Print Inspection: HRI5

The findings of the initial survey, conducted 09/06/22 through 09/08/22, 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 first re-visit to the re-licensure survey of 09/08/22, conducted 01/03/23 through 01/06/23, 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

MCCMemory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the 2nd revisit to the re-licensure survey of 09/08/22, conducted 03/27/23 through 03/29/23 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 and OARs 411 Division 57 for Memory Care Communities.

Based on observation, interview and record review, it was determined the licensee failed to provide effective oversight to ensure the quality of care and services that were rendered in the facility. Findings include, but are not limited to:

During the revisit survey, conducted 01/03/23 through 01/06/23, oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number of repeat and new citations.

Refer to deficiencies in report.

What actions will be taken to correct the rule violation? The Executive Director will discuss and review the POC during facility stand ups to monitor status.

· How will the system be corrected so this violation will not happen again? Regular review of the systems will be gone over during stand up and with home office team.

· How often will the area needing correction be evaluated and who is responsible for the evaluation? The Executive Director will check in with the team daily during the work week to ensure POC is being followed and VP and/or COO will review with the management team each week.

· Who on your staff will be responsible to see that all corrections are completed/monitored? The Executive Director, VP of Management Services and COO.

Based on interview and record review, it was determined the facility failed to maintain a complete and accurate record for 2 of 7 sampled residents (#s 7 and 8) whose records were reviewed. Findings included, but are not limited to:

Resident 7 and 8's records were reviewed during the survey and found to be incomplete and inaccurate in the following areas:

* During the record review, the surveyor noted multiple discrepancies between facility progress notes and ADL task sheets regarding shower assistance; and

* Multiple blanks on ADL task sheets.

On 01/05/23, failure to ensure the Resident 7 and 8's records were complete and accurate was discussed with Staff 1 (Executive Director), Staff 2 (RN) and Staff 3 (RCC). They acknowledged the findings.

What actions will be taken to correct the rule violation? Review of all POC documentation, re-training of all care staff to demonstrate Point of Care directions, documentation, as well as proper procedure for changes needed for tasks. Shower sheets implemented.

· How will the system be corrected so this violation will not happen again? POC audit forms will be generated to determine if there are any discrepancies. If so, the omissions will be addressed same day. Shower sheets will be completed and turned into RN for each shower.

· How often will the area needing correction be evaluated and who is responsible for the evaluation? Point of Care (POC) documentation will be reviewed daily by Executive Director and the RCC will address any omissions immediately. This will occur during her 5 day work week.

· Who on your staff will be responsible to see that all corrections are completed/monitored? The Executive Director will ensure that the reports are being generated and omissions are addressed timely. VP of Management Services and/or COO will review during weekly stand ups.

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 1 of 1 sampled resident (# 1) who was identified to have physical injury of unknown origin. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 05/2022 with diagnoses including dementia.

Observations of Resident 1 throughout the survey revealed the resident was dependent on staff for most ADLs.

Review of Resident 1's clinical records during the survey revealed the following:

* On 08/03/22, staff documented in progress notes that the resident had bruises on both wrists.

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 09/07/22 at 8:20 am, Staff 3 (Resident Care Coordinator) confirmed the physical injury had not been investigated nor reported to the local unit. The surveyor requested Staff 3 to report the incident to local SPD office. Confirmation the report had been sent to local SPD office was provided.

The need to investigate incidents of injury of unknown cause and to report the incidents to the local SPD when the facility's investigation was unable to rule out abuse or neglect care was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 on 09/07/22 and 09/08/22.

·What actions will be taken to correct the rule violation?

Incident was reported to local APD. In-service to be provided 9/30/22 to all staff on proper reporting via incident report completion and temporary service plan/alert charting.

·How will the system be corrected so this violation will not happen again?

In-service to be held regarding proper procedure for abuse reporting, incident report completion and temporary service plan/alert charting.

·How often will the area needing correction be evaluated and who is assigned to evaluating the changes?

The progress notes will be reviewed weekly, Incident reports daily, and TSP's/Alert Charting daily.

·Who on your staff will be responsible to see that all the corrections are completed and monitored?

The Med Aides, RCC, RN, and Executive Director will be responsible for review. The RCC, RN and ED will be responsible for ensuring the corrections are completed

2. Resident 9 was admitted to the facility in 2022 with diagnoses including dementia.

Review of Resident 9's clinical records during the survey noted the following:

* Progress note dated 12/31/22 -"It was noticed that big right toe was bleeding" and "resident is unsure if [s/he] hit toe on anything". Alert charting was started to monitor the wound.

The investigation into the injury of unknown cause was not conducted immediately to reasonably conclude and document the injury was not the result of abuse or neglect as the cause of the injury. The investigation did not rule out abuse until it was completed on 01/05/23.

The need to immediately investigate injures of unknown cause to reasonably rule out abuse and neglect or report the injury to the local SPD office was discussed with Staff 1 (Executive Director), Staff 2 (RN), and Staff 3 (RCC) on 01/06/23. They acknowledged the findings. The survey team requested the facility submit the report. Documentation was provided prior to survey exit.

Based on interview and record review, it was determined the facility failed to immediately investigate injuries of unknown cause, to rule out possible abuse or neglect or report the injuries to the local SPD office for 2 of 7 sampled residents (# 9 and 14) whose records were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 14 was admitted to the facility in 2022 with diagnoses including dementia.

Review of Resident 14's clinical records during the survey noted the following:

* 12/02/22 - "Resident has a skin tear on right forearm, resident wasn't sure how it got there."

The 12/08/22 investigation into the injury of unknown cause was not conducted immediately and failed to reasonably conclude and document the injury was not the result of abuse as the cause of the injury. The injury was not reported to the local SPD office.

The need to immediately investigate injures of unknown cause to reasonably rule out abuse and neglect or report the injury to the local SPD office was discussed with Staff 1 (Executive Director) and Staff 2 (RN) on 01/06/23. They acknowledged the findings. The survey team requested the facility submit the report. Documentation was provided prior to survey exit.

What actions will be taken to correct the rule violation? All incidents will be reviewed in a timely manner. Progress notes reviewed to identify any issues not reported in an incident report. Additional training provided to the care staff for proper protocol of reporting.

· How will the system be corrected so this violation will not happen again? Progress notes will be reviewed regularly to ensure that any potential abuse can be properly documented and reported. Incident reports will be reviewed regularly and proper investigation done. If facility cannot rule out abuse, they will report to APS.

· How often will the area needing correction be evaluated and who is responsible for the evaluation? The RCC and/or RN will review progress notes weekly and Incident Reports daily. Investigation will be done quickly and notification to APS will occur if abuse cannot be ruled out immediately.

· Who on your staff will be responsible to see that all corrections are completed/monitored? The Executive Director will ensure that progress notes and Incident Reports are monitored. VP of Management Services and/or COO will review during weekly stand ups.

Based on observation, interview and record review, it was determined the facility failed to provide a daily activity program of social and recreational activities based on individual and group interests, physical, mental and psychosocial needs, and create opportunities for active participation in the community at large. Findings include, but are not limited to:

During the survey, the MCC had four units (Alderwood, Birchwood, Cedarwood and Dogwood) and was home to 50 residents.   

Random resident observations made in all four units on 01/03/23 from 1:00 pm to 6:00 pm, on 01/04/23 from 8:00 am to 5:00 pm, on 01/05/23 from 8:00 am to 4:00 pm, review of the activity calendar, and interviews with staff revealed the following:

a. The January 2023 Memory Care Activity Program calendar provided during the entrance conference indicated the following activities would occur on 01/03/23 between 1:00 pm and 5:00 pm:

* 1:00 pm: Music Appreciation;

* 2:00 pm Resident Choice;

* 3:00 pm Snack and Hydration;

* 4:00 pm Movie; and

* 5:00 pm Dinner.

On 01/03/23, no facility led activities were observed. Although movies, documentaries, and game shows played on the televisions sporadically, snack and hydration were provided to a few residents, and dinner occurred at 5:00 pm, no other activities were observed in the individual units between 1:00 pm and 5:00 pm.

b. On 01/04/23, the activity calendar noted the following activities would occur in each unit:

* 8:00 am Breakfast;

* 9:00 am Relax/Morning News;

* 10:00 am Morning Walk;

* 11:00 am Snack and Hydration;

* 12:00 pm Lunch;

* 1:00 pm Art;

* 2:00 pm Movie;

* 3:00 pm Snack and Hydration;

* 4:00 pm Card Games; and

* 5:00 pm Dinner.

