure all alerts are checked and cleared.

4. Administrator reviews reporting to identify problem areas and/or slow response times.

Based on observation and interview, 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 231, C 420, C 510, C 513 and C 555.

Please refer to Plan of correction for C231, C420, C510, C513 and C555)

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 C420 and C555.

Referral Tag - Service plans

Please refer to Plan of correction for  C420 and C555

Based on interview and record review, it was determined the facility failed to ensure 2 of 4 newly hired staff (#s 10 and 17) completed all required pre-service training and 1 of 4 long term staff (# 11) completed a total of 16 hours of annual training. Findings include, but are not limited to:

A review of staff training records revealed the following:

a. There was no documented evidence Staff 10 (Housekeeper), hired 02/18/22, and Staff 17 (CG) hired 02/17/22 completed all required pre-service training in the following areas:

* Dementia disease process including progression of the disease, memory loss and psychiatric & behavioral symptoms;

* Techniques for understanding, communicating and responding to distressful behavioral symptoms;

* Strategies for addressing social needs and engaging persons with dementia in meaningful activities;

* Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food/fluids, preventing wandering, use of person-centered approach;

* Environmental factors that are important to a resident's well-being (e.g. staff interactions, lighting, room temperature, noise, etc.);

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

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

b. There was no documented evidence Staff 11 (CG), hired 07/23/18, completed the required 16 hours of annual training.

The facility's failure to ensure staff completed all required training in a timely manner was discussed with Staff 1 (Executive Director), Staff 2 (Previous Executive Director) and Staff 9 (Operations Specialist) on 03/30/22. They acknowledged the findings.

Individualized employee checklist in place completed by the staffing co-ordinator for each new hire to ensure completion of Cares (dementia) training as part of pre-orientation process. Dept. managers to review training plans of their teams to ensure compliance. Administrator to review training completion reports and follow up on any staff not completing their training.

RSC to ensure all care staff including med techs have completed their nessasary training in ADLs, COC's (physical, emotional and mental functioning) and are able to identify and  document resident change of condition as part of 1st 30 day training. After current training is complete, annual CEU will be monitored for each staff member by Business office. BOM will identify and post relevant training for staff to complete mandatory training. These lists will be supplied at monthly All staff meeting and updates reported to Administrator on training completion.

Based on interview and record review, it was determined the facility failed to ensure 1 of 1 newly hired Staff (#25) completed all required pre-service dementia training and demonstrated competence in job duties within 30-days after hire. This is a repeat citation. Findings include, but are not limited to:

Staff training records were reviewed on 06/21 and 06/22/22.

a. Staff 25 (CG), hired 05/18/22, lacked documented evidence of completing the required pre-service dementia training prior to working with residents, including:

* Dementia disease process including progression of the disease, memory loss and psychiatric and behavioral symptoms;

* Techniques for understanding, communicating and responding to distressful behavioral symptoms;

* Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities;

* Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food/fluids, preventing wandering, use of person-centered approach;

* Environmental factors that are important to resident's well-being (e.g. noise, staff interactions, lighting, room temperature, etc.);

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

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

b. Staff 25 (CG) failed to have documented evidence of competency demonstrated in assigned job duties within 30 days of hire in the following areas:

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

* The use of supportive devices with restraining qualities in memory care communities;

* Role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Identification, documentation and reporting of changes of condition;

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

* General food safety, serving and sanitation.

The facility's failure to ensure staff documented completed required training was discussed with Staff 1 (ED) and Staff 26 (Staffing Coordinator) on 06/22/22. No additional information was provided.  

Referral Tag - Training

1. Staffing coordinator to review completion of preorientation (Cares training) as well as 1st 30 competency checklist and ensure there is a signed copy for training file.

2. Staffing Coordinator to ensure all care staff has completed1st 30 day training. This will be scheduled as new team members are hired, and and reviewed weekly. This will also be reviewed during performance check-ins with RSC to ensure training is complete and up to date.

3. Staffing Coordinator will continually review trainng completion, and will be reviewed by Administrator during weekly 1:1.

4. Training documents to be kept in Staffing coordinator office with completion checklist attached for review.

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 and C 330.

Move In assessments and Care plans will be coordinated and updated as outlined above (refer to C252, C260 and C330.)

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 C260.

Referral Tag - Compliance with Health Care Rules

Please refer to Plan of correction for  C260

Based on interview and record review, it was determined the facility failed to evaluate and develop individualized activity plans for 3 of 4 sampled residents (#s 1, 2 and 3) whose service 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 their 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 03/30/22, the lack of an activity evaluation and individualized activity plan was discussed with Staff 2 (Previous ED), Staff 3 (RN), Staff 4 (LPN) and Staff 5 (MC Resident Services Coordinator). They acknowledged the findings.

Activities:

Individualized activity plans are developed for each resident based on their activity evaluation. The plan reflects their individual preferences and needs including the following:

-current abilities and skills

-emotional and social needs

-activities for behavioral interventions

documentatin on changes will be captured and plans updated to ensure current needs are being met. These plans will be updated with quarterly assessments.

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 5, 6 and 7) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

Residents 5, 6 and 7's records were reviewed during the survey. There was no documented evidence an activity evaluation had been completed and individualized activity plans developed including:

* Current abilities and skills;

* Emotional/social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for the resident to participate in activities; and

* Identified activities for behavior interventions.

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 06/22/22, the need to ensure residents were evaluated and had an individualized activity plan was discussed with Staff 1 (ED), Staff 4 (LPN) and Staff 5 (MCC Resident Services Coordinator). No additional information was provided.  

Activities:

Meaningful activities that promote the physical and emotional well being of residents are planned, calendared and executed daily.

1. Individualized activity plans are developed for each resident based on their activity evaluation that is complete prior to move-in. The plan reflects their individual preferences and needs including the following:

-past and current interests

current abilities and skills

-emotional and social needs

-physical abilities and limitations

-activities for behavioral interventions

2.Each resident will have ongoing documentation on changes that will be captured and Care plans updated to ensure current needs are being met.

3. These plans will be updated with quarterly assessments, but will be monitored during weekly Quality meetings to capture any changes that may occur. The Life Enrichment Director will be attending these weekly meetings to ensure all are involved in each resident plan.

4. The Administrator and Director of Health Services attend the meetings and oversee the process.

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 not aid in elopement. Findings include, but are not limited to:

On 03/29/22 a tour of the facility's outdoor area revealed the following:

* The secured backyard had several chairs and small tables which were easily moveable and not of sufficient weight and design to not aid in elopement.

On 03/30/22, 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 (Executive Director), Staff 2 (Previous Executive Director and Staff 8 (Plant Operations Director). They acknowledged the findings.

Secure outdoor recreation area:

Tables and chairs to be permanently affixed to not allow furniture to create elopment risk to residents.