Print Inspection: V5ZP

The findings of the re-licensure survey conducted 09/11/23 through 09/14/23 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.

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 revisit to the re-licensure survey of 09/14/23, conducted on 02/28/24, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.

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

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

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 09/14/23, conducted 05/15/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.

2. Resident 1 was admitted to the facility in 07/2023 with diagnoses including Alzheimer's disease.

Review of the resident's 07/31/23 service plan noted s/he required stand-by assistance with showering. Neither the service plan or the facility's bathing schedule instructed staff when they should provide shower assistance to the resident.  

The resident's 08/2023 ADL Sign Off Sheet noted staff assisted the resident with showers three times between 08/01/23 and 08/13/23. There was no ADL Sign Off Sheet for 09/2023 for Resident 1.

In a 09/13/23 interview Staff 10 (Care Associate) stated she was unsure when staff were to provide standby assistance with showers for Resident 1.

In an 09/13/23 interview, Staff 2 (Memory Care Director) acknowledged while the resident's name was on the facility shower schedule, there was no instruction on the shower schedule or the resident's service plan informing staff when to provide shower assistance. She also stated she was unable to confirm if the resident had received assistance with showers between 08/13/23 and 09/12/23.

The need to ensure the facility provided services to assist residents in performing all activities of daily living was discussed with Staff 1 (ED) and Staff 2 on 09/14/23. They acknowledged the findings.

3. Resident 2 was admitted to the facility in 07/2023 with diagnoses including Alzheimer's disease with late onset.

The resident's 07/18/23 service plan indicated s/he was a standby assist for showers two to three times per week in the evening. Neither the service plan or the facility's bathing schedule instructed staff when they should provide shower assistance to the resident.

Caregiver ADL task sheet reviewed from 08/01/23 through 08/16/23 revealed Resident 2 had received four showers during the reviewed time period. The ADL task sheet for Resident 2 reflected no documentation after 08/16/23.

The current shower schedule was reviewed with Staff 8 (Care Associate) and Resident 2's name was listed on the sheet, however, was not on the schedule to receive showers. In an interview with Staff 2 (MC Director) on 09/12/23 at 2:50 pm she could not confirm whether Resident 2 had received a shower between 08/16/23 to 09/12/23.

On 09/14/23, the need to ensure the facility provided services to assist the resident in performing all activities of daily living, on a 24-hour basis, including assistance with bathing as outlined in their service plan was reviewed with Staff 1 (ED), Staff 2 (Memory Care Director) and Staff 3 (RN). They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to provide services to assist the residents in activities of daily living in the area of showers for 2 of 3 sampled residents (#s 1 and 2), and nutrition and hydration for 1 of 1 sampled resident (#5). Findings include, but are not limited to:

1. Resident 5 was admitted to the facility in 05/2021 with a diagnosis of Alzheimer's disease.

Observations of Resident 5 during the survey revealed s/he was dependent on staff for eating and drinking and did not advocate for him/herself.

A review of Resident 5's service plan and HH speech therapy notes revealed Resident 5 was on a minced and moist diet with nectar liquids, and required 1:1 feeding assistance. In addition, the resident's service plan, including ADL sheets, instructed caregivers to provide two full glasses of liquid at each meal, as well as a glass of liquid at each snack and hydration pass: daily at 10:30 am, 2:30 pm, and 6:30 pm.

a.  During breakfast on 09/12/23 and 09/13/23 Resident 5 was observed to be given only one glass of liquids.

b. During the snack and hydration passes at 10:30 am and 2:30 pm on 09/12/23 Resident 5 was observed to be given a snack but not offered a glass of liquid.

c. On 09/12/23 at 2:45 pm a CG was observed giving Resident 5 a churro as a snack.

On 09/13/23 at 9:15 am these findings were discussed with Staff 2 (Memory Care Director) who stated she would speak with Staff 3 (RN) immediately and promptly come up with a plan to ensure Resident 5 received hydration and modified food texture according to the service plan.

1.) TSP in place at time of survey for staff to ensure resident #5 is provided 2 full glasses of liquids at each meal and during all snack and hydration passes. Staff education provided on importance of hydration.Resident diet was immediately reviewed. Speech Therapy called back out to reassess diet and resident's diet has since been changed back to regular texture. Resident #1 and #2 were added to the shower schedule immediately.

