Print Inspection: ZBIJ

The findings of the re-licensure survey, conducted 2/15/22 through 2/17/22, 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.

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

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first re-visit of the re-licensure survey on 02/17/22, conducted from 07/18/22 through 07/20/22, 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, and OARs 411 Division 57 for Memory Care Communities.

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 02/17/22, conducted on 02/21/23, 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, 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 provide effective oversight to ensure quality of care and services that were rendered in the facility. Findings include, but are not limited to:

During the survey, conducted 02/15/22 through 02/17/22, administrative oversight to ensure adequate resident care and quality of services rendered in the facility were found to be ineffective based on the number of citations.

Refer to deficiencies in report.

ED will complete 40 hour admin class and apporoved administrator course required for Oregon Health licensing.   

The community will hire an outside state approved consultant to provide additional oversight and training and oversight the new leadership team through the next 4-6 weeks.

Quartley reivew of systems and on going quality assurance will be reviewd with ED and ops support.

Operations support and Mosaic Management.

Based on observation and interview, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety, or welfare of residents. Findings include, but are not limited to:

Observations during survey, conducted 02/15/22 through 02/17/22, multiple Oregon Department of Human Services (ODHS) infection control guidelines, which were established to protect the facility staff and residents from the spread of COVID-19 and made available to all facilities, were not being followed by the facility. The following issues were identified:

* The facility was not consistently screening visitors or outside providers upon entering the building;

* Staff were unaware of the screening procedure for visitors;

* The PPE cleaning and storage area was disorganized with scattered PPE and garbage containing used PPE was uncovered and overfilled;  

* A used face shield was found on a shelf in the dry food storage area;  

* A caregiver was observed touching her mask multiple times without subsequent use of hand sanitizer or washing hands. That same caregiver was observed in the serving area preparing snacks for the residents without wearing any PPE; and

* The facility failed to ensure residents were assisted with hand hygiene throughout the day.

The need to ensure the facility practiced effective methods of infection control and conducted regular auditing of those practices was discussed with Staff 3 (Admin Assistant) and Staff 12 (Operations Personal Support) on 02/17/22. They acknowledged the findings.

All staff will be required to take the Oregon Care Partners COVID precautions class online.

All staff will be provided training on reporting signs and symptoms of COVID along with what actions need to be taken when a resident exhibits signs or symptoms of COVID.

All staff will be retrained on the procedures for screening visitors upon entering the community.

All staff will be retrained on the proper guidelines for donning and doffing face shields. Information will also be posted in all break rooms and will be reviewd monthly at all staff meetings.

The ED will provide oversight.

2. The following observations were made during the lunch meal on 07/18/22:

* Staff 20 (MT) failed to sanitize her hands between residents when she passed medications.

* A resident was observed to touch the handle of a communal water dispenser with her hand and the spout with her used glass. Care staff and Staff 14 (ED) were apprised immediately of the potential for the spread of infection related to the use of the communal water dispenser.

The need to ensure reasonable precautions were exercised against any condition that could threaten the health, safety or welfare of the residents was discussed with Staff 14, Staff 12 (Operations Personal Support), Staff 15 (Home Office RN), Staff 3 (Administrator Assistant), and Staff 16 (Resident Services Manager) on 07/20/22. They acknowledged the findings and reported the communal water dispenser had been removed.

Based on observation and interview, it was determined the facility failed to implement effective methods of infection control. This is a repeat citation. Findings include, but are not limited to:

1. The use of medical masks by all staff is required during the COVID-19 pandemic.

On 07/18/22, Staff 16 (Resident Services Manager) was observed without a mask on while eating food inside an office with an unsampled resident present.

On 07/18/22, the need to ensure all staff were appropriately and consistently using Personal Protective Equipment during the COVID-19 pandemic was discussed with Staff 14 (Executive Director) and Staff 16. They acknowledged the findings.

All staff will follow proper infection control precautions while caring for residents.  The communal water dispenser was removed during visit and will not be reinstated.

All staff will be in-serviced on the necessity of wearing masks appropriately and consistentley as requiered

Managers will round on the floor daily and monitor proper infection control practices are being followed.  Immediate education will be provided and documented for any staff found not following proper infection control precautions.

