The findings of the re-licensure survey, conducted 11/15/22 through 11/17/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.

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

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the revisit to the re-licensure survey of 11/7/22, conducted 07/24/23, 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 interview and record review, it was determined the facility failed to investigate incidents to rule-out abuse, document all required areas of an investigation and report to the local SPD office, if abuse or neglect could not be ruled out, for 1 of 2 sampled residents (# 2) with injuries of unknown cause. Findings include, but are not limited to:

Resident 2 was admitted to the MCC in 07/2017 with diagnoses including Alzheimer's disease.

The resident's progress notes, dated 08/18/22 through 11/15/22, and facility incident reports were reviewed. The following was identified:   

* On 09/01/22 staff documented, "...resident had a regular little bandaid [sic] over this [sic] skin tear from sometime earlier, that had bled through..."

* On 09/16/22 an outside provider documented, "...[s/he] has what appears to be a bruise on [his/her] left breast."

* On 09/17/22 staff initiated alert charting for "skin tear on right elbow."

* On 09/28/22 an outside provider documented, "...[s/he] has what appears to be yellow bruising on [his/her] chest area and on [his/her] left arm and shoulder."

There was no documented evidence the four occurrences had been investigated or reported to the local SPD or AAA office, if abuse and/or neglect could not be ruled out.

The need to ensure injuries of unknown cause were immediately investigated, contained all required areas of documentation, including if abuse and neglect could be ruled out and if not, the injuries were reported to the local SPD office was discussed with Staff 1 (Resident Care Manager), Staff 2 (LPN) and Staff 12 (Regional Operations Director) on 11/17/22. They acknowledged the findings.

The surveyor requested Staff 1 report the four injuries to the local SPD office on 11/17/22 and verification was received on 11/21/22.

1. C231: Staff will receive inservice training in the response for brusing, suspected abuse, and how to follow-up timely. Incidents will be reported immediately snf if needed APS, and 911 will be called when there is suspected abuse which has not been ruled out by the investigations process.

2. C231: Staff will receive continued incident training using the Root Cause Analysis per investigation for any and all incidents. All staff will receive mandatory training on Elder Abuse and Mandated Reporting.This will include orientation to Abuse and how to report. This will be completed during the new hire training process and on-going.

3. C231: Incidents will be evaluated through a quality improvement system to manage any open incidents and this will be reviewed daily in the stand-up meeting as well as clinical meetings.

4. C231: Incidents will be managed by the team which will include the Nurse, Administrator, and Resident Care Coordinator. This will ensure the corrections are completed and monitored. All incidents will be reviewed and discussed daily at the clinical meeting.

5. C231: Any outside agencies are required to report directly to the RCC, Nurse, and Administrator any injuries of unknown origin and any changes in resident condition. They will be required to complete the Outside agency form and submit to the clinical team for follow up as necessary to ensure compliance with Abuse reporting.  

2. Resident 3 was admitted to the facility in 08/2022.

The facility completed the initial evaluation for the resident on 08/24/22. There was no documented evidence the facility had used the evaluation to develop an initial service plan to meet the resident's needs and had made it available to staff. Resident 3's service plan was dated 09/24/22, 30 days after the resident had moved into the facility.

The need to ensure the facility developed the initial service plan from the initial evaluation and that it was accessible to staff was discussed with Staff 1 (Resident Care Manager) and Staff 2 (LPN) on 11/17/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure resident move-in evaluations contained all required elements for 1 of 1 resident (#1) whose move-in evaluation was reviewed and initial evaluations were used to develop an initial service plan to meet the resident's needs for 2 of 2 sampled residents (#s 1 and 3) whose evaluations were reviewed. Findings include, but are not limited to:

1. Resident 1 moved into the facility in 09/2022 with diagnoses including dementia.

a. The move-in evaluation lacked information on the following required elements:

* Customary routines related to eating and bathing;

* History of treatment for mental health issues and effective non-drug interventions;

* Cognition, including confusion and decision making ability;

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

* Ability to understand;

* Assistance needed with activities of daily living including grooming, bathing and personal hygiene;

* Pain, including how a person expresses pain or discomfort;

* Nutritional habits;

* Fall risk or history;

* Emergency evacuation ability; and

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

b. The facility completed the initial evaluation for Resident 1 on 09/27/22. There was a lack of documented evidence a service plan was then developed from the evaluation and provided to staff. The most recent service plan provided was dated 10/26/22 (30 days later).

