Print Inspection: FCBW

The findings of the re-licensure survey, conducted 07/22/24 through 07/25/2024, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.

Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. 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 first re-visit to the re-licensure survey of 07/25/24, conducted 11/12/24 through 11/13/24, are documented in this report. The survey was conducted to determine 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.

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

MCCMemory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the second re-visit to the re-licensure survey of 07/25/24, conducted on 02/06/25, 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 OARs 411 Division 004 Home and Community Based Services Regulations.

Based on observation and interview, it was determined the facility failed to ensure the residents' rights to be treated with dignity and respect and to receive services in a manner that protects privacy and dignity. Findings include, but are not limited to:

During an interview on 07/24/24 with Staff 1 (Memory Care Director) and Staff 2 (Resident Care Coordinator) it was revealed that multiple shared rooms lacked a barrier between the two sides of the room to protect privacy and dignity during ADL care.  

Observations during the survey revealed that all resident bathroom doors were not lockable for resident privacy.

The need to ensure residents' rights of privacy and dignity were upheld was discussed with Staff 1 and Staff 2 on 07/25/24. They acknowledged the findings.

1. Tanner Spring will implement privacy screening for all shared apartments, ensuring views between residents are blocked by a mobile privacy screen or a permanent curtain. Locks will also be installed on all bathroom doors in memory care.

2. We will hold an in-service training on the resident bill of rights, which will cover issues related to residents' privacy and dignity.  

3. The administrator will conduct weekly evaluations at random times to ensure that privacy screens are being used.

4. The Memory Care Administrator will be responsible for ensuring that these corrections are completed.  

3. Resident 1 was admitted to the facility in 03/2021 with diagnoses including dementia and delusional disorder.

The resident's current service plan, dated 07/10/24, was reviewed, observations were made, and interviews were conducted. The service plan was not reflective of the resident's needs and preferences, did not provide clear instruction to staff, and/or was not implemented in the following areas:

* Toileting assistance, including frequency and clear direction on delivery of services;

* Fall interventions for shower safety; and

* Interventions related to behaviors.

The need to ensure service plans were reflective of resident needs and preferences, provided clear direction to staff, and were implemented was discussed with Staff 1 (Memory Care Director) and Staff 2 (Resident Care Coordinator) on 07/25/24. They acknowledged the findings.

2. Resident 4 was admitted to the facility in 03/2023 with diagnoses including dementia. The resident was hospitalized on 07/09/24 through 07/11/24 and returned with diagnoses including acute renal failure, congestive heart failure and with hospice services.

Observations with the resident, interviews with staff, review of the resident's service plan dated 06/10/24, hospice visit notes, and progress notes, dated 04/03/24 through 07/22/24, were completed.

The resident's service plan was not reflective, lacked resident-specific direction for staff and/or was not implemented in the following areas:

* Indwelling catheter care instructions;

* Bed bound;

* Two person assist for bed mobility, dressing, incontinence care, and evacuation;

* Bathing;

* Oxygen use with instructions;

* Meal assistance;

* Fluid intake instructions;

* Personal hygiene;

* Location of pain, to include non-pharmacological interventions;

* Hospice services and instructions for when/how to contact;

* Apartment room kept locked;

* Elopement risk;

* Skin conditions and interventions; and

* Updated activities plan after significant change of condition.

The need to ensure resident service plans were reflective of current care needs, provided clear direction to staff and were implemented was discussed with Staff 1 (Memory Care Director) and Staff 2 (Resident Care Coordinator) on 07/24/24. They acknowledged the findings.

4. Resident 3 moved into the MCC in 04/2022 with diagnoses including chronic myeloproliferative disease.

Observations of the resident, interviews with staff, and review of the most recent service plan, dated 06/22/24, and temporary service plans showed the service plan was not reflective of the resident's current care needs, did not provide clear direction to staff, and was not being implemented in the following areas:

* Level of assistance required for eating;

* Use of high back reclining wheelchair;

* Use of side rails;

* Frequency of routine incontinence care;

* Schedule of hospice services;

* Current wound status and treatment;

* RN to perform weekly skin assessments of wound and treatment;

* Padded heel protectors to be worn during the day; and

* Geri-sleeves to be worn on upper and lower extremities during the day.

