The findings of the re-licensure survey, conducted 08/22/22 through 08/24/22, 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 revisit to the re-licensure survey of 08/24/22, conducted 03/01/22 through 03/02/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.

Based on observation, interview and record review, it was determined the facility failed to ensure investigations of incidents were thorough and complete in order to rule out abuse or neglect for 3 of 3 sampled residents (#s 1, 2 and 3) whose incidents were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 08/2019 with diagnoses including dementia.

Observations of Resident 1 throughout the survey revealed the resident was dependent on staff for most ADLs and used pool noodles at the edge of the bed to prevent the resident from rolling out of bed.

The resident experienced two unwitnessed falls between 05/23/22 and 08/22/22, which included skin injuries. Review of the incident reports revealed the facility failed to initiate or complete the investigation of the falls to reasonably rule out abuse or neglect. There was no documented evidence the facility reviewed whether current interventions were in place or other service planned directions were followed at the time of the incident in order to properly rule out abuse or neglect.

On 08/24/22 at 9:10 am, Staff 1 (Administrator) confirmed there was no documented evidence the facility conducted an immediate investigation to reasonably conclude the unwitnessed falls were not the result of abuse or neglect.

The surveyor requested Staff 1 to report the incident to local SPD office. Confirmation the reports had been sent to local APD office was provided.

2. Resident 2 was admitted to the facility in 06/2022 with diagnoses including dementia.

Observations of Resident 2 throughout the survey revealed the resident was dependent on staff for most ADLs and used a Hoyer lift for transfers.

Review of the resident 2's clinical records during the survey revealed the following:

* On 07/16/22, staff documented in progress notes that the resident had a bruise on top of the left hand.  

There was no documented evidence the facility conducted an immediate investigation to reasonably conclude the above physical injury was not the result of abuse and it was not reported to the local SPD office.

On 08/23/22 at 8:20 am, Staff 1 (Administrator) confirmed the physical injury had not been investigated nor reported to the local unit. The surveyor requested Staff 1 to report the incident to local SPD office. Confirmation the report had been sent to local APD office was provided.

3. Resident 3 was admitted to the facility in 04/2021 with diagnoses including Alzheimer's disease.

During the acuity interview on 08/22/22, Resident 3 was identified to be involved in a resident to resident altercation.

Resident 3's incident report regarding the altercation was requested and revealed the following:

* Resident 3 was involved in a resident to resident altercation on 06/22/22; and

* Staff documented on the facility incident report that the resident "was being accused on possibly hitting/pulling of hair of the roommate..."

There was no documented evidence the incident had been thoroughly investigated to rule out the possibility of abuse and there was no documented evidence the incident was reported to the local SPD.

On 08/22/22, the surveyor requested Staff 1 (Administrator) to report the incident to SPD. Subsequently, the surveyor received verification the incident had been reported.

The need to ensure incident investigations included and documented a review of whether staff were following the provisions of the service plan in order to rule out abuse or neglect was discussed with Staff 1, Staff 2 (Owner) and Staff 4 (Marketing Director) on 08/24/22 during the exit. They acknowledged the findings.

1. The examples given were immediately reported to APS upon request of the surveyor.

2. Immediately upon any incident that could have the potential for abuse or neglect the facility administrator and RN will be notified and conduct an immediate investigation, documenting findings and assure charting accurately reflects the investigation.                                                                                  3. Evaluation will occur monthly to during an IDT to assure compliance.

4. Administrator and RN (owner)

Based on observation and interview, it was determined the facility failed to ensure the kitchen was kept clean and in good repair, and food was prepared and served in accordance with the Food Sanitation Rules OAR 333-150-00. Findings include, but are not limited to:  

1. On 08/22/22 and 08/23/22, during the kitchen tour, the following was observed to be in need of cleaning or repair:

* The side of the two compartment sink had water damage and was missing part of the laminate;

* An edge of a shelve in the cabinet had missing laminate;

* A manual can opener attached to the countertop, had a thick layer of black matter build-up; and

* Cabinet surfaces throughout the kitchen were sticky to the touch.

