Print Inspection: V81G

The findings of the re-licensure survey, conducted 06/26/23 through 06/28/23, 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 for 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

MCCMemory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first re-visit to the re-licensure survey of 06/28/23, conducted 11/20/23 through 11/21/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.

Based on observation, interview, and record review, it was determined the facility failed to ensure injuries of unknown cause and resident-to-resident altercations were promptly investigated to rule out abuse and/or neglect and reported to the local SPD office as required for 1 of 1 sampled memory care resident (#8) whose incidents were reviewed. Findings include, but are not limited to:

Resident 8 was admitted to the facility in 10/2022 with diagnoses including dementia.

Observations of the resident, interviews with staff, and review of the resident's 06/10/23 service plan, 03/26/23 through 06/26/23 temporary service plans, progress notes, physician communications, and incident investigations were completed.

The resident was noted to be confused, required one to two staff assistance for ADL care, and needed frequent redirection by staff throughout the day. The resident could not make his/her needs known, inconsistently answered yes/no questions appropriately, and had frequent agitation. The resident had frequent physical and verbal aggression towards staff, including hitting, yelling, throwing dishes and ramming others with his/her walker or wheelchair.

a. Review of the resident's records showed the following:

* An incident report dated 04/12/23 indicated the resident was found on the floor on 04/01/23. The investigation was not completed until 04/12/23;

* An incident report dated 05/02/23 indicated the resident was found on the floor on 04/28/23, no injuries were noted. The investigation was not completed until 05/16/23;

* An incident report dated 05/01/23 indicated the resident had an assisted fall, no injuries were noted. The investigation was not completed until 05/16/23;

* An incident report dated 05/09/23 indicated the resident had an assisted fall to the ground outside. No injuries were noted. The investigation was not completed until 05/16/23;

* An incident report dated 05/11/23 indicated the resident had an assisted fall to the floor. No injuries were noted. The investigation was not completed until 05/16/23;

* An incident report dated 05/22/23 indicated the resident had a fall in his/her room. No injuries were noted. The investigation was not completed until 06/20/23;

* An incident report dated 05/27/23 indicated the resident was found on the floor in the living room. No injuries were noted. The investigation was not completed until 06/16/23;

* An incident report dated 06/04/23 indicated the resident threw himself/herself out of the wheelchair while experiencing a hallucination. No injuries were noted. The investigation was not completed until 06/20/23;

* An incident report dated 06/06/23 indicated the resident was found on the floor near the couch. No injury was noted. The investigation was not completed until 06/22/23; and

* An incident report dated 06/08/23 indicated the resident sustained skin tears to the right shin when his/her leg fell down between the foot rest and chair. The investigation was not completed until 06/13/23.

The investigations were not completed promptly after the incidents, to rule out abuse and neglect and to determine actions to prevent reoccurrence as a result of the incidents.

b. Additional review of the resident's progress notes and investigations showed the following:

* A progress note dated 04/06/23 indicated the resident was involved in a resident-to-resident altercation. Resident 8 grabbed another resident's arm while yelling at them and was extremely agitated with staff.

No investigation was completed of the altercation, and it was not reported to the local SPD office.

* A progress note dated 04/11/23 indicated the resident was involved in a resident-to-resident altercation. Resident 8 was hit in the face by another resident and Resident 8 was agitated and upset.

No investigation was completed of the altercation, and it was not reported to the local SPD office.

* An incident report dated 05/16/23 indicated the resident was found to have a skin tear and had a fall the night before. No injury was noted for the fall of 05/15/23. The investigation of the skin tear found on 05/16/23 was not completed until 05/23/23. A progress note dated 05/19/23 indicated a new skin tear was sustained to the forearm.

The investigation was unclear how many skin tears were found and how they occurred. The investigation was unclear how abuse and neglect was ruled out and any further information about the previous fall's relationship to the new injuries.

* A progress note dated 06/05/23 indicated the resident was involved in a resident-to-resident altercation. Resident 8 chased and kicked another resident in the memory care as well as chasing and striking out at staff at the time.

No investigation was completed of the altercation, and it was not reported to the local SPD office.

* An investigation dated 05/15/23 indicated the resident sustained a fall in the courtyard. Another resident witnessed the fall and stated the resident caught his/her walker on a corner and fell. No injuries were noted.