The only group activities observed between 8:00 am and 5:00 pm were meals, snacks and hydration. Televisions in each unit played continuously. No facility led group activities were observed.

c. On 01/05/23, the activity calendar noted the following activities would occur:

* 8:00 am Breakfast;

* 9:00 am Relax/Morning News;

* 10:00 am Morning Stretch;

* 11:00 am Snack and Hydration;

* 12:00 pm Lunch;

* 1:00 pm Music Appreciation;

* 2:00 pm Resident Choice;

* 3:00 pm Snack and Hydration;

* 4:00 pm Movie; and

* 5:00 pm Dinner.

The only activities observed between 8:00 am and 5:00 pm were meals, snacks and hydration. Televisions in each unit played movies, game shows or documentaries continuously. No facility led group activities were observed.

Failure to provide a daily activity program of social and recreational activities based on individual and group interests, physical, mental, and psychosocial needs, and that created opportunities for active participation in the community at large was discussed with Staff 1 (Executive Director) on 01/05/23 at 3:45 pm. She acknowledged the findings. She added that the facility was in process of hiring an Activity Director.

What actions will be taken to correct the rule violation? New activity director hired, carestaff to all complete "Teepa Snow: Filling the Day with Meaning" class prior to 2/20/23.

· How will the system be corrected so this violation will not happen again? Staff and activity director will ensure that scheduled and non-scheduled activities occur daily. Activity Logs will be kept up to date for each resident that specify what activity they participated in and which they declined.

· How often will the area needing correction be evaluated and who is responsible for the evaluation? Daily walk throughs to occur by the management team including: RCC, RN, and/or Executive Director; will review Activity logs weekly.

· Who on your staff will be responsible to see that all corrections are completed/monitored? The RCC and Executive Director will ensure that activities are done daily and Activity Director. VP of Management Services and/or COO will review during weekly stand-ups

Based on observation, interview and record review, it was determined the facility failed to consistently provide assistance with ADLs for 5 of 7 sampled residents (#s 6, 7, 8, 11 and 14) who required ADL assistance for care. Findings include, but are not limited to:

1. Resident 6 was admitted to the facility 03/2021 with diagnoses including Alzheimer's disease.

Resident 6 was identified during the acuity interview as needing assistance with ADLs.

Observation of the resident on 01/05/23 at 11:15 am, revealed s/he had long, thick yellow toenails with the nails on the big toes curved in. During the observation Staff 9 (MT) stated she had tried to cut the toenails, but they were too thick, and she was unable to cut through them. She said it had been an on-going problem with the resident. She stated she had let Staff 2 (RN) and Staff 3 (RCC) know and they were going to have someone come in to trim them.

In interview on 01/05/23, Staff 18 (CG) stated Resident 6 needed assistance with all ADL care. She said the resident had long toenails when admitted and it was an on-going problem. She stated she had tried to trim his/her toenails multiple times, but they were too thick to cut. She said she had even attempted to file the nails but was unsuccessful.

Failure to ensure Resident 6's toenails were trimmed and not of excessive length was discussed with Staff 2 and Staff 3 on 01/05/23 at 4:15 pm. Staff 2 stated a podiatrist had been scheduled to come 01/10/23 to the facility to trim the resident's nails. They acknowledged the findings.

2. Resident 7 was admitted to the facility 08/2021 with diagnoses including dementia.

Resident 7 was dependent in most of ADLs including personal hygiene and toileting assistance.

The resident's 12/05/22 service plan indicated s/he required assistance in oral hygiene, toileting and bathing service.

a. Observation of Resident 7 during the survey on 01/04/23, revealed the resident was not provided oral care including brushing teeth as part of the morning care and hand hygiene after the resident was assisted to use the bathroom.

b. Review of the 11/07/22 through 01/04/23 ADL flowsheets showed multiple blanks in brushing teeth, showers and bathroom assistance without documentation that explained why the care was not provided.

Failure to ensure Resident 7's showers and personal hygiene including brushing teeth was discussed with Staff 1 (Executive Director), Staff 2 (RN) and Staff 3 (RCC) on 01/05/23 at 3:50 pm. They acknowledged the findings and no additional documentation was provided prior to exit.

3. Resident 8 was admitted to the facility 08/2022 with diagnoses including dementia.

The 11/22/22 service plan indicated the resident required assistance in showers and nail care after the shower.

a. Observation of the resident on 01/04/23, revealed Resident 8 had long, thick yellow toenails with the nails curved in.

b. Review of 11/07/22 through 01/04/23 ADL flowsheets showed multiple blanks in showers assistance without documentation explaining why the care was not provided.

In interview on 01/05/23 at 10:10 am, Staff 3 (RCC) stated the facility was in the process of developing podiatry service and the first service would be on 01/10/23.

Failure to ensure Resident 8's toenails were trimmed and shower assistance was provided was discussed with Staff 1 (Executive Director), Staff 2 (RN) and Staff 3 on 01/05/23 at 3:50 pm. They acknowledged the findings.

3. Resident 14 was admitted to the facility in 2022.

The resident's 11/09/22 service plan and 11/2022, 12/2022 and 01/01/23 through 01/03/23 ADL logs were reviewed.

Observations made during the survey indicated the resident was dependent on staff for all ADL care, including oral hygiene.

The service plan instructed staff to assist Resident 14 with oral hygiene twice daily.

Review of the resident's ADL logs for oral hygiene assistance revealed blanks on 11/26/22, 11/27/22 and 11/29/22 and 12/04/22 and 12/31/22.

In a 01/06/23 interview with Staff 3 (RCC), she confirmed blanks on the ADL logs indicated the tasks had not been completed.

The failure to ensure residents were provided assistance with ADL care was discussed with Staff 1 (Executive Director), Staff 2 (RN) and Staff 3 (RCC) on 01/06/23. They acknowledged the findings

4. Resident 11 was admitted 08/2022 with diagnoses which included Alzheimer's dementia.

Resident 11 was observed to be dependent for all care needs, including assistance with bathing.

Review of the service plan dated 10/03/22 revealed Resident 11 needed the assistance of one to two staff members for all bathing needs. The service plan, shower schedule available to staff and ADL task lists were reviewed and provided documented evidence Resident 11 was scheduled for bathing twice weekly. ADL task lists were reviewed for 11/2022 and 12/2022 and revealed one shower having taken place on 11/08/22 for the month of 11/2022. For the month of 12/2022, the ADL task list revealed documented evidence of showers having taken place on 12/06/22, 12/09/22, 12/23/22, 12/27/22 and 12/30/22.

In an interview on 01/05/23, Staff 2 (RN) and Staff 3 (RCC) reviewed the shower documentation and were unable to verify if Resident 11 received showers as scheduled.

Failure to ensure Resident 11 was provided bathing assistance as scheduled was discussed with Staff 1 (Executive Director), Staff 2 and Staff 3 on 01/05/23. They acknowledged the findings.

What actions will be taken to correct the rule violation? Review of all POC documentation, re-training of all care staff to demonstrate Point of Care directions, documentation, as well as how to properly document refusals of care and procedure of re-approaching resident x3, then change of face for all refused tasks.

· POC audit forms will be generated to determine if there are any discrepancies. If so, the omissions will be addressed same day.

· How often will the area needing correction be evaluated and who is responsible for the evaluation? Point of Care (POC) documentation will be reviewed daily and the RCC will address any omissions immediately. This will occur during her 5 day work week.

· Who on your staff will be responsible to see that all corrections are completed/monitored? The Executive Director will ensure that the reports are being generated and omissions are addressed timely. VP of Management Services and/or COO will review during weekly stand ups.

3. Resident 3 was admitted to the MCC in 11/2021 with diagnoses which included dementia.

During the entrance conference on 09/06/22, staff reported the resident had a recent significant overall decline in health.

Interviews with care staff and observations of Resident 3 during the survey revealed s/he was incontinent, dependent on staff for ADL care, did not use a call light to summon assistance, was on a pureed diet and needed meal assistance.

Resident 3's evaluation, dated 06/04/22, revealed it had not been updated when the resident experienced a decline in health care status and was not reflective of  his/her needs in the following areas:

* Activities;

* Dressing/undressing;

* Grooming/oral hygiene;

* Toileting;

* Communication;

* Medication administration;

* Ability to use a call light; and

* The resident's ability to express pain or discomfort.

The need to ensure the evaluation was updated with significant changes in condition and was reflective of Resident 3's current care needs was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (Resident Care Coordinator) during interviews on 09/07/22 and 09/08/22. They acknowledged the findings. No further information was provided.

