Print Inspection: OYM3

The findings of the re-licensure survey, conducted 07/29/24 through 08/01/24, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 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. Tag numbers beginning with the letter H refer to the Home and Community Based Services rules.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first re-visit to the re-licensure survey of 08/01/24, conducted 12/02/24 through 12/03/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.

Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter H refer to the Home and Community Based Services rules.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the second re-visit to the re-licensure survey of 08/01/24, conducted on 06/26/25 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 for Home and Community Based Services Regulations.

Based on observation, interview, and record review, it was determined the facility failed to ensure the service plan was reflective of resident's needs, was readily available to staff, and provided clear direction regarding the delivery of services for 1 of 1 sampled resident (#3) who had a history of elopement. Findings include, but are not limited to:

Resident 3 moved into the facility in 06/2024 with diagnoses including dementia, and was identified during the acuity interview as having recently eloped.

The resident's current service plan dated 07/07/24, temporary service plans (TSPs) dated 06/28/24 to 07/29/24, and progress notes dated 06/28/24 to 07/29/24 were reviewed, interviews with staff were conducted, and observations of the resident were made. The following was identified:

a. The resident's service plan and TSPs were not reflective and/or did not provide clear direction to staff regarding the resident's elopement behaviors. During an interview at 2:18 pm on 08/01/24, Staff 14 (Resident Care Assistant) stated Resident 3 would often wear a badge and carry papers around to "look official," and would attempt to convince visitors to the MCC that s/he was not a resident. During an interview at 2:05 pm on 08/01/24 Staff 18 (Resident Care Assistant) stated the resident would approach visitors and ask to be let out, telling them s/he forgot his/her key. This information was not in the resident's current service plan or TSPs.

b. Review of the record revealed TSPs were typically located in the "Memory Care TSPs" binder, available in the staff break room. Two TSPs both dated 06/28/24 with instructions to staff regarding the resident's elopement that same day were located in the resident's hard chart in the locked medication room. The instructions were not on the resident's current service plan available to staff. During an interview at 2:15 pm on 08/01/24, Staff 12 stated, "We are supposed to redirect [him/her] but I haven't been given specific instructions what to do when [s/he] is looking like [s/he] wants to leave."

An updated TSP regarding Resident 3's elopement behaviors with clear directions to staff was requested and received by the survey team at 4:00 pm on 08/01/24.

The need to ensure service plans were reflective of resident's needs, made readily available to staff, and provided clear direction regarding the delivery of services was discussed with Staff 1 (Memory Care Director), Staff 2 (ED), Staff 3 (Health and Wellness Director), Staff 15 (LPN), and Staff 16 (Assisted Living Coordinator)on 08/01/24. They acknowledged the findings.

New TSP was placed for Resident 3 with more details on elopement behaviors. It will be added to the service plan at the next quarterly update. Care staff have been retrained to read and sign TSPs.

On going training will occur from the Clinical team to ensure care staff are reading and signing the TSPs. The Health and Wellness Director will input all relevant TSPs to the service plan at each update (quarterly and as needed).

Memory Care Director will check each service plan update to ensure that the relevant TSPs have been entered.

Administrator will be responsible that the items above are completed and documented timely.

2. Resident 2 was admitted to the facility in 06/2024 with unspecified dementia and type 2 diabetes. Review of the current service plan, dated 07/28/24, indicated s/he was dependent on staff for toileting and incontinent care and required two person assist for transfers.

