Print Inspection: IVJR

The findings of the re-licensure survey, conducted 10/09/23 through 10/11/23, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 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 10/11/23, conducted 01/29/24 through 01/30/24, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004.

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

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the second revisit to the re-licensure survey of 10/11/23, conducted on 04/17/24, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 Home and Community Based Services Regulations.

Based on observation and interview, it was determined the facility failed to ensure required postings were displayed, in a routinely accessible and conspicuous location to residents and visitors. Findings include, but are not limited to:

A tour of the facility conducted on 10/09/23 identified the following required postings were not in place:

* The name of the administrator or designee in charge; and

* A copy of the most recent re-licensure survey, including all revisits and plans of correction.

The need to ensure all required postings were in an accessible and conspicuous location for the public was discussed with Staff 1 (ED). She acknowledged the findings.

1.  The name of the administrator or designee in charge was updated. Survey and POC is posted.

2. All other postings were reviewed for accruacy by the ED.

3. ED was educated on required postings in community-based care.

4. Will be evaluated by the executive director or designee and results reported to the quality assurance committee quarterly for continued compliance.

Based on interview and record review, it was determined the facility failed to ensure incidents and injuries of unknown origin were promptly investigated to rule out abuse and neglect, and failed to report incidents of abuse for 2 of of 2 sampled resident (#s 1 and 2) whose incidents were reviewed. Findings include, but are not limited to:

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

Review of the resident's progress notes and incident investigations from 07/13/23 through 10/07/23 identified the following incidents:

* 07/13/23 -  "[Resident 1] kept grabbing, & following [female resident] all day. [Female resident] told [him/her] not to do that type of stuff, but [s/he] wouldn't listen."

* 07/28/23 - "...resident seems to be touchy with other female residents

reminded resident that some of the girls may be uncomfortable with [him/her] touching them..."

* 09/14/23 -  "[Resident 2] was walking back to the dining room and told [Resident 1] that was [his/her] w/c... [Resident 2] said it was [his/hers] and grabbed [Resident 1's] arm and started to hit [him/her]. [Resident 1] tried to slap [him/her] back. Separated the [residents], texted [RN] and [Administrator]."

* 09/17/23 -  "[Resident 1] kissed a female resident without her permission. We stopped [him/her] and separated them."

* 09/19/23 - "[Resident 1] was pestering a female resident and almost had her falling a couple of times. The caregiver put the female resident to bed to keep her safe from falling."

There was no evidence the five incidents were immediately reported to the local SPD office.

The need to immediately report any incident of abuse and neglect to the local SPD office as required was discussed with Staff 1 (ED). She acknowledged the findings and reported the incidents to the local SPD. Confirmation of the reporting was received.

2. Resident 2 was admitted to the facility in 08/2022 with diagnoses including dementia and was evaluated to be at risk for falls.

Resident 2's service plan included interventions to reduce falls.

Resident 2 was identified to require assistance with toileting and transfers.

Review of the resident's progress notes and incident investigations from 07/10/23 through 10/07/23 identified the following incidents:

* Fifteen unwitnessed falls on 07/14/23, 07/16/23, 07/18/23, 08/03/23, twice on 08/23/23, 08/25/23, twice on 09/14/23, twice on 09/18/23, twice on 09/26/23, 10/02/23, and twice on 10/05/23.

Resident 2 obtained skin tears, bruises, abrasions, and subdural hematomas as a result of the falls.

* 07/17/23  -"[Resident 2] was bumping another residents w/c and wouldn't quit even when the resident told [him/her] to stop. I interfered and pulled [Resident 2] out of the way from the resident."

* 08/24/23 - skin tear identified on left wrist after found wandering into other resident rooms.

* 09/14/23 -  "[Resident 2] was walking back to the dining room and told [Resident 1] that was [his/her] w/c... [Resident 2] said it was [his/hers] and grabbed [Resident 1's] arm and started to hit [him/her]. [Resident 1] tried to slap [him/her] back. Separated the [residents], texted [RN] and [Administrator]."