2. Resident 2 moved into the facility in 05/2022.

The current move-in evaluation was not dated, did not indicate who was involved in the evaluation process, and failed to address the following elements:

* Interests, hobbies, social, leisure activities;

* Spiritual, cultural preferences and traditions;

* Physical health status including list of diagnoses, list of medications and PRN use and vital signs if indicated by diagnosis, health problems or medications;

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

* Cognition, including decision making abilities;

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

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

* Nutrition habits, fluid preferences or weight if indicated;

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

* Indicators of nursing needs including potential for delegated nursing tasks;

* Fall risk or history;

* Complex medication regimen;

* History of dehydration or unexplained weight loss or gain;

* Recent losses;

* Unsuccessful prior placements; and

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

The need to address all required elements on the move-in evaluation was discussed with Staff 1 (ED),  Staff 2 (RN) and Staff 3 (Resident Care Coordinator) on 09/08/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure resident move-in evaluations addressed all required elements, were dated and indicated who was involved in the evaluation process, and/or failed to ensure evaluations were reviewed and updated when a resident experienced a significant change of condition for 3 of 5 sampled residents (#s 2, 3 and 4) whose most recent evaluations were reviewed. Findings include, but are not limited to:

1. Resident 4 moved into the facility in 08/2022.

The new move-in evaluation was not dated, did not indicate who was involved in the evaluation process, and failed to address the following elements:

* Eating and bathing routines;

* Visits to health practitioner(s), ER, hospital or NF in the past year;

* Mental health issues including the presence of depression, thought disorders or behavioral or mood problems;

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

* Hearing;

* Dental status/assistive devices;

* Ability to use call system;

* Fall risk or history;

* History of dehydration or unexplained weight loss or gain;

* Elopement risk or history;

* Smoking, ability to smoke safely; and

* Alcohol and drug use.

The need to ensure new move-in evaluations contained all the required elements was discussed with Staff 1 (ED) on 09/08/22. She acknowledged the findings.

What actions will be taken to correct the rule violation?

Staff will use the most current version of the evaluation/assessment form in PCC which addresses all required information per the OAR's. A change of condition was done for Resident #3.

·How will the system be corrected so this violation will not happen again?

Staff will use the new evaluation/assessment form in PCC to perform all initial, quarterly and change of condition evaluations/assessments and service plans. A caregiver service plan review form has been created to have care staff write changes in cares for each resident prior to service plan review.

·How often will the area needing correction be evaluated and who is assigned to evaluating the changes? Forms triggering a change of condition will be reviewed daily, all scheduled evaluations are reviewed weekly.

·Who on your staff will be responsible to see that all the corrections are completed and monitored? The RCC, ED and RN will be responsible for correcting and monitoring.

Based on observation, interview and record review, it was determined the facility failed to ensure quarterly evaluations were reflective of current care needs for 1 of 7 sampled residents (#7) whose evaluation was reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 7 was admitted to the facility in 08/2021 with diagnoses which included dementia.

During the acuity interview on 01/03/23, staff reported the resident required hands-on assistance in most ADLs.

Observation of Resident 7 during the survey revealed s/he had a scab on the face, no brace on his/her leg and used a wheelchair for ambulation.

Interviews with staff and review of the resident's current evaluation, dated 11/29/22, revealed the evaluation did not address or was not reflective of the resident's current status in the following areas:

* Ambulation status with use of a device;

* Toileting assist with leg brace caution;

* Reoccurring UTI; and

* Skin status on cheek.

The need to ensure the evaluation addressed all care areas and was reflective of Resident 7's current care needs was discussed with Staff 1 (Executive Director), Staff 2 (RN) and Staff 3 (RCC) on 01/05/23. They acknowledged the findings.

What actions will be taken to correct the rule violation? Resident 7's evaluation and care plan made to be reflective of actual needs.

· How will the system be corrected so this violation will not happen again? Staff provided additional training on implementing Temporary Service Plans for changes in residents ADL assistance needed. The RCC and RN will review all new TSP's and add additional direction as needed. Permanent changes will be added to the residents quarterly evaluation and service plan upon review, unless it triggers a change of condition, in which the eval and service plan will be updated promptly. Caregiver Service Plan Review forms will be used for care staff comments on any changes.

· How often will the area needing correction be evaluated and who is responsible for the evaluation? All TSP's will be reviewed daily during the work week and the Caregiver Service Plan Review forms will be reviewed prior to quarterlies by the RCC, RN, and/or the Executive Director.

· Who on your staff will be responsible to see that all corrections are completed/monitored? The Executive Director will ensure that TSP's are monitored and the VP of Management Services and/or COO will review during weekly stand ups.

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 regarding the delivery of services and were followed for 3 of 4 sampled residents (#s 1, 2 and 3) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 3 was admitted to the MCC in 11/2021 with diagnoses which included dementia.

Interviews with care staff and observations of Resident 3 during the survey revealed s/he was incontinent, dependent on staff for ADL care, did not use a call light to summon assistance, was on a pureed diet and needed meal assistance.

Resident 3's service plan, dated 06/04/22, revealed it was not reflective of the resident's needs and lacked clear direction regarding the delivery of services in the following areas:

* Activities;

* Dressing/undressing;

* Grooming/oral hygiene;

* Toileting;

* Communication;

* Crushed medication; and

* Verbalization of pain.

The need to ensure the service plan was reflective of Resident 3's current care needs and provided clear direction to staff was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (Resident Care Coordinator) during interviews on 09/07/22 and 09/08/22. They acknowledged the findings. No further information was provided.

2. Resident 1 was admitted to the facility in 04/2021 with diagnoses including dementia.

Resident 1 was observed to utilize a wheelchair for mobility and needed to be assisted with food intake during the breakfast and lunch meal.

Observations of the resident, interviews with staff, review of the current 07/13/22 service plan and clinical records during the survey revealed Resident 1's service plan was not reflective of his/her status, did not provide specific directions to staff, and was not followed in the following areas:

* Use of glasses;

* Denture care status;

* Weight changes including plans;

* Oral care status;

* Use of side rail including what to monitor and who to report;

* Hospice service status including when and what to report or who to report;

* Use of oxygen;

* Behavior status;

* Personal hygiene including level of assistance;

* Transfer status, 1-person versus 2-person assistance;

* Skin status; and

* Health shakes 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 (ED), Staff 2 (Registered Nurse) and Staff 3 (Resident Care Coordinator) on 09/07/22 and 09/08/22. They acknowledged the findings.

3. Resident 2 was admitted to the facility in 05/2022 with diagnoses including dementia.

Observation of Resident 2 throughout the survey revealed the resident was dependent on staff for most ADLs due to poor eyesight.

Observations of the resident, interviews with staff, review of the current 06/16/22 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 direction in the following areas:

* Use of call light system;

* Fall risks and interventions; and

* Mental health status including hallucinations.

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 (ED), Staff 2 (RN) and Staff 3 (Resident Care Coordinator) on 09/07/22 and 09/08/22. They acknowledged the findings.

What actions will be taken to correct the rule violation?

Staff will use the most current version of the evaluation/assessment form in PCC which addresses all required information per the OAR's. A change of condition was done for Resident #3.

·How will the system be corrected so this violation will not happen again?

Staff will use the new evaluation/assessment form in PCC to perform all initial, quarterly and change of condition evaluations/assessments and service plans. A caregiver service plan review form has been created to have care staff write changes in cares for each resident prior to service plan review.

·How often will the area needing correction be evaluated and who is assigned to evaluating the changes? Forms triggering a change of condition will be reviewed daily, all scheduled evaluations are reviewed weekly.

·Who on your staff will be responsible to see that all the corrections are completed and monitored? The RCC, ED and RN will be responsible for correcting and monitoring.

4. Resident 9 was admitted to the facility in 2022 with diagnoses including dementia.

Review of Resident 9's clinical record, interviews with care staff, and observations during the survey revealed the service plan dated 12/01/22 was not reflective of the resident's needs and lacked clear direction regarding the delivery of services in the following areas:

* Home Health wound care and Hospice care were not listed on the service plan;

* Oxygen concentrator and tubing were set up in the room, but not listed on the service plan; and

* The service plan instructed staff to assist Resident 9 with using hearing aids and a call pendant, however, staff stated the hearing aids and pendant were missing on all days of the survey.

The need to ensure the service plan was reflective of Resident 9's current care needs and provided clear direction to staff was discussed with Staff 1 (Executive Director), Staff 2 (RN) and Staff 3 (Resident Care Coordinator) on 01/05/23. They acknowledged the findings and updated the service plan.

2. Resident 7 was admitted to the facility in 08/2021 with diagnoses including dementia.

Resident 7 was observed to utilize a wheelchair for mobility and needed to be assisted with toileting care.