During an ADL observation on 07/29/24 at 11:18 am the following was observed:

*Two caregiving staff provided two person assist to help Resident 2 sit up in bed and transfer into the wheelchair. Once out of the bed, Staff 7 (Resident Care Assistant) removed the soiled disposable pad from the bed and placed it on the bathroom floor next to the trash can;

* Resident 2 was escorted to the bathroom and both staff assisted the resident transfer to the toilet, lowered his/her soiled briefs and pants, and assisted the resident onto the toilet. The soiled brief was placed on the floor on top of the soiled pad;

* With the same gloved hands, Staff  19 (Resident Care Assistant) donned a clean brief and pants, picked up the pile of dirty clothes and placed them in the hamper, lifted up a blanket on his/her bed, retrieved slippers, returned to the bathroom and put the slippers on the resident's feet. Staff 19 bagged up the soiled briefs and pad, removed her gloves and donned a new pair of single use gloves with no hand hygiene prior;

* Staff 7, wearing the same single use gloves, removed the resident's shirt and assisted the resident into a clean shirt;

* Resident 2 was assisted to stand by both staff and Staff 7 provided perineal care that included using wipes. Both staff pulled up the resident's briefs and pants, adjusted his/her shirt and gait belt, and assisted the resident transfer into the wheelchair. With the same soiled gloves, Staff 7 then touched the push handles of the wheelchair to move the resident closer to the sink, ran her fingers through the resident's hair, picked up a comb and combed his/her hair.

* After the resident washed his/her hands, Staff 7 removed her gloves, donned new gloves with no hand hygiene prior, pushed the resident out of the bathroom and into the hallway while a third staff arrived to escort Resident 2 to lunch.

The need to maintain effective infection prevention and control while providing ADL care was reviewed with Staff 1 (Memory Care Director), Staff 2 (ED), Staff 3 (Health and Wellness Director), Staff 15 (LPN), and Staff 16 (Assisted Living Coordinator) on 08/01/24 at 12:15 pm. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to maintain infection prevention and control protocols to provide a safe, sanitary, and comfortable environment for 2 of 2 sampled residents (#s 1 and 2) and multiple unsampled residents dependent on staff for care needs and meal service. Findings include, but are not limited to:

1a. Resident 1 was admitted to the facility in 04/2022 with diagnoses including Alzheimer's disease. Review of the resident's current service plan dated 07/10/24 indicated s/he was dependent on staff for toileting and incontinence care.

At 12:30 pm on 07/29/24, Staff 9 (Resident Care Assistant) was observed providing toileting assistance for Resident 1. Staff 9 escorted the resident to his/her bathroom wearing the same single use gloves from lunch service. Staff 9 assisted Resident 1 with pulling pants and briefs down wearing the single use gloves from lunch service. She then provided pericare and assisted Resident 1 in pulling his/her briefs and pants up without disposing of single use gloves and performing hand hygiene between dirty and clean tasks.

1b. General observations were conducted in the MCC from 07/29/24 to 08/01/24. The following was identified:

* Multiple care staff were observed entering and exiting unsampled residents' rooms, donning and doffing single use gloves without performing hand hygiene prior to and before assisting residents with ADLs, touching their devices, and touching other surfaces in the community.

* Staff 8 was observed exiting an unsampled resident's room with incontinent trash on 07/31/24 at 10:32 am. He was observed to touch another resident's wheelchair handlebar while holding the incontinent trash. He proceeded to another unsampled resident's room and placed the incontinent trash on the resident's floor. He then assisted the unsampled resident to his/her bathroom to provide toileting assistance without first performing hand hygiene.

1c. Observations of meal service were conducted from 07/29/24 to 07/30/24. Caregiving staff were observed serving food and feeding residents without wearing a protective covering over potentially contaminated clothing.

The need to maintain effective infection prevention and control protocols was discussed with Staff 1 (Memory Care Director), Staff 2 (ED), Staff 3 (Health and Wellness Director), Staff 15 (LPN), and Staff 16 (Assisted Living Coordinator) on 08/01/24. They acknowledged the findings.

Aprons have been purchased for clothing protection during meal service. Staff have been educated to utilize these at each meal. All staff will be retrained during monthly all staff meeting by the Health and Wellness Director on when to wash hands/change gloves during perineal care/care in the bathroom.