On 08/23/22 at 12:20 pm, the kitchen was toured with Staff 3 (Lead Kitchen). Staff acknowledged the areas needed cleaning and repair.

2. On 08/23/22 at 11:20 am to 12:20 pm, Staff 3 (Lead Kitchen) was observed and the following was noted:  

* Staff 3 prepared barbeque chicken and egg sandwich with plastic gloved hands;

* During the preparation of barbeque chicken, Staff 3 walked away from the tray line and went to cabinet to retrieve utensil and a blender with the gloved hands;

* Staff 3 went back to the tray line without changing gloves or washing her hands;

* Staff 3 was observed touching a piece of bread with the same gloved hands to make egg sandwich; and

* The surveyor directed Staff 3 to change gloves during the meal preparation.

On 08/23/22 at 3:15 pm, the observation was shared and infection control practice was discussed with Staff 1 (Administrator).  She acknowledged the findings.

The need to ensure the kitchen was kept clean and in good repair, and food was prepared and served in accordance with the Food Sanitation Rules was discussed with Staff 1, Staff 2 (Owner) and Staff 4 (Marketing Director) on 08/24/22 during the exit. They acknowledged the findings.

1. Cabinet with water damage and missing a piece of laminate is being re-made by a local cabinet shop.

2. Cabinet shelf with missing laminate was resurfaced on 9-12-22

3. Can opener was added to kithcen cleaning list and will be cleaned every evening.

4. Kitchen cabinets were cleaned and degreased thoroughly on 9-7-22

5. Kitchen staff were re-trained on glove wearing at staff meeting on 9-8-22. On-going training for kitchen sanination rules will continue every other month by administrator and lead kitchen manager

6. Administrator and owner

Based on interview and record review, it was determined the facility failed to ensure an initial move-in evaluation included all required elements, for 1 of 1 sampled resident (#2) whose move-in evaluation was reviewed. Findings include, but are not limited to:

Resident 2 moved into the facility in 06/2022.

a. The new move-in evaluation failed to address the following elements:

* Mental health issues including depression, thought disorders or behavioral or mood problems including history of treatment and non-drug interventions;

* Personality including how the person copes with changes or challenging situations;

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

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

* Indicator or nursing needs including potential for delegated nursing tasks;

* Elopement risk or history;

* Alcohol and drug use; and

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

b. There was no documented evidence the facility updated and modified the evaluation during the 30 days following the resident's move into the facility.

The need to complete all required components for move-in evaluation and update the evaluation within 30 days of move-in was reviewed with Staff 1 (Administrator) on 08/23/22.

1. The residents in the report had evaluation and care plans updated to reflect compliance.

2. The Move-in evaluation form was updated to reflect all missing components. (See example) The facility administrator will assure all move-in, 30 day, and quarterly evaluations and care plan updates are completed.

3. At each new move in- the administrator will assure all components of the move-in evaluation is complete.

4. Administrator and RN( owner)

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

1. Resident 1 was admitted to the facility in 08/2019 with diagnoses including dementia.

Resident 1 was observed to utilize a wheel-chair for mobility and needed to be supervised for food intake.

Observations of the resident, interviews with staff, review of the current 06/03/22 service plan and clinical records during the survey, revealed Resident 1's service plan was not reflective of the resident's status and did not provide specific directions to staff, and was not followed in the following areas:

* Evacuation status and level of assistance needed;

* Denture care status;

* Fall including interventions and use of pool noodles;

* Skin status;

* Health shakes status; and

* Activity status.

The need to ensure the service plan provided clear instruction to staff, was reflective of the resident's needs and was followed was discussed with Staff 1 (Administrator) on 08/23/22. Staff acknowledged the findings.