There was no evidence the injuries of unknown origin were investigated to rule out possible abuse or neglect nor evidence the incidents were immediately reported to the local SPD.  There was no documented evidence the resident to resident altercations were immediately reported to the local SPD.

The need to investigate incidents to rule out the possibility of abuse or neglect and to immediately report any incident of abuse and neglect to the local SPD office as required was discussed with Staff 1 (ED). She acknowledged the findings and reported the incidents to the local SPD. Confirmation of the reporting was received.

1. Incidents have been reported to the local SPD office.

2. All staff will be in-serviced on Abuse.

3. Incident reports will be reviewed daily on weekdays by the facility leadership team to identify and ensure reporting ongoing.

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

During the re-licensure survey 10/09/23 through 10/11/23, there was a lack of scheduled and unscheduled activities provided for residents living in the facility.

An activity calendar was provided for the community campus, including the ALF and Nursing facility, and noted scheduled activities for each day of the week.   

Coffee and Men's Club at 10:00 am on Mondays was the only activity routinely scheduled in the Memory Care Unit and was observed on 10/09/23.

On 10/10/23, one Memory Care resident participated in a bean bag toss game.

No other scheduled or unscheduled activities were provided or observed during the survey.

Residents were observed sleeping in their rooms, wandering the halls, or sitting in front of the TV in the common living room area through the days of the survey.

The lack of an activity program was discussed with Staff 1 (ED). She acknowledged the findings.

1.  Will provide education for activity director on memory care activities and calendar planning. Will educate care staff on engaging activites to meet the needs of residents based on their physical, psychosocial and mental needs.

2. Will update activity calendar to provide more variety and frequency of resident-centered activites.

3. Activity calendar will be reviewed by administrator monthly and provided to quality council quarterly for feedback.

Based on observation, interview, and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (#3) and failed to ensure quarterly evaluations were accurate and used as the foundation to develop service plans for 2 of 2 sampled residents (#s 1 and 2) whose evaluations were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 12/2022 with diagnoses including dementia and insulin dependent diabetes.

Resident 1 was observed to independently mobilize with the use of a wheelchair.

In interviews with caregiving staff, Resident 1 was identified as being inappropriate with female residents, intrusive into other resident rooms, requiring assistance with showers, and would refuse cares.

Resident 1's most recent quarterly evaluation, completed 07/31/23, was not reflective of:

* Assistance with bathing;

* Resisting care; and

* Behaviors towards others.

The need to ensure resident evaluations accurately reflected care needs to develop the service plan was discussed with Staff 1 (ED) on 10/10/23. She acknowledged the findings.

2. Resident 2 was admitted to the facility in 08/2022 with diagnoses including dementia, edema with ulcers, and insulin dependent diabetes.

Resident 2 was observed to independently mobilize with the use of a wheelchair.

In interviews with caregiving staff, Resident 2 was identified as requiring assistance with all care needs, having altercations with other residents, frequent falls, weeping edema currently with open areas, and to have pain.

In progress notes it was noted Resident 2 had urinated in front of the closet.

Resident 2's most recent quarterly evaluation, completed 08/04/23, was not reflective of:

* The use of hearing aids;

* Inappropriate toileting;

* Behaviors;

* Frequent falls;

* Skin issues; and

* Pain.  

The need to ensure resident evaluations accurately reflected care needs to develop the service plan was discussed with Staff 1 (ED) on 10/10/23. She acknowledged the findings.

3. Resident 3 was admitted to the facility in 07/2023 with diagnoses including dementia.

Resident 3's initial evaluation did not address:

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

*Interests, hobbies, social, leisure activities.

*Spiritual, cultural preferences & traditions.

*Personality: including how the person copes with change or challenging situations.

The need to ensure initial evaluations addressed all of the required components was discussed with Staff 1 (ED), Staff 4 (Regional RN) and Staff 5 (Regional Director of Operations) on 10/11/23. No further information was provided.

1. New quarterly evaluation will be completed for residents

#1, #2, and #3.