Observations of the resident, interviews with staff, review of the current 12/05/22 service plan and clinical records during the survey revealed Resident 7's service plan was not reflective of his/her status, did not provide specific directions to staff, and was not followed in the following areas:

* Use of glasses;

* Toileting status with leg brace caution;

* Oral hygiene; and

* Use of a wheelchair for ambulation;

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 (Executive Director), Staff 2 (RN) and Staff 3 (RCC) on 01/05/23. They acknowledged the findings.

3. Resident 8 was admitted to the facility in 08/2022 with diagnoses including dementia.

Resident 8 was observed to utilize a wheelchair for mobility.

Observations of the resident, interviews with staff, review of the current 11/22/22 service plan and clinical records during the survey revealed Resident 8's service plan was not reflective of his/her status, did not provide clear instruction to staff, and was not followed in the following areas:

* Use of wheelchair;

* Use of gait belt during transfer; and

* Sleeping in the recliner or preference.

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 (Executive Director), Staff 2 (RN) and Staff 3 (RCC) on 01/05/23. 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 status and care needs and provided clear instruction to staff for 4 of 7 sampled residents (#s 7, 8, 9 and 11) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 11 was admitted to the facility in 08/2022 with diagnoses including Alzheimer's dementia.

Interviews with care staff and observations of Resident 11 during the survey revealed s/he was incontinent, dependent on staff for ADL care, and did not use a call light to summon assistance.

Resident 11's current service plan, dated 10/03/22, failed to reflect the resident's care needs and lacked specific instruction to staff in the following areas:

* Activities;

* Bathing;

* Dressing;

* Communication;

* Mobility; and

* Evacuation.

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 (Executive Director), Staff 2 (RN) and Staff 3 (RCC) on 01/05/23. They acknowledged the findings.

What actions will be taken to correct the rule violation? Residents mentioned have completed service plan reviews and updated service plans reflective of residents current abilities.

· How will the system be corrected so this violation will not happen again? Staff will ensure that the "Caregiver Service Plan Review" form will be set out for caregivers to complete 1 week prior to review. Staff will also ensure that all TSP's are reviewed as well as progress notes to implement any necessary changes to the service plan.

· How often will the area needing correction be evaluated and who is responsible for the evaluation? Service plans will be reviewed initially, 30 days, quarterly and as needed.

· Who on your staff will be responsible to see that all corrections are completed/monitored? The RCC will update the service plans and notify the RN and Executive Director for Review and the VP of Management Services and/or COO will review during weekly stand up.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that included the resident, the resident's legal representative if applicable, any person of the resident's choice, the Administrator or designee, and at least one other staff person who was familiar with or who was going to provide services to the resident for 4 of 4 sampled residents (#s 1, 2, 3 and 5). Findings include, but are not limited to:

Resident 1, 2, 3 and 5's current service plans were reviewed during the survey.

The service plans lacked evidence the residents or their legal representative's participated in the development of the service plans and that a Service Planning Team was used to develop the service plan.

The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (Resident Care Coordinator) on 09/08/22. They acknowledged the findings.

What actions will be taken to correct the rule violation?

Care conferences were offered to the residents and family members, documentation received of both the resident/family and staff involvment/participation in the development and agreement of the service plan.

·How will the system be corrected so this violation will not happen again?

Care conferences will be offered via phone, video conference, or in person. Staff will document if the review was done on the phone or in video conference, The RCC, ED and RN will be a part of the Service Planning Team and document so.

·How often will the area needing correction be evaluated and who is assigned to evaluating the changes? All evaluations/assessments and service plans are reviewed per schedule weekly and daily for change of condition. Resident/Family involvment will be documented in PCC.

·Who on your staff will be responsible to see that all the corrections are completed and monitored?

The RCC will offer the care conferences and the RN/ED will monitor and ensure documentation is done.

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, and service planned interventions were reviewed for effectiveness for 1 of 1 sampled resident (# 2) who had documented repeated falls. Findings include, but are not limited to:

Resident 2 was admitted to the Memory Care Unit in 05/2022 with diagnoses including dementia.

During the survey, s/he was identified as having recent falls.

Observations of Resident 2 throughout the survey revealed the resident was dependent on staff for most ADLs due to poor eyesight/blindness and used a pressure sensor to prevent falls.

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

The clinical record provided the following information:

* 06/01/22 fall in the room;

* 07/11/22 fall in the room resulting in back pain;

* 08/11/22 fall in the bathroom resulting in emergency room visit;

* 08/19/22 fall in the room; and

* 08/19/22 TSP identified a pressure alarm under the resident's chair and bed.

A 06/01/22 fall incident report indicated new fall interventions including safety checks, no clutter on floor, shoes and socks were on, staff redirection and encouragement to come to common area. There was no TSP for the new interventions.

The 06/16/22 service plan indicated to guide the resident by holding hands and cuing the direction for locomotion and to assist for all toileting needs.

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 toileting assistance status, and were evaluated for effectiveness. There were no new interventions communicated to staff.

On 09/08/22, the above findings were reviewed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (Resident Care Coordinator). Staff acknowledged findings.

What actions will be taken to correct the rule violation?

Fall interventions updated for the resident mentioned in the residents service plan. Training provided to the team on proper tsp and intervention implementation.

·How will the system be corrected so this violation will not happen again?

Staff will ensure that an incident report is done in PCC, a tsp is implemented for any/all falls and that a new intervention is implemented for each fall.

·How often will the area needing correction be evaluated and who is assigned to evaluating the changes? Incident reports and TSP's will be monitored on each working day.

·Who on your staff will be responsible to see that all the corrections are completed and monitored? The RCC, RN, and/or ED will monitor the documents on working days.

Based on observation, interview and record review, it was determined the facility failed to determine and document what action or intervention were required, monitor the changes through resolution and/or refer to the RN for 6 of 8 sampled residents (#s 7, 9, 11, 13, 14 and 15) who had changes of condition. This is a repeat citation. Findings include, but are not limited to:

1. Resident 15 was admitted to the facility in 08/2022 with diagnoses including dementia.

The resident's progress notes dated 11/07/22 through 01/03/23, service plan, and temporary service plans were reviewed. The following short-term change of condition was identified:

On 12/26/22 the resident fell and hit his/her head. The resident was sent to the ER and diagnosed with a closed head injury.

There was no documented evidence the facility determined and documented what action or intervention was needed for the resident or monitored the resident until the condition resolved.

The need to ensure the facility determined and documented what action or intervention was needed for the resident's short-term change of condition and monitored the resident until the condition was resolved was discussed with Staff 2 (RN) and Staff 3 (RCC) on 01/05/23. They acknowledged the findings.  

5. Resident 9 was admitted to the facility in 2022 with diagnoses including dementia.

During the entrance conference on 01/03/23, staff stated the resident had a blister on his/her left foot that was being treated by home health.

On 01/05/23, an RN Surveyor completed observations along with Staff 2 (RN), confirming the presence of the left foot wound.

The resident's progress notes dated 11/07/22 through 01/03/23, service plan, and temporary service plans were reviewed. The following change of condition was identified:

An RN note dated 12/02/22 documented "pressure ulcer noted to L [left] heel that RN was unaware of." A temporary service plan was developed, and the wound was monitored daily until 12/06/22.

Home Health provided wound care, however, there was no documented evidence showing how the wound was monitored from 12/06/22 until 01/03/23.

The need to ensure the facility monitored and documented the progress of Resident 9's wound was discussed with Staff 2 (RN) and Staff 3 (RCC) on 01/05/23. They acknowledged the findings.

4. Resident 7 was admitted to the facility in 08/2022 with diagnoses including dementia.

Resident 7's progress notes and facility incident reports dated 11/07/22 through 01/03/23 were reviewed and revealed the following:

* The resident had a fall on 11/27/22 in the dining room and was sent to the emergency room; and

* S/he fell on 12/03/22 in the common area.

The facility listed current fall interventions on the facility investigation records. However, there was no documented evidence the facility evaluated the effectiveness of current fall interventions and determined new interventions when indicated.

The need to ensure the facility evaluated the resident's status and the effectiveness of current fall interventions was discussed with Staff 1 (Executive Director), Staff 2 (RN) and Staff 3 (RCC) on 01/05/23 at 3:55 pm. The findings were acknowledged.

2. Resident 14 was admitted to the facility in 2022 with diagnoses including dementia.

The resident's 11/08/22 through 01/03/23 progress notes and 11/2022 through 01/2023 weight records were reviewed.

a. Resident 14's progress notes revealed s/he experienced the following changes of condition:

* 11/02/22 - Medication change, begin trazadone (insomnia) 25 mg PRN; and

* 12/22/22 - Medication change, begin microbid (urinary tract infection) 100 mg a day for five days.