In an interview on 06/28/23, Staff 1 (Director of Health Services) indicated at the time of the fall there were deep edges along the sidewalk which the resident caught his/her walker on. Staff 1 stated the maintenance director rectified the issue at the time of the resident's fall. Staff 1 acknowledged the investigation did not address how the resident fell or properly rule out abuse and neglect.

The need to ensure all incidents were promptly investigated to rule out abuse and/or neglect and reported to the local SPD as needed was discussed with Staff 1 (Health Services Director), Staff 2 (Clinical Services Manager), and Staff 4 (Resident Care Manager/LPN) on 06/28/23. The staff acknowledged the findings.

Staff 1 was asked to report the five incidents and provided confirmation of the reports prior to survey exit.

C231 Abuse Reporting & Investigation

Action(s) taken:

1. The Fall Scene Investigation (FSI) form's high reliability organization checklist was updated to clarify identification of abuse and neglect along with the self-reporting process. Screening takes place at the time of the event by the first responder and is double checked by the licensed nurse or shift lead who is on duty at the time with instructions to report unknown cause and suspicions of abuse or neglect. The findings are then reviewed and confirmed when the investigation is completed.  The revised form was re-distributed to clinical staff on 7/6/23 for immediate use.

2. Facility's Abuse Reporting and Investigation policy and procedure was updated to clarify process for facility self-reports for unknown cause and suspected abuse or neglect events and new FSI form was attached. Policy to be re-distributed to clinical staff 7/14/23.

3. Med Techs were re-educated 7/14/23 on importance of reporting resident to resident interactions to a supervisor, or a person in charge if after hours, immediately.

4. Charge nurses were also instructed to utilize "Safety/Security/Conduct" incident report in electronic event reporting tool to initiate investigation.

System correction:

1. Fall scene investigation (FSI) form updated and is required to be completed by first responder before end of shift on day of incident per policy.

2. FSI form instructions expanded for Charge Nurse or shift lead to screen for unknown cause and suspected abuse or neglect (including failing to follow service plan) and more specific follow up instructions to complete by end of shift same day as incident; notify supervisor or on-call individual immediately if applicable.

3. Reporting and Investigation policy updated to clarify resources for follow up outside of business hours.

4. Lead pocket guide is always available in charge nurse office and instructs the charge nurse or shift lead when and how to contact a nursing supervisor or designated on-call leader.

Method & frequency of evaluation:

1. Charge nurses or shift leads to monitor completion of FSI forms with preliminary abuse and neglect screening and follow up guidance prior to end of shift. Charge Nurses to assure completion of all fields in FSI form which include double-checking screening for abuse and neglect.

2. Third check added to FSI checklist for Nurse Manager to review Reporting and Investigation protocol and assure self-report was completed for any incident with cause unknown or suspected abuse or neglect

3. Electronic clinical care dashboard is monitored weekdays for high priority progress notes (includes behavior notes) by clinical leadership

4. Care managers monitor progress notes weekdays

Responsible person(s): Care Coordinator, Care Manager, Clinical Manager, Health Services Director

2.  Resident 4 was admitted to the facility in February 2023 with diagnoses including dementia, impaired mobility, obstructive sleep apnea, and major depressive disorder.

The resident's current service plan, dated 05/23/23, was reviewed, observations were made, and interviews were conducted between 06/26/23 and 06/28/23. Resident 4's service plan was not reflective and did not provide clear instruction to staff in the following areas:

* Two-person assist with transfers, brief changes, and dressing;

* Specific assistance needed with incontinence care provided in bed;

* Use of tilt-in-space wheelchair;

* Enjoyed participating in music activities; and

* Ability to use the call light.

The need to ensure resident service plans were reflective of current status and care needs, and provided clear direction to staff was reviewed with Staff 1 (Director of Health Services), Staff 4 (Resident Care Manager/LPN), and Staff 9 (Resident Care Coordinator) on 06/28/23. 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' needs, provided clear direction to staff regarding care and services, and were implemented by staff for 2 of 7 sampled residents (#s 4 and 8). Findings include, but are not limited to:

1. Resident 8 was admitted to the facility in 10/2022 with diagnoses including dementia.  

Observations of the resident, interviews with staff, and review of the service plan, dated 06/10/23, showed the service plan was not reflective of the resident's current care needs, did not provide clear direction to staff, and/or was not consistently implemented by staff in the following areas:

* Hearing aides;

* Fall risk interventions, including fall mat and motion mat;

* Behaviors, including aggression toward staff, hitting and kicking;

* Bathing and toileting assistance;

* One- versus two-person transfer assistance and gait belt use;

* Wheelchair versus walker use;

* Dining preferences including use of finger foods versus utensils, use of paper plates and plastic utensils, favorite foods to help with refusals, and location of meals; and

* Hospice comfort care interventions, including floating heels when laying down, repositioning every two hours, and oral care every two hours.  