Ongoing training and observation by supervisory team members will occur to insure compliance and appropriate Infection Control measures ongoing.

Memory Care Director will observe bathroom cares monthly to ensure compliance. Memory Care Director to ensure there are aprons for meals.

Health and Wellness Director will be responsible for scheduling/conducting training. Memory Care Director to supervise monthly audits.

Based on interview and record review, it was determined the facility failed to ensure PRN psychotropic medications were administered only after documented, nonpharmacological interventions were tried with ineffective results for 1 of 1 sampled resident (#1) who had an order for PRN psychotropic medications. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 04/2022 with diagnoses including Alzheimer's disease.

The resident's 07/01/24 to 07/29/24 MAR and progress notes and current physician orders were reviewed. The following was identified:

The resident had an order for lorazepam, administer one tablet by mouth every four hours as needed for anxiety. The MAR indicated staff administered the PRN medication on six occasions from 07/01/24 to 07/29/24. There was no documented evidence staff attempted non-drug interventions with ineffective results prior to administering the medication.

The need to ensure documentation that staff administered PRN psychotropic medications only after attempting nonpharmacological interventions with ineffective results was discussed with Staff 1 (Memory Care Director), Staff 2 (ED), Staff 3 (Health and Wellness Director), Staff 15 (LPN), and Staff 16 (Assisted Living Coordinator). They acknowledged the findings.

Before giving a psychotropic medication as PRN, the Med Tech will document that they have tried all listed nonpharmacological interventions.

Med Techs will be re-trained during a Med Tech meeting to ensure they are aware of where to document that the nonpharmacological interventions were completed.

The Health and Wellness Director will evaluate this quarterly.

Licensed Nursing staff, led by Health and Wellness Director will work to ensure compliance.

Based on observation, interview, and record review, it was determined the facility failed to have a sufficient number of direct care staff to meet the 24-hour scheduled and unscheduled needs of each resident and to meet the fire safety evacuation standards during the night shift. Findings include, but are not limited to the following:

The facility was licensed as a Residential Care Facility (RCF) with a capacity of 30 beds.

a. On 07/29/24 during the entrance conference, survey requested a facility staffing policy or a tool to determine number of caregiving staff needed to provide scheduled and unscheduled residents' care needs. Staff 1 (Memory Care Director) stated the facility used the service plan points generated to determine staffing levels, and provided a key that corresponded with the points assigned for care tasks. The facility acuity-based staffing tool (ABST) was reviewed during the survey.

b. During the acuity interview on 07/29/24 with Staff 1 (Memory Care Director) and Staff 3 (Health and Wellness Director), the following care needs were identified:

* The facility had a census of 23 residents;

* Five residents required two-person assistance for transfers, including three who required the use of a mechanical lift;

* Four residents required cueing/redirection during meals and/or one-on-one assistance with feeding; and

* Ten residents were reported to require high levels of caregiving assistance due to hospice, exit-seeking/wandering, need for frequent safety checks, and/or due to fall risk.

c. The facility ABST did not generate the minutes needed for staff to provide care in all 22 ADL areas, and did not capture all 22 ADLs for facility residents. Therefore, the tool could not be used to determine an appropriate staffing plan.

d. The staffing plan provided by the facility on 07/30/24 was as follows:

* Day shift - Three resident care assistants and one MT;

* Evening shift - Three resident care assistants and one MT; and

* Night shift - Two resident care assistants and one MT.

e. Observations and interviews conducted from 07/29/24 to 08/01/24 revealed the following:

*Four residents were provided with one-on-one meal assistance for breakfast, lunch, and dinner;

*Resident 1 and multiple unsampled residents needed redirection from staff to stay seated to eat meals;

* Multiple non-direct care staff, including Staff 1, Staff 2 (ED), Staff 3, Staff 15 (Licensed Practical Nurse) and Staff 17 (Assistant Sales Director) were observed providing meal assistance, serving food/beverages, and escorting residents to and from meals;

* A total of nine direct care and non-direct care staff were observed serving residents and/or providing care during meals;

* Resident 1 and an unsampled resident, both identified as at high risk for falls, were observed unsupervised while walking around the unit and/or pushing furniture for up to 25 minutes. They were both observed to leave their walkers behind while walking; and

* Resident 3 was observed to elope from the locked unit into the lobby twice.