The facility failed to show documented evidence interventions for the medication changes were resident specific and made a part of the resident record with weekly progress noted until resolution.

b. Resident 14's weight records revealed the following:

* 11/03/22 - 176.6 pounds;

* 12/03/22 - 186.2 pounds; and

* 01/03/23 - 181.6 pounds.

The resident's recorded weight increased by 9.6 pounds between 11/03/22 and 12/03/22, which was a 5.43% gain of total body weight in one month. The weight gain constituted a significant change in condition.

In a 01/05/23 interview with Staff 2 (RN), she stated she was not made aware of Resident 14's weight gain.

The facility failed to show documented evidence the resident's significant change of condition was referred to the facility RN for assessment.

Changes of condition were discussed with Staff 1 (Executive Director) and Staff 2 (RN) on 01/06/23. They acknowledged the findings.

Refer to C280, example 2.

3. Resident 13 was admitted to the facility in 2022.

The resident's 11/03/22 through 01/01/23 progress notes and 11/03/22 through 01/01/23 weight records were reviewed and revealed the following:

* 11/01/22 - 160.4 pounds;

* 12/01/23 - 163.4 pounds; and

* 01/01/23 - 155.2 pounds.

The resident's recorded weight decreased by 8.2 pounds between 12/01/22 and 01/01/23, which was 5.01% of his/her total body weight in one month. The weight loss constituted a significant change in condition.

In a 01/05/23 interview with Staff 2 (RN), she stated she was not made aware of Resident 13's weight loss.

The facility failed to show documented evidence that the resident's significant change of condition was referred to the facility RN for assessment.

Changes of condition were discussed with Staff 1 (ED) and Staff 2 on 01/06/23. They acknowledged the findings.

Refer to C280, example 1.

6. Resident 11 was admitted to the facility 08/2022 with diagnoses including Alzheimer's dementia.

Resident 11's progress notes and facility records dated 11/01/22 through 01/03/23 were reviewed and revealed the following:

A progress note dated 12/25/22 revealed Resident 11 was sent to the hospital "at POA's [Power of Attorney] request for unknown pain, and difficulty breathing. RCC, RN, MD, and ED notified". Resident 11 returned the same day with a diagnosis of influenza.

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.

The need to ensure residents were evaluated, actions or interventions needed were determined, and monitoring was documented at least weekly through resolution was discussed with Staff 1 (Executive Director), Staff 2 (RN) and Staff 3 (RCC) on 01/05/23. The findings were acknowledged. No further information was provided.

What actions will be taken to correct the rule violation?

Additional training on proper procedure will be done at the next all staff in-service. RN, RCC, and ED oversight will increase.

· How will the system be corrected so this violation will not happen again? Incident Report process will include RN review of the TSP created as a result of the IR, as well as any additional instructions to staff. Weekly RN notes will be done until the temporary change of condition is resolved. Weights will be reviewed by the RN on the 10th of each month to determine who needs to have a COC completed. For any residents on COC the RN will document weekly until resolved.

· How often will the area needing correction be evaluated and who is responsible for the evaluation? Incident Reports and TSP's will be reviewed each day during the work week with any additional instructions entered, Progress notes will be reviewed weekly and an RN note will be done weekly for all change of conditions.

· Who on your staff will be responsible to see that all corrections are completed/monitored? The Executive Director and the VP of Management Services and/or COO will review during weekly stand up.

2. Resident 3 was admitted in 11/2021 with diagnoses which included dementia.

During the entrance conference on 09/06/22, staff reported that the resident had a recent significant overall decline in health and weight loss.

Review of facility progress notes, weight records, MARs and current service plan, from 06/09/22 through 09/06/22, revealed the following:

a. Weight records indicated the resident weighed 149.4 lbs. on 06/14/22. On 07/01/22, the resident's weight dropped to 137.4 lbs.

Between 06/14/22 and 07/01/22, s/he lost 12 lbs. or 6.6 % of his/her weight in less than one month which constituted a severe loss and significant change in condition.

There was no documented facility RN assessment to address the weight loss.

b. On 09/01/22, Staff 2 (RN) documented in progress notes that she "reached out to patient's daughter explaining that it may be time to consider hospice care. Patient has noted to decline overall ..."  

The decline in health constituted a significant change in condition for which an assessment by the facility RN was required.

There was no documented evidence the facility RN conducted an assessment.

During an interview on 09/07/22 at 2:20 pm, Staff 2 (RN) acknowledged the lack of a documented RN assessment for the significant changes in condition.

The need to ensure documented RN assessments for significant changes in condition was discussed with Staff 1 (Executive Director) on 09/08/22 at 8:30 am. She acknowledged the findings. No further information was provided.

Based on observation, interview and record review, it was determined the facility failed to ensure the RN performed an assessment and interventions were developed based on the condition of the resident for 2 of 2 sampled residents (#s 1 and 3) who experienced a significant change of condition in weight status and overall health decline. Resident 1 continued to have weight loss. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 04/2021 with diagnoses including dementia.

Observations of the resident on 09/07/22 revealed s/he was on a pureed diet, nectar thickened liquids and required hands-on assistance to eat.

a. Resident 1's weight records were reviewed during the survey and revealed the following:

* 12/2021 - 89.8 pounds;

* 01/2022 - 78.4 pounds;

* 04/2022 - 74.0 pounds;

* 07/2022 - 60.4 pounds;

* 08/2022 - 55.0 pounds; and

* 09/2022 - 52.6 pounds.

From 12/2021 to 01/2022, Resident 1 lost 11.4 pounds or 12.69 % of his/her body weight in one month, which represented a significant change of condition.

Weights documented after 04/2022 revealed the resident experienced another significant weight loss of 18.37 % in three months from 04/2022 to 07/2022. There were no weight records in 02/2022, 03/2022, 05/2022 and 06/2022 during the record review.

There was no documented evidence the RN completed an assessment of the resident's condition, which included whether the weight loss had been evaluated, actions or interventions determined, or actions and interventions reviewed for effectiveness to address the weight loss.

During an interview on 09/07/22, the surveyor shared with Staff 2 (RN) that there were no weight records for the resident from 04/2022 through 06/2022.

On 09/08/22 at 8:30 am, Staff 2 stated she searched the resident's records and was able to locate additional weight records that had been archived. The weights had not been entered into the resident's clinical record at the time they were obtained, and were transferred into the resident's record during the survey. The updated weight records were provided to the surveyor on 09/08/22.

Failure to ensure an RN assessment was completed for the weight loss was discussed with Staff 2 on 09/07/22 at 5:00 pm. She acknowledged a documented assessment had not been done.

b. The resident had a physician order, dated 01/20/22, to administer 250 ml of high-protein liquid (health shake) three times daily and it was scheduled at 10:00 am, 2:00 pm and 7:00 pm.

During the survey on 09/07/22 the following was observed:

* From 10:00 am - 11:00 am, the resident was in the room, in his/her recliner. During the observation, staff did not provide or offer a health shake to the resident as planned;

* From 12:05 pm - 12:40 pm, the resident was in the dining room for lunch. Staff helped the resident to eat his/her lunch. The resident consumed approximately 50 % of lunch; and

* From 2:00 pm - 3:00 pm, the resident was not observed to be offered a health shake. The resident was in bed, resting during the observation.

The facility failed to ensure an RN assessment at the time of the significant weight loss, the resident's continued weight loss and an evaluation of interventions including administration of health shakes and for effectiveness resulted in further weight loss. Between 12/2021 and 09/2022, Resident 1 lost 37.3 pounds or 41.3 % of his/her body weight.

On 09/07/22 and 09/08/22, the above findings was shared with Staff 1 (Administrator), Staff 2 (RN) and Staff 3 (Resident Care Coordinator). They acknowledged the findings.

What actions will be taken to correct the rule violation? All residents weights reviewed for any significant changes.

·How will the system be corrected so this violation will not happen again?

Weights will be entered into PCC each month. They will be reviewed for significant changes. Upon identification of the significant changes the RN will do a focused assessment on weight. Proper interventions will be put into place.

·How often will the area needing correction be evaluated and who is assigned to evaluating the changes? The RN will review weights monthly, assess and ensure that proper interventions are in place. For those identified to have a significant weight change, the RN will document on them weekly until the weight stabilizes.

·Who on your staff will be responsible to see that all the corrections are completed and monitored?

The RCC, RN and ED will ensure that the interventions are being properly performed by the care team.

4. Resident 9 was admitted to the facility in 2022 with diagnoses including dementia.

During the entrance conference on 01/03/23, staff stated the resident had a blister on his/her left foot that was being treated by home health.

