The findings of the re-licensure survey conducted 06/24/24 through 06/27/24 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 06/27/24, conducted 01/29/25 through 01/30/25, 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 the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter H refer to the Home and Community Based Services 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 second re-visit to the re-licensure survey of 06/27/24, conducted 04/25/25, 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 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. Tag numbers beginning with the letter H refer to the Home and Community Based Services 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 third re-visit to the re-licensure survey of 06/27/24, conducted on 09/11/25 are documented in this report. It was determined the facility was in substantial compliance with 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.

Based on observation and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:

Observations of the facility kitchen, reviewed on 06/24/24 from 9:00 am through 2:00 pm, revealed the following:

a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and/or black matter was visible on or underneath the following:

* Open stainless-steel shelving;

* Fan cage;

* Industrial mixer, slicer, and blender;

* Exterior of cooking appliances, refrigerators, freezers throughout kitchen;

* Scattered walls throughout kitchen including under shelving and counters;

* Sinks throughout kitchen;

* Coffee machine exterior;

*Juice machine exterior and underneath where juice was dispensed;

* Ice machine (interior/exterior) and filter;

* Rack across from kitchen entry;

* Trash cans throughout kitchen;

* Drains throughout kitchen;

* Carts;

* Warmer rack;

* Fryer grease trap;

* Exterior and interior of oven;

* Cooktop and grill;

*Stainless steel backsplash behind cooktop;

* Fans in walk-in refrigerator;

* Floors under racks and equipment;

* Floors in walk-in refrigerator and freezer;

* Floor drainage sink with heavy dark sediment in room labeled Janitor Kitchen Only; and

* Cabinet under sink in dining room with soiled washcloths and debris.

b. The following needed repair or replacement:

* Cutting board on service line stained and scored which created an uncleanable surface.

c. Industrial mixer, slicer, blender uncovered while not in use.

d. CG's not wearing aprons when serving food to residents.

e. Fan with dust on cage blowing air over food prep area.

f. Trash can next to kitchen entry uncovered during non-prep times.

g. Walk-in refrigerator and walk-in freezer with several food items uncovered/not dated or with no use by date indicated.

h. Two dry storage food items open with no use by date indicated.

On 6/25/24 the identified areas above were reviewed with Staff 4 (Director of Culinary Services) and Staff 1 (Interim ED/Director of Operations). They acknowledged the findings.

1. The kitchen has been thoroughly cleaned and necessary repairs have been made.  All items identified from list under C240 have been addressed according.

In regards to the items needing repair and or replacement, all items have been addressed/replaced and are in compliance. All food items in dry storage that are currently opened have been disposed of and new food items opened will be dated on date of opening and with a use by date noted.

2. We will add this to our monthly CQI process to identify areas needed attention.

3. and 4. Director of Culinary Services will monitor all areas daily and Executive Director will confirm weekly.

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 to staff regarding care and services, and were implemented for 2 of 3 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted in 08/2022 with diagnoses including dementia with behaviors.

The service plan dated 05/07/24, temporary service plans and progress notes dated 03/01/24 through 06/24/24 were reviewed. Interviews with care staff and observations were made. The resident's service plan was not reflective or failed to provide clear instruction to staff and/or was not implemented in the following areas:

* Compression socks;

* Transfers;

* Assistive devices (bed cane); and

* Falls.

The need to ensure service plans were reflective of current care needs, provided clear direction to staff, and were implemented by staff was discussed with Staff 1 (Interim ED/Director of Operations), and Staff 2 (Director of Clinical Services) on 06/26/24 at 3:20 pm. They acknowledged the findings.

2. Resident 2 was admitted to the facility in 12/2021 with diagnoses including dementia without behavioral disorder.

The service plan dated 05/31/24, temporary service plans and progress notes dated 04/01/24 through 06/24/24 were reviewed. Interviews with care staff and observations were made. The resident's service plan was not reflective or failed to provide clear instruction to staff in the following areas:

* Bathing;

* Dressing/Undressing;

* Personal hygiene;

* Toileting;

* Transferring;

* Evacuation;

* Ability to use pendant; and

* Side rail use.