The need to ensure move-in evaluations included information on all required elements and the facility developed the initial service plan from the initial evaluation was discussed with Staff 1 (Resident Care Manager), Staff 2 (LPN) and Staff 12 (Regional Operations Director) on 11/16/22. They acknowledged the findings.

1. C252:Facility screening at move-in: The resident evaluation process will be completed prior to the resident moving into the facillity. Items identified during the evaluation process will include the residents functional capabilities with aspects of ADL's, diagnosis, and current medication orders. This information will be gathered by the Wellness team and reviewed with the facility administrator prior to entering into an agreement of care with the facility. The facility admistrator will ensure the resident service plan is generated at the time of evaluation.

2. C252: The facility administrator will conduct an audit of all the resident move in paperwork to ensure accuracy and completeness before the resident is allowed to move in to the community. Admission will not be allowed to occur until the Administrator and Nurse have the necessary paperwork and the checkoff list is complete.  

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of resident's current care needs and provided clear direction to staff for 1 of 3 sampled residents (#3) whose service plans were reviewed. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 08/2022 with diagnoses including dementia with behaviors and a left proximal femur fracture.

Observations of the resident, interviews with staff, review of the clinical record and the most recent service plan dated 09/24/22, indicated the service plan was not reflective of the resident's current care needs and lacked specific instruction to staff in following areas:

* Resident specific transfer assistance needed including hip precautions;

* Increased behaviors and interventions;

* Physical therapy services; and

* Emergency evacuation ability.

The need to ensure service plans were reflective of the resident's current care needs and provided clear direction to staff was discussed with Staff 1 (Resident Care Manager), Staff 2 (LPN) and Staff 12 (Regional Operations Director) on 11/17/22. They acknowledged the findings.

1. C260: Resident Service Plans will be the RCC/Administrators responsibility. Resident service plans will be reviewed for each resident and updated according to needs and changes in the level of care needed by the individual resident. Service Plans must include resident preferences. Each resident will be reviewed prior to admission,30 days after admission, and qurterly thereafter. Service plans will also be updated upon change of condition. Service plan updates and changes will be reviewed with the resident family member or responsible party, the care team, and if possible the resident.

2. C260: Administrator and RCC will set up a ticker file to assist in tracking when service plans are due for review and updates. This will ensure compliance with Service Plan updates and changes.

3. C260: Monthly audits will be conducted by the facility administrator to ensure Service Plans are being updated when due.

4. C260: Administrator, Resident Care Coordinator, and Wellness Nurse will review changes monthly and weekly. Home health and Hospice reports will be included in the review to ensure the service plans are accurate and that the resident needs are reflective of the current care needs.  

3. Resident 3 was admitted to the facility with diagnoses including dementia with behaviors.

The resident's current service plan and initial evaluation indicated the resident was a high risk for falling and had a history of falls.

Resident 3's clinical record and charting notes, reviewed from 08/24/22 through 11/15/22, revealed the following:

* On 09/22/22, the resident was going around hitting and pushing the other residents and staff. There was no documented evidence interventions were determined and implemented or the resident's behavior was monitored until resolved;

* On 09/22/22, the resident sustained a skin tear to the right arm. Documentation indicated the facility treated the skin tear and initiated monitoring; however, the record revealed no documented monitoring of the skin injury at least weekly until resolved; and

* On 10/25/22, the resident fell backwards while attempting to self transfer from the recliner. There was no documented evidence the resident was evaluated to determine what action or intervention was needed or that the change of condition was monitored through resolution.