Review of the resident's clinical record revealed an RN note dated 12/02/22, which documented "pressure ulcer noted to L [left] heel that RN was unaware of."

The wound constituted a significant change in condition for which an assessment by the facility RN was required.

There was no documented evidence the facility RN conducted an assessment until 01/05/23, after observing the wound with an RN Surveyor.

In interview on 01/05/23 Staff 2 (RN) acknowledged she did not document an assessment of the wound. The findings were shared with Staff 1 (Executive Director), Staff 2 (RN) and Staff 3 (RCC) on 01/06/23. They acknowledged the findings.

3. Resident 8 was admitted to the facility in 08/2022 with diagnoses including dementia.

Observation of the resident during the survey showed the resident required a 2-3 person assistance with transfers and incontinence care.

During the acuity interview, the resident was identified to have a decline in condition in multiple areas including mobility and ADL assistance due to increased weakness.

The facility progress notes and temporary service plan, dated 11/07/22 to 01/03/23, were reviewed during the survey and revealed the following:

* 12/04/22: Open sore on right knee area;

* 12/18/22: Emergency visit with a diagnosis of cellulitis and treated with antibiotic;

* 12/21/22: Required two care staff persons with a gait belt and walker for transfers;

* 12/26/22: Emergency visit due to leg pains; and

* 12/27/22: Staff assisted the resident to the floor to prevent a fall.

During the survey, Staff 9 (MT/CG) reported the resident had an overall decline in status for last "3 to 4 weeks" in the following areas:

* No longer ambulating independently with a walker, use of wheelchair;

* No longer transferred independently and needed 2-3 staff for assistance with transfers; and

* Required staff assistance or supervision in ADLs including toileting and meal intake.

Resident 8's changes represented a significant change of condition.

The facility RN conducted the assessment on 12/26/22 and stated the resident had open area on the right leg. However, there was no documented evidence of the resident's overall status which included findings, a description of the resident status, and interventions made as a result of the assessment.

The failure to complete an RN assessment following a significant change in status was discussed with Staff 1 (Executive Director), Staff 2 (RN) and Staff 3 (RCC) on 01/05/23. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure significant changes of condition were assessed by a facility RN for 4 of 7 sampled residents (#8, 9, 13 and 14), reviewed for significant changes of condition. This is a repeat citation. Findings include, but are not limited to:

1. Resident 13 was admitted in 2022 with diagnoses including Alzheimer's disease.

The resident's clinical record was reviewed and revealed a significant weight loss of 8.2 pounds or 5.01% of his/her total body weight in one month, from 12/01/22 through 01/01/23. The weight loss constituted a significant change in condition requiring an RN assessment.

The resident experienced a fall and a vertical fracture to the left femur on 12/19/22 and was hospitalized from 12/19/22 through 12/30/22. On 12/28/22 the facility RN received report from the hospital and documented the following progress note:

* "Case manager states the patient is bedbound and eating approximately 5% of meals and only taking sips."  

The resident was re-admitted to the facility on 12/30/22. The facility RN performed an assessment of the resident on 01/03/23, however the resident's weight loss was not addressed in the assessment.

Observations of the resident between 01/03/23 and 01/05/23 showed the resident ate less than ten percent of dinner on 01/03/23 and zero percent of breakfast on 01/04/23. Staff did not offer to assist the resident with his/her meals.

In a 01/03/23 interview with Staff 12 (CG), when asked what instructions were in place if Resident 13 did not eat his/her meal, he stated "I don't know,  I guess I can offer [him/her] a snack."

The 01/03/23 observations and interview with Staff 12 were relayed to Staff 2 (RN) and Staff 3 (RCC) on the same date.

There was no documented evidence the facility RN conducted an assessment regarding the resident's significant weight loss. The lack of an RN assessment was confirmed during a 01/05/23 interview with Staff 2 (RN).

The need to ensure significant changes of condition were assessed by an RN and interventions were determined was discussed with Staff 1 (ED), Staff 2 and Staff 3 on 01/06/23. They acknowledged the findings.

2. Resident 14 was admitted in 2022 with diagnoses including dementia.

Observations of the resident between 01/03/23 and 01/05/23 showed the resident was able to feed himself/herself once provided food. The resident did not seek out or ask for food items during the survey observations but would accept items when staff offered. The resident ate 100% of his/her dinner on 01/03/23, 100% of breakfast, lunch and snacks offered on 01/04/23.

The resident's clinical record was reviewed and revealed a significant weight gain of 9.6 pounds or 5.43% of his/her total body weight in one month, from 11/03/22 through 12/03/22. The weight gain constituted a significant change in condition requiring an RN assessment.

There was no documented evidence the facility RN conducted an assessment regarding the resident's significant weight gain. The lack of an RN assessment was confirmed during an interview with Staff 2 (RN) on 01/05/23.

The need to ensure significant changes of condition were assessed by an RN and interventions were determined was discussed with Staff 1 (Executive Director) and Staff 2 on 01/06/23. They acknowledged the findings.

What actions will be taken to correct the rule violation? Resident weights will be monitored upon admission, re-admission and monthly. All TSP's will be reviewed and monitored until resolved or until a change of condition requires a permanent service plan change.

· How will the system be corrected so this violation will not happen again? Residents will be weighed upon admit, return from hospital, and monthly unless otherwise instructed by the physician. The RN will monitor all weights in the same incriments. Monthly weights will by reviewed by the 10th of each month. For those residents with a 5% weight gain/loss in 1 month, 7.5% gain/loss in 2 mos, or 10% gain/loss in 6 mos. a change of condition assessment will be done and weekly notes by the RN until weight stabilizes. TSP's will be reviewed and monitored to determine if a permanent change of condition has occurred and if so, a change of condition assessment and service plan will be completed.

· How often will the area needing correction be evaluated and who is responsible for the evaluation? The RN will asses upon admit, re-admit, monthly and otherwise instructed by physician. The ED/RCC/and/or RN will review the TSP's daily during work week. The RN will complete weekly notes until resident stabilizes or a permanent change of condition is done.

· Who on your staff will be responsible to see that all corrections are completed/monitored? The Executive Director and the VP of Management Services and/or COO will review during weekly stand up.

Based on observation and interview, it was determined the facility failed to implement effective methods of infection control for 3 of 4 sampled residents (#s 7, 8 and 11). Findings include, but are not limited to:

Observations were made in the MCC during the survey to determine adherence to universal precautions for infection control.

1. Resident 11 was admitted to the MCC in 08/2022 with diagnoses which included Alzheimer's dementia.

Observations and interviews with staff during the survey revealed s/he was incontinent, relied on staff for incontinence care needs, and had open sores on his/her bottom.

On 01/04/23 at 09:30 am, the surveyor obtained permission and observed Staff 14 and 16 (CGs) provide ADL care to Resident 11. During the observation, both staff donned gloves and assisted the resident onto the toilet. While wearing the same gloves, Staff 16 wiped the resident's perineum, then proceeded to apply barrier cream to the resident's open wounds. The surveyor intervened and asked Staff 16 to don clean gloves prior to application of the barrier cream. Per the surveyor's request, Staff 16 donned clean gloves before applying the barrier cream to the resident's bottom.

The above observation was discussed with Staff 2 (RN) and Staff 3 (RCC) on 01/05/23 at 1:30 pm. They acknowledged appropriate infection control practices were not implemented. No further information was provided.

2. On 01/04/23 at approximately 11:30 am, the surveyor obtained permission and observed Staff 9 (MT/CG) provide incontinence care to Resident 7. During the observation, Staff 7 failed to provide or assist Resident 7 with hand hygiene after the resident used the toilet and touched the toilet seat. Staff 7 then escorted Resident 7 to the dining room for lunch without hand hygiene.

The need to ensure staff consistently used universal precautions was discussed with Staff 1 (Executive Director), Staff 2 (RN) and Staff 3 (RCC) on 01/05/23 at 3:50 pm. They acknowledged the findings

3. On 01/04/23 approximately 9:35 am, the surveyor obtained permission and observed Staff 9 (MT/CG) and Staff 19 (CG) provided incontinence care to Resident 8 while the resident was in bed. During the observation, Staff 19 removed soiled and wet linens and put them on the carpet floor without placing a barrier on the floor.

The need to ensure staff consistently used universal precautions was discussed with Staff 1 (Executive Director), Staff 2 (RN) and Staff 3 (RCC) on 01/05/23 at 4:55 pm. They acknowledged the findings.

What actions will be taken to correct the rule violation? Infection Control Training provided at all staff.

· How will the system be corrected so this violation will not happen again? 2023 Training guide includes pre-service infection control class.