The need to ensure service plans were reflective of the resident's care needs and provided clear caregiving instruction was discussed with Staff 1 (Interim ED/Director of Operations), and Staff 2 (Director of Clinical Services) on 06/26/24 at 3:20 pm.  They acknowledged the findings.

1. Resident #1 service plan has been corrected to provide care staff instructions on compresson socks and transfers, assistive devices and falls. Resident #2 service plan has been corrected to reflect clear instruction to care staff regarding bathing, dressing and undressing, personal hygeiene, toileting, transferring, evacuation, ability to use call pendant and side rail use.

Residents service plans have been reviewed and updated accord to residents personal perferences, level of assistance with ADL's, and clear direction to staff has been discussed and added to task lists for all care team.

2. DRS and licensed nurses will monitor to ensure service plans and task lists are updated and that the care team has reviewed, after each service plan upon completion.  

3. This will be added to our monthly CQI process and reviewed by all clincial team, and ED monthly.

4. Clinical team and ED are responsible.

Based on interview and record review, it was determined the facility failed to ensure the RN performed a timely assessment, and developed interventions based on the condition of the resident for 1 of 3 sampled residents (#1) who experienced significant changes of condition. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 08/2022 with diagnoses including dementia with behaviors.

Observations of the resident, interviews with staff, review of the resident's 05/07/24 service plan, and progress notes were reviewed. The following was identified:

a. A progress note, dated 03/26/24, indicated Resident 1 was admitted to the hospital due to a decline in functioning after he/she experienced multiple falls.

A progress note dated 03/27/24, noted a significant change of condition by the facility RN and indicated Resident 1 had three falls (03/16/24, 03/24/24 and 03/25/24) and was admitted to the hospital due to a decline in functioning.

On 04/10/24, Resident 1 returned to the facility. There was no documented evidence the facility RN had completed an assessment to include findings, resident status and interventions.

b. Progress notes dated 05/04/24, 05/14/24 and 05/21/24, noted Resident 1 was on alert charting due to falls.

On 05/28/24, a significant change of condition assessment by the facility RN indicated Resident 1 had multiple falls. There was no documented evidence the facility RN developed interventions as a result.

During an interview with Staff 1 (Administrator) and Staff 2 (Director of Clinical Services) on 06/26/24 at 3:20 pm, they acknowledged Resident 1's return to the facility from the hospital on 04/10/24 constituted a significant change of condition assessment and the significant change of condition assessment dated 05/28/24 was not timely, and lacked interventions for staff.

The facility RN was not available during the survey for interview.

The need to ensure the facility RN performed timely assessments, and developed interventions was reviewed with Staff 1 and Staff 2 on 06/26/24 at 3:20 pm. They acknowledged the findings.

1. Resident #1 service plan has been updated significant change of condition has been completed. The RN has received inservice on significant change procedure and when significant changes are necessary.

2. Training has been completed, RN understands the process.

3. Clinical will review all at risk residents weekly and ensure significant changes are completed accordinly.

4. Licensed clinical team and the Executive Director.

Based on interview and record review, it was determined the facility failed to have policy and procedures in place for exclusion of food service workers when sick or ill with potential or actual contagious food related illness. Findings include, but are not limited by:

On 06/25/24 Staff 4 (Director of Culinary Services) was unable to provide a policy and procedure for when employees who prepared food were sick and had illnesses or symptoms that may be related to a potentially contagious pathogen.

On 6/26/24 Staff 1 (Interim ED/Director of Operations) acknowledged there was no policy that outlined what symptoms/illnesses the PIC (person in charge) was to be aware of for exclusion for working with food or that needed to be reported to health department as outlined in Oregon food sanitation rule.  