2. Evaluation tool will be modified to ensure it includes all required components.

3. Random audits of move-in and quarterly evaluations will be conducted monthly by the administrator or desginee to ensure continued compliance.

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

1.  Resident 1 was admitted to the facility in 12/2022 with diagnoses including dementia.

Resident 1 was observed to independently mobilize with the use of a wheelchair.

In interviews with caregiving staff, Resident 1 was identified as being inappropriate with female residents, intrusive into other resident rooms, requiring assistance with showers and would refuse care.

Resident 1's service plan, dated 08/07/23, was not reflective of the resident's current needs, was not followed and/or did not provide clear direction in the flowing areas:

* Use of glasses;

* Behaviors;

* Refusal of care; and

* Specific fall interventions.

On 10/10/23, the service plan was discussed with Staff 1 (ED). She acknowledged the service plan was not reflective of the resident's status, was not followed, and lacked clear caregiving instruction.

2. Resident 2 was admitted to the facility in 08/2022 with diagnoses including dementia and edema with ulcers.

Resident 2 was observed to independently mobilize with the use of a wheelchair with dressings to the left forearm and left lower leg.

In interviews with caregiving staff, Resident 2 was identified as requiring assistance with all care needs, having altercations with other residents, frequent falls, weeping edema currently with open areas, and to have pain.

In progress notes it was noted Resident 2 had urinated in front of the closet.

Resident 2's service plan, dated 08/07/23, was not reflective of the resident's current needs, was not followed, and/or did not provide clear direction in the flowing areas:

* Non-skid socks or tennis shoes at all times;

* Specific "mood problems";

* Specific behaviors;

* Instructions for skin care;

* Hearing aids; and

* Glasses.

On 10/10/23, the service plan was discussed with Staff 1 (ED). She acknowledged the service plan was not reflective of the resident's status, was not followed, and lacked clear caregiving instruction.

1. Residents #1 and #2 will have service plans reviewed and updated with Interim Service Plans completed as necessary.

2. Initial and quarterly evaluation tool will be updated to prompt updates to the service plan.  Facility leadership team will be educated on the completion of service plans.

3. Random audits of service plans will be conducted by the administrator or designee to ensure continued compliance.

Based on observation, interview, and record review, it was determined the facility failed to ensure short-term changes of condition had specific actions or interventions identified and communicated to staff on each shift, and the condition monitored with weekly progress noted until resolved for 2 of 2 sampled residents (#s 1 and 2) who experienced short-term changes of condition. The facility failed to determine and monitor service-planned interventions for 1 of 1 sampled resident (#2) who had repeated falls. Resident 2 had on-going falls requiring emergency department visits and resulting in injuries. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 08/2022 with diagnoses including dementia and was evaluated to be at risk for falls.

Resident 2's service plan directed staff to ensure the resident was wearing non-skid socks or tennis shoes, provide safety checks, monitor location in facility, assist with toileting, assist with hearing aids and glasses, and provide bathroom assistance before every meal.

Observations of the resident from 10/09/23 to 10/11/20 noted the resident used a wheelchair for mobility and required staff assistance with transfers and toileting.

a. The resident's progress notes and incident reports dated 07/10/23 through 10/10/23 indicated the following:

* 07/14/23 6:09 pm - Care Staff found resident on floor with a "...goose egg on [his/her] forehead..." Resident 2 was sent to the emergency department.

* 07/16/23 5:00 pm - Care Staff found resident on the floor with "...two skin tears..." Resident 2 was sent to the emergency department.

* 07/18/23 1:36 pm - Care Staff found resident on the floor surrounded by two other residents. Resident 2 stated s/he hit the back of his/her head.

* 08/03/23 1:57 am - Care Staff found resident on the floor with "...skin tear on right elbow...bruise on right knee..."] Resident 2 was sent to the emergency department and found to have a subdural hematoma (bleeding in the brain caused by traumatic injury).

* 08/23/23 5:40 am - Care Staff found resident on the floor and not responding verbally, indicating pain to the head and buttock. Resident 2 was sent to the emergency department.