· How often will the area needing correction be evaluated and who is responsible for the evaluation? The Business Office Manager will be responsible for entering in completion dates on a spreadsheet for all staff training. Staff will not be permitted to work the floor until pre-service infection control class requirements are met.

· Who on your staff will be responsible to see that all corrections are completed/monitored? The Executive Director and the VP of Management Services and/or COO will review during weekly stand up.

Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 1 of 2 sampled resident (# 2) whose MARs and Controlled Substance Drug Disposition logs were reviewed for accuracy. Findings include, but are not limited to:

Resident 2 was admitted in 05/2022 and had diagnoses which included surgeries to left arm and a torn rotator cuff from a past fall.

Resident 2 had an order for Hydrocodone/Acetaminophen 5-325 mg, one tablet twice daily as needed for pain, and Hydrocodone/Acetaminophen 7.5-325 mg two times daily scheduled.

Resident 2's Controlled Substance Disposition Logs and MARs, reviewed from 08/19/22- 09/06/22, revealed two occasions when staff signed on the drug disposition log that the medication was given. However, the MAR lacked documentation that the resident received the medication.

The inconsistencies between the MARs and Controlled Substance Disposition logs were reviewed with Staff 1 (ED) and Staff 2 (RN) and Staff 3 (Resident Care Coordinator) on 09/07/22 and 09/08/22. They reviewed the documentation and acknowledged the discrepancies.

What actions will be taken to correct the rule violation? A narcotic log audit will be performed on each resident with narcotics by 9/30/22.

·How will the system be corrected so this violation will not happen again? Regular Narcotic Book audits will be done weekly.

·How often will the area needing correction be evaluated and who is assigned to evaluating the changes? Weekly

·Who on your staff will be responsible to see that all the corrections are completed and monitored?

·The RCC/RN and ED

Based on observation, interview and record review, it was determined the facility failed to ensure an assessment by a PT, OT or RN was completed for assistive devices with potentially restraining qualities for 1 of 1 sampled resident (# 1) who used a side rail in bed. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 04/2021 with diagnoses including dementia.

During the acuity interview on 09/06/22, Resident 2 was identified as having a side rail on his/her bed.

Observations of the resident and the resident's room on 09/07/22 showed a half-length side rail was installed at the head of the hospital bed and was in the up position while the resident was in bed. The side rail appeared intact and in good repair.

Review of Resident 1's record revealed there was documented evidence an assessment of the side rails had been completed by an RN in 04/2021, however, there was no recent quarterly assessment for the side rail use.

The resident's 07/13/22 service plan indicated the resident used the side rail, however, there was no information providing instruction to caregivers on reason for  use and precautions related to the devices.

In an interview on 09/07/22 at 5:00 pm, Staff 2 (RN) and Staff 3 (Resident Care Coordinator) confirmed no recent quarterly assessment had been completed for Resident 1's side rail use.

The lack of a quarterly assessment and service plan with clear instruction for side rail use was discussed with Staff 1 (ED), Staff 2 and Staff 3 on 09/07/22 and 09/08/22. They acknowledged the findings.

What actions will be taken to correct the rule violation? Request sent to discontinue side rails for Resident 1, scoot mattress to be ordered and assessed for safety. Service plan will be updated.

·How will the system be corrected so this violation will not happen again?

A schedule will be implemented for any residents that have supportive devices with restraining qualities and will be maintained by the nurse.

·How often will the area needing correction be evaluated and who is assigned to evaluating the changes? Weekly

·Who on your staff will be responsible to see that all the corrections are completed and monitored? The RCC/RN and ED

Based on interview and record review, it was determined the facility failed to ensure 1 of 3 sampled newly-hired direct care staff (#8) completed all required training within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed on 09/07/22. There was no documented evidence Staff 8 (CG), hired 07/21/22, completed training in the use of abdominal thrust and First Aid.

The need to ensure staff completed First Aid and abdominal thrust training within 30 days of hire was discussed with Staff 1 (ED) on 09/08/22. She acknowledged the findings.

What actions will be taken to correct the rule violation? All staff audit to ensure that first aid/abdominal thrust training occurred. Audit of all new staff 30 day training is complete.

·How will the system be corrected so this violation will not happen again? Staff will utilize a training form/spreadsheet to track all trainings for new employees.

·How often will the area needing correction be evaluated and who is assigned to evaluating the changes? The Business Office Manager will monitor weekly.

·Who on your staff will be responsible to see that all the corrections are completed and monitored? The Executive Director will ensure that the spreadsheet is updated and BOM is ensuring trainings are completed.

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

Fire and Life Safety records for the previous six months were reviewed on 09/07/22.

Review of the documentation provided identified the following:

a. There was no documented evidence fire and life safety instruction was provided to staff on alternate months from fire drills; and

b. Fire drill records did not contain the following required elements:

* Escape route used; and

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

The requirements regarding fire and life safety instruction for staff and fire drill record components were reviewed with Staff 1 (ED) and Staff 4 (Maintenance Director) on 09/08/22. They acknowledged the findings.

What actions will be taken to correct the rule violation? In-service to be provided to staff with fire safety training 9/30/22. Fire drill form reviewed for proper information.

·How will the system be corrected so this violation will not happen again? Fire Drills and Fire Safety

In-services will be scheduled out by the Maintenance Director.

·How often will the area needing correction be evaluated and who is assigned to evaluating the changes? Monthly sign off will be done by the ED.

·Who on your staff will be responsible to see that all the corrections are completed and monitored? The Executive Director will monitor monthly and sign the forms.

Based on interview and record review, it was determined the facility failed to ensure fire drills included all required components on fire drill records. This is a repeat citation. Findings include, but are not limited to:

On 01/04/23, fire drill and fire/life safety training records for the previous three months were requested.

Review of the documentation identified the following:

* Fire drill records lacked the following components:

- Escape route used;

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

- Evidence alternate routes were used during fire drills.

The requirement regarding fire drill documentation was reviewed with Staff 1 (Executive Director) on 01/04/23 at 5:00 pm. The findings were acknowledged.

What actions will be taken to correct the rule violation? Fire Drill paperwork will be completed to show evacuation location.

· How will the system be corrected so this violation will not happen again? Fire Drills will be initiated every other month, including evacuation with all paperwork completed and turned into the Executive Director for review. On alternating months Fire Safety will be reviewed at the All Staff meeting and documented.

· How often will the area needing correction be evaluated and who is responsible for the evaluation? The Maintenance Director will be responsible for initiating all drills, completing required paperwork and ensuring that staff are instructed on the proper evacuation procedures as well as fire safety.

· Who on your staff will be responsible to see that all corrections are completed/monitored? The Executive Director and the VP of Management Services and/or COO will review during weekly stand up.

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

On 09/08/22 the surveyor met with Staff 1 (ED) to review the facility's fire and life safety training procedures. Staff 1 stated the facility did not have a process for reinstructing residents at least annually in fire safety.

The surveyor reviewed the rule with Staff 1 (ED). Staff 1 stated she understood the requirements and would be able to implement a procedure for providing instruction to residents.

What actions will be taken to correct the rule violation? House meetings will be held by 9/30/22 with all residents to discuss fire safety/evacuation procedures.

·How will the system be corrected so this violation will not happen again? Annual Resident fire safety meetings to be scheduled and performed each September.

·How often will the area needing correction be evaluated and who is assigned to evaluating the changes? The Maintenance Director will be responsible for ensuring that the annual trainings occur.

·Who on your staff will be responsible to see that all the corrections are completed and monitored? The Executive Director will ensure that the trainings occur annually.

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

Refer to Z155, Z162, C231, C252, C260, C270, C280, C420 and C513.

What actions will be taken to correct the rule violation? Refer to Z165, Z162, C231, C252, C260, C270, C280, C420, and C513. COO and VP are reviewing weekly to ensure POC is being followed.

· How will the system be corrected so this violation will not happen again? VP and/or COO will be going over each area of POC weekly.

· How often will the area needing correction be evaluated and who is responsible for the evaluation? Weekly review on all POC areas with the VP and/or COO.

· Who on your staff will be responsible to see that all corrections are completed/monitored? Executive Director and the VP of Management Services and/or COO will review during weekly stand up.

Based on observation and interview, it was determined the facility failed to ensure the design of the RCF supported the installation of handrails at one or both sides of resident-use corridors. Findings include, but are not limited to:

The interior of the building was toured on 09/06/22. The corridor between the kitchenette and resident rooms in each of the four communities was lacking a handrail.

The need to ensure handrails were installed along resident-use corridors was discussed with Staff 1 (ED) and Staff 4 (Maintenance Director) on 09/08/22. They acknowledged the findings.