The need to ensure service plans were reflective of current care needs, provided clear direction to staff, and were implemented by staff was discussed with Staff 1 (Director of Health Services), Staff 2 (Clinical Services Manager), and Staff 4 (Resident Care Manager/LPN) on 06/28/23. They acknowledged the findings.

C260 Service Plan: General

Action(s) taken:

1. New Care Manager for resident # 8 has provided hands-on care theirself, re-evaluated resident, and revised service plan to more accurately reflect resident's care and individual needs as of 7/5/23.

2. Resident Care Manager for resident #4 interviewed caregivers and provided resident hands-on care theirself in order to evaluate accuracy of service plan. SP was accurate with the exception of 1 care area, toileting, and this area was updated as of 7/5/23.

3. Care staff have been re-instructed in July 2023 monthly inservice to notify Care Coordinator or Care Manager when a resident's actual care needs have changed or are not accurately reflected on their service plan.

System correction:

1. New Resident Care Manager for memory care neighorhood has scheduled re-evaluation and service plan update as applicable for all residents in care area, to be completed by 8/1/23.

2. Quarterly evaluations, service plan updates and care conference will proceed on schedule under new RCM's experienced leadership.

3. Annual caregiver in-service training on the topic of what to document, observe for, and notify the licensed nurse of, is scheduled for each January.

4. Onboarding and annual required training plans include a module on "Monitoring Changes in Condition."

5. See also C231 for system corrections to falls investigations and Z164 for Activities.

Method & frequency of evaluation:

1. Admission, quarterly, and change of condition evaluation and service plan updates are scheduled automatically in electronic medical record, visible on EMAR dashboard to be monitored by RN and Care Managers.

Responsible person(s): Resident Care Managers, Clinical Services Manager (RN), Health Services Director

Based on observation, interview, and record review, it was determined the facility failed to ensure residents who had short-term changes of condition were evaluated, resident-specific instructions or interventions were developed and reviewed for effectiveness, and progress was documented weekly until resolution for 1 of 1 sampled memory care resident (#8). Findings include, but are not limited to:

Resident 8 was admitted to the facility in 10/2022 with diagnoses including dementia.

Interviews with staff and review of the resident's 06/10/23 service plan, 03/26/23 through 06/26/23 progress notes, incident investigations, and physician communications were completed.

a. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness, and/or lacked resident-specific directions to staff in the following areas:

* New medications and medication changes;

* Injury and non-injury falls;

* Skin issues, including skin tears; and

* Behaviors, including resident-to-resident altercations.

b. The resident experienced non-injury falls on 03/29/23, 04/01/23, 04/28/23, 05/01/23, 05/09/23, 05/10/23, 05/11/23, two falls on 05/16/23, 05/22/23, 05/27/23, 06/06/23, and 06/07/23.

There was no documentation in the resident's record the facility had promptly documented complete investigations of the falls to determine the cause, minimize reoccurrence, determine actions and interventions, and communicate them to staff for each fall.

c. The resident experienced a severe weight gain of 11.8 pounds, or 8.8%, from 05/08/23 to 06/03/23.

In interview on 06/28/23, Staff 2 (Clinical Services Manager) indicated she was not aware of the weight changes for the resident and had not completed an assessment of the changes.

The need to ensure short-term changes of condition had weekly progress documented until resolution, provided clear, resident-specific directions to staff, and significant changes were reported to the RN for assessment was discussed with Staff 1 (Director of Health Services), Staff 2, and Staff 4 (Resident Care Manager/LPN) on 06/28/23. The staff acknowledged the findings.

C270 Changes of Condition & Monitoring

Action(s) taken:

1. Weight change assessment and change of condition assessment completed for Resident #8 by RN on 6/29/23. Weight inaccuracies were indentified and new scale for memory care area has been ordered.