1. Staff for, Director of Culinary services, was provided with a policy and procedure for when employees are deemed ill, and how to manage possible contaminated foods.

2. Infection prevention inservice have been completed to existing staff and will be provided to new hires, upon hire.

3. Will be reviewed with our CQI process monthly.

4. Director of Culinary Service, RN Infection preventionist, and Executive Director.

Based on observation, interview and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities was assessed by an RN, PT or OT prior to use, documented other less restrictive alternatives prior to use, provided instruction to caregivers on correct use and precautions, and documented use of the rails in the resident's evaluation and service plan for 1 of 1 sampled resident (# 2) who had side rails.  Findings include, but are not limited to:

Resident 2 was admitted to the facility in 12/2021 with diagnoses including dementia without behavioral disturbance.

On 06/25/24, Resident 2's hospital bed was observed to have half-length side rails on both sides of the bed. The side rails were in the up position and securely fastened to the bed.

In an interview with Staff 2 (Director of Clinical Services) on 06/25/24 at 12:40 pm, side rail assessment documentation was requested. There was no documented evidence the device with restraining qualities had been assessed by an RN, PT or OT, documentation of less restrictive alternatives prior to use, instruction to caregivers on correct use and precautions, and documentation of the use of the rails in the resident's evaluation and service plan.

The need to ensure supportive devices with potentially restraining qualities were assessed prior to use and addressed all required elements was discussed with Staff 1 (Interim ED/Director of Operations) and Staff 2 on 06/26/24 at 3:20 pm. They acknowledged the findings.

1. Resident #2 side rails have been adjusted and secured based on state recommendation for safety.

Service Plan has been corrected, assessment is completed on supportive device. Care staff inserviced on proper positioning of side rails for safety.

2. All supportive devices will have an assessment completed upon installation ensuring resident safety.

3. Licensed clinical will evaluate all supportive devices weekly. Care staff will report to any licensed clincial staff of any concerns regarding supportive device.

4. Licensed clinical staff will monitor ongoing.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 sampled newly hired direct care staff (#s 17, 18, and 19) completed first aid and abdominal thrust training within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed on 06/26/24. The following deficiencies were identified:

Staff 17 (CG), Staff 18 (CG), and Staff 19 (MT) hired on 05/23/24, 03/08/24 and 03/15/24 respectively, did not have documented evidence first aid and abdominal thrust training had been completed within 30 days of hire.

The need to ensure staff completed all required training as specified in the OARs was discussed with Staff 1 (Interim ED/Director of Operations), and Staff 2 (Director of Clinical Services) on 06/26/24 at 3:20 pm. They acknowledged the findings.

1. All staff files will be audited for missing required training components, including first aid training and CPR.  Once idenified, staff will be scheduled to complete all required training. If indicated, staff will be removed from the schedule until all training is completed.

2. All new hires will be required to completed all state required trainings prior to working within the community.

3. Upon each new hire the OM and ED will audit to ensure compliance, along with a new hire checklists will be completed and signed off on by all parties.

4. Office Manager, Executive Director and DRS will be responsible to see that corrections are completed and monitored going forward to stay within state compliance.

Based on interview and record review, it was determined the facility failed to ensure 1 of 2 sampled newly hired direct care staff (#28) completed first aid and abdominal thrust training within 30 days of hire. This is a repeat citation. Findings include, but are not limited to:

Staff training records were reviewed on 01/29/25. The following deficiencies were identified:

Staff 28 (CG), hired on 12/18/24, did not have documented evidence first aid and abdominal thrust training had been completed within 30 days of hire.

The need to ensure staff completed all required trainings as specified in the OARs was discussed with Staff 26 (Office Manager), Staff 24 (Director of Resident Services), and Staff 25 (Director of Alderbrook) on 01/30/25. They acknowledged the findings.

1. All new hires will complete First Aid and Abdominal thurst training within 30-days of hire date. All current employee will complete this training by 3/16/25

2. All employees will complete required training before providing care and renew annually as required.  Office Manager, Director of Resident Services and Executive Director will ensure training is tracked and completed as required.