2. Resident 2 was admitted to the facility in 06/2022 with diagnoses including dementia.

Resident 2 was observed to utilize a wheel-chair for mobility.

Observations of the resident, interviews with staff, review of the current 06/30/22 service plan and clinical records during the survey, revealed Resident 2's service plan was not reflective of the resident's status and did not provide specific directions to staff in the following areas:

* Evacuation status and level of assistance needed;

* Use of side rails;

* Coumadin therapy status;

* Pain status;

* Use of glasses;

* Elevated legs instruction;

* Transfer status 1-person versus 2-person assist;

* Skin status; and

* Outside provider service including when to contact and who to contact.

The need to ensure the service plan provided clear instruction to staff and was reflective of the resident's needs was discussed with Staff 1 (Administrator) on 08/23/22. Staff acknowledged the findings.

The residents in the report had evaluation and care plans updated to reflect compliance.

2. The move-in evaluation form was updated to reflect all missing components. (See example) The facility administrator will assure all move-in, 30 day, and quarterly evaluations and care plan updates are completed. The same evaluation form will be used for move-in, 30 day, and quarterly evaluations to assure compliance and that all areas are addressed.

3. At each new move in- the administrator will assure all components of the move-in evaluation is complete.

4. Administrator and RN(owner)

Based on observation, interview and record review, it was determined the facility failed to ensure residents who experienced changes of condition were evaluated, actions/interventions were determined, service planned interventions were reviewed for effectiveness, and/or were monitored weekly through resolution for 2 of 2 sampled residents (#s 1 and 2) who had documented changes of condition. Findings include, but are not limited to:

1. Resident 1 was admitted to the memory care unit in 08/2019 with diagnoses including dementia. During the survey, s/he was identified as having recent falls.

Observations of Resident 1 throughout the survey revealed the resident was dependent on staff for most ADLs and used pool noodles at the edge of the bed to prevent rolling out of bed.

a. Clinical records, including the service plan, temporary service plans (TSP's), incident reports and investigations, provider notes and charting notes were reviewed.

The clinical record provided the following information:

* 06/03/22 service plan indicated safety check and required incontinent care for every 2 hours;

* 06/11/22 fall in the bathroom resulting in abrasion on the back;

* 06/21/22 fall in the room;

* 08/14/22 fall in the room resulting in skin tear and bruising; and

* 08/16/22 TSP identified a twin mattress to be placed on the floor, next to the bed.

The records documented information on the falls. However, there was no documented evidence the facility conducted an investigation of the incidents to determine if service planned interventions were followed in the area of safety checks and incontinent care and were evaluated for effectiveness and there were no new interventions communicated to staff.

b. The resident experienced three falls between 05/22/22 and 08/22/22 as the following:

* 06/11/22 in the bathroom resulting in abrasion on the back;

* 06/21/22 in the room; and

* 08/14/22 in the room resulting in skin tear and bruising.

There was no documented evidence that the resident's short-term changes of condition and skin status were monitored, at least weekly, to resolution.

On 08/23/22, the above findings were reviewed with Staff 1 (Administrator). Staff acknowledged findings.

2. Resident 2 was admitted to the memory care unit in 06/2022 with diagnoses including dementia.

Clinical records reviewed from 06/29/22 to 08/17/22 and staff interview noted the following:

* 06/29/22 - New move into the facility;

* 06/29/22 - Skin issues including scattered bruising on legs, scabbed abrasions, open wound on left shin and dark purple bruise on right knee and shoulders; and

* 07//16/22 - Bruise on top of the left hand.

There was no documented evidence that the resident's short-term changes of condition were consistently monitored, at least weekly, to resolution.

On 08/23/22 and 08/24/22, the above findings were reviewed with Staff 1 (Administrator). Staff acknowledged findings.

1. These were past incidents.  Care plans were updated to reflect any new interventions associated with the falls reviewed.