* 08/23/23 9:52 PM - Care Staff found resident on the floor "...hit head...complaining about head hurting..." Resident 2 was sent to the emergency department.

* 08/25/26 9:41 am - Care Staff found resident on the floor and was assisted up, with legs giving out and falling again. Resident reported s/he hit his/her head.

* 09/11/23 4:39 am - Care Staff found resident on the floor with a scrape to the left knee and skin tear below left elbow.

* 09/14/23 1:15 am -  Care Staff found resident on the floor "...said hit head and it was hurting..." Resident 2 was sent to the emergency department.

* 09/18/23 12:45 pm- Care Staff found resident on the floor "...hit head hard on doorframe ...bump on head..."

* 09/26/23 10:50 am- Care Staff found resident on the floor. Resident 2 was sent to the emergency department and found to have a subdural hematoma.

* 09/26/23 8:00 pm - Care Staff found resident on the floor.

* 10/02/23 4:00 am- Care Staff found resident on the floor with left hip pain.

* 10/05/23 1:00 pm - Care Staff found resident on the floor.

* 10/06/23 11:00 pm - Care Staff found resident on the floor. Resident 2 was sent to the emergency department.

* 10/10/23 1:30 am - Care Staff found resident on the floor complaining of pain in neck, shoulder, and head. Resident 2 was sent to the emergency department.

The resident experienced 15 falls between 07/10/23 through 10/6/23, had multiple emergency department visits due to the falls, and physical injuries including subdural hematoma's, head injuries, skin tears, bruising, and pain.

The facility failed to thoroughly review each incident to determine if the resident's specific fall interventions and service plan directions were implemented and effective.

Actions and interventions were noted in progress notes. There was no documented evidence they were communicated to staff on all shifts and monitored for effectiveness. This placed Resident 2 at further risk of repeated serious injury.

b. Resident 2's progress notes and incident reports dated 07/10/23 through 10/06/23 indicated the following:

* 07/12/023 - Cut from soda can.

* 07/14/23 - Head injury from fall.

* 07/16/23 - Skin tears from fall.

* 08/03/23 - Head injury from fall.

* 08/23/23  - Head injury from fall.

* 08/24/23 - Skin tear on left wrist when found wandering in other resident apartments.

* 09/11/23 -  Scrape to the left knee and skin tear below left elbow.

* 09/18/23 - Bump on head from fall.

* 09/18/23 - Redness on knees from crawling.

* 09/26/23 - Redness and blistering to inner thigh.

* 09/26/23 - Head injury from fall.

There was no documented evidence the resident's short-term changes of condition were consistently monitored and progress documented weekly until resolved.

The need to ensure resident-specific actions or interventions were developed, communicated to all staff, and monitored until resolved was discussed with Staff 1 (ED) and Staff 3 (LPN) on 10/10/23 and 10/11/23. They acknowledged the findings.

2. Resident 1 was admitted to the facility in 12/2022 with diagnoses including dementia.

Resident 1 was observed to independently mobilize with the use of a wheelchair.

Care Staff reported Resident 1 was "handsey with the ladies" and had been in altercations with other residents.

The resident's progress notes and incident reports dated 07/13/23 through 10/07/23 indicated the following changes in condition or behavior:

* 07/13/23, 07/28/23, 09/17/23, and 09/19/23  - Resident 2 inappropriate with female residents.

* 07/19/23 and 09/04/23 - Altercations with another resident.

* 08/05/23 - Medication error.

* 09/11/23 - Emergency room visit after fall with possible head injury.

*09/28/23 - Two vaccinations.

There was no documented evidence the resident's short-term changes of condition and behavior were consistently monitored and progress documented weekly until resolved.

The need to ensure resident-specific actions or interventions were developed, communicated to all staff, and monitored until resolved was discussed with Staff 1 (ED) on 10/10/23 and 10/11/23. She acknowledged the findings.

1. Resident #1 and #2's service plan has been updated.  Actions and interventions for resident #2's falls will be communicated to staff on all shifts.