* During an interview on 07/30/24 at 1:00 pm, Staff 1 indicated the facility had identified the need to add seven additional hours per day to the staffing plan. She confirmed there was no current plan in place to fill the hours.

* During an interview at 3:28 pm on 08/01/24, Staff 13 (MT) stated when the MCC was short-staffed due to staff calling out for their shift, Staff 16 (Assisted Living Coordinator) was supposed to cover the shift, "but that only happens when we're down to one caregiver." Staff 13 further stated that residents often didn't receive showers or other care when staff called out for their shift.

* During an interview at 9:34 am on 07/31/24, Staff 7 (Resident Care Assistant) stated weekend day shifts were short staffed due to not having a server for meals, so direct care staff had to serve in addition to providing escorts, one-on-one meal assistance, and redirection.

* During an interview on 07/30/24 Staff 11 (Maintenance Director) reported the facility was not relocating residents during fire drills. He further indicated facility procedure during fire drills was to use staff from the separately licensed assisted living facility as part of the fire drill plan.

The facility lacked a sufficient number of direct care staff to meet the scheduled and unscheduled needs and fire evacuation standards of the multiple residents who required the assistance of two care staff for transfers and had high levels of care needs.

A plan of correction to address the insufficient staffing was requested from Staff 1 and Staff 2 at 1:26 pm on 07/31/24, and was received by the survey team at 3:09 pm on 07/31/24.

The need to have a sufficient number of staff to meet all scheduled and unscheduled needs of residents for all shifts was discussed on 08/01/24 with Staff 1, Staff 2, Staff 3, Staff 15 (LPN) and Staff 16 (Assisted Living Coordinator). They acknowledged the findings

On 7/31/24 during survey, a third caregiver for NOC shift was added to the schedule, as well as an extra carestaff during day shift and a half shift for swing. A server is also being hired to ensure that every meal in Memory Care has a server present.

The ODHS ABST will be utilized from now on to ensure appropriate staffing.

Review of labor will occur at each service plan update by Administrator, Health and Wellness Director, and Resident Care Coordinator.

Review and completion will be ongoing by Administrator or designee.

Based on interview and record review, it was determined the facility failed to ensure implementation of an acuity-based staffing tool (ABST) that included all required ADLs and the amount of staff time needed to provide care. Findings include, but are not limited to:

On 07/30/24 at 1:00 pm, the facility's ABST was reviewed and discussed with Staff 1 (Memory Care Director) and Staff 2 (ED). Staff 1 and 2 confirmed they used a proprietary ABST using a point system and the ABST was driven by the service plan for each resident.

Review of the facility ABST tool revealed there was no documented evidence all 22 of the required ADLs were individually addressed for each resident, nor was the amount of staff time needed for each of the 22 ADL elements.

On 08/01/24 at 12:15 pm, the need to ensure the facility used an ABST which met the regulation was discussed with Staff 1 and Staff 2. They acknowledged the findings.

The community will be utilizing the ODHS ABST tool in place of their previous tool to ensure all 22 ADLs are individually addressed for each resident and the amount of staff time needed for each ADL.

The service planning team, specifically the Health and Wellness Director, will update the ODHS ABST at each service plan update (quarterly and as needed for any change of condition and for the resident prior to move in when we enter their service plan for our team. It will also be reassessed at 30 days when we administer the service plan as well with any changes.

The ABST will be updated at each service plan update.

Administrator or desginee will be responsible for accuracy ongoing.  