2.Upon any fall or incident any resident will be added to alert charting to assure that all short term changes of conditions are reflected.  An ISP system will be utilized to assure that an interim service plan is put into placed to reflect the change.  The ISP and alert charting system will be utilized and staff have been further trained in documentation, ISP, and alert charting guidelines.

3. Monthly during an IDT this will be reviewed to assure that procedures are being followed.

4. Administrator and RN (owner)

Notation- The community is reviewing the use of a different Electronic Health Record system that has been recommended due to ease of use and compliance.  

Based on observation, interview and record review, it was determined the facility failed to ensure the RN performed an assessment including interventions developed based on the condition of the resident for 1 of 1 sampled resident (# 1) who experienced a significant change of condition in weight status. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 08/2019 with diagnoses including dementia.

Observations of the resident on 08/22/22 and 08/24/22 revealed the resident required supervision and encouragement for food intake.

Resident 1's weight record was reviewed during the survey and revealed the following:

* 02/08/22 - 117.0 pounds;

* 05/08/22 - 107.5 pounds; and

* 08/08/22 - 102.5 pounds.

From 02/2022 to 08/2022, Resident 1 had weight loss of 14.5 pounds or 12.39 % of his/her body weight in 6 months, which represented a significant change of condition.

The service plan was updated 06/03/22 and directed staff to offer a health shake in between meals.

The facility RN completed an assessment on 08/22/22 and noted weekly weight checks and health shakes three times a day with meal, however, there was no documented evidence the RN evaluated if the current service planned intervention was implemented or effective to address the weight loss. Also, the RN assessment was not completed timely.

On 08/23/22, the failure to complete a RN assessment including an evaluation of the effectiveness of serviced planned interventions and completing assessments timely was discussed with Staff 1 (Administrator). Staff acknowledged the findings.

1. The resident reflected in this citation is being reviewed every two weeks by RN and the RN will assure and document that interventions are being done and document resident outcome. The RN will assure that response to interventions is documented.

2. Training of contracted RN ('s) will be completed to assure understanding of rule and need for intervention follow-up for effectiveness of said intervention.

3. This correction will be evaluated monthly during an IDT to assure compliance. This intervention will not only be for weight loss but for all significant changes of condition.

4. Administrator and RN (owner)

Based on interview and record review, it was determined the facility failed to coordinate care with outside providers in order to ensure the continuity of care, for 1 of 1 sampled resident (# 2) who received outside services. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 06/2022 with diagnoses including dementia.

Resident 2's clinical record, dated 06/29/22 through 08/17/22, was reviewed during the survey and revealed the following:

* 07/01/22 home health nursing note indicated staff to use lotion on the resident legs and to replace dressing on wound if it became soiled or dislodged;

* 07/06/22 occupational therapy instructed the facility to encourage the resident to self propel his/her wheelchair for short distances if possible throughout the day; and

* 07/27/22 physical therapy provided the facility with a handout of exercises to be completed one time per day.

There was no documented evidence the recommendations were communicated to staff or implemented.

On 08/23/22, the need to ensure on-going coordination of care was discussed with Staff 1 (Administrator). Staff acknowledged the findings.

1. Resident who was identified in this citation has had service plan updated to reflect current home health interventions.  Other residents with home health or hospice have had their service plan updated to reflect home health or hospice involvement.

2. Outside services will be reflect on all service plans as directed by the OAR. RN will supervise coordination of care. Contracted RN will receive further training on outside services documentation.

3. The service plans will be reviewed monthly with IDT to assure compliance.

4. Administrator and RN (owner)

Based on interview and record review, it was determined the facility failed to carry out orders as prescribed for 1 of 2 sampled residents (# 1) whose orders and MAR/TARs were reviewed. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 08/2019 with diagnoses including dementia.

The resident's 06/03/22 service plan indicated the resident "has been holding [his/her] bowels causing one to not be regular or have difficulties with passing."