2.)Shower schedule will be audited weekly and updated as necessary by Memory Care Director and findings will be reported to Executive Director monthly

3.)Audit will be completed weekly. These Audits will be presented monthly.

4.)Memory Care Director to ensure compliance.  

Based on interview and record review, it was determined the facility failed to ensure initial evaluations were updated and modified as needed during the 30 days following the resident's move into the facility for 2 of 2 sampled residents (#s 1 and 2) whose move-in evaluations were reviewed, and failed to ensure evaluations were performed at least quarterly for 1 of 1 sampled resident (#4) whose record was reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 07/2023 with diagnoses including Alzheimer's disease. The resident's clinical record was reviewed on 09/11/23 and noted the following:

The facility lacked documented evidence the resident's initial evaluation dated 07/06/23 was updated and modified as needed during the 30 days following  admission into the facility.

The need to ensure initial evaluations were updated within the 30 days of admission into the facility was discussed with Staff 1 (ED) and Staff 2 (Memory Care Director) on 09/14/23. They acknowledged the findings.

2. Resident 2 moved to the facility in 07/2023 with diagnoses including Alzheimer's disease with late onset.

The resident's records including an initial evaluation dated 06/27/23 was reviewed. In an interview with Staff 2 (Memory Care Director) and Staff 3 (RN) on 09/13/23 it was stated the facility lacked documented evidence the 30 day evaluation had been updated with changes for Resident 2.

The need to ensure that initial evaluations were updated within the first 30 days of admission was discussed with Staff 1 (ED), Staff 2 (Memory Care Director) and Staff 3 (RN).

3. Resident 4 was admitted to the facility in 04/2023 with diagnoses including Alzheimer's disease and vascular dementia.

A review of the resident's record identified his/her quarterly evaluation had not been completed.

The need to ensure resident evaluations were completed quarterly was discussed with Staff 2 (Memory Care Director) on 09/13/23. She acknowledged the findings.

1.) Resident #1 and #2 service plan has been updated and reviewed.

2.) At date of admission move-in coordinator will schedule 30-day care conference with family and Memory Care Director will complete 30 day assesment.

3.) Service plans will be Audited monthly to ensure all assesments and care conferences are scheduled/completed. Audits will be completed and presented quarterly to Executive Director.

4. Memory Care Director to ensure compliance.

3. Resident 3 was admitted to the facility in 12/2018 with diagnoses including dementia.

The resident's clinical record was reviewed on 09/11/23. The following was noted:

During the acuity interview on 09/11/23, Staff 2 (Memory Care Director) reported resident service plans were made accessible to staff and located in binders in the memory care unit's medication room. Review of the service plan binders on 09/11/23 at 10:22 am found no service plan for Resident 3. In a subsequent interview with Staff 2, she stated she was unsure as to why the service plan was not in its place and confirmed she would print a copy and make it available to staff.

The need to ensure resident service plans were made available to staff was discussed with Staff 1 (ED) and Staff 2 on 09/14/23. 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 as identified in the evaluation including residents preferences, were readily available to staff, and provided clear instruction to staff for 3 of 4 sampled residents (#s 2, 3 and 5) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 07/2023 with diagnoses including Alzheimer's disease with late onset.

The resident's current service plan dated 07/18/23 and initial evaluation of 06/27/23 were reviewed. Observations were made, and interviews with the resident's caregivers were conducted between 09/12/23 and 09/14/23. The initial evaluation dated 06/27/23 was reviewed and revealed the resident's current status was identified in the evaluation, however, was not reflected in Resident 2's service plan in the following areas:

* Safety/Evacuation;

* Pendant use;

* Bathing;

* Elopement history; and

* Recent losses.  

The need to ensure service plans were reflective of the resident's current status and care needs as identified in the evaluation was discussed with Staff 1 (ED), Staff 2 (Memory Care Director) and Staff 3 (RN). They acknowledged the findings.

2. Resident 5 was admitted to the facility in 05/2021 with a diagnosis of Alzheimer's disease.

Observations and review of the current service plan identified the following:

a. Throughout the survey, Resident 5's service plan was not in the service plan binder available to caregivers.

b. The service plan lacked clear direction to staff in the area of modified diet texture.