Executive director or designee will be responsible for ensuring compliance.  

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-0000. Findings include, but are not limited to:

a. The servery of the Memory Care Community was toured on 02/16/22. The following areas were in need of cleaning or repair:

* Food splatters and particles inside the refrigerator and microwave;  

* Undated opened foods and condiments in the refrigerator;

* Debris on bottoms of drawers and cabinet shelves;

* Accumulation of dust and debris along perimeter of the baseboards; and

* Unfastened kick plate below the stove.

b. Meal service for the Memory Care unit was observed on 02/17/22 at 12:30 pm. Food was cooked at the main kitchen in the Assisted Living Building. The food was covered with aluminum foil, and transported on a pushcart to the unit, where it was served and plated to the residents. Staff reported they were unable to use the heated meal cart for it required two people for maneuvering and they both could not leave the building. The lunch meal temperatures were not taken prior to serving the residents. Three unsampled residents reported the food was not always hot when served, excessive wait times for meals, menus not being offered and condiments such as butter were not provided with the meals.

The findings and concerns were reviewed with Staff 3 (Admin Assistant) and Staff 12 (Operations Personal Support) on 02/17/22. They acknowledged the findings.  

The kitchen will receive a deep clean by the new dining manager and team.

Daily, weekly and monthly cleaning tasks sheets will be implemented to include daily sign off by the kitchen team. The Dining Manager will assure completion daily.

The ED will inspect the kitchen weekly with the new Dining Manager to assure compliance.

The ED will complete a weekly on one meeting with the new Dining Manager to assure compliance is being met.

The new Dining Manager has been provided training offsite and will implement the weekly QA programs in the kitchen and complete his own weekly QA.

The Dining Manager will have a kitchen team meeting weekly for the next 4 weeks and 2 times monthly after to provide training and oversight to general cleaning, food storage, labeling and overall kitchen compliance needs.

The new Dining Manager will track food delivery times for the next 4 weeks to assure and evaluate the delivery times. This will be evaluated daily at stand up with all managers and the ED.

Meals will be tempted prior to serving from the steam tables to the residents and tracked on the temperature charts. The new Dining Manager will review temperature charts daily to assure compliance is met.

The Dining Manager will implement a QA tool that requires that cooks taste all meal prior to being served and review all dining feedback cards with the team.

All staff will receive retraining on proper handwashing, and this will be observed by the new Dining Manager daily and observations tracked on the Dining Manager weekly QA followed by a weekly one on one meeting with the Dining Manager.

The ED will provide oversight.

Based on interview and record review, it was determined the facility failed to ensure initial move-in evaluations addressed all required elements and included accurate and sufficient information to develop an initial service plan to meet the resident's needs, for 1 of 1 sampled resident (#3) whose initial move-in evaluation was reviewed. Findings include, but are not limited to:

Resident 3's initial move-in evaluation, dated 01/31/22, failed to address the following required elements:

* Personality, including how a person copes with change or challenging situations; and

* Environmental factors that impact the resident's behavior including, but not limited to: Noise, lighting, room temperature.

The new move-in evaluation was reviewed with Staff 2 (RN), Staff 3 (Admin Assistant) and Staff 12 (Operations Personal Support) on 02/17/22. They acknowledged the findings.

Resident 3 service plan and evaluation has been updated to include personality, including how this resident cope with change or challenging situations to include environmental factors that impact the resident's behavior including noise lighting and room temperature.

All resident service plans and evaluations will be audited to assure that all these areas are addressed in in each service plan.

The leadership team will receive additional training in regard to the move in evaluations requirements.

Initial, Quarterly, and COC.

The ED will provide oversight.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that consisted of the resident, the resident's legal representative if applicable, any person of the resident's choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services, for 2 of 2 sampled residents (#s 1 and 2) whose service plans were reviewed.  Findings include, but are not limited to:

Resident 1 and 2's most recent service plans lacked documentation that a Service Planning Team reviewed and participated in the development of the service plans.

The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (Executive Director) and Staff 3 (RN) on 02/16/22. They acknowledged there was no service planning team.

The management team will meet each Wednesday and review all service plans that are due and complete the QA tool that is labeled Interdisciplinary Team Meeting. All Managers will be required to attend.