The need to ensure the facility determined and documented what actions or interventions were needed for a resident and monitored the resident and documented on the progress of the condition at least weekly until resolved following a change of condition was discussed with Staff 1 (Resident Care Manager), Staff 2 (LPN) and Staff 12 (Regional Operations Director) on 11/17/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure residents who had short-term changes of condition were evaluated, resident-specific instructions or interventions developed and the condition monitored, at least weekly, until resolved for 3 of 3 sampled residents (#s 1, 2 and 3) who experienced short-term changes of condition. Findings include, but are not limited to:

1. Resident 2 was admitted to the MCC in 07/2017 with diagnoses including Alzheimer's disease.

Resident 2's progress notes, dated 08/18/22 through 11/15/22, were reviewed and revealed the following short-term changes of condition:

* 08/23/22 - Red area on little toe of left foot;

* 09/01/22 - Skin tear in undocumented location;

* 09/04/22 - Inability to take medications and change in blood pressure;

* 09/16/22 - Bruising on chest;

* 09/28/22 - Bruising to chest, left arm and left shoulder; and

* 09/29/22 - Vomiting and refusal of medications.

There was no documented evidence the facility evaluated the resident, determined or documented actions or interventions needed for the resident nor was the change of condition monitored through resolution for each change of condition.

The need to ensure residents were evaluated, interventions determined and monitoring documented at least weekly through resolution was discussed with Staff 1 (Resident Care Manager), Staff 2 (LPN) and Staff 12 (Regional Operations Director) on 11/17/22. They acknowledged the findings, and no additional documentation was provided.

2. Resident 1 was admitted to the facility 09/2022 with diagnoses including dementia and atrial fibrillation.

The resident's clinical records including incident reports, progress notes from 09/26/22 to 11/15/22, a "body audit sheet" dated 09/27/22 and interim service plans (ISP's) revealed the following:

a. On 09/27/22 upon move-in, staff identified multiple bruises on the resident's "abdomen, inner thigh, wrist and forearm and reddened areas on both heels, a toe and on peri-area".

There was no documented evidence the facility evaluated the resident's skin conditions or monitored them until resolved.

b. Resident 1 experienced 11 falls between 09/28/22 and 11/15/22. Progress notes and incident reports showed the following:

* 09/28/22: fall in bathroom, intervention identified to remind resident to ask for assistance and use the call light, awaiting start of care for physical therapy;

* 10/16/22: fall in bedroom, no new interventions identified, PT recently discontinued;

* 10/21/22 through 10/25/22: four falls, LPN did a fall evaluation note and added new intervention to "ensure the resident is using the wheelchair". Physician updated and the facility requested permission to discontinue use of the cane and four wheeled walker;

* 10/26/22: an ISP was completed instructing staff to discontinue resident's use of cane and walker. Awaiting a new PT provider to do an evaluation; and

* 11/06/22 through 11/15/22: six falls, found on floor in bedroom. Documentation showed several of the "falls" occurred when the resident may have placed him/herself on the floor to sleep.

While the resident was placed on "alert monitoring" following each fall, the facility lacked consistent development of interventions and monitoring for effectiveness.

On 11/16/22, the above information was discussed with Staff 1 (Resident Care Manager) and Staff 2 (LPN) who stated the resident's medical provider was working with a cardiologist to determine possible causes of the falls related to atrial fibrillation. The need to determine new interventions and evaluate their effectiveness to reduce the incidence of falls was discussed. They acknowledged the findings.

1. C270: Change of Condition: Wellness Nurse and Administrator will look at all residents, including residents who are receiving home health and hospice care. Outside agency notes will be reviewed and monitored to look for any changes in condition.  

2. C270:The RN will assess any resident change in condition and update the service plan as necessary.

3. C270: Any changes in condition will be brought up in the daily clinicals. The facility 24 hour report, current resident list, and any clinical information will be brought to the clinical meetings and discussed with the facility administrator and  wellness team. Clinical meetings will be conducted at least twice weekly to address concerns and resident changes.

C270: The facility Administrator will be responsible to provide oversight and ensure that any changes in resident condition are noted and service plans are updated as required. The facility administrator will train the care staff to identify and report changes to the Wellness nurse for follow up as needed.  

Based on interview and record review, it was determined the facility failed to ensure written recommendations made by outside service providers were incorporated in resident's service plan as applicable, and the instructions were made available to staff for provision of supplemental care for 3 of 3 sampled residents (#s 1, 2 and 3) who received outside services. Findings include, but are not limited to:

1. A review of Resident 3's clinical record noted s/he had been receiving Physical Therapy. Outside providers entered their after visit notes and recommendations through the facility's electronic charting system. Physical therapy notes indicated the outside provider had left the following recommendations for care:

* 10/26/22: "Please assist resident with seated exercises daily to maintain strength"; and

* 11/03/22: "Please assist resident with daily exercises to prevent further decline."