3. Trainings will be reviewed upon new hire orientation and monthly thereafter to ensure modules are completed, certificates are printed and all employees are compliant and their employee files are updated with completed trainings.

4. Office Manager, Executive Director, Alderbrook Director and Director of Resident Services will be overseeing all training

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted according to the Oregon Fire Code (OFC) and failed to provide fire and life safety instruction to staff on alternate months. Findings include, but are not limited to:

On 06/26/24, fire drill records from 12/01/23 through 06/01/24 were reviewed with Staff 5 (Director of Plant Operations). Fire drill records lacked documentation of the following required elements:

* Fire drills were conducted every other month; and

* Fire drills were conducted at different times of the day, evening, and night shifts.

The facility provided no documented evidence staff were given fire and life safety training on alternate months.

On 6/26/24 in an interview with Staff 5, he acknowledged the facility did not conduct fire drills every other month and at different times of the day or provided staff fire and life instruction on alternate months.  

On 06/26/24 at 2:30 pm, the OFC requirements regarding fire drills and fire and life safety instruction for staff was reviewed with Staff 1 (Interim ED/Director of Operations), and Staff 2 (Director of Clinical Services). They acknowledged the findings.

1. Director of Maintenance has been educated of the requirements per licensing for both AL and MC and will conduct fire drills every other month and provide fire and life safety instruction to staff and residents on alternate months. A written fire drill record will be kept to document fire drills that include date and time of day, location of simulated fire orgin, the escape route used, any problems encountered, comments relating to residents who resisted or failed to parcipate in the drill. Evacuation time period needed and a list staff members on duty and particapting in fire drill. Fire alarm will be activated during each fire drill unless otherwise directed by Fire authority.

2. Fire and Safety binders will be audited monthly as apart of our CQI process to insure compliance.

3. On a Monthly basis.

4. Managed by Maintenance Director and Executive Director for compliance.

Based on interview and record review, it was determined the facility failed to ensure residents were instructed on fire and life safety procedures within 24 hours of admission and re-instructed annually. Findings include, but are not limited to:

Review of facility records on 06/26/24 identified the following deficiencies:

*There was no documented evidence residents were instructed on fire and life safety procedures before admission or within 24 hours of admission to the facility; and

*There was no documented evidence annual re-instruction on fire and life safety was provided to residents.

In an interview on 6/26/24 Staff 5 (Director of Plant Operations) acknowledged the facility was not providing fire and life instruction to residents on admission or annually.

On 6/26/24, the need to provide and document fire safety instruction to residents within 24 hours of admission, and to re-instruct residents annually, in accordance with the Oregon Fire Code was discussed with Staff 1 (Interim ED/Director of Operations), and Staff 2 (Director of Clinical Services) on 06/26/24. They acknowledged the findings.

1. Director of Maintenance has been educated of the requirements per licensing for both AL and MC and will conduct fire drills every other month and provide fire and Life Safety instruction to current residents. All new residents will be educated upon move-in within 24-hours. Drills and training will be monthly and annually.

2. Fire and Safety binders will be audited monthly as apart of our CQI process to ensure compliance.

3. On a monthly basis.

4. Managed by Maintenance Director and Executive Director for 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 372, Z 155, and Z 164.

1. C372, Z155 and Z164 will be corrected and satisified by March 16, 2025.

2. Tracking of all trainings and process and procedures are being documented and filed in each employees.

3. Training upon new hire and again within 30-days of hire and annually thereafter.

4. Office Manager keeping tracker updated, Alderbrook Director confirming training is completed, Director of Residents Service to oversee, and Executive to sign off.

Based on observation, interview and record review, it was determined the facility failed to ensure their first revisit survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include, but are not limited to:

Refer to C 372, Z 142, Z 155, and Z 164.

1. Executive Director and Director of Resident Service are taking immediate action to ensure inspection and investigation is in compliance by May 25th, and continue compliant going forward.