Resident 1 had a physician's order, dated 06/08/22, to administer Polyethylene (to treat constipation) if the resident had no bowel movement (BM) in three days as needed and report to facility RN when there was no BM for three days .

A progress note dated 08/15/22 indicated the resident did not have BM for eight days.

Resident 1's 08/01/22 through 08/22/22 MAR revealed the medication was administered on 08/13/22 when the resident had no BM in five days, not when the resident had no BM in three days as prescribed and there was no documented evidence the facility RN was notified when the resident went three days without a BM.  

On 08/23/22, the physician orders and the MARs were reviewed with Staff 1 (Administrator). Staff acknowledged the findings.

1. For the resident identified bowel charting alerts were placed in the electronic care plan (ETAR).

2. Alert Charting, Bowel charting, and ISP training will be completed with all med techs. ETar updated to reflect bowel charting accuracy.  Med Techs further trained on reviewing bowel charting, interventions, and licensed nursing notification.

3. Monthly at IDT to assure accuracy.

4. Administrator and RN (owner)

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

1. Resident 1 was admitted to the facility in 08/2019 with diagnoses including dementia.

Resident 1's 08/01/22 through 08/22/22 MARs were reviewed during the survey and were found to be lacking accurate information and resident specific parameters to guide unlicensed staff in the following area:

* Multiple PRN cream, ointment and power had no indication of location to apply for the treatment.

On 08/23/22, the above findings were reviewed with Staff 1 (Administrator). Staff acknowledged the findings.

2. Resident 2 was admitted to the facility in 06/2022 with diagnoses including dementia.

Resident 2's 08/01/22 through 08/22/22 MARs were reviewed during the survey and were found to be lacking accurate information and resident specific parameters to guide unlicensed staff in the following area:

a. Resident 2 had a physician's order, dated 06/28/22, to administer Mylanta (400/400/50) 10 ml every 6 hours as needed for indigestion and heartburn.

Resident 2's 08/01/22 through 08/22/22 MAR was noted to administer the medication 30 ml every 4 hours as needed, not 10 ml and every 6 hours as prescribed. The resident did not receive the medication.

b. Multiple PRN cream, ointment and powder had no indication of location to apply for the treatment.

c. Multiple PRN bowel care medications lacked clear parameters for when to administer and which one should be given first.

On 08/23/22, the above findings were reviewed with Staff 1 (Administrator). Staff acknowledged the findings.

1. Per conversation with Eunsuk An RN on 9/7/22 we will continue to have PRN protocol medications placed on the EMAR due to the need to renew for orders every 90 days. However a new tag within the EMAR will state on the protocol that RN to be notified prior to implementing.  RN will be instructed to then place the appropriate documentation of location and time parameters that the powder, lotion, and/or creams are to be used.

2. The EMAR will be updated to reflect the new change with the notification of RN prior to the implementation of the PRN Skin and Constipation protocols. The current Constipation protocol has the  parameters of which laxative to use first and notification of RN.

3. Every 90 days this will be evaulated with the 90 day physician orders.

4. RN (owner) and Administrator.

Based on interview and record review, it was determined the facility failed to keep an accurate treatment record of all treatments ordered by a legally-recognized practitioner and administered by the facility, for 1 of 2 sampled residents (#2) whose TARs were reviewed. Findings include, but are not limited to:

Resident 2's records indicated that between 06/29/22 and 08/17/22, facility staff administered treatments, including first aid and wound care, for the following conditions:

* A skin tear;

* A wound to the left shin; and

* A wound to the left lower leg.

The facility failed to document on Resident 2's TAR that the treatment was administered.

The need to ensure all treatments administered by the facility were documented on the TAR was discussed with Staff 1 (Administrator). Staff acknowledged treatments administered by the facility were not being documented on the resident TARs.