2. Residents experiencing a short-term change of condition will be evaluated, actions and interventions identified communicated to staff through an Interim Service Plan, and monitoring in place. Residents experiencing a change of condition will have progress documented weekly until resolved.

3. Audits of change of conditions will be conducted weekly by the executive director or designee and results reported to the Quality Assurance Committee.

Based on interview and record review, it was determined the facility failed to maintain signed orders in the resident's facility record for all medications and treatments the facility was responsible to administer  for 1 of 2 sampled residents (# 2) whose physician orders were reviewed. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 08/2023 with diagnoses including dementia, edema, and insulin dependent diabetes.

Resident 2's 09/01/23 through 10/09/13 MARs and current physician's orders were reviewed.

Facility staff were administering:

* Levemir insulin 5 units at bedtime for diabetes;

* Pioglitazone 15 mg one daily for diabetes;

* Potassium Chloride 20 meq daily for supplement;

* Acetaminophen 325 mg 2 tablets three times daily for pain;

* Glucose 4 gm chew one as needed for blood sugar below 70; and

* Gvoke hypopen 0.2 ml as needed for blood sugar less than 50.  

There were no signed medication orders for the medications and treatments the facility was managing for Resident 2. Signed orders were requested on 10/09/23.

On 10/10/23 Staff 1 (ED) explained Resident 2's physician had retired and the facility was attempting to establish care with a new physician.

The need to ensure signed orders were maintained in the resident record was reviewed with Staff 1. She acknowledged the findings.

On 10/11/23 Staff 4 (Regional RN) contacted the pharmacy to obtain signed orders. Signed orders were provided on 10/12/23.

1. Resident #2's signed orders were located and provided to the surveyor on 10/12/23.

2. Current physician orders will be printed for physician review and signature quarterly for all residents.

3. Review of signed orders will be done by the executive director or designee and results reported to the Quality Assurance Committee quarterly.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 7, 13, and 14) completed the required pre-service infectious disease prevention training prior to beginning their job responsibilities. Findings include, but are not limited to:

Training records were requested on 10/9/23 and 10/10/23.

Staff 7 (MA), hired 08/03/23, Staff 13 and 4 (CGs), hired 06/26/23 and 08/21/23 respectively, lacked documented evidence of completing the required pre-service infectious disease prevention training.

The need to ensure all required pre-service training was completed prior to beginning their job responsibilities was reviewed with Staff 1 (ED) on 10/10/23. She acknowledged the findings.

1. Staff 7, 13, and 4 will complete the pre-service infectious disease prevention training.  

2. All other staff will be reviewed and requested to complete the pre-service infectious disease prevention training if needed.  

3. New hires will complete the pre-service infectious disease prevention training prior to beginning their job responsibilities.

4. Training records will be reviewed by the administrator or designee for each new hire prior to beginning job responsibilities ongoing.  The executive director or designee will conduct audits quarterly and report results to the Quality Assurance Committee to ensure continued compliance.

Based on interview and record review, it was determined the facility failed to ensure one of two newly hired staff (#17) completed the required pre-service infectious disease prevention training prior to beginning their job responsibilities. This is a repeat citation. Findings include, but are not limited to:

Training records were reviewed on 01/30/24.

Staff 17 (Activities), hired 12/29/23, lacked documented evidence of completing the required pre-service infectious disease prevention training.

The need to ensure all required pre-service training was completed prior to beginning their job responsibilities was reviewed with Staff 15 (Memory Care Administrator) on 01/30/24. She acknowledged the findings.

C370

1. Staff #17 is no longer employed by the facility.

2. All other staff will be reviewed and requested to complete preservice trainings as required.

3.All new hires will complete all pre-service trainings prior to working on the floor.

4.Training records will be reviewed by the administrator or designee for each new hire prior to beginning job responsibilities ongoing.  The executive director or designee will conduct audits quarterly and report results to the Quality Assurance Committee to ensure continued compliance.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 staff (#s 8 and 10) completed the required annual infectious disease prevention training. Findings include, but are not limited to:

Training records were requested on 10/9/23 and 10/10/23.