2. Weight data collection system revised, see system correction below.

3. New RN is enrolled in "Nursing Practice in Community Based Care" course, attended July 11-13.

4. Chair scale to be removed from memory care due to questions regarding accuracy, to be replaced with wheelchair scale (on order).

5. Re-education of charge nurses to use email distribution group for "Nursing Supervisors" and to notify Clinical Services Manager, Care Manager and Administrator of changes in condition and other critical clinical issues per Lead Pocket Guide.

System Correction:

1. Weights system correction

a. First Monday of the month: Care Coordinators will obtain resident's weights. They will have a weights history list printed off so they can see if there are any big discrepancy in weight. If a weight seems off, they will reweigh the resident at that time. By the end of the business day, the list of weights will get input into the EMAR by the Care Coordinators.

b. First Tuesday of each month: the Care Managers (licensed nurses) will review weights and evaluate those that may constitute a significant change.

c. First Wednesday of each month: Care Managers and facility RN will meet to review weights, allowing for RN input and opportunity to document an initial note addressing weight changes before the end of Wednesday (within 48 hours of identification).

d. Care Coordinators will follow up with residents who are unavailable on the first Monday, track their return to the facility and obtain their weight at that time. Care Managers and RN to follow the process above for those that were unavailable on "weigh-in Monday."

2. Alerts and Tasks (Temporary Service Plans) are created in the EMAR for monitoring and caregiver information related to changes in condition. Care Coordinators and Care Managers review these together daily, and as a group with the RN three times a week.

3. Resident Care Managers update service plans with resident-specific interventions to address changes in condition as applicable.

4. Documentation of changes in condition includes weekly progress notes by a trained, experienced staff until the condition is resolved or represents a new baseline or permenent change.

5. The RN assessment consists of information to assure essential care needs are identified, the service plan is updated and interventions are implemented in response to the significant change of condition.

Method & frequency of verification:

1. Care Coordinators to track residents weighed in their respective neighborhood on the first Monday of each month, follow up with those who were unavailable, and assure all resident weights are reported to the Care Manager either on the first Monday of each month or upon the resident's return to the facility.

2. Care Managers to track and assure that all potential significant weight changes, and all other potential significant changes in condition, are referred to the RN in writing.

3. RN to track change of condition referrals and cross-check with 24-hour reports.

Responsible person(s): Resident Care Managers, Clinical Services Manager (RN), Health Services Director

Based on observation, interview, and record review, it was determined the facility failed to ensure an RN assessment was completed timely and documented findings, resident status, and interventions made as a result of the assessment for 1 of 1 sampled memory care residents (#8) who experienced significant changes of condition. Findings include, but are not limited to:

Resident 8 was admitted to the facility in 10/2022 with diagnoses including dementia.   

Weight records, dated 03/03/23 through 06/28/23, and progress notes, dated 03/26/23 through 06/26/23, indicated the resident experienced the following:

* An 11.8 pound weight gain between 05/08/23 and 06/03/23, which constituted an 8.8% gain in one month.

Progress notes, temporary service plans, and physician communications dated 03/26/23 through 06/26/23 indicated the resident had experienced a recent decline in ADL abilities, as well as an increase in behaviors and agitation. The resident was admitted to hospice services on 06/10/23.   

Multiple observations of the resident between 06/26/23 and 06/28/23 showed the resident attended all meals served in either the living room or the dining room. Staff sat with the resident for all meals and assisted the resident to eat. The resident inconsistently initiated intake and primarily used his/her fingers to eat rather than utensils. The resident ate less than 25% at the meals observed.

In interviews between 06/26/23 and 06/28/23, Staff 20 (CG), Staff 16 (CG), Staff 24 (CG), Staff 10 (LPN), and Staff 25 (Agency CNA) indicated the resident's intake varied and that s/he became overwhelmed if there was too much activity or noise. The resident was not able to consistently make his/her needs known. The staff indicated the resident frequently used his/her fingers to eat, regardless of what type of food was being served. The staff further indicated the resident required staff assistance with his/her meals to ensure any intake occurred.

In interview on 06/28/23, Staff 2 (Clinical Services Manager) indicated she was not aware of the weight changes for the resident and had not completed an assessment of the changes. She questioned the accuracy of the weight as the resident's intake was poor and s/he did not typically have issues with edema.