The need to ensure service plans were readily available and provided clear direction to staff was discussed with Staff 1 (ED), Staff 2 (Memory Care Director) and Staff 3 (RN) on 09/14/23. They acknowledged the findings.

1.) Resident 2's Service plan has been reviewed and updated to include * Safety/Evacuation; * Pendant use; * Bathing; * Elopement history; and * Recent losses. Resident 5's Service plan was printed immediately and placed in the service plan binder for staff access, TSP added immediately clarifying resident's modified diet and textures. Resident #3 Service plan was printed immediately and placed in the service plan binder.

2.) Service plan Audits will be completed by Memory Care Director quarterly and at all COC to ensure all components are included. Binder will be audited monthly to ensure all Service Plans are in Binder.

3.Audits will be completed and presented quarterly to Executive Director.

4. Memory Care Director to ensure compliance.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of resident's current status and care needs and included a written description of who shall provide the services and what, when, how, and how often the services shall be provided for 1 of 2 sampled residents (# 8) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 8 was admitted to the facility in 07/2023 with diagnoses including Alzheimer's disease and an abdominal hernia.

The resident's current service plan, dated 02/11/24, was reviewed. Observations were made of Resident 8 and interviews with caregivers were conducted on 02/28/24. The following was not reflective of the resident's current status and lacked clear instruction to staff:

* Instruction relating to a tilt-in-space wheelchair including repositioning, padding on the left arm of chair, and trunk support;

* Providing step by step instructions to the resident for ADLs;

* Instructions relating to donning and doffing a hernia binder;

* Full assistance with grooming and hygiene;

* Showing the resident the food choices to determine what s/he would like to eat for each meal;

* The resident's ability to feed his/herself during breakfast, lunch, and dinner;

* Caregivers to request barrier cream for each incontinence episode;

* Spouse's involvement including bringing the resident's dog to visit; and

* Emergency evacuation needs.

The need to ensure service plans were reflective of their current status and care needs which included a written description of who shall provide the services and what, when, how, and how often the services shall be provided, was discussed with Staff 1 (ED), Staff 3 (RN), and Staff 14 (Memory Care Director) on 02/28/24. They acknowledged the findings.

Resident #8 care plan updated to reflect the following information: Instruction relating to a tilt-in-space wheelchair including repositioning, padding on the left arm of chair, and trunk support; Providing step by step instructions to the resident for ADLs; Instructions relating to donning and doffing a hernia binder; Full assistance with grooming and hygiene; Showing the resident the food choices to determine what s/he would like to eat for each meal; The resident's ability to feed his/herself during breakfast, lunch, and dinner; Caregivers to request barrier cream for each incontinence episode; Spouse's involvement including bringing the resident's dog to visit; and Emergency evacuation needs.

Audit of assessment and care plan to assure parts of the resident assessment is transferred to the care plan audit completed by Memory Care Director and MC Community RN. Review to be done prior to 30 day care review, prior to 90 day review and upon change of condition.

Memory Care Director and MC RN will audit and report to Executive. Executive Director to assure compliance.     

Based on observation and interview, it was determined the facility failed to establish and maintain infection prevention and control protocols to provide a safe and sanitary environment for residents. Findings include, but are not limited to:

On 09/12/23 at 9:15 am, incontinence care for Resident 5 was observed to determine adherence to universal precautions for infection control.

Staff 10 (Care Associate) was observed to don gloves prior to the task. After performing bowel incontinence care, Staff 10 touched the resident's clean pants, clean bedding, and Hoyer sling prior to doffing gloves.

The need to ensure staff consistently used universal infection control precautions for the protection of residents was discussed with Staff 1 (ED), Staff 2 (Memory Care Director) and Staff 3 (RN) on 09/14/23. They acknowledged the findings.

1.) All staff have been retrained on proper don and doffing of gloves when providing personal care. Compatency's have been completed with each health care member.

2.) Staff compatency added for don and doffing gloves and usage.

3.) Staff compatencies will be completed annually and turned into business office manager for record keeping.

4.) Memory Care Director to ensure compliance  

Based on observation and interview, it was determined the facility failed to establish and maintain infection prevention and control protocols to provide a safe and sanitary environment for residents, and the facility failed to comply with masking requirements to control the spread of COVID-19. This is a repeat citation. Findings include, but are not limited to:

a. On 02/28/24 at 10:38 am, incontinence care for Resident 8 was observed to determine adherence to universal precautions for infection control.