1. This was past documentation and is not currently reflected by the resident identified in the citation.

2. Med techs have been retrained to not only document first aid wound care in the chart notes but also to document on the treatment record. (See example Form)

3. Monthly during an IDT these interventions will be reviewed to assure compliance with the rule.

4. Administrator and RN (owner)

Based on interview and record review, it was determined the facility failed to have a written policy describing how prescription drugs, not prepare as unit dose or blister packs, shall be dispensed to reduce errors in the tracking and administration of the drugs. Findings include, but are not limited to:

A copy of the facility's medication administration policy that addressed how prescription drugs, that were not prepared as unit dose or blister packs (such as ointment, cream, liquids, etc) were dispensed was requested on 08/22/22.

Staff 1 (Administrator) provided a printed copy of the medication administration policy. Review of the policy revealed there was no information describing what process the facility used to dispense medications that were not in blister packs or unit dose.

Staff 1 confirmed that there was no facility policy which describing the process of dispensing the prescription drugs that were not prepare as unit dose.

The need to develop and train staff on a facility policy to ensure accurate administration of prescription drugs that were not prepared as unit dose or blister packs, was discussed with Staff 1 on 08/23/22. She acknowledged the findings.

1. An updated policy and procedure was added to the medication policies to reflect the use of non unit dose packaging, ie bottles. (See Attached)

2. This is now updated and this policy will remain in effect unless other changes are made to the Oregon Administrative rules requiring updated policies.

3. Annually with policy and procedure reviews by administration.

4. Administrator and RN (owner).

Based on interview and record review, it was determined the facility failed to ensure fire and life safety instruction to staff was provided on alternate months and that documentation reflected all required fire drill components. Findings include, but are not limited to:

On 08/22/22, fire drill and fire and life safety records were reviewed from 02/2022 through 08/2022. The following deficiencies were identified:

1. There was no documented evidence the facility was providing fire and life safety training on alternating months for staff; and

2. The evacuation/drill documentation did not contain information on:

* Location of simulated fire origin;

* The escape route used;

* Evidence of alternate escape routes used;

* Residents who resisted or failed to participate in the drills;

* Evacuation time period needed; and

* The number of occupants evacuated.

The need to meet all requirements for fire drills and fire and life safety instruction was reviewed with Staff 1 (Administrator) on 08/22/22. She acknowledged the findings.

1. Staff training on fire drills will be documented and include stimulated fire and safe zone in various locations of the building. Staff will evacuate 2 residents per drill. Training and drills will occur every other month at staff meetings

2. -administrator and owner

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements for residents were met. Findings include, but are not limited to:

Fire drill records from 02/2022 through 08/2022 were reviewed on 08/22/22 with Staff 1 (Administrator). The facility lacked documentation of the following required elements:

* Evidence residents were being instructed on fire and life safety procedures, including designated meeting places inside or outside of the building in the event of an actual fire, within 24 hours of admission and re-instructed at least annually.

The need to have documented evidence of all fire and life safety training components was discussed with Staff 1 on 08/22/22. She acknowledged the findings.

1. Facility created a template questionaire for safety and evcuation traning for residents. These questions will be asked upon 24 hr of move in.

2. The safety and evacuation process will be re-assessed every 90 days with resident service plan and care conference

3.administrator and owner  

Based on observation and interview, it was determined the facility failed to ensure exit door alarms were functioning to alert staff when residents exited the unit. Findings include, but are not limited to:

The facility was toured on 08/22/22 and 08/23/22 and the following was identified:

* There were two exit doors that opened into the secured courtyard. The doors had alarms installed, but the alarms had been manually disabled.

On 08/23/22 at 10:20 am, the exit doors and exit door alarm system was discussed with Staff 1 (Administrator).  Staff 1 manually activated the alarm system, but the alarm system did not work properly.

The need to ensure the facility had operable exit door alarms was discussed with Staff 1 on 08/23/22. She acknowledged the findings.

1. Exit door hinges were realigned and batteries updated in the alarm system. System is functioning as intended on 9-6-22

2. -Owner

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 231, C 240, C 420, C 422 and C 555.