Service plan reminder letters will be mailed to families, caseworkers and residents at the beginning of each month with a proposed time and date to review the service plan.

All current families, residents and caseworkers will be given a copy of their current service plans.

Initial, 30 day, Qaurterly and COC.

The ED will provide oversight.

Based on observation, interview and record review, it was determined the facility failed to provide sufficient numbers of caregiving staff to meet the 24 hour scheduled and unscheduled needs of residents to compensate for staff duties beyond direct resident care. Findings include, but are not limited to:

The facility was an endorsed Memory Care Community home to 35 residents at the time of the relicensure survey. During the acuity interview on 02/15/22 the facility was identified to have residents with high ADL care needs, behavioral interventions and dementia diagnoses.   

The MCC Staffing Plan posted on the wall indicated two caregivers and one med tech per day and evening shift and one caregiver and one med tech for the overnight shift.

During observations and interviews, it was revealed that staff were not direct caregivers, but universal workers. In addition to caregiving and medication duties, staff were observed to provide:

* Housekeeping;

* COVID-19 Infection Control procedures;

* Laundry service for all residents; and

* All meal service including, preparing, serving, delivering, cleaning, and providing hydration and snacks throughout the day.

The regulation required that if a facility used universal workers, whose duties included other tasks (i.e., housekeeping, laundry, food service, etc.), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services. That number was not increased to meet resident needs.

Staff 3 (Admin Assistant) was asked during the survey if she could provide a copy of the facility's procedure for determining appropriate staffing levels. A screen shot of the current acuity report was provided.

The acuity report failed to evaluate residents ADL care needs and service needs and the facility's procedure to determine staffing levels based on the calculated number was not provided.

Observations and interviews during the survey on 02/15/22 through 02/17/22 revealed the following:

* No activities were offered. At times, a television was left on in the dining room and living room;

* There was no designated activity worker on the unit and there was no available activity calendar or schedule;

* Multiple residents wandered the halls confused and two residents were observed to go in out of other resident's rooms;

* Multiple residents had a disheveled appearance;

* Residents' meals were cooked from the main kitchen in the Assisted Living Building. Caregivers were responsible for transporting the food from main kitchen to the MC. Caregivers were unable to use the heated meal cart because it took two people to maneuver and there was not enough staff to leave the building. A regular pushcart was used. Caregivers had to dish out the food individually on plates, serve to the residents, clean up after the meals and do the dishes;

* Unsampled resident interviews during the lunch meal on 02/17/22, expressed the following concerns: long wait times for meals, residents waiting so long in the dining room, they get up and walk away, by the time the food gets here, it is always cold, and there's only one caregiver serving the dining room; and

* An interview with a caregiver reported, she had left work at 3pm last week and the residents had still not received their lunch.

The need to ensure sufficient number of caregiving staff to meet the 24 hour scheduled and unscheduled needs of residents to compensate for staff duties beyond direct resident care was discussed with Staff 3 (Admin Assistant) and Staff 12 (Operations Personal Support) on 02/17/22. No additional information was provided.

The community will initiate the staffing acuity tool provided by the state until an in-house tool is approved for use.

A complete review of resident acuity will be completed by shift to assure appropriate staff are scheduled to work to meet the scheduled and unscheduled needs of the residents.

Staff turnover will be evaluated weekly by the ED and management team at every level. Exit interviews will be conducted for all staff that are termed.

The Community will have a staffing agency contract in place for emergency use.

Dining room attendants/servers will be added to the staffing plan for the kitchen.

A laundry attendant that focuses on resident laundry will be added to the staffing.

An activity calendar has been posted.

This will be reviewed and updated daily depending on resident needs.

The ED will provide oversight.

Based on interview and record review, it was determined the facility failed to ensure the minimum staffing requirement, per the condition placed by the Department of Human Service on 6/14/22, to ensure the 24-hour scheduled and unscheduled needs of the residents were met, was satisfied. This is repeat citation. Findings include, but are not limited to:

The 06/14/22 condition per the Department of Human Service required the facility to have three care partners and one medication technician on both the day and swing shifts, and one care partner and one medication technician on the night shift.

The posted staffing schedule on 07/18/22 indicated the facility staffed 2.5 care partners and one medication technician on the day and swing shifts.