There was no documented evidence the facility had communicated the recommendations to staff.

On 11/17/22, the need to ensure recommendations from outside service providers were reviewed and interventions added to the service plan and communicated to staff as appropriate for provision of care was discussed with  Staff 1 (Resident Care Manager), Staff 2 (LPN) and Staff 12 (Regional Operations Director) on 11/17/22. They acknowledged the findings.  

3. Resident 2 was admitted to the MCC in 07/2017 with diagnoses including Alzheimer's dementia.

During the acuity interview, conducted on 11/15/22, Staff 1 (Resident Care Manager) indicated Resident 2 received hospice services.

The "Outside Agency Visit" progress notes, dated 08/18/22 through 11/14/22, were reviewed and revealed the following:  

* On 08/23/22, a HH CNA (Certified Nursing Assistant) documented, "[s/he] has what appears to be a red area on [his/her] little toe on [his/her] left foot."

* On 09/16/22 a HH CNA documented, "...[s/he] has what appears to be a bruise on [his/her] left breast."

* On 09/28/22 a HH CNA documented, "...[s/he] has what appears to be yellow bruising on [his/her] chest area and on [his/her] left arm and shoulder."

* On 09/29/22 a HH provider documented, "...caregivers state patient has some bruising on chest...patient did not eat breakfast due to throwing up and not feeling good per caregivers. Patient laying on right side. Advised med tech to monitor patient frequently due to vomiting."

* On 09/30/22 a HH CNA documented, "[S/he] still has what appears to be yellow bruises on [his/her] chest and left arm."

There was no documented evidence the facility reviewed the "Outside Agency Notes" and provided instruction to staff for care and monitoring regarding the resident's bruising and vomiting.

The need to ensure the facility management or a licensed nurse was notified of the services provided by an outside provider to ensure staff were informed of new interventions and reporting protocols were in place was discussed with Staff 1, Staff 2 (LPN) and Staff 12 (Regional Operations Director) on 11/17/22. They acknowledged the findings. No additional information was provided.

2. Resident 1 was admitted to the facility in 09/2022 with diagnoses including dementia.

The record indicated Resident 1 received Physical Therapy services in the facility from 09/29/22 until 10/13/22.

* Review of the "Outside Agency Visit" in progress notes indicated the facility had outside providers document on-site visits directly in the electronic system.

* On 09/29/22, PT documented "recommend CGA [contact guard assistance] ambulation with 4WW [four wheeled walker].

* On 10/13/22, PT documented "facility to manage HEP [home exercise program] as patient not participating in skilled PT at this time".

There was no documented evidence the facility had reviewed the notes and provided instruction to staff on the recommendations as instructed by PT.

In an interview on 11/16/22 with Staff 1 (Resident Care Manager), Staff 2 (LPN) and Staff 12 (Regional Operations Director), the lack of a process to ensure outside provider notes and recommendations were reviewed was discussed. Staff 1 and Staff 2 were not aware of an exercise program for Resident 1. They acknowledged the findings.

1. C290: The facilty Administrator will ensure that all outside providers have a sign in book and outside agency forms located by the facility entrance.All outside providers will be required to complete and outside agency form which will include the type of care, noted resident changes, recommendations, and any changes of condition.

2. C290: The RCC will review the outside agency sign in binder  and ensure that any changes in condition or areas of concern are reported to the Wellness Nurse for follow up.

3. C290: The Wellness Nurse along with the RN will ensure that any changes in condition are updated in the service plan and made available o the care team for implementation.

4. C290: RCC, Wellness nurse, and Administrator will meet on a weekly basis during clinicals to discuss and review care plan changes of condition.  

2. Resident 3 was admitted to the facility in 08/2022 with diagnoses including dementia, chronic pain and atrial fibrillation.