The need to ensure resident service plans reflected current care needs, provided clear direction to staff, and was implemented was discussed with Staff 1 (Memory Care Director) and Staff 2 (Resident Care Coordinator) on 07/25/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs and preferences, provided clear direction regarding the delivery of services, or was implemented for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 11/2022 with diagnoses including dementia and cognitive communication deficit.

The resident's current service plan, dated 06/10/24, was reviewed, observations were made, and interviews were conducted. The service plan was not reflective of the resident's needs and preferences, did not provide clear instruction to staff, and/or was not implemented in the following areas:

* How resident expressed pain and/or discomfort;

* Non-pharmaceutical interventions regarding pain and anxiety;

* Facility nurse to perform weekly skin assessment and wound treatment;

* Wound monitoring, including ensuring wound was covered and unsoiled;

* Use of an air pressure mattress for pressure ulcer;

* Toileting assistance, including number of staff, clear direction on delivery of services, and assistive devices used;

* Evening care needs, including toileting;

* Sleep schedule including times assisted in and out of bed;

* Use of a hospital bed; and

* Environmental factors, including noise level, tolerance and preference.

The need to ensure service plans were reflective of resident needs and preferences, provided clear direction to staff, and were implemented was discussed with Staff 1 (Memory Care Director) and Staff 2 (Resident Care Coordinator) and on 07/25/24. They acknowledged the findings.

1. The community will take the following actions to correct rule violations for the residents noted in the SOD:

The community RN will reassess Resident 2, and the memory care administrator will create a service plan to reflect the current needs related to pain, skin, wounds, toileting, DME, and environment.

Resident 4 passed away on July 26, 2024.

The community RN will reassess Resident 1, and the MC administrator will create a service plan to reflect the current needs related to toileting assistance, fall interventions, and behavior interventions.

The community RN will reassess Resident 3, and the MC Administrator will create a service plan to reflect the current needs related to nail assistance, DME, incontinence care, wound care, and hospice services.

2. Tanner Spring will review service plans, COC, and nursing support during the daily clinical meeting and update service plans when warranted.

3. Service plans will be evaluated and updated quarterly and as needed based on daily observations and discussions.

4. The community RN and Memory Care Administrator will be responsible for monitoring and completion.  

2. Resident 4 was admitted to the facility in 03/2023 with diagnoses including dementia.

Resident 4's service plan, dated 06/10/24, and progress notes, dated 04/03/24 through 07/22/24 were reviewed. Observations were made and care staff were interviewed during the survey.

The following changes of condition lacked documentation of resident-specific actions or interventions needed for the resident and/or progress noted at least weekly through resolution:

* 06/07/24, bruise to the back of the left wrist approximately three inches long; and

* 07/12/24, the resident returned to facility after hospitalization with new diagnoses including acute rental failure, congestive heart failure, had an indwelling catheter, decline in ADLs and hospice services implemented.

The need to ensure resident-specific actions or interventions for changes of condition were determined and progress noted at least weekly through resolution was discussed with Staff 1 (Memory Care Director), and Staff 2 (Resident Care Coordinator) on 07/24/24. Staff acknowledged the findings and no additional information was provided.

Based on observations, interview, and record review, it was determined the facility failed to determine resident-specific actions or interventions needed for residents following a short-term change of condition, communicate the determined actions or interventions to staff, and document progress until the condition resolved for 2 of 4 sampled residents (#s 3 and 4) who experienced changes of condition. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 04/2022 with diagnoses including chronic myeloproliferative disease.

Observations of Resident 3, interviews with staff, and review of the resident's 06/22/24 service plan, temporary service plans, and 04/03/24 through 07/19/24 progress notes were reviewed. Resident 3's progress notes identified the following:

* 04/28/24: Fall with skin tear to left ankle;

* 05/24/24: Staff noted Resident 3 needed assistance with eating "resident benefits greatly from assistance with feeding" and ate their entire meal;

* 06/06/24: Staff noted "wound is looking worse than yesterday and seems [his/her] leg is also starting to swell and become more reddish pink;" and

* 06/06/24: Staff noted a new injury "wound to top of head scabbed over and healing."

The above short-term changes of condition lacked documentation the facility determined what resident-specific action or intervention was needed for the resident, communicated the determined action or intervention to staff, or documented weekly progress until the condition resolved.