Staff 10 (Care partner), Staff 19 (MT), and Staff 21 (Care partner) reported during interviews on 07/18/22 and 07/19/22 that they were often short-staffed on the day and swing shifts.

Review of the 07/10/22 through 07/17/22 staffing schedule and payroll records revealed the facility failed to meet the required the minimum staffing requirements on the following dates and shifts:

07/10/22: Day and swing shifts;

07/11/22: Day shift;

07/12/22: Day and swing shifts;

07/13/22: Swing shift;

07/16/22: Swing shift; and

07/17/22: Day and swing shifts.

The failure of the facility to ensure the minimum staffing requirements to ensure the 24-hour scheduled and unscheduled needs of the resident were met per the condition placed by the Department of Human Service on 06/14/22 was discussed with Staff 14 (ED) Staff 12 (Operations Personal Support), Staff 15 (Home Office RN), Staff 3 (Administrator Assistant) and Staff 16 (Resident Services Manager). No further documentation was provided.

Facitily will ensure staffing levels are met per the acuity based staffing tool.

Community is actively hiring through ads on indeed, communicating with agency to meet any shortages.

Staff shcedules will be reviewed daily at stand up to ensure adequate staffing levels are met.

Executive director or designee will be reponsible for ensuring proper staffing levels.

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

Fire and life safety records for August 2021 through January 2022 were reviewed with Staff 4 (Maintenance) on 02/17/22 . Staff 4 revealed the facility did not relocate or evacuate the  residents during the monthly fire drills. Therefore, documentation was lacking regarding the escape route used, residents who resisted or failed to participate in the drills, evacuation time period needed, and number of occupants evacuated.

The need to evacuate residents during fire drills unless there was documented evidence an alternative fire drill plan had been developed with the Oregon Fire Authority and documentation of the fire drills included all necessary components was discussed with Staff 3 (Admin Assistant) and Staff 4 on 02/17/22. They acknowledged the findings.

The ED and Maintenance Manager will receive training on the rules regarding the requirements for fire drills by the Director of Environmental Services at Mosaic.

Moving forward, documentation of resident participation and routes of evacuation will be reviewed by ED after each fire drill.

Monthly

ED will provide oversight.

Based on interview and record review, it was determined the facility failed to provide evidence that evacuation assistance to residents from the building to a designated point of safety were used during fire drills, that staff were aware of the designated point of safety, and that residents received training about the facility's fire and safety procedures within 24 hours of move in and annually. Findings include, but are not limited to:

Fire and life safety records reviewed on 02/17/22, for August 2021 to January 2022 lacked the following components:

* The facility was not evacuating residents to a designated point of safety during fire drills;

* Interviews with staff on 02/17/22, revealed they did not consistently know the designated point of safety; and

* There was no documented evidence the facility was instructing residents on fire and life safety procedures within 24 hours of move in and annually.

The need to ensure the facility provided evacuation assistance to residents to a designated point of safety, and residents received training about the facility's fire and safety procedures was discussed with Staff 3 (Admin Assistant) and Staff 4 (Maintenance) on 02/17/22. They acknowledged the findings.

The ED and Maintenance Manager will receive training on the rules regarding the requirements for fire drills by the Director of Environmental Services at Mosaic.

All staff will be trained on alternate evacuation routes and proper fire drill policy and procedures.

Monthly

ED will provide oversight.

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 160, C 360, C 555, and Z 155.

Refer to C 160, C 360, C 555, and Z

155.

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

Observations and interviews during the survey on 02/16/22 and 02/17/22 identified the following:

* Carpet throughout the common areas and hallways had spots and stains;

* Multiple resident doors and walls had splatters, drips, and chips;

* Furniture throughout the facility including chairs, benches and tables had stains;

* The lower aspect of the kitchenette bar counter located in the living room had pieces missing along the base exposing wood;

* The utility/laundry room needed to be cleaned and sanitized;

* Room 9 had pieces of ceiling caulk that had fallen onto the carpet. Staff 4 (Maintenance) stated there had been a leak from the ceiling and they were in the process of fixing it and they would move the resident until it was fixed; and

* Room 16 had sputum on the walls, floor, and bed. Staff reported the resident does this all over his/her room on a daily basis and they have tried many interventions; however, the resident continues the behavior. Housekeeping routinely cleans the room and the facility was working on getting housekeeping help on the days the housekeeper was off.