Review of the resident's 10/01/22 through 11/15/22 MARs identified the following medications were not administered as prescribed on the following dates:

* Celecoxib 200 mg capsule daily (for chronic pain) on 10/31/22 through 11/06/22. The reason documented on the MAR for not administering the medication was "awaiting delivery"; and

* Isosorbide mononitrate 60 mg tablet daily (for atrial fibrillation) on 11/02/22, 11/07/22 and 11/08/22. The reason documented on the MAR for not administering the medication was

"held per parameters"; however, the physician had not written blood pressure parameters and there were no blood pressure parameters documented on the MARs for the medication.

Interview on 11/17/22, Staff 2 (LPN) confirmed the resident had not received the above medications and the facility was working with the pharmacy.

The need to ensure orders were administered as prescribed was discussed with Staff 1 (Resident Care Manager), Staff 2 and Staff 12 (Regional Operations Director) on 11/17/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 2 of 3 sampled residents (#s 1 and 3) whose orders were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted in 09/2022 with diagnoses including dementia with behavioral disturbance and atrial fibrillation.

Physician's orders, signed 09/27/22, included the following:

* Aspirin 81 mg daily at 8:00 am for heart health;

* Divalproex ER (Depakote ER) 500 mg daily at 8:00 am and 5:00 pm for dementia with behaviors;

* Levothyroxine 75 mg daily at 5:30 pm for hypothyroidism;

* Sertraline 100 mg daily at 8:00 am for depression; and

* Tamsulosin 0.4 mg daily at 8:00 am for benign prostatic hyperplasia.

A review of the 10/01/22 through 11/15/22 MAR showed the following:

The morning doses of the medications listed above had an administration time range of  "8:00 am to 12:00 pm" on the MAR.

In an interview on 11/16/22, the range of administration times on the MAR and time sensitivity of certain medications were discussed with Staff 2 (LPN) and Staff 12 (Regional Operations Director). The need to ensure medication administration times were listed on the MAR and followed as ordered by the physician was discussed. They acknowledged the findings.

1. C303: The facility will conduct a mandatory Med Tech refresher training to include physician orders, medication parameters, and working with the pharmacy to ensure that all medicaions are available for the resident.

2. C303: Administrator and RCC will run a daily report of all med exceptions. RCC and clinical team will follow up on  all med-excemptions to ensure that the medication order are carried out as per the md order.

3. C303:The Wellness nurse will review QuickMar to ensure all parameters are accurrate. Audits will be conducted weeklly and monthly to ensure accuracy.

4. RCC, Wellness nurse, and Administrator will review daily and weekly reports for any missed meds and any problems with obtaining medications from family or pharmacy.

Based on interview and record review, it was determined the facility failed to notify the physician when a resident refused to consent to orders for 1 of 1 sampled resident (#1) who had documented refusals. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 09/2022 with diagnoses including dementia. Review of the current physician's orders did not provide any instruction on the physician's preference of when to be notified of any refusals. The resident's 10/01/22 through 11/15/22 MARs revealed the resident refused to consent to orders for the following medications and treatments:  

* 10/01/22 - temperature and oxygen saturation level;

* 10/04/22 - aspirin, tamsulosin, divalproex, carvedilol, sertraline;

* 10/05/22 - levothyroxine; and

* 10/18/22 - levothyroxine.

The clinical record lacked evidence the physician was notified of the refusals.

The need to ensure the physician or other practitioner was notified when a resident refused consent to an order and that subsequent refusals were reported was discussed with Staff 1 (Resident Care Manager) and Staff 2 (LPN). They acknowledged the findings.

1. C305: The facility will contact all physician's and obtain orders on how often they would like to be notified when a resident refuses his/her medications.

2. RCC, Administrator, and Wellness nurse will review all missed medications and resident refusals of medications will be added to the resident service plan.

3. Wellness team, RCC, and facility Administrator will be responsible for oversight of all physician orders. Monthly audits will be conducted to ensure orders are appropriate and that physician's are contacted when medications are missed for any reason.    

Based on interview and record review, it was determined the facility failed to ensure PRN medications used to treat residents' behaviors had written, resident-specific parameters for 2 of 2 sampled residents (#s 1 and 3) who received a PRN psychotropic medication. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 08/2022 with diagnosis of dementia with behaviors.

Review of the 10/01/22 through 11/15/22 MARs and physician orders revealed Resident 3 was prescribed a PRN psychotropic medication for anxiety. There were no resident-specific parameters on the MARs indicating how the resident exhibited signs and symptoms of anxiety.