2. Tracking systems are being put in place to ensure training are in compliance at all times.

3. Upon new onboarding of employees, monthly and ongoing to ensure always in timely and current.

4. Executive Director, Director of Resident Services, and Office Manager.      

Based on observation and interview, it was determined the facility failed to ensure exit doors were equipped with an alarming device 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 06/24/24, doors to the interior MCC courtyard were found to lack a working alarm or other system to alert staff when a resident exited the building. This lack of alarm or system was confirmed by an interview with Staff 16 (CG) on 06/24/24.  

The need to ensure all exit doors were equipped with an acceptable system to alert staff when a resident exited the building was discussed Staff 1 (Interim ED/Director of Operations), and Staff 2 (Director of Clinical Services) on 06/26/24 at 3:20 pm. They acknowledged the findings.

1. Exit door alarms have been added to the secure internal courtyard to provide alert notification of any residents going out to the courtyard.

2. Alarm will be monitored for operational purposes.

3. 24-7 monitoring will be provided by clinical team.

4. All clinical team members and Director of Maintenance will be responsible for the ongoing monitoring of the secure internal courtyard doors with alarms to ensure that they are in working order.

During the survey, concerns were identified in the following area and the facility was provided with technical assistance:

H 1511 Individual Rights Settings: OAR 411-004-0020 (1)(d)

(1) Residential and non-residential HCB settings must have all of the following qualities:

(d) The setting ensures the individual the right to freedom from restraints, except in accordance with the standards set forth in ORS

443.739, OAR chapters 309 and 411, 1915(c) HCBS Waivers, 1915(i) State Plan HCBS, or 1915(k) Community First Choice (K State Plan Option). When the right to freedom from restraints must be limited due to a threat to the health and safety of an individual or others, an individually-based limitation as described in OAR 411-004-0040 must apply in any residential or non-residential setting.

Refer to C 340.

During the survey, concerns were identified in the following area and the facility was provided with technical assistance:

H 1517: Individual Privacy: Own Unit. OAR 411-004-0020(2)(d):

(d) Each individual has privacy in his or her own unit. This was regarding no lock on the apartment side of the door to shared bathrooms.

Concerns were identified and technical assistance was provided in the following:

H 1518: OAR 411-004-0020(2)(e): Individual Door Locks: Key Access.

(e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit.

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 C 240, C 295, C 372, C 420, C 422, and C 555.

Please review the above as stated on C240, C295, C372, C420, C422 and C555. All listed citations have been addressed and provided with POC.

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 C 372.

Review to C372 plan of correction.

Based on interview and record review, it was determined the facility failed to have documented evidence of required pre-service orientation and dementia training completed, and demonstrated competency in assigned duties within 30 days of hire for 3 of 3 newly hired direct care staff (#s 17, 18, 19, 21, 22 and 23), and a total of 16 hours of in-service training completed annually, including six hours related to dementia care topics for 1 of 1 long-term direct care staff (#20) . Findings include, but are not limited to:

Training records were reviewed on 06/26/24. The following deficiencies were identified:

1. Training records for Staff 17 (CG), Staff 18 (CG), and Staff 19 (MT), hired 05/23/24, 03/08/24, and 03/15/24 respectively, identified the following:

a. Staff 17 lacked documented evidence pre-service orientation training was completed prior to beginning job responsibilities in the areas of:

* Fire safety and emergency procedures;

* Written job description;

* Infectious disease prevention;

* Approved HCBS course.

Staff 18 lacked documented evidence pre-service orientation training was completed prior to beginning job responsibilities in the areas of:

* Fire safety and emergency procedures.

b. Staff 17 and 19 lacked documented evidence pre-service dementia training was completed prior to independently providing care and services to residents.

c. Staff 17 lacked documented evidence of knowledge and performance demonstrated within 30 days of hire in the following required areas:

* Role of service plans in providing individualized care; and

* Changes associated with normal aging.