Staff 21 (MT) was observed to don gloves prior to the task. After performing incontinence care, Staff 21 touched the arms, seat, and handles of the resident's wheelchair prior to doffing gloves.

b. The facility had a confirmed COVID-19 outbreak.

Observations of the unit were made on 02/28/24. There were three staff members observed to either wear their surgical mask under their nose or under their chin between 9:48 am through 1:09 pm.  

The need to ensure staff maintained infection prevention and control protocols to provide a safe and sanitary environment for residents, and comply with masking requirements to control the spread of COVID-19 was discussed with Staff 1 (ED), Staff 3 (RN), and Staff 14 (Memory Care Director) on 02/28/24. They acknowledged the findings.

Associates retrained on proper donning and doffing of gloves when providing personal care including replacing gloves after incontinence care is completed prior to redressing resident or touching other items.

Proper use of PPE during a COVID outbreak training provided to all associates. All associates complete proper use of PPE/infection control training at time of hire, annually and with review during all infectious outbreaks.

Associate competency for proper PPE use and other infection control measures will be completed annually and placed in assocaite training record.Competency confirmed by Memory Care Director and MC RN.      

Memory Care Director to assure compliance.     

Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) that met the regulation. Findings include, but are not limited to:

On 09/13/23, the ABST was reviewed and identified the following:

* The ABST noted 48 residents. At the time of survey the facility census was 41;

* Resident 1 admitted to the facility on 07/31/23, the resident's ABST record was created on 09/12/23;

* Resident 4 admitted to the facility on 04/12/23, the resident's ABST record was created on 07/31/23, and was not updated quarterly;

* Resident 6 was admitted to the facility on 08/16/23. There was no ABST record created for Resident 6; and

* The facility failed to staff to the ABST generated staffing level.

The need to ensure the facility's ABST was updated when residents moved in or out and no less than quarterly, and the facility staffed to the ABST generated staffing level was discussed with Staff 1 (ED) and Staff 2 (Memory Care Director) on 09/14/23. They acknowledged the findings.

1.) All residents have been updated and added to the ABST. Empty rooms have been removed.

2.) ABST to be updated with all move-ins, 30-day assesments, quarterly assesments, and COC.

3.)ABST to be audited monthly to ensure all residents are added and accurate based on current service plan.

4.) Memory Care Director to ensure compliance

Based on interview and record review, it was determined the facility failed to update an acuity-based staffing tool (ABST) before a resident moved in to the facility. This is a repeat citation. Findings include, but are not limited to:

Upon review of the ABST on 02/28/24, the ABST did not include data for Resident 7, who was admitted to the facility on 02/23/24.

During an interview on 02/28/24 at 1:24 pm, Staff 1 (ED) confirmed Resident 7 had not been entered into the ABST.

The need to ensure the ABST was updated before a resident moved in to the facility was discussed with Staff 1. She acknowledged the findings.

Resident #7 was added to ABST, all residents have been updated and added to the ABST.

ABST will be updated prior resident move-in, at 30-day assesment, at quarterly assesment, and with change of condition.

ABST to be audited monthly to ensure all residents are added and accurate based on current service plan by Memory Care Director.

Memory Care Director and Executive Director to ensure compliance.     

Based on interview and record review, it was determined the facility failed to ensure unannounced fire drills included all required components and fire and life safety instruction was provided to staff on alternate months of fire drills. Findings include, but are not limited to:

Facility fire drill records dated 03/2023 through 09/2023 were reviewed with Staff 4 (Plant Operations Director) on 09/13/23. The facility lacked documented evidence all fire drills included the following components:

* Location of simulated fire;

* Escape route used; and

* Number of occupants evacuated.

In addition, the facility lacked documented evidence fire and life safety instruction was provided to staff on alternate months of fire drills.

The need to ensure unannounced fire drills included all required components and fire and life safety instruction was provided to staff on alternate months of fire drills, was discussed with Staff 2 (Memory Care Director) and Staff 4 on 09/13/23. They acknowledged the findings.

1. Plant Operations Director was educated on missing component including * Location of simulated fire; * Escape route used; and * Number of occupants evacuated. Also educated on requirements of documented evidence fire and life safety instruction to be provided to staff on alternate months of fire drills. Every other month drills and education will be completed on alternating months going forward.