Staff 8 (MA), hired 02/10/10, and Staff 10 (CG), hired 08/08/22, lacked documented evidence of completing the required annual infectious disease prevention training.

The need for employees to complete annual training on infectious outbreaks and infection control was reviewed with Staff 1 (ED) on 10/10/23. She acknowledged the findings.

1. Staff #8 and Staff #10 will complete the annual infectious disease prevention training.  

2. All other staff will be reviewed for completion of annual infectious disease prevention training and will complete if needed.

3. The executive director or designee will conduct audits quarterly and report results to the Quality Assurance Committee  to ensure continued compliance.

Based on interview and record review, it was determined the facility failed to provide fire and life safety training at least every other month. Findings include, but are not limited to:

Fire and life safety records from 04/2023 to 10/2023 were reviewed with Staff 6 (Maintenance) on 10/10/23.

A life safety training was completed on 08/17/23. There was no other fire and life safety training documented as completed in the six month timeframe.

The need to provide fire and life safety training was reviewed with Staff 1 (ED) on 10/11/23. She acknowledged the findings.

1. Additional life safety training has been completed and documented.

2. Maintenance Director was educated on the requirement to provide life safety training.

3. Life safety trainings and fire drills will be reviewed by the administrator or designee each month and the Quality Assurance Committee quarterly.

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 370 and Z 155.

C455

1. See plan of correction for C370 and Z155

Based on observation and interview, it was determined the facility failed to ensure all exterior pathways were maintained in good repair. Findings include, but are not limited to:

The facility grounds were toured on 10/09/23. The secured courtyard was observed with drop-offs up to approximately eight inches from the sidewalk to the adjacent yard and planting beds which created tripping hazards.

The building exterior was toured with Staff 1 (ED) and Staff 6 (Maintenance) on 10/10/23 and 10/11/23. They acknowledged the findings.

1. Will seek and obtain quotes to add material to courtyard to address drop offs.

2. Maintenance director will audit courtyard monthly for any drop offs or tripping hazards and report findings to the administrator.

Based on observation and interview, it was determined the facility failed to provide a one way flow of soiled items from the soiled area to the clean area in order to preclude the potential for contamination of clean linens and clothing. Findings include, but are not limited to:

During a tour of the facility with Staff 6 (Maintenance), observation of the hopper room, designed to be used for processing soiled laundry, identified there was not a one way flow of soiled items. The entry door to the soiled processing area was blocked and the hopper was not accessible for use.

The need to ensure the one way flow of soiled laundry was discussed with Staff 1 (ED) on 10/10/23. She acknowledged the findings.

1. Hopper room has been cleaned and entry door access cleared to ensure a one way flow of soiled laundry.

2. Staff have been educated on maintaining a clean hopper room with one way flow of soiled laundry.

3. Access and flow of hopper room will be monitored weekly by the administrator or designee to ensure ongoing compliance.

Based on observation and interview, it was determined the facility failed to ensure covers, grates, or screens of wall heaters and associated heating elements did not exceed 120 degrees Fahrenheit when installed in locations that were subject to incidental contact by individuals. Findings include, but are not limited to:

During a tour of the facility on 10/10/23 wall heaters were observed, with surface temperatures up to 157 degrees Fahrenheit, installed in resident unit bathrooms, where residents could potentially come into incidental contact.

Staff 1 (ED) and Staff 6 (Maintenance) were informed of the temperatures and acknowledged the need to ensure wall heater covers did not exceed 120 degrees Fahrenheit.

Staff 6 immediately began disconnecting the the wall heaters.

1. Wall heaters in resident bathrooms have been disconnected to ensure safety.

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

A tour of the facility on 10/09/23 and 10/10/23, revealed the following:

*The shared bathroom in the common area had water that when turned on, was hot to the touch. The hot water temperature, taken by the surveyor, was 123 degrees Fahrenheit;

*Various residents' bathroom sinks hot water was 123.5 degrees Fahrenheit;

*The surveyor and Staff 6 (Maintenance) measured water temperatures in the common bathroom with the facility thermometer. The temperature measured 123 degrees Fahrenheit.