Staff 18 and 19 lacked documented evidence of knowledge and performance demonstrated within 30 days of hire in the following required areas:

* Changes associated with normal aging.

2. Staff 20 (LPN) hired 05/24/21 lacked documented evidence of completion of 16 hours of annual in-service training which included at least six hours of dementia care training annually from 05/2022 to 05/2023.

3. The following long-term and/or non-direct care staff failed to complete infectious disease prevention at hire and/or annually thereafter:

* Staff 21 (Cook), hired 01/14/22.

4. The following long-term direct and non-direct care staff failed to complete HCBS training:

* Staff 22 (Receptionist), hired 11/08/21, and

* Staff 23 (Server), hired 07/01/22.

The need to ensure all required training was completed in the specified time frames was reviewed with Staff 1 (Interim ED/Director of Operations), and Staff 2 (Director of Clinical Services) on 06/26/24 at 3:20 pm. They acknowledged the findings.

1. Direct care staff employee files have been audited for dementia training. Additional training will be provided to include how to identify and address pain, provide food and fluids, prevent wandering and elopement, and use of person centered approach. Employees that need to complete required training will be removed from the schedule until all required training is completed. Training will also be provided on environmental factors, familial support and recongnizing behaviors. Staff will have 16-hours of annual inservice dementia training. 6 of the 16-hours will include dementia training. All staff will have inservice on infectious disease prevention and will complete HCBS course as required.

2. Proper onboarding checklists will be signed off on by OM, and ED to ensure all trainings are completed.

3. Upon each new hire.

4. OM, ED and DRS will monitor to ensure compliance.

Based on interview and record review, it was determined the facility failed to ensure documented evidence of required pre-service orientation and dementia training completed for 2 of 2 newly hired direct care staff (#s 27 and 28), and of a system in place to ensure all direct care staff completed a minimum of 16 hours of inservice training annually, and failed to ensure 1 of 2 long-term non-direct care staff (#22) completed Home and Community-Based Services (HCBS) training. This is a repeat citation. Findings include, but are not limited to:

Staff training records were reviewed on 01/29/25. The following deficiencies were identified:

1. Training records for Staff 27 (MT) and Staff 28 (CG), hired 11/20/24 and 12/18/24 respectively, identified the following:

a. Staff 27 lacked documented evidence pre-service orientation training was completed prior to beginning job responsibilities in the areas of:

* Resident rights and values of CBC care; and

* Approved HCBS course;

Staff 28 lacked documented evidence pre-service orientation training was completed prior to beginning job responsibilities in the areas of:

* Abuse reporting requirements;

* Fire safety and emergency procedures; and

* Approved HCBS course.

b. Staff 27 lacked documented evidence pre-service dementia training was completed prior to independently providing care and services to residents in the areas of:

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

* 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.

c. There was no documented evidence Staff 27 and Staff 28 completed the required additional dementia care pre-service training topics, including:

* 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;

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

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

* Use of supportive devices with restraining qualities in memory care communities.

2. During an interview at 11:15 am on 01/28/25, Staff 26 (Office Manager) was asked to explain the facility's process for providing annual in-service training to staff. Staff 23 stated the facility's goal was to assign courses through an online training program and the facility would monitor the courses and hours of training completed by staff. Staff 23 stated this had not been initiated yet.

3. There was no documented evidence Staff 22 (Receptionist) hired 08/25/23, completed required HCBS training.

The need to ensure all required training was completed in the specified time frames and the need to ensure a system was in place to ensure all direct care staff completed a minimum of 16 hours of inservice training annually, and that long-term non-direct care staff completed HCBS training was reviewed with Staff 26, Staff 24 (Director of Resident Services), and Staff 25 (Director of Alderbrook) on 01/30/25. They acknowledged the findings.

1. Post resurvey, all staff training requirements listed in Z155 will be implemented in our onboarding process. 2. All current employee, and all new employees will be required to completed by March 16, 2025, and continue required training going forward to ensure policy is corrected and is maintained.