The facility failed to ensure an RN assessment was completed for the weight gain from May 2023 to June 2023 which documented findings, resident status, and interventions made as a result of the assessment.

The need to ensure an RN assessment was completed which documented findings, resident status, and interventions made as a result of the assessment was discussed with Staff 1(Director of Health Services), Staff 2, and Staff 4 (Resident Care Manager/LPN) on 06/28/23. The staff acknowledged the findings.

C280 - Resident Health Services

See C270

Based on interview and record review, it was determined the facility failed to develop a staffing plan based on care minutes calculated by the acuity-based staffing tool (ABST) and to update the ABST to accurately reflect the time needed to provide care for 6 of 7 sampled residents (#s 2, 4, 5, 7, 8, and 9). Findings include, but are not limited to:

The facility's ABST was reviewed with Staff 1 (Health Services Director) on 06/27/23 and 06/28/23.

Staff 1 reported the facility was not staffing according to the plan generated by the ABST. She stated medication administration times were not included in the minutes by which the ABST calculated a staffing plan. Staff 1 indicated the facility was struggling to determine the number of minutes for the required 22 ADLs.

ABST data for seven sampled residents (#s 1, 2, 4, 5, 7, 8, and 9) was reviewed. For six of the seven residents the data was not reflective of their current care needs.

The need to ensure ABST entries accurately reflected resident care needs and a staffing plan was developed based on the ABST data was discussed with Staff 1 (Health Services Manager), Staff 2 (Clinical Services Manager), and Staff 5 (Resident Care Manager/LPN) on 06/28/23. They acknowledged the findings.

C361 Acuity-Based Staffing Tool

Action(s) taken:

1. The Health Services Director sought consultation with the Department's  ABST Policy Analyst and as a result:

a. Revised facility ABST procedure to include medication administration and documentation of regular updates.

b. Advised Care Managers to work with Care Coordinators to return medication administration/med tech time to the ABST and to double check to assure that the ABST and each resident's service plan match.

c. Revised internal facility tracking spreadsheet to better compare facility direct care worked hours (excluding unpaid lunch breaks) to ABST recommended hours thereby assure facility staffing plan exceeds ABST.

System correction:

1. Policy and procedure reflects recommendations from ABST Policy Analyst and survey coordinator.

2. Revised internal facility instructions for completion of ABST, was discussed with and distributed to those responsible for updating data regularly.

3. Links to the 4/26/23 ABST ODHS Training Hour presentation and 09/22 Provider Guide were added to the internal facility instructions for easy access by all internal users.

4. Uploaded or updated the 4/26/23 ABST ODHS Training Hour presentation and 09/22 Provider Guide as attachments to facility policy and procedure for easy access by all internal users.

Method & frequency of evaluation:

1. ABST data and facility staffing calculations are compared weekly and adjustments to staffing plan are made accordingly.

2. Administrator to assure that weekly staffing levels exceed ABST recommendation. Weekly checks will assure that posted staffing plan takes ABST data into consideration, that the staffing plan is re-posted as indicated, and that the facility is consistently staffing to the posted staffing plan.

3. Resident Care Managers to audit approximately 5% of ABST questionnaires (approximately 4.25 residents) per month to compare questionnaire responses and service plans to assure accuracy.

Responsible person(s): Care Coordinators, Resident Care managers, Clinical Services Manager, Health Services Director

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

The courtyard of the MCC was toured on 06/26/23. There were drop-offs of up to one to three inches along the edges of the pathways of the courtyard. This created a potential tripping hazard for residents.

The drop-off areas were shown to and discussed with Staff 1 (Director of Health Services), Staff 3 (MT), and Staff 12 (Facility Services Supervisor) on 06/28/23. They acknowledged the findings.

Action(s) taken:

1. Work order submitted:

a. Gardenview walkway path drop off  was evaluated by maintenance supervisor and landscaping supervisor. Landscaping contractor is now aware they are responsible to monitor and repair excessive drop offs. All are scheduled for repair by 8/1/23.

b. Drop offs inside walkway circle were caused by shrinkage due to lack of irrigation which had been cut off by construction. Irrigation has been repaired.