Staff 6 immediately turned down the water temperature. The temperatures were within a range of 110 to 120 degrees Fahrenheit on 10/11/23.

On 10/10/23, the hot water temperatures were reviewed with Staff 1 (ED). No further information was provided.

1. Hot water temperatures have been reduced to ensure they remain within range of 110 to 120 degrees Farenheit.

2. Hot water temperatures are monitored by the maintenance director or designee monthly.

3. Audits of water temperature logs will be conducted by the administrator or designee monthly to ensure ongoing 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 152, C231, C 242, C 370, C 374, C 420 C 510, C 530, C 540 and C 545.

See plans of correction for C152, C231, C242, C370, C374, C420, C510, C530, C540 and C545.

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

Refer to C 370.

Z142

1. See plan of correction for C370

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 sampled newly-hired staff (#s 7, 13 and 14) had documentation of completed pre-service orientation, pre-service dementia training, and demonstrating competency in all required areas within 30 days of hire. The facility failed to ensure 2 of 2 sampled staff (#s 8 and 10) completed 16 hours of annual in-service training. Findings include, but are not limited to:

Staff training records were requested on 10/09/23 and 10/10/23.

1. Staff 7 (MA), hired 08/03/23, Staff 13 and 14 (CGs), hired 06/26/23 and 08/21/23 respectively, lacked documented evidence of completing required pre-service orientation and training prior to beginning job duties.

There was no documented evidence of Staff 7, 13, and 14 demonstrating competence in job duties within 30 days.  

The need to ensure Staff 7 demonstrated competence in medication pass before working independently was discussed with Staff 1 (ED). She acknowledged the requirement and agreed to ensure Staff 7 demonstrated medication pass competency before working independently.

2. Staff 8 (MA), hired 02/10/22, and Staff 10 (CG), hired 08/08/22, lacked evidence of 16 hours of annual in-service training.

The need to ensure staff completed all required pre-service orientation and training, competency demonstration, and annual training was discussed with Staff 1 on 10/10/23. She acknowledged the findings.

1. Staff 7, 13, and 14 will complete the pre-service orientation, pre-service dementia training, and competencies.  Staff #8 and 10 will complete 16 hours of annual in-service training.  

2. All other staff will be reviewed and requested to complete the pre-service infectious disease prevention training if needed.  

3. New hires will complete the pre-service infectious disease prevention training prior to beginning their job responsibilities.

4. Training records will be reviewed by the administrator or designee for each new hire prior to beginning job responsibilities ongoing.  The executive director will conduct audits quarterly and report results to the Quality Assurance Committee to ensure continued compliance.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 sampled newly-hired staff (#s 16 and 17) had documentation of completed pre-service orientation and pre-service dementia training. This is a repeat citation. Findings include, but are not limited to:

Staff training records were reviewed on 01/30/24.

1. Staff 16 (CG), hired 11/21/23, lacked documented evidence of completing required pre-service dementia training in:

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

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

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

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

2. Staff 17 (Activities), hired 12/19/23, lacked documented evidence of completing the required pre-service orientation and dementia training.

The need to ensure staff completed all required pre-service dementia training and orientation was reviewed with Staff 15 (Memory Care Administrator) on 01/30/24. She acknowledged the findings.

Z155

1. Staff #17 is no longer employed by the facility. Staff # 16 will complete the perservice dementia trainings. All new hires to sign documentation on restraints on hire.

2.All other staff will be reviewed and requested to complete the required preservice dementia trainings if needed.

3.New hires will complete the required dementia training prior to beinging their job responsibilities.

4.Training records will be reviewed by the administrator or designee for each new hire prior to beginning job responsibilities ongoing.  The executive director or designee will conduct audits quarterly and report results to the Quality Assurance Committee to ensure continued compliance.

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

Refer to C 252, C 260, C 270, and C 303.