1. Refer to C231,C240 ,C420, C422, and C555

2. - administrator, RN(owner)

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 sampled newly-hired staff (#s 6, 7 and 8) had documentation of completed orientation, 2 of 2 sampled newly-hired direct care staff (#s 6 and 7) completed pre-service dementia training prior to performing any job duties and 2 of 2 sampled newly hired direct care staff (#s 6 and 7) completed demonstrated competency in all required areas within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed with Staff 1 (Administrator) on 08/23/22 and revealed the following:

1. Staff 6 (Universal worker) hired 04/08/22, Staff 7 (Universal worker) hired 04/20/22 and Staff 8 (Kitchen) hired 02/04/21, lacked documented evidence of having completed required orientation prior to performing any job duties.

2. Staff 6 and 7, lacked documented evidence of having completed pre-service dementia training prior to performing any job duties.

3. Staff 6 and 7, lacked documented evidence of having completed competency demonstration in all required areas within 30 days of hire.   In addition, Staff 6 lacked documented evidence of abdominal thrust training within 30 days of hire.

The need to ensure newly hired staff completed all required orientation, pre-service and competency training prior to providing care and services independently was discussed with Staff 1 on 08/23/22. She acknowledged the findings.

1. Facility will insure that all staff including new and long term employees reach the minimum requirements of Pre-service, 30 day training and the ongoing of 16 hours of continued education and 6 dementia specific education. This will be implemented by having quarterly training sessions. A quarterly training sessiosn was held on 9-7-22 to ensure that this process was implemented. The adminstrator will compile and review all training records.

2.  administrator and owner

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

Refer to C 252, C 260, C 270, C 280, C 290, C 303, C 310, C 315 and C 320.

Facility will add to current service plans to include more information regarding current interest, current abilities and skills, emotional and social needs/patterns, physciial abilities and limiations, as well as adaptation necessary for res to participate in activites of interest.

2. Facility will also include more information on person centered activities to custom an individualized activity plan  

3. Questions regarding the above information will be asked in greater detail prior to move in.

4. Service plans will be updated every 90 days to include current abiltiies to engage in activites and ways to encourage participation as desired.

5. - owner and administrator  

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 1 and 2) whose service plans were reviewed. Findings include, but are not limited to:

Residents 1 and 2's service plans offered some information relating to the resident's past interests; however, the facility had not thoroughly evaluated the resident's:

* 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.

Observations of the residents from 08/22/22 through 08/24/22 revealed the lack of activity programs that included the residents in one to one or group interaction.

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

The lack of an activity evaluation and individualized activity plan was discussed with Staff 1 (Administrator) on 08/23/22 and 08/24/22. She acknowledged the findings.

1. Facility will add to new move in service plans to include more information regarding missing components.

2. Facility will also include more information on person centered activities to custom an individualized activity plan  

3. Questions regarding the above information will be asked in greater detail prior to move in.

4. Service plans will be updated every 90 days to include current abilities to engage in activites and ways to encourage participation as desired.

5. - owner and administrator  

Based on observation and interview, it was determined the facility failed to ensure the fence surrounding the perimeter of the outdoor recreation area was not less than six feet in height. Findings include, but not limited to:

During a tour of the environment on 08/22/22, the perimeter fence in the secure outdoor recreation area was measured by Staff 10 (Contract maintenance) at the request of survey and found to be between 5'6" and 5'8" in height.

The need to ensure the fence surrounding the perimeter of the outdoor recreation area was not less than six feet in height was discussed with Staff 1 (Administrator) during a tour of the environment on 08/23/22 and with Staff 2 (Owner) and Staff 4 (Marketing Director) on 08/24/22 during the exit. They acknowledged the findings.

1. The curent fence surrounding the perimeter of the outdoor courtyard area is going to be modified to obtain a height of 6 ft

2. - Owner and administrator