System correction:

1. Landscaper to fill sidewalk drop offs. Company now understands necessity to prevent tripping hazards and to repair any that develop in the future.

2. Landscaper to report malfunctioning irrigation system to maintenance supervisor for immediate repair.

3. Maintenance supervisor has created a Preventative Maintenance schedule to have sidewalk drop offs evaluated by facility maintenance personnel and schedule regular sidewalk pressure washing.

Method & frequency of evaluation:

1. Landscaper will evaluate drop offs during weekly lawn maintenance.

2. Facility maintenance personnel is scheduled to check drop offs once a month during inspection and following power washing.

Responsible person(s): Maintenance supervisor, Facilities Director, Health Services Director

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

Observations made on 06/26/23 revealed the following areas needed cleaning or repair:

A. On the third floor Residential Care Facility (RCF) unit:

* The chair rails in the common area near nurse's station and near the exam/medication room were chipped, scratched, and rough to touch.

* The two elevator door frames were chipped and scratched.

B. On the second floor RCF unit:

* The two elevator door frames were chipped and scratched.

C. On the MCC unit:

* The second column in hallway had a chipped edge of drywall and paint.

* The exit side of the door to the Health Center was scratched and had chipped paint.

The environment was toured on 06/28/23 with Staff 1 (Director of Health Services), Staff 3 (MT), and Staff 12 (Facility Services Supervisor). The need to ensure all interior and exterior materials and surfaces were kept clean and in good repair was discussed with Staff 1, Staff 3, and Staff 12. They acknowledged the findings.

Action(s) taken:

1. Work order submitted:

a. Gardenview paint and wall repairs to be completed by 8/1/23.

b. RCC chair rail repair and elevator door frames to be painted and/or touched up by 8/1/23.

System correction:

1. Maintenance supervisor to schedule facility painter to routinely inspect wall finishes in licensed care areas for need of repair or touch up and to correct as applicable.

2. Maintenance supervisor to schedule facility maintenance personnel to routinely inspect for physical plant items that are not clean or in good repair and to correct as applicable.  

3. Administrator to train new maintenance crew members on environmental requirements

Method & frequency of evaluation:

1. Inspections and repairs by painter and maintenance personnel will be scheduled in licensed neighborhoods quarterly by way of facility preventative maintenance software.

Responsible person(s): Maintenance Supervisor, Facilities Director, Health Services Director

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 C231, C361, C510, and C513.

Z 142 - Administration Compliance

See C231, C361, C510, C513

Based on interview and record review, it was determined the facility failed to have documented evidence of required pre-service orientation and dementia training completed, demonstrated competency in assigned duties within 30 days of hire for 3 of 3 newly hired direct care staff (#s 26, 27, and 28), and a total of 16 hours of in-service training completed annually, including six hours related to dementia care topics, for 3 of 3 long-term direct care staff (#s 6, 18, and 30). Findings include, but are not limited to:

Staff training records were reviewed with Staff 11 (HR Staffing Coordinator) on 06/28/23. The following deficiencies were identified:

a. There was no documented evidence Staff 26 (Cook), Staff 27 (CG), and Staff 28 (CG) hired 08/13/22, 02/11/23, and 04/18/23 respectively, completed one or more of the following pre-service orientation topics prior to beginning their job duties:

* Abuse reporting requirements; and

* Written job description.

b. There was no documented evidence Staff 27 and Staff 28 completed the following dementia care training topics prior to providing resident care and services to residents independently:

* Dementia disease process, including the 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 of persons with dementia and engaging them with 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 which 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;

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

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

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

c. There was no documented evidence Staff 27 and Staff 28 demonstrated competency in one or more assigned duties within 30 days of hire:

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

* General food safety, serving, and sanitation; and

* Other duties as applicable, including safe medication and treatment administration.

d. There was no documented evidence Staff 6 (RCC), hired 12/07/19, Staff 18 (CG), hired 03/19/18, and Staff 30 (CG/MT), hired 11/20/19, completed 16 hours of annual in-service training which included at least six hours of dementia care training.

The need to ensure all required training was completed in the specified time frames was reviewed with Staff 1 (Director of health Services) and Staff 11 on 06/28/23. They acknowledged the findings.

Z155 Staff Training

Action(s) taken:

1. The erroneously removed pre-service dementia training has been returned to the onboarding training plan and assigned as required for employees who missed it and will be completed by 8/25/23.