The need to ensure the MAR included a description of how the resident exhibited anxiety was discussed with Staff 1 (Resident Care Manager), Staff 2 (LPN) and Staff 12 (Regional Operations Director) on 11/17/22. They acknowledged the findings.

2. Resident 1 was admitted to the facility in 09/2022 with diagnoses including dementia with behavioral disturbance.

Review of the record indicated Resident 1 had orders for, and was administered, PRN Haloperidol for "dementia with behaviors" on 10/04/22. The following deficiency was identified:

* There were no specific reasons for use documented on the MAR which described the circumstances and behaviors exhibited by the resident in order for staff to administer the PRN medication.

The need to ensure there were specific reasons for use for PRN psychotropic medication was reviewed with Staff 1 (Resident Care Manager) and Staff 2 (LPN) on 11/16/22. They acknowledged the findings.

1. C330: All psychrotropic medications s's medication shall include parameters and orders on when to give. The staff shall receive training on managing resident behaviors and how to handle a situation before a psych medication is given. Wellness nurse and RCC  make will review all residents who are taking psychrotropic medications to make sure everythingis being done to de-esclate the resident behavior before giving the medication. Wellness will also audit med orders to ensure that the parameters for giving are appropriate for the behavior of the resident.

2. C330: The MAR's will be reviewed monthly by the Wellness nurse and quarterly by the Pharmacist. The physician will also review the resident's medication list quarterly and make any changes needed.

3. C330: The facility Administrator will provide oversight for the facility and care staff. The Administrator will work with the nurse to ensure all psych medications are complete with orders and parameters on how to provide care.

Based on interview and record review, it was determined the facility failed to provide fire and life safety instruction to staff on alternating months. Findings include, but are not limited to:

Fire and life safety records, dated 04/2022 through 11/2022, were reviewed and revealed the following:

Fire and life safety instruction was not consistently provided to staff on alternating months.

In an interview on 11/16/22 with Staff 1 (Resident Care Manager) Staff 2 (LPN) and Staff 12 (Regional Operations Director) acknowledged the facility failed to consistently provide life safety instruction to staff on alternating months.

1. C420: Fire drills will be in accordance with Fire life Safety for Residential Care Communities. Maintenance will oversee the fire life safety and the evacuation process with documentated fire evacuation and escape routes. This will be done monthly along with training and simulated fire drills to point of safety.

2. C420:Administrator will ensure that fire documented training is be conducted monthly and in accordance with regulations.

3. C420: Training will be documented. Live training will be conducted every other month and wwill include evacuation routes to the point of safety. A refresher will be conducted in the months when live training is not required. Documents of the training will be maintained by the facility administrator.

4. C420: Maintenance director and the Administrator will be responsible to oversee the training for fire safety and drills and documenttion for those staff who attended on a monthly basis.

Based on observation and interview, it was determined the facility failed to ensure hot water temperatures in residents' units were maintained within a range of 110 - 120 degrees Fahrenheit. Findings include, but are not limited to:

On 11/15/22, the surveyor measured water temperatures in occupied resident unit bathrooms. Water temperatures were above 120 degrees Fahrenheit.

In an interview with the Staff 13 (Maintenance) on 11/15/22, she stated she had issues being able to lower the water temperatures since 01/2022 and acknowledged the water temperatures were too hot.

The need to ensure hot water temperatures in residents' units were maintained within a range of 110 - 120 degrees Fahrenheit was discussed with Staff 1 (Resident Care Manager), Staff 2 (LPN) and Staff 12 (Regional Operations Director) on 11/15/22. They acknowledged the findings. Water temperatures were fixed to be within the appropriate range of 110 - 120 degrees F on 11/16/22.

1. C545: The facility water heater was adjusted at the time of the site visit and when checked aain the water temperatures were within normal limits.

2. C545: Resident rooms will be spot checked on a weekly basis to ensure water temps are within the required range of 110 degrees and 120 degrees. A log of the temperature check will be maintained by the maintenance director.

3. C545: The Community will call in a professional if needed to assist in making sure all water heaters are maintained in working order.

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

Refer to C 231, C 420 and C 545.