On 07/25/24 the need to ensure the facility determined what resident-specific action or intervention was needed for the resident following a short-term change of condition, communicated the determined action or intervention to staff, and documented progress until the condition resolved was reviewed with Staff 1 (Memory Care Director), and Staff 2 (Resident Care Coordinator) on 07/25/24. They acknowledged the findings.

1. The community will take the following actions to correct rule violations for the residents noted in the SOD:

Resident 4 passed away on July 26, 2024.

The community RN will reassess Resident 3, and the MC administrator will initiate a service plan to reflect COC for wounds and dietary needs. Any relevant interventions will be noted.

2. Tanner Spring will complete an in-service training for all health services staff for COCs, and the MC administrator or designee will review the 24/72 hour report to see progress notes that require follow-up.

3. The COC process will be evaluated weekly during clinical meetings.

4. The Community RN and Memory Care Administrator will be responsible for monitoring and completing these tasks.   

Based on observation, interview, and record review, it was determined the facility failed to evaluate the resident, refer to the facility nurse, document the change, and update the service plan for 1 of 1 sampled resident (#6) who experienced a significant change of condition. The resident experienced ongoing, severe weight loss. This is a repeat citation. Findings include, but are not limited to:

Resident 6 moved into the facility in 03/2021 with diagnoses including dementia and was identified during the acuity interview as having experienced a significant weight loss.

The resident's 11/08/24 service plan, temporary service plans and progress notes from 09/23/24 to 11/12/24, and weight records from 09/2024 to 11/08/24 were reviewed. Observations of the resident were made, and interviews with staff and the resident were conducted.

The following weights were documented in the resident record:

09/03/24- 159 pounds;

10/03/24- 150.4 pounds;

11/03/24- 148.7 pounds;

11/08/24- 143.6 pounds; and

11/12/24- 143.8 pounds (taken during survey).

Between 09/03/24 to 10/03/24 the resident lost 8.6 pounds, or five percent of his/her bodyweight, constituting a severe weight loss. Resident 6 continued to lose weight and experienced a 15.2-pound weight loss between 09/03/24 and 11/12/24, or 9.5% of his/her bodyweight, constituting a severe weight loss. The weight loss constituted a significant change of condition for which the facility was required to evaluate, refer to the facility nurse, document the change, and update the service plan. Review of the resident's record revealed no documented evidence the weight loss was evaluated, the facility nurse was notified, the change was documented, and the service plan was updated, and there were no documented interventions for the weight loss.

During an interview at 10:55 am on 11/12/24, Staff 2 (Resident Care Coordinator) confirmed there was no documented evidence the weight loss was referred to the facility nurse. The nurse was no longer employed at the facility and not available for interview. Staff 2 further confirmed Resident 6's weight loss had not been evaluated or documented, and the service plan had not been updated.

The resident was observed eating lunch on 11/12/24 and 11/13/24. S/he was independent with eating and was able to verbalize his/her choice of meal offerings. S/he was observed to consume approximately 50% of the food and liquid offered during both meal observations, including a taco, soup, mashed potatoes, apple juice, and water.

Resident 6 experienced a severe weight loss in one month without an evaluation, referral to the facility nurse, documentation of the change, or a service plan update. S/he continued to lose weight, resulting in a severe weight loss in three months.

On 11/13/24 at 12:45 pm, the need to ensure resident significant changes of condition were evaluated, referred to the facility nurse, documented, and the service plan was updated was discussed with Staff 1 (Memory Care Director) and Staff 2. They acknowledged the findings.

1. Resident 6 placed on alert for weight loss. Weekly weights and meal monitoring added to MAR for resident 6. PCP faxed regarding weight loss. TSP placed indicating resident's preferences of meals and snacks. Resident 6 added to Nursing significant change of condition monitoring due to weight loss.

2. All med techs will take oregon care partners course "understanding changes of condition for community based care facilities in Oregon." Med tech meetings will be held monthly for continued coaching and trainings including changes of condition, documentation, and when to notify LN of changes.

3. Progress notes will be reviewed daily by clinical team. weight review will be increased to weekly (previously was monthly) to capture declines earlier and place needed interventions when appropriate.

4. Administrator and facility nurse will be responsible for oversight and training of care team and reviewing progress notes daily and weights weekly.