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted in accordance with Oregon Fire Code (OFC). Findings include, but are not limited to:

Review of fire drill records for February 2024 through July 2024 identified the following:

* The facility lacked documented evidence that fire drills were done every other month after April 2024. No further documented evidence was provided upon request; and

* The facility had not documented residents being relocated or evacuated during fire drills, therefore there was no documentation of the problems encountered, evacuation time-period needed, number of occupants evacuated and comments relating to residents who resisted or failed to participate in the drills.

The need to ensure the facility conducted fire drills per the OFC was reviewed with Staff 11 (Maintenance Director) on 07/30/24 and with Staff 1 (Memory Care Director) and Staff 2 (ED), Staff 3 (Health and Wellness Director), Staff 15 (LPN) and Staff 16 (Assisted Living Coordinator) on 08/01/24 at 12:15 pm. They acknowledged the findings.

One fire drill per shift will be conducted and documented. Each drill will rotate which shift is is completed on. Additionally, all planned fire drills are to be communicated to the Memory Care Director to ensure compliance. Each fire drill conducted will involve evacuating or relocating residents. Assisted Living staff and Memory Care staff will only be used for their designated sections for fire drills.

Monthly review of Life Safety requirements, specifically Fire Drills, to be conducted and documented by Maintenance Director.

Fire drills will be conducted effective immediately and every other month following with documentation of any problems that occurred, evacuation time period, number of occupants that were evacuated and any comments relating to any resident that resisted or failed to participate in the drills.

Administrator will be responsible for oversight of corrections and compliance ongoing.

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 H 1510.

The facility will review and comply with all regulations under OAR 411-054-0105.

The facility will continue to conduct audits for each apartment on a weekly basis.

The Memory Care Director will conduct weekly audits of the bathroom doors for each shared apartment to ensure we are in compliance.

The Memory Care Director, Maintenance Director and the Executive Director will work closely together to ensure we are in compliance.

Based on observation and interview, it was determined the facility failed to ensure privacy and dignity related to no locks on residents who had shared bathrooms and were not bedbound. Findings include, but are not limited to:

Observations of toileting and incontinence care on 07/29/24 and 07/30/24 revealed Residents 1 and 2 did not have a locking mechanism on their respective shared bathroom doors to ensure privacy.

During an interview on 07/30/24 at 1:00 pm, Staff 1 (Memory Care Director) and Staff 2 (ED) confirmed that residents who used the toilet in their shared bathrooms did not have locks that would ensure privacy and dignity. They revealed the majority of the residents had shared bathrooms.  

The inability to lock the door for residents who had shared bathrooms and used the bathroom for their toileting needs jeopardized residents' rights to privacy and dignity.

The observations were reviewed with Staff 1, Staff 2, Staff 3 (Health and Wellness Director),  Staff 15 (LPN) and Staff 16 (Assisted Living Coordinator) on 08/01/24 at 12:15 pm. No additional information was provided.

Maintenance Director to install a locking mechanism on the inside of shared bathroom doors to ensure privacy and dignity of the resident.

Memory Care Director will ensure that the locks are still in place and not broken. If broken, the Memory Care Director will contact the Maintenance Director to fix the lock.

Memory Care Director completes weekly room audits and will check the locks in each room once weekly.

The Maintenance Director and the Memory Care Director will work together to ensure the locks are placed, and functioning on the shared bathroom doors.

Based on observation and interview, it was determined the facility failed to ensure privacy and dignity related to no locks on bathroom doors for residents who had shared bathrooms and were not bedbound. This is a repeat citation. Findings include, but are not limited to:

Observations on 12/02/24 of shared bathrooms revealed there was no locking mechanisms on shared bathroom doors to ensure privacy.

During an interview on 12/02/24, Staff 11 (Maintenance Director) and Staff 2 (ED) confirmed that residents who used the toilet in their shared bathrooms did not have locks that would ensure privacy and dignity.