3. Upon onboarding, 30-days after hire, and annually thereafter for each employee retained.

4. Overseen by Office Manager for record tracking of completed trainings including date of certificate and printed record of completion, confirmed by Director of Resident Services, Alderbrook Director and Executive Director.

Based on interview and record review, it was determined the facility failed to ensure documented evidence of required pre-service orientation and pre-service dementia training was completed for 4 of 4 newly hired direct care staff (#s 34, 37, 38, and 42) and failed to ensure 2 of 3 direct care staff (#s 33 and 36) completed the required annual Home and Community-Based Services (HCBS) training. This is a repeat citation. Findings include, but are not limited to:

On 04/25/25, staff training records were reviewed, and the following was identified:

a. The facility lacked documented evidence Staff 37 (CG), Staff 38 (CG), Staff 34 (MT), and Staff 42 (MT), hired 04/06/25, 04/09/25, 04/22/25, and 03/26/25, respectively, completed each of the following pre-service orientation training topics:

* Resident rights and values of CBC care;

* Abuse reporting requirements;

* Fire and emergency procedures;

* Food handlers certificate;

* Infectious disease prevention;

* Approved HCBS course; and

* Approved LGBTQIA+ course.

b. The facility lacked documented evidence that Staff 37, Staff 38, Staff 34, and Staff 42 completed each of the following additional pre-service dementia training topics:

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

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

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

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

* Use of supportive devices with restraining qualities in memory care communities.

c. On 04/25/25, Staff 31 (ED) confirmed there was not a current system in place to ensure all required annual in-service training was completed, that included documented evidence of HCBS training for Staff 33 (CG) and Staff 36 (MT).

The need to ensure staff completed all required training was reviewed with Staff 31 and Staff 20 (Director of Resident Services/LPN) on 04/25/25 at 3:55 pm. They acknowledged the findings.

1. All staff in Memory care have attended all the required trainings. Staff #34, 37, 38 and 42, have completed all trainings. These trainings are documented in our new training staff binder with evidence of training certificates. Binder also includes documented trainings for Staff #33 and 36.

2. System correction is now implemented with a training binder tracking each employees trainings required and dates of required trainings due.  Each department head are assigned training login by their supervisor to ensure tracking of completion going forward.

3. Trainings are evaluated weekly in standup to ensure all are in compliance by all team leadership of each department.

4.  Office Manager and Executive Director will be responsible to see that the corrections are completed and monitored to stay in compliance.

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, C 280, and C 340.

1. Please refer to above C260, C280 and C340. As each have been addressed.All listed citations have been addressed and have been provided with a POC.

Based on interview and record review, it was determined the facility failed to ensure an individualized activity plan was developed for each resident, based on an activity evaluation, for 2 of 3 sampled residents (#s 1 and 2) whose records were reviewed. Findings include, but are not limited to:

Resident 1 and 2's service plans and evaluations were reviewed. There was no documented evidence the facility had fully evaluated the residents':

* Past and current interests;

* Current abilities and skills;

* Emotional and social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for the resident to participate; and

* Identification of activities for behavioral interventions, if necessary.

On 06/26/24 at 3:20 pm, the failure to ensure all residents had individualized activity plans developed and implemented, based on their activity evaluations, was discussed with Staff 1 (Interim ED/Director of Operations) and Staff 2 (Director of Clinical Services). They acknowledged the findings.

1. Residents #1 and #2 services plans have been reviewed and updated, along with any memory care resident's service plan to included past and current interest, current abilities and skills, emotional and social needs, physical abilities and limitations, adaptions necessary for the resident to particpate, indenification of activities for behavorial interventions.