Based on observation, interview, and record review, it was determined the facility failed to ensure an RN assessment was completed timely and documented findings, resident status, and interventions made as a result of the assessment for 2 of 2 sampled residents (#s 2 and 4) who experienced significant changes of condition, and failed to have a licensed nurse who was regularly scheduled for onsite duties at the facility, and assure adequate number of nursing hours relevant to the census and acuity of the resident population. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 03/2023 with diagnoses including dementia and chronic kidney disease.

Review of the resident's service plan, dated 06/10/24, temporary service plans and progress notes, physician and hospital communications and hospice visit notes dated 04/03/24 through 07/22/24 was completed.

Resident 4 was hospitalized for chest pain, shortness of breath, and elevated blood pressure from 07/09/24 to 07/11/24. The resident returned with new diagnosis of acute renal failure, congestive heart failure, and an indwelling catheter and was on hospice services prior to return.

Multiple observations of the resident between 07/22/24 and 07/24/24 showed the resident in bed, asleep most of the time, requiring two person assistance with bed mobility, incontinent cares and dressing, and full assistance with all other ADL activities. The resident was refusing or unable to take food and fluids, with staff observed using a water moistened swab for oral care and to provide fluids.

Care staff interviewed reported that prior to hospitalization the resident was independent with bed mobility, toileting, ambulation with a walker, ate independently in the dining room, needed set up and cueing assistance with ADLs and shower assistance from staff.

The resident experienced a significant change related to an overall decline, hospice services, and placement of an indwelling catheter.

The facility failed to ensure an RN assessment was completed related to the resident's decline, catheter and admission to hospice services which documented findings, resident status, and interventions made as a result of the assessment.

The need to ensure an RN assessment was completed which documented findings, resident status, and interventions made as a result of the assessment was discussed with Staff 1 (Memory Care Director) and Staff 2 (Resident Care Coordinator) on 07/24/24. The staff acknowledged the findings.

2. During an interview with Staff 1 (Memory Care Director), she stated the facility's RN worked primarily in the ALF, coming to the memory care facility when needed or called. She stated the RN did not have regularly scheduled hours for onsite duties in the memory care facility.

The need to ensure the facility had a licensed nurse who was regularly scheduled for onsite duties at the facility, and assured adequate number of nursing hours relevant to the census and acuity of the resident population was discussed with Staff 1 (Memory Care Director) on 07/24/24.  She acknowledged the findings.

3. Resident 2 was admitted to the facility in 11/2022 with diagnoses including dementia and cognitive communication deficit.

Resident 2's clinical records were reviewed. On 03/05/24 an outside provider visit note identified the resident had developed a stage II pressure ulcer to the right lateral heel.

There was no documented evidence the RN had assessed the status of the resident, documented findings as a result of the assessment, and developed interventions related to the resident's significant change of condition.

On 07/25/24 at 11:01 am, Staff 1 (Memory Care Director) stated there was no documented evidence of an RN assessment for Resident 2. This surveyor requested to interview the facility RN on 07/22/24, 07/23/24, and 07/24/24 and the facility RN was not available to interview.

The need to ensure an RN assessment was completed for all residents with a significant change of condition was discussed with Staff 1 and Staff 2 (Resident Care Coordinator) on 07/25/24. They acknowledged the findings.

1. The community will take the following actions to correct rule violations for the residents noted in the SOD:

Resident 4 passed away on July 26, 2024.

The Community RN will assess Resident 2's wound and collaborate with the hospice nurse on wound management.

2. Tanner Spring will assign a licensed nurse to the memory care neighborhood for approximately 20 hours per week (8 hours devoted to RN), and they will be available at other times as needed. Tanner Spring has hired a second licensed nurse to augment the number of nursing hours within the community.

3. Tanner Spring will evaluate nursing hours during daily clinical meetings and weekly COC discussions and adjust hours as necessary.

4. The Memory Care Administrator and Community Executive Director will monitor that this change is being successfully implimented.

Based on interview and record review, it was determined the facility failed to address all evaluated care needs of residents, including the amount of staff time needed to provide care in the facility's acuity-based staffing tool (ABST) for 4 of 4 sampled residents (#s 1, 2, 3, and 4) whose ABST input was reviewed. Findings include, but are not limited to:

The facility's ABST was reviewed and discussed with Staff 1 (Memory Care Director) and Staff 2 (Resident Care Coordinator) on 07/23/24.

