Print Inspection: Z83G

Based on interview and record review, conducted during a site visit on 01/02/24, it was confirmed that the facility failed to ensure that prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training for 3 of 3 sampled staff (#4, 5 & 6) staff whose training records were reviewed. Findings include, but are not limited to the following:

In an interview on 01/02/24, Staff 1 (Administrator) stated staff complete dementia training as part of the facility's orientation program and the facility uses a Memory Care Orientation and Training Checklist.

A review of Staff 4 (Med Tech), Staff 5 (Med Tech) and Staff 6s' (Caregiver) training records indicated 1 of 3 (# 6) staff did not have a completed Memory Care Orientation and Training Checklists.

Training records for 3 of 3 staff lacked training in the following areas:

* Education on the 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, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses;

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

* Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to:

· Identify and address pain;

· Provide food and fluids;

· Prevent wandering and elopement; and

· Use a person-centered approach.

In an email correspondence on 01/11/24, Staff 1 stated the facility primarily uses Relias for pre-orientation memory care training and the checklist is done in addition to the online training.

The facility failed to ensure that prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Administrator) and Staff 2 (Life Enrichment Director).

Facility Verbal Plan of Correction: Administrator and life enrichment director will complete an audit of staff training records to determine if other staff are missing pre-service dementia training and review OAR to ensure staff and facility is complying with pre-service training requirements.

Based on observation and interview, conducted during a site visit on 01/02/24, it was confirmed the facility failed to have a secured janitor closet for storing supplies and equipment; and have the capacity for locked storage of chemicals and equipment. Findings include, but are not limited to the following:

In a walkthrough of Emerald house at 11:05 am on 01/02/24, the laundry room  'Out' door was observed to be partially ajar. Laundry detergent, laundry chemicals and cleaning chemicals were observed in the unlocked laundry room.

In a walkthrough of Astor house at 1:39 pm on 01/02/24, the housekeeping closet was observed to be unlocked with a housekeeping cart and multiple chemicals present. At 1:41 pm, the laundry room was observed to be unlocked with laundry detergent and chemicals present.

In an interview on 01/02/24, Staff 7 (med tech) stated the laundry room door lock in Emerald house is broken and maintenance is supposed to come fix it. S/he stated chemicals that staff use for cleaning get stored in the janitors closed which is locked.

The facility failed to have a secured janitor closet for storing supplies and equipment; and have the capacity for locked storage of chemicals and equipment.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Administrator) and Staff 2 (Life Enrichment Director).

Facility Verbal Plan of Correction: The administrator will ensure maintenance fixes the broken lock on the laundry room door by the end of the day and they will have an in service to ensure staff know to keep chemical storage locked.