2.) Plant operations director will complete every other month drills and education will be completed on alternating months ensuring all components are completed and documented. This will be recurring thoughout the year.

3.) Every other month drills and education will be completed on alternating months ensuring all components are completed and documented. Memory Care Director will audit quarterly and report to Executive Director.

4.) Memory Care Director and Plant Operations Director to ensure complaiance.

Based on interview and record review, it was determined the facility failed to ensure fire drills conducted every other month documented all required components in accordance with the Oregon Fire Code and fire and life safety instruction was provided to staff on alternate months of fire drills. This is a repeat citation. Findings include, but are not limited to:

Review of fire and life safety records for 01/2024 through 02/2024 and an interview with Staff 1 (ED) and Staff 15 (Plant Operations Director) on 02/28/24 revealed the following:

a.  One fire drill occurred on 01/03/24 at 9:50 am which lacked documentation of the following required elements:

* Escape route used;

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

* Evacuation time needed; and

* Number of occupants evacuated.

b. There was no documented evidence the facility was providing fire and life safety instruction on alternating months.

On 02/28/24, the need to ensure the facility conducted fire drills every other month, staff received required fire and life safety training, and fire drill documentation included required components according to the Oregon Fire Code was reviewed with Staff 1. She acknowledged the findings.

Plant Operations Director was given proper documentation to use during fire drills to assure all required elements are included; Escape route used, problems encountered, comments relating to residents who resisted or failed to participate in the drills, evacuation time needed, number of occupants evacuated.

Fire drills will be performed on "odd" months and fire life safety education to be reviewed with all staff during "even" months.

Executive Director, Memory Care and Plant Operations Director to assure compliance quarterly and plan upcoming drills and education.  

Based on interview and record review, it was determined the facility failed to ensure residents were instructed in fire and life safety procedures within 24 hours of admission and at re-educated at least annually. Findings include, but are not limited to:

Fire and life safety records were reviewed on 09/13/23, Staff 4 (Plant Operations Director) was interviewed, and the following was identified:

There was no documented evidence residents were educated in general fire and life safety procedures, evacuation methods, responsibilities and designated meeting places inside or outside the building in the event of an actual fire within 24 hours of admission and re-educated at least annually

On 09/14/23, the need to ensure fire and life safety instruction was provided to each resident within 24 hours of admission and at least annually as required by the OFC was discussed with Staff 2 (Memory care Director). The findings were acknowledged.

1.) All residents have been educated on fire and life safety instructions.

2.) Memory Care Director to complete fire and life safety instructions on day of move-in and at each quarterly assesment.

3.) Memory Care Director will complete annual audits of fire and life safety instructions and report finding to Executive Director

4.)Memory Care Director to ensure compliance.

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 C 260, C 295,  C 361, C 420, C 545, Z 155, and Z 164.

All findings during re-licensure survey on 2/28/2024 have been addressed and have planned compliance audits in place. Findings included: C 260, C 295, C 361, C 420, C 545, Z 155, and Z 164. Refer to evidence found in attached POC for correction plan and assurance of ongoing compliance.

Executive Director to audit at least quarterly to assure compliance with C 260, C 295, C 361, C 420, C 545, Z 155, and Z 164 are ongoing and in place.  

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

During a tour of the interior of the facility on 09/12/23 at 8:50 am, multiple dining room chair seats were observed to be worn and discolored.

The surveyor toured the environment with Staff 1 (ED) and Staff 2 (Memory Care Director) on 09/13/23 at 11:45 am. They acknowledged the findings.

1.) Dinning room chairs have been purchased and will be replaced once received

2.) Memory Care Directror to complete weekly audits of enviroment to be completed to ensure all surfaces are in good repair and clean kept.

3.)Weekly findings to be reported to Executive director monthly to ensure all areas are in good repair and clean kept.

4.) Memory Care Director to ensure compliance.  

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

On 09/12/23, the surveyor measured water temperatures in three resident units.  The water temperature ranged from 124.5 to 133.5 degrees Fahrenheit.  Staff 2 (Memory Care Director) was present for testing of the water temperatures.

On 09/14/23, Staff 2 provided documentation to the survey team which confirmed a vendor was scheduled to come to the facility on 09/20/23 to adjust the water temperatures to be within the range of 110 and 120 degrees Fahrenheit.