What actions will be taken to correct the rule violation? Hand rails to be installed

·How will the system be corrected so this violation will not happen again? Hand rails to be installed

·How often will the area needing correction be evaluated and who is assigned to evaluating the changes? Maintenance will ensure that the handrails are installed

·Who on your staff will be responsible to see that all the corrections are completed and monitored? The Executive Director

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

The interior of the building was observed on 09/06/22 through 09/08/22. The following areas needed cleaning or repair:

Alderwood Community:

* Carpet stains in multiple areas;

* Uncovered garbage can in the kitchenette;

* Rough splintered wood along length of the chair rail on the kitchenette wall; and

* Missing transition strip between the carpet and the common use bathroom.

Birchwood Community:

* Carpet stains in multiple areas;

* Varnish worn off arms of the chairs in front of the fireplace; and

* Uncovered garbage can in the kitchenette.

Cedarwood Community:

* Carpet stains in multiple areas;

* White debris ground into the carpet and black debris on top of the carpet by the fire extinguisher outside rooms C7 and C8;

* Broken blinds in room C3; and

* Stains on the fabric seats of the chairs in common area.

Dogwood Community:

* Carpet stains in multiple areas;

* Varnish worn off the arms of the chairs in front of the fireplace;

* Sharp, broken edge on the left corner of fireplace hearth; and

* Stains on the fabric seats of the chairs in common area.

The areas needing cleaning and repair were shown to and discussed with Staff 1 (ED) and Staff 4 (Maintenance Director) on 09/08/22. They acknowledged the findings.

What actions will be taken to correct the rule violation? Carpets cleaned in all mentioned areas, garbage cans with lids purchased, rough splintered chair rail repaired, varnish repair being done, blind replacement occurring, sourcing new dining room chairs, fire place repaired.

·How will the system be corrected so this violation will not happen again? The building will be walked weekly by the Maintenance Director and he will address safety concerns and environment issues. Staff will have access to a maintenance log to identify environmental issues that need attention.

·How often will the area needing correction be evaluated and who is assigned to evaluating the changes? The Maintenance Director will review the log each working day.

·Who on your staff will be responsible to see that all the corrections are completed and monitored? The Executive Director will ensure that the log is being addressed and that environmental concerns are taken care of.

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

The interior of the building was observed on 01/03/23. The following areas needed cleaning or repair:

Alderwood Community:

* Carpet in common areas was stained in multiple areas;

* The courtyard door had scraped paint; and

* The wall behind a recliner in the television area had several scraped areas.

Birchwood Community:

* Carpet in common areas was stained in multiple areas; and

* The activity cabinet, located against the wall at the rear of the dining room, was missing an approximate 2X3 inch strip of laminate from the left front edge.

Cedarwood Community:

* Carpet in common areas was stained in multiple areas;

* The courtyard door had scraped paint; and

* The activity cabinet, located against the wall at the rear of the dining room, was missing an approximate 2X10 inch strip of laminate from the right edge.

Dogwood Community:

* Carpet in common areas was stained in multiple areas; and

* The activity cabinet, located against the wall at the rear of the dining room, was missing an approximate 2X18 inch strip of laminate from the right edge.

The surveyor and Staff 1 (Executive Director) toured the environment on 01/05/23 at 2:20 pm. She acknowledged the areas needing cleaning and repair.

What actions will be taken to correct the rule violation?

Alderwood Community:

* Carpet in common areas- Cleaned,

* The courtyard door painted;and

* The wall behind a recliner in the

television area repaired

Birchwood Community:

* Carpet in common areas was cleaned;

* The activity cabinet, located against the

wall at the rear of the dining room, was repaired;

Cedarwood Community:

* Carpet in common areas was cleaned;

* The courtyard door had scraped paint;

and

* The activity cabinet, located against the

wall at the rear of the dining room, was repaired.

Dogwood Community:

* Carpet in common areas was cleaned; and

* The activity cabinet, located against the

wall at the rear of the dining room was repaired.

· How will the system be corrected so this violation will not happen again? Maintenance Director will do walk throughs of the building and repair scuffs, trim, laminate and shampoo dirty carpet as needed.

· How often will the area needing correction be evaluated and who is responsible for the evaluation? The Maintenance Director is reponsible to walk through daily during work week and provide all repairs necessary or contract with the appropriate vendor.

· Who on your staff will be responsible to see that all corrections are completed/monitored? The Executive Director and the VP of Management Services and/or COO will ensure compliance.

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 372, C 420, C 422, C 511, and C 513.

Refer to: C 231, C 372, C 420, C 422, C 511, & C 513

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 C150, C155, C231, C242, C420, C455 and C513.

What actions will be taken to correct the rule violation? Refer to TAGS: C150, C155, C231, C242, C420, C455, and C513

· How will the system be corrected so this violation will not happen again? Refer to above tags

· How often will the area needing correction be evaluated and who is responsible for the evaluation? Weekly by Executive Director

· Who on your staff will be responsible to see that all corrections are completed/monitored? Executive Director, VP of Management Services and/or COO.

Based on interview and record review, it was determined the facility failed to ensure 1 of 4 sampled newly-hired staff (#8) completed all required pre-service dementia training, and 1 of 3 sampled newly-hired direct care staff (#8) completed competency training within 30 days of hire. Findings include, but are not limited to:

Training records were reviewed on 09/07/22. The following deficiencies were identified.

1. Staff 8 (CG) was hired 07/21/22. There was no documented evidence the following pre-service training requirements were completed:

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

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

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

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

* Environmental factors that are important to a resident's well-being;

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

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

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

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

2. There was no documented evidence that Staff 8 demonstrated competency in her job duties within 30 days of hire in the following areas:

* The role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Changes associated with normal aging;

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

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

The need to ensure all required training was completed within the specified time frames was discussed with Staff 1 (ED) on 09/08/22. She acknowledged the findings.

What actions will be taken to correct the rule violation? All staff audit to ensure that first aid/abdominal thrust training occurred. Audit of all new staff's pre-service dementia training and 30 day training and competency's completed.

·How will the system be corrected so this violation will not happen again? Staff will utilize a training form/spreadsheet to track all trainings for new employees.

·How often will the area needing correction be evaluated and who is assigned to evaluating the changes? The Business Office Manager will monitor weekly.

·Who on your staff will be responsible to see that all the corrections are completed and monitored? The Executive Director will ensure that the spreadsheet is updated and BOM is ensuring trainings are completed.     

Based on interview and record review, it was determined the facility failed to ensure 3 of 4 sampled newly hired staff (#s 11, 12 and 13) completed all required pre-service training. This is a repeat citation. Findings include, but are not limited to:

Staff training records, reviewed on 01/04/23, revealed the following:

a. Staff 11 (CG) was hired 11/02/22. There was no documented evidence she completed the following elements of the required pre-service orientation prior to performing any job duties:

* Resident rights and values of CBC care; and

* Infectious Disease Prevention.

b. Staff 12 (CG) was hired 12/09/22. There was no documented evidence he completed the following elements of the required pre-service orientation prior to performing any job duties:

* Resident rights and values of CBC care.

c. Staff 13 (CG) was hired 10/12/22. There was no documented evidence she completed the following elements of the required pre-service orientation prior to performing any job duties:

* Resident rights and values of CBC care; and

* Infectious Disease Prevention.

The need to ensure staff completed all required pre-service training was discussed with Staff 1 (Executive Director) on 01/04/23 at 5:30 pm. She acknowledged the findings. No further information was provided.

What actions will be taken to correct the rule violation? Resident Rights in CBC and Infectious Disease trainings done for all staff

· How will the system be corrected so this violation will not happen again? Resident Rights in CBC and Infection Disease pre-service course listed on the requirements for each new staff member. New staff will not be permitted to work the floor until all pre-service trainings are complete. Training Completion Spreadsheet will be reviewed prior to scheduling any new staff.

· How often will the area needing correction be evaluated and who is responsible for the evaluation? RCC will review the staff training spreadsheet prior to scheduling any new staff. The BOM will enter dates of training completion into the spreadsheet.

· Who on your staff will be responsible to see that all corrections are completed/monitored? The Executive Director and the VP of Management Services and/or COO.

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 262, C 270, C 280, C 302 and C 340.

Refer to C 252, C 260, C 262, C 270, C 280, C 302, &

C 340

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 C243, C252, C260, C270, C280 and C295.

What actions will be taken to correct the rule violation? REFER to C243, C252, C260, C270, C280 and C295

· How will the system be corrected so this violation will not happen again? See above Tags

· How often will the area needing correction be evaluated and who is responsible for the evaluation? See above Tags

· Who on your staff will be responsible to see that all corrections are completed/monitored? The Executive Director and VP of Management Services and/or COO.