The inability to lock the door for residents who had shared bathrooms and used the bathroom for their toileting needs jeopardized residents' rights to privacy and dignity.

The observations were reviewed with Staff 2, Staff 3 (Health and Wellness Director), and Staff 20 (Memory Care Director) on 12/03/24. They acknowledged the findings.

Maintenance Director to install a locking mechanism on the inside of shred bathroom doors to ensure privacy and dignity of the resident. Maintenance Director is currently getting several bids for door locks.

Memory Care Director will ensure that the locks are still in place and not broken. If broken, the Memory Care Director will contact the Maintenance Director to fix the lock.

Memory Care Director completes weekly room audits and will check the locks in each room once weekly.

The Maintenance Director and the Memory Care Director will work together to ensure the locks are placed, and functioning on the shared bathrrom doors.

Based on observation and interview, it was determined the facility failed to ensure the individual and only appropriate staff had a key to access the unit for multiple sampled and unsampled residents. Findings include, but are not limited to:

During an interview on 07/30/24 at 1:15 pm, Staff 1 (Memory Care Director) and Staff 2 (ED) confirmed the majority of the residents did not have keys to their rooms.  

Review of Resident 2's evaluation revealed the resident was independent with the use of a key locking device. In an interview with Resident 2 on 07/30/24 at 2:00 pm, s/he indicated s/he did not think s/he had a key to lock his/her room.

The need to ensure the individual and only appropriate staff had a key to access their unit was discussed with Staff 1, Staff 2, Staff 3 (Health and Wellness Director), Staff 15 (LPN) and Staff 16 (Assisted Living Coordinator) on 08/01/24 at 12:15 pm. No additional information was provided.

The Memory Care Director will document and give each resident a key to their lockable unit. The key will be placed in each residents closet on the wall.

Upon move in for new residents, the Memory Care Director will offer a key to access to their lockable unit and document that it was given.

Documentation will be kept in the service plan. The service plan is reviewed and updated quarterly and as needed The key documentation will be reviewed during each service plan review and update.

The Memory Care Director and the service planning team will work together to ensure the correct documentation is in each service plan.

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 295, C 360, C 361 and C 420.  

See plans for C 295, C 360, C 361 and C 420.

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

Refer to C 260 and C 330.

See plans for C 260 and C 330.

Based on interview and record review, it was determined the facility failed to ensure each resident was evaluated for activities addressing all required elements and to develop an individualized activity plan based on their activity evaluation for 2 of 2 sampled residents (#s 1 and 2) whose evaluations and services plans were reviewed.

The most recent evaluations and current service plans were reviewed for Residents 1 and 2. The following was identified:

a. There was no documented evidence an activity evaluation had been completed for Resident 1 that addressed the following:

* Current abilities and skills;  

* Physical abilities and limitations; and

* Adaptations necessary for the resident to participate.

b. There was no activity evaluation completed for Resident 2.

c. There was no documented evidence an individualized plan was developed for both sampled residents.

The need to ensure activity evaluations were completed and individualized activity plans were developed was discussed with Staff 1 (Memory Care Director), Staff 2 (ED), Staff 3 (Health and Wellness Director), Staff 15 (LPN), and Staff 16 (Assisted Living Coordinator)on 08/01/24. They acknowledged the findings.

Life Enrichment Director will complete the activities evaluation for the two sampled residents. The Life Enrichment Director will use the activity evaluation to complete the individualized activity plan for each resident.

Upon move in, the Life Enrichment Director will complete the resident activity evaluation and the individualized activity plan as well as all of the residents individualized activity evaluations updated and completed for Memory Care by 9/30/24. The Life Enrichment Director will post the information in a binder in the breakroom for all the staff to review.

The Life Enrichment Director will review all the individualized activity plans every six months unless a resident experiences a significant chagne of condition which we will update with the residents abilities.

The Memory Care Director or designee will be responsible to see that the corrections are completed.