2. Skills checkslists will be/have been updated to include both employee's initials/signatures.

3. Monthly inservice content, agenda and length of time are now being added to the Relias attendance module.

System correction:

1. Skills checklist audits will assure they are signed off by both the trainee and trainer and completed by the fourth shift of on-the-floor training. Completed checklists are uploaded into Relias for tracking and visibility on employee transcript.

2. Required dementia trainings are assigned automatically to applicable new hires in Relias. New employees are not released for training on the floor until all Relias trainings are completed. All onboarding training, including the dementia training module, is required to be completed within 30 days of hire and, per Friendsview policy, must be completed before new employees can be scheduled for on-the-floor training.

3. Staffing coordinator will maintain an Inservice Tracker and notify supervisors monthly of compliance/non-compliance for individual employees. Supervisors will follow up with individual employees through Coaching for Success program.

Method & frequency of evaluation:

1. Department Staffing Coordinators, in collaboration with Human Resources, will verify all onboarding trainings have been assigned and completed by applicable employees within time required.

2. Dining Services department will upload food Handler Cards into Relias to make them readily available and to track compliance of renewals.

3. Monthly required inservices are being tracked via a, new to us, system in Relias called "requirement tracker." A list of noncompliant employees is being generated for supervisors. If the employee does not complete the make-up training as assigned by the end of the month, the staffing coordinator will remove them from the schedule until they do.

Responsible person(s): Care Coordinators, Care Managers, Clinical Services Manager, Staffing Coordinators, Health Services Director, Senior Administrative Leadership Team

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 C260, C270, and C280.

Z 162 - Compliance with Rules Health Care

See C260, C270, C280     

Based on interview and record review, it was determined the facility failed to evaluate residents for activities, to develop individualized activity plans from the evaluations, and ensure a selection of daily structured and non-structured activities were provided and included on the resident's activity service or care plan as appropriate based on residents' evaluations for 1 of 1 sampled memory care resident (#8) whose service plan was reviewed. Findings include, but are not limited to:

A review of the service plan for Resident 8 and an interview with Staff 13 (Therapeutic Rec Coordinator) and Staff 14 (Therapeutic Rec Assistant) on 06/27/23 revealed the following:

A. The facility had not completed an activity evaluation which addressed the following:

* Past and current interests;

* Current abilities and skills;

* Emotional and social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for the resident to participate; and

* Identification of activities for behavioral interventions.

B. There was no documented evidence an individualized activity plan had been developed based on their activity evaluation which was reflective of the resident's activity preferences and needs.

C. There was no documented evidence a selection of daily structured and non-structured activities were provided and included on the resident's activity service or care plan as appropriate and based on the resident's evaluation.

The need to ensure the facility completed an activity evaluation addressing the required elements, developed an individualized activity plan based on the evaluation for each resident, and provided daily structured and non-structured activities based on the evaluation was discussed with Staff 1 (Director of Health Services), Staff 2 (Clinical Services Manager), and Staff 4 (Resident Care Manager/LPN) on 06/28/23. They acknowledged the findings.

Z164 Activities

Action(s) taken:

1. Recreation/Activities Evaluation form has been updated for ease of use and to assure all required elements are included.

2. Recreation Coordinator to reevaluate all residents and update service plans based on updated evaluation.

3. Recreation Coordinator and new Resident Care Manager for resident #8 identified activities as behavior interventions.

4. Recreation Coordinator and new Resident Care Manager reviewed recreation supplies and resources available for spontaneous activities between structured events available to resident #8 and all memory care residents.

5. New Resident Care Manager has identified multiple caregiver-driven spontaneous activities to support residents and has begun to teach caregivers about them, directing them toward available tools and resources.

System correction:

1. Recreation evaluation form and review schedule added to electronic medical record.

2. Activities service plan in electronic medical record has been updated to prompt for, at a minimum, person-centered activity preferences, interests and needs, current abilities and skills, social and emotional needs and patterns, physical abilities and limitations, necessary adaptations, and activities identified as behavioral interventions.

Method & frequency of evaluation:

1. Scheduled evaluations and service plan updates will be monitored monthly in electronic medical record to assure completion.

Responsible person(s): Therapeutic Recreation Coordinator, Community Life Director, Health Services Director