See plans of correction for C252, C260, C270, and C303.

Based on observation, interview, and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan for each resident was developed and included in residents' service plans for 2 of 2 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to:

Residents 1 and 2's current service plans were reviewed during survey. Each of the service plans lacked information and staff instructions related to individualized nutrition and hydration status and needs.

The need to develop individualized service plans addressing residents' nutrition and hydration needs was discussed with Staff 1 (ED) on 10/10/23. She acknowledged the findings.

1. Service plans for residents #1 and 2 will be updated to include individualized nutrition and hydration needs.

2. All other resident service plans will be reviewed during their next quarterly service plan or change of condition to ensure they include nutrition and hydration needs.

3. Random audits of resident service plans will be reviewed quarterly by the executive director with results reported to the Quality Assurance Committee to ensure they include nutrition and hydration needs.

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

Resident 1 and 2's records were reviewed during the survey. There was no documented evidence an activity evaluation had been completed and the service plans individualized to reflect the following required components:

*Residents' current preferences;

*Abilities and skills;

*Emotional/social needs and patterns;

*Physical abilities and limitations;

*Adaptations necessary for the resident to participate; and

*Identification of activities for behavioral interventions.

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

The need to evaluate and develop individualized activity plans, including all required components for each memory care resident, was discussed with Staff 1 (ED) on 10/10/23. She acknowledged the findings.

1. Residents #1 and 2 will have their service plans updated to include individualized activity plans.

2. All other residents will have their service plans reviewed during their next quarterly evaluation or change of condition and updated to include their individualized activity plans.

3. Random audits of resident service plans will be conducted by the executive director or designee and reviewed quarterly by the Quality Assurance Committee to ensure they include nutrition and hydration needs.

Based on interview and record review, it was determined the facility failed to provide an individualized service plan for behavioral symptoms that negatively impacted the resident or others in the community for 2 of 2 sampled residents (#s 1 and 2) with documented behaviors. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 12/2022 with diagnoses including dementia.

Resident 1's record documented behaviors including refusal of care, aggression and sexually inappropriate behaviors towards other residents including hitting and grabbing.

The resident's service plan, dated 08/07/23, did not address the behaviors and lacked individualized interventions to assist staff in minimizing the negative impact of the behaviors.  

2. Resident 2 was admitted to the facility in 08/2022 with diagnoses including dementia.

Resident 2's record documented behaviors including anxiety, exit seeking, yelling, hitting staff and aggression, towards other residents including hitting and grabbing.

The resident's service plan, dated 08/07/23, did not address the behaviors and lacked individualized interventions to assist staff in minimizing the negative impact of the behaviors.

On 10/10/23 the need to develop individualized behavior plans for residents with behavioral symptoms was discussed with Staff 1 (ED). She acknowledged the findings.

1. Resident #1 and 2's service plans have been updated to address their behaviors and include individualized interventions.

2. All other service plans will be reviewed during their next quarterly evaluation or change of condition to ensure they include a description of any resident behaviors and individualized interventions.

3.Random audits of resident service plans will be conducted by the executive director or designee and reviewed quarterly by the Quality Assurance Committee to ensure they include nutrition and hydration needs.

Based on observation and interview, it was determined the facility failed to individually identify residents' rooms to assist residents in recognizing their room. Findings include, but are not limited to:

The facility was toured on 10/09/23 and 10/10/23. Occupied resident rooms  3, 4, 6, 8, 9, 11, and 12 lacked any individually specific means of identifying the room for the residents. Shadow boxes outside each room were empty.

The need to ensure each resident room was identified to assist the resident in identifying their room was reviewed with Staff 1 (ED) on 10/10/23. She acknowledged the findings.

1. Resident rooms 3, 4, 6, 8, 9, 11, and 12 will have their shadow boxes and/or other area outside their room updated to include information to assist with room identification.

2. All other rooms will be reviewed to ensure they have updated shadow boxes and/or other area outside their room for room identification.

3. Administrator or designee will audit monthly ongoing for continued compliance.