The need to ensure water temperatures in resident apartments were maintained within the required range was discussed with Staff 1 (ED), Staff 2 and Staff 3 (RN) on 09/14/23. They acknowledged the facility needed to implement a system for monitoring water temperatures.

1.) Water temperatures will be adjusted to ensure they are within the range of 110-120 degrees. We are currently continuing to work on this with our outside vendors.

2.) Housekeepers to check room temps weekly on scheduled housekeeping days. Housekeeper will complete and return to Plant operations director who will report fininds to Executive Director Monthly.

3.)Plant operations director will audit findings weekly and correct and address discrepancies with Executive Director. Plant operations director will also report monthly to executive director.

4.) Plant operations director will ensure compliance.

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

On 02/28/24, the surveyor measured water temperatures in a bathroom located in a common area and two resident units. The water temperature ranged from 106.3 to 125.4 degrees Fahrenheit.

At 10:58 am, Staff 21 (MT) was present for testing the water temperature in a resident room and confirmed the resident did receive his/her showers in the shared bathroom. The water temperature was 106.3 degrees Fahrenheit.   

The need to ensure water temperatures in resident apartments were maintained within the required range was discussed with Staff 1 (ED), Staff 3 (RN), and Staff 14 (Memory Care Director) on 02/28/24. They acknowledged the findings.

Recirculation pump replacement initiated on 3/12/2024. Water temperatures will be adjusted to ensure they are within the range of 110-120 degrees.

All associates educated on importance of proper water temperatures and reporting concerns for potential out of temperature range to Plant Operations Director who will address and report out of compliance areas to Executive Director Monthly.

Plant Operations Director will audit random resident apartments throughout the community weekly to assure temperature proper range, correct and address discrepancies with Executive Director.

Plant Operations Director 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 361, C 420, C 422, C 513 and C 545.

Refer to: C361, C420, C422, C513 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 361, C 420, and C 545.

Refer to: C 361, C 420, and C 545.

Based on interview and record review, it was determined the facility failed to ensure 1 of 2 newly hired staff completed all required pre-service training prior to providing services independently, and 2 of 2 long-term staff completed a total of 16 hours of annual training, including six hours of dementia care training. Findings include, but are not limited to:

Staff training records were reviewed on 09/12/23 and 09/13/23. The following was identified:

a. Staff 11 (Care Associate), hired 08/08/23, lacked documented evidence of completion of the following pre-service dementia training topics:

* Dementia disease process including progression of the disease, memory loss and psychiatric and 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 (e.g. staff interactions, lighting, room temperature, noise, etc.);

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

* How to recognize behaviors that indicate a change in the resident's condition and report behaviors that require ongoing assessment.

b. There was no documented evidence Staff 6 (MT), hired 11/02/17, and Staff 8 (Care Associate), hired 06/15/17, completed 16 hours of annual training related to the provisions of care in Community Based Care, including six hours related to dementia care.

The need to ensure all newly hired staff completed pre-service training, and all long-term staff completed 16 hours of annual training was discussed with Staff 1 (ED), Staff 2 (Memory Care Director) and Staff 3 (RN) on 09/14/23. They acknowledged the findings.

1.) Staff #11 will complete pre-service dementia training, Staff #6 and Staff #8 will complete required 16 hours of annual training.

2.) All staff will complete required pre-service training within 30 days of hire. All staff are assigned monthly relias training. Memory Care Director to review records monthly to ensure annual training is being completed.

3.)Memory Care Director will review records monthly and report findings to Executive Director.

4.) Memory Care Director to ensure compliance.  

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff completed all required pre-service training prior to providing services independently. This is a repeat citation. Findings include, but are not limited to:

Staff training records were reviewed on 02/28/24 and the following was identified:

Staff 18 (Care Associate), hired 01/26/24, lacked documented evidence of completion for the following pre-service dementia training topics:

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

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

* How to recognize behaviors that indicate a change in the resident's condition and report behaviors that require ongoing assessment.

Staff 21 (MT), hired 11/15/23, and Staff 22 (Care Associate), hired 01/22/24, lacked documented evidence of completion in multiple areas for the following pre-service dementia training topics:

* Dementia disease process including progression of the disease, memory loss and psychiatric and 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 (e.g. staff interactions, lighting, room temperature, noise, etc.);

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

* How to recognize behaviors that indicate a change in the resident's condition and report behaviors that require ongoing assessment.