2. System has been corrected and will be maintained and monitored going forward.

3. Z164 will be included in our monthly CQI process.

4. Alderbrook Director, and both Assistant Social Coordinator, along with Executive Director.

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 4, 5 and 6) whose activity plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

Residents 4, 5 and 6's records were reviewed during the survey. There was no documented evidence activity evaluations had been completed and the service plans individualized to reflect one or more of the following required components:

*Residents' current preferences;

*Abilities and skills;

*Emotional/social needs and patterns;

*Physical abilities and limitations;

*Adaptations necessary for the resident to participate; and

*Identification of activities for behavioral  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 01/30/25 at 11:20 am, the need to evaluate and develop individualized activity plans which included all required components for each memory care resident was discussed with Staff 24 (Director Resident Services), who acknowledged the findings.

1. Life story form and CBC Individualized Activity Plan will be completed for each resident in Memory Care by March 16, 2025.

2. Individualized Activity Plan has been implemented to our move-in process and will be required to be completed, idenify abilities and skills, emotional/social needs and patterns. Physical abilities/limitations, and identify activities for behavioral interventions.

3. Area will be evaluated upon service planning, 30-days after move-in and quarterly thereafter.  

4. Activity Director/Social Coordinator to complete Individualized Activity Plan and Director of Resident Services and clinical team update activity quarterly, signed off by Executive Director.

Based on observation, interview and record review, it was determined the facility failed to evaluate and develop individualized activity plans for 2 of 2 sampled residents (#s 7 and 8) whose activity plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

During the acuity interview on 04/25/25, Resident 8 was identified as bedbound and the resident was observed in bed and appeared to be sleeping during the survey.

Residents 7 and 8's records were reviewed during the survey. There was no documented evidence activity evaluations had been completed and the service plans individualized to reflect one or more of the following required components:

*Residents' current preferences;

*Abilities and skills;

*Emotional/social needs and patterns;

*Physical abilities and limitations;

*Adaptations necessary for the resident to participate; and

*Identification of activities for behavioral  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.

Observations on 04/25/25 showed multiple small group activities being led by facility staff. Residents 8 was in bed. The television was on, but the resident appeared to be sleeping and was not watching television. No other activity was provided to the resident.

On 04/25/25 at 12:35 pm, the need to evaluate and develop individualized activity plans which included all required components for each memory care resident was discussed with Staff 20 (Director of Resident Services/LPN) and Staff 31 (ED). They acknowledged the findings.

1. Resident #7 and #8 activity plans were reviewed and updated and documented activity evaluations has been completed and the service plan individualized to reflect residents perferences, abilities and skills, emotional and social needs and patterns. Physical abilities and limitations, adaptations necessary for the resident to participate and of activities for behavioral interventions.

2. Staffing will evaluate every resident in memory care for their activity preferences and develop an individualized activity plan that reflect those preferences.

3.Upon each new move-in and ongoing as their activity preferences change or develop and upon quarterly reviews.  

4. Director of Memory, Executive Director and Social Coordinator.

Based on observation and interview, it was determined the facility failed to ensure residents were not locked outside of their rooms. Findings include, but are not limited to:

During observations on 06/24/24 through 06/27/24, doors to resident rooms on the memory care unit were observed closed. Further observations revealed many of the closed doors were locked. Multiple residents were observed being unable to go into their rooms without locating staff and asking to be let in.

In an interview on 06/24/24 at 3:15 pm, Staff 16 (CG) stated resident's doors were locked to prevent wandering residents going into other's rooms. If residents wanted access to their rooms, they could let staff (who had keys) know and they would let them in.

The need to ensure residents were not locked out of their rooms was discussed on 06/26/24 at 3:20 pm with Staff 1 (Interim ED/Director of Operations), and Staff 2 (Director of Clinical Services). They acknowledged the findings.

1. All memory care resident room doors have been unlocked and will remain unlocked for ease of access. Each resident or family member have been provided with a key to their room.

2. This has been corrected for current residents and new residents or family members will be provided a key upon move-in.

3. This will be monitored daily and on-going.

4. Alderbrook Director and/or designee, Care staff, Med Techs and licensed nurses.