A review of Residents 1, 2, 3 and 4's ABST input revealed multiple care areas were not reflective as to the number of minutes the residents' evaluated care needs required. Therefore, the ABST staffing plan did not accurately reflect the number of care hours required for each shift.

The need to ensure the facility's ABST addressed all evaluated care needs of residents, including the amount of staff minutes needed to provide care, was discussed with Staff 1 and Staff 2 on 07/24/24. They acknowledged the findings.

1. The community will take the following actions to correct rule violations related to the use of the ABST as noted in the SOD: The community will update service plans for Resident 1, Resident 2, and Resident 3. Resident 4 is diseased. Each resident's ABST will be updated accordingly.  

2. Tanner Spring will review updated ABST guidelines and adjust procedures for using the ABST to assess staffing needs. The review will include adjustments to the times associated with tasks.

3. The ABST will be updated every time a service plan is updated, including after quarterly evaluations and COCs are completed.

4. The Memory Care Administrator and Executive Director will oversee the ongoing use of the ABST for compliance.

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

Fire and life safety records, reviewed between 02/2024 and 07/2024, revealed the following:

a. The facility failed to relocate or evacuate residents during fire drills; therefore, documentation was lacking in the following areas:

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

* Evacuation time-period needed; and

* The number of occupants evacuated.

b. There was no documented evidence fire and life safety instruction was provided to staff on alternating months from fire drills.

The need to ensure fire drills and fire and life safety training was provided and documented as required was reviewed with Staff 1 (Memory Care Director) and Staff 5 (Maintenance Coordinator) on 07/25/24. They acknowledged the findings.

1. Actions taken to correct this rule violation are as follows:

a. The facility will implement an annual training plan that includes fire drills to be completed alternating months of fire and life safety training and includes:

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

* Evacuation time-period needed; and

* The number of occupants evacuated.

b. The facility will implement an annual training plan that includes fire and life safety training to be completed on alternating months of fire drills.

2. System will be corrected so that violation will not happen again by;

a. Comprehensive review of current fire drill forms to ensure they meet all required components.

b. In servicing provided to administration and or designee conducting fire and life safety drills and education on process and documentation required.

3. Area needing correction will be evaluated monthly by the Administrator and Maintenance Director.

4. The Administrator, Maintenance Director and/or designee will be responsible to ensure corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to re-instruct residents at least annually in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. Findings include, but are not limited to:

On 07/23/24 the facility fire and life safety records were reviewed. The facility lacked documented evidence residents who were capable were re-instructed at least annually on general safety procedures, evacuation methods, and responsibilities.

On 07/24/24 at 9:15 am, Staff 5 (Maintenance Coordinator) reported that currently there was not a system in place for re-instructing residents annually on fire and life safety procedures.

The need to develop a system for re-instructing residents at least annually on fire safety procedures was discussed with Staff 1 (Memory Care Director) and Staff 5 on 07/25/24. They acknowledged the findings.

1. Action taken to correct this rule violation includes;

    a. All residents capable will be instructed on General safety procedures, evacuation methods, responsibilities during fire drills and designated meeting places outside the building or within the fire safe area in the event of an actual fire by 9/23/24. Annual re-instruction will be completed in the third quarter of every year thereafter.

2. Fire & Life Safety Training for Residents: This system is being corrected to eliminate future violations as follows:

    a. All new residents will be instructed of fire &

life safety, within 24hrs of move-in, and reinstructed annually thereafter.

    b. All resident fire and life safety documentation will be filed and kept on-site,

    c. Facility Maintenance Director will keep an on-going spreadsheet of residents' admission dates, and dates of re-instruction

    d. Facility Maintenance director will bring all fire & life safety training for residents, to  Quality Improvement Meetings for review.

3. This system will be evaluated as follows:

    a. Within 24hrs of a new resident admission, &

    b. Annually thereafter,

    c. Facility administrator will review fire & life safety for residents, at least once monthly to ensure compliance.

4. The Administrator, Maintenance Director and/or designee will be responsible to ensure corrections are completed and monitored.

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

Refer to C270.

Please see POC for C270

Based on observation and interview, it was determined the facility failed to ensure residents rights of privacy and dignity. Findings include, but are not limited to:

Refer to C200.

1-4.  Please see POC response for C200.