The need to ensure newly hired staff completed all pre-service training prior to beginning job responsibilities was discussed with Staff 1 (ED) and Staff 24 (Move-In Coordinator) on 02/28/24. They acknowledged the findings.

Staff #18 will complete pre-service dementia training, Staff #21 and Staff #22 will complete required missing areas of preservice dementia training. All staff will complete required pre-service training within 30 days of hire.

All staff are assigned monthly relias training. Memory Care Director to review records to assure annual training is being completed. Memory Care DIrector to work to allow for staffing to permit associates to work on their training within their scheduled time of work.

Memory Care Director will review records monthly and report findings to Executive Director.

Memory Care Director to assure compliance.

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

Refer to C 243, C 252, C 260 and C 295.

Refer to C243, C252, C260 and C295.

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

Refer to C 260 and C 295.

Refer to C 260 and C 295.

Based on observation, interview and record review, it was determined the facility failed to ensure the activity evaluation addressed all required components and an individualized activity plan was developed based on the activity evaluation, for 3 of 3 sampled residents (#s 1, 2 and 4) whose activity plans were reviewed. Findings include, but are not limited to:

Residents 1, 2 and 4's records were reviewed and observations were made during the survey. The current activity evaluations did not address the following required components:

* Current abilities and skills;

* Emotional/social needs and patterns;

* Physical abilities and limitations;

* Adaptations needed to participate; and

* Identification of activities for behavioral interventions.

The current activity plans were not individualized to each resident based on their activity evaluation, and lacked instructions for staff on what activities to provide, how to provide them, when and how often.

The need to ensure activity evaluations addressed all required components and individualized activity plans were developed was discussed with Staff 1 (ED), Staff 2 (Memory Care Director) and Staff 3 (RN) on 09/14/23. They acknowledged the findings.

1.) Resident #1, #2 and #4 have been re-evaluated to include * Current abilities and skills; * Emotional/social needs and patterns; * Physical abilities and limitations; * Adaptations needed to participate; and * Identification of activities for behavioral interventions.TSP created for each resident.

2.) Individual activity plan and needs will be audited quartely during care conferenced as well as the Memory Care life enrichment team and Memory Care Director will meet monthly to discuss any changes in skills, ability, interest, behaviors, etc.

3. Audits will be preformed quarterly. These findings will be discussed quarterly with Executive Director

4. Memory Care Director will ensure compliance.  

Based on observation, interview, and record review, it was determined the facility failed to ensure the activity evaluation addressed all required components and an individualized activity plan was developed based on the activity evaluation, for 2 of 2 sampled residents (#s 7 and 8) whose activity plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 7 and 8's records were reviewed and observations were made during the survey. The current activity evaluations did not address one or more of the following required components:

* Past and current interests;

* Current abilities and skills;

* Emotional/social needs and patterns;

* Physical abilities and limitations;

* Adaptations needed to participate; and

* Identification of activities for behavioral interventions.

The current activity plans were not individualized to each resident based on their activity evaluation and not included on the resident's activity service or care plan.

In an interview with Staff 16 (Life Enrichment Director) on 02/28/24 at approximately 11:45 am, she confirmed Resident 7 and 8 did not have an activity evaluation. Staff 16 reported hiring an Activity Assistant designated to the MCC who would be starting in "a couple of weeks."

The need to ensure activity evaluations addressed all required components and individualized activity plans were developed was discussed with Staff 1 (ED), Staff 3 (RN), Staff 14 (Memory Care Director), and Staff 16 on 02/28/24. They acknowledged the findings.

Resident #7 and #8 have been re-evaluated to include Current abilities and skills; Emotional/social needs and patterns; Physical abilities and limitations; Adaptations needed to participate; and Identification of activities for behavioral interventions.

Activity Evaluation form created and implemented for all residents. Evaluation form will be utilized during initial assessment, 30 day assessment, quarterly assessment and with change of condition for all residents. All residents will be reassessed to meet individualized life enrichment needs.

Memory Care life enrichment associate and Memory Care Director will meet monthly to discuss any changes in skills, ability, interest, behaviors, etc.

Audits will be preformed quarterly. These findings will be discussed quarterly with Executive Director

Memory Care Director will ensure compliance.