See tags C231, C420, and C545

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 9, 10 and 14) completed all required elements of the pre-service training and had documentation of demonstrated competency in all required training topics within 30 days of hire; and 3 of 3 long term staff (#s 3, 4 and 5) lacked evidence of 10 hours of annual in-service training related to CBC and six hours of annual training related to dementia care. Findings include, but are not limited to:

On 11/15/22, staff training was reviewed with Staff 1 (Resident Care Manager).

Review of staff training records on 11/15/22 revealed Staff 9, 10 and 14 (CGs), hired on 08/22/22, 09/20/22 and 06/10/22 respectively, lacked the following documentation of pre-service orientation before providing care and services independently:

* Resident rights and values of CBC;

* Abuse reporting requirements;

* Infectious disease prevention; and

* Fire safety and emergency procedures.

Review of staff training records revealed 9, 10 and 14 (CG) lacked the following documentation of demonstrated competencies within 30 days of hire:

* Role of service plans;

* Providing assistance with ADLs;

* Changes associated with normal aging;

* Identification, documentation and reporting of changes of condition; and

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

Review of annual training records on 11/15/22 revealed Staff 3, 4 and 5 (CG) hired on 08/09/21, 09/21/21 and 07/22/21 respectively, lacked the following documentation of annual in-service training.

The facility did not have documented evidence Staff 3, 4 and 5 had completed 16 hours of annual in-service training, 10 hours related to provision of care in CBC and six hours related to dementia care.

The need to ensure newly hired staff completed all required elements of the pre-service training and had documentation of demonstrated competency in all required training topics within 30 days of hire and long-term staff received 16 hours of annual in-service training was discussed with Staff 1 (Resident Care Manager), Staff 2 (LPN) and Staff 12 (Regional Operations Director) on 11/16/22. They acknowledged the findings.

See tags C231, C420, and C545

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 305 and C 330.

See tags C252, C260, C270, C280, C290, C303, C305, and C330

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

* Current abilities and skills;

* Emotional/social needs and patterns;

* Physical abilities and limitations;

* 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 the resident with individualized activities.

On 11/17/22, the lack of an activity evaluation and individualized activity plan was discussed with Staff 1 (Resident Care Manager), Staff 2 (LPN) and Staff 12 (Regional Operations Director). They acknowledged the findings.

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

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

* Current abilities and skills;

* Emotional and social needs and patterns; 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 the resident with individualized activities.

The lack of an activity evaluation and individualized activity plan was discussed with Staff 1 (Resident Care Manager) and Staff 12 (Regional Operations Director) on 11/16/22. No additional information was provided.

1. Z164: Meaningful Activities:All residents will be re-evaluatith ed with the activities preferences assessment.  The activities director will complete the evaluationn for each resident. The administrator will check the evaluations and assist with the review

2. Z164: The activities director will look at the on-line classes with dementia training for activities. The director will be given a tool with information on how to stay engaged with residents for focus on activities per their preferences.

3. Z164: The activity director will inform the RCC and administrator of residents who are not participating in atcivities so that they can follow up with any health concerns. Activity director will  report in the daily stand up meeting on how the participation level is going with the residents. Activities will document on choices and who's attending.

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

A tour of the facility courtyard on 11/15/22 revealed there were five patio chairs and one patio table which were easily moveable and not of sufficient weight or design to prevent potential elopement.

The need to ensure outdoor courtyard furniture in the outdoor recreation area was of sufficient weight and design to prevent resident injury or aid in elopement was discussed with Staff 1 (Resident Care Manager), Staff 2 (LPN) and Staff 12 (Regional Operations Director) on 11/15/22. They acknowledged the findings. The facility removed the chairs and tables from the patio prior to the end of the survey.

1. Z173:Ppatio furniture. The patio furniture will be replaced with heavier weight to prevent residents from moving, throwing, and standing on un-weighted furniture.Furniture will be evaluated by operations for safety.

2. Z173: When new furniture is placed on the patio it will be weighted to prevent harm or movement.

3. Z173: Evaluation of the outside space will be done monthly to ensure the safety of the furniture.

4. Z173: The administrator will notify operations and the ownersof ny significant issues that may require replacement due o wear and tear.