Based on observation and interview, it was determined the facility failed to ensure residents rights of privacy in his or her own unit. Findings include, but are not limited to:

Refer to C200.

1-4.  Please see POC response for C200.

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 200, C 361, C 372, C 420, and C 422.

1-4. Please refer to POC items C200, C361, C420, and C422.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 12, 13 and 14) completed all required pre-service orientation, 2 of 3 new staff (#s 12 and 14) demonstrated competency in all job duties within 30 days of hire, and 2 of 3 long-term staff (#s 6 and 15) completed the required number of hours of annual in-service training. Findings include, but are not limited to:

Staff training records were reviewed on 07/23/24 through 07/24/24.

a. There was no documented evidence Staff 12 (MT), Staff 13 (CG) or Staff 14 (CG), hired 04/26/24 and 05/08/24, respectively, completed the following pre-service orientation topics prior to beginning their job duties:

* Resident rights and values of CBC care;

* Abuse reporting requirements;

* Fire safety and emergency procedures; and

* Written job description.

b. There was no documented evidence Staff 12 or Staff 14 demonstrated competency in one or more assigned duties within 30 days of hire:

* Role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Identification, documentation, and reporting changes of condition;

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

* General food safety, serving, and sanitation; and

* Other duties as applicable (e.g., med pass, treatments).

c. There was no documented evidence Staff 6 (CG), hired 07/18/22, or Staff 15 (MT), hired 04/22/20 completed 16 hours of annual in-service training, with 10 hours being related to the provision of care in Community Based Care and six hours related to dementia care, or infectious disease training.

The need to ensure all staff training was completed in the required time frames was discussed with Staff 1 (Memory Care Director) an 07/24/24. She acknowledged the findings. Staff 12 completed documented MT training on 07/24/24 with Staff 2 (Resident Care Coordinator).

1. All staff members identified in the survey will complete pre-service training and any other identified training deficiencies immediately.

2. Tanner Spring will review all policies and procedures for conducting and recording training and audit employee files to ensure that staff member training is complete and up to date.  

3. Training records will be audited semi-annually to communicate potential deficiencies well in advance of due dates.

4. The Memory Care Administrator and Community Executive Director will be responsible for completing and monitoring these actions.

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 270, and C 280.

1-4. Please refer to POC items C260, C270, and C280.  

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

Refer to C270.

Please see POC for C270

Based on observation, interview, and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan was developed and documented in the resident's service plan for 2 of 3 residents (#s 2 and 3) whose records were reviewed. Findings include, but are not limited to:

Resident's 2 and 3's current service plans were reviewed during survey. Each of the service plans lacked information and staff instructions related to individualized nutrition and hydration status and needs.  

The need to develop individualized service plans addressing residents' nutrition and hydration needs was discussed with Staff 1 (Memory Care Director) and Staff 2 (Resident Care Coordinator) on 07/25/24. They acknowledged the findings.

1. Tanner Spring will reevaluate Resident 2 and Resident 3 and create an individualized nutrition and hydration plan as part of their service plan. This plan will address issues like the need for using adapted eating utensils and creating visual contrasts during meals.

2. All service plans will be audited for individualized nutrition and hydration needs and will be updated as required.

3. Nutrition and hydration plans will be re-evaluated during quarterly evaluations or when there is a COC.

4. Memory Care Administrator or designee.

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 4 of 4 sampled residents (#s 1, 2, 3, and 4) whose records were reviewed. Findings include, but are not limited to:

Resident service plans and activity evaluations were reviewed. There was no documented evidence the facility had fully evaluated and developed individualized plans based on the residents':

* 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 07/24/24 at 1:20 pm, the failure to ensure residents had individualized activity plans developed based on their activity evaluations, was discussed with Staff 4 (Life Enrichment Director) and Staff 1 (Memory Care Director). They acknowledged the findings.

1. Tanner Spring will reevaluate Resident 1, Resident 2, and Resident 3 and create an individualized activity plan as part of their service plan. This plan will address their current abilities and skills, emotional and social needs, past and current interests, physical abilities and limitations, and activities needed for behavioral interventions. Resident Four passed away on July 26.

2. All service plans will be audited for individualized activity plans and will be updated as required.

3. Activity plans will be re-evaluated during quarterly evaluations or when there is a COC.

4. The Memory Care Administrator and Life Enrichment Director will be responsible for monitoring activity plan updates.