The areas in need of cleaning and repair were reviewed and discussed with Staff 3 (Admin Assistant) and Staff 12 (Operations Personal Support) on 02/17/22. They acknowledged the findings.

Carpets are scheduled to be cleaned and are added to a monthly cleaning schedule.

All touch up paint is scheduled to be completed.

The utility room has been cleaned.

Weekly cleanliness QA walk through program has been implemented.

A housekeeping checklist to report repairs will be implemented so that each apartment in the community is reviewed weekly for repair needs.

Room 9 is scheduled for caulking repair.

Room 16 is scheduled for a deep cleaning and evaluation of the resident's appropriateness is underway.

Faciltiy walk throughs will be implimented daily.

The ED will provide oversight.

Based on observation and interview, it was determined the facility failed to have an operational call system that connected residents' units to the care staff.  Findings include, but are not limited to:

On 02/17/22, the surveyor tested room two's call system. After ten minutes, the surveyor walked out of the room and asked staff 5 (MT/Care partner) how they were alerted to residents call lights. Staff 5 stated the staff carry a fob that shows a call light was activated. When asked if there was an alert for room two. She stated she did not have a fob. Staff 5 went into the room where the fobs were kept, and the two fobs were on the counter unplugged and not charged. Staff 5 proceeded to charge them. There were no other fobs available for staff.

The need to ensure the facility provided a call system that connects residents units to care staff was discussed with Staff 3 ( Admin Assistant) and Staff 12 (Operations Personal Support) on 02/17/22. They acknowledged the findings.

Contacted Ciscor, our call system company. All residents have been entered into the system. BOM is entering in all staff members for correct log in information. We have more Ipods for our notifications in route. ED went into Ciscor and seperated Assisted Living and Memory Care pull cord calls.

BOM will be entering in all new staff and residents into the system as soon as they are hired or moved into the facility. All managers, during walk throughs are going to ensure that all staff have their Ipods on them and are logged into the system. ED, RN, BOM will have Ciscor on their laptops and will be able to hear and see all resident calls that are going off.

This will be reviwed daily from several managers during our daily routine walk throughs.

ED will provide oversight.

Based on observation and interview, it was determined the facility failed to have an operational call system that connected residents' units to the care staff. This is a repeat citation. Findings include, but are not limited to:

On 07/18/22, Staff 19 (Care partner) was asked to activate a resident call light. After activating a call light, Staff 19 explained that the call system alerts iPods, but that only one was currently available and was charging. In addition, Staff 19 reported that many staff did not have the ability to log in to activate the iPod. The activated iPod was found beeping on the charger in an empty room behind a closed door. Staff 17 (Care partner) and Staff 21 (Care partner) reported they were not carrying iPods connected to the call system.

The need to ensure the facility provided a call system that connected residents' units to care staff was discussed with Staff 14 (Executive Director) on 07/19/22. She acknowledged the findings.

Community has an operational call system that connects resident units to care staff.

All care staff have been in-serviced on use of the call system.  All staff have been re-instructed on log in and password for use of call system.

Random auidts will be done by maintenance to ensure staff are using the ipods.

Administrative assistant/RSM will train all new staff on the use of the ipods.  

Execuitve Director or designee will be responsible for ensuring staff are using the call system

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 150, C 160, C 240, C 360, C 420, C 422, C 510, C 513 and C 555.

Refer to C150, C160, C240, C360, C420, C422, C510, C513, C555

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 160, C 360, C 455 and C 555.

Refer to C 160, C 360, C 455 and C 555

Based on interview and record review, it was determined the facility failed to ensure 3 of 4 newly hired direct care staff (#s 9, 11 and 13) had documentation of demonstrated competency in all required training topics within 30 days of hire. Findings include, but are not limited to:

Review of staff training records on 02/17/22, identified Staff 9, 11, and 13 (Carepartners), hired on 12/13/21, 12/06/21 and 12/15/21 respectively, lacked the following documentation of demonstrated competencies within 30 days of hire:

* Role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Changes associated with normal aging;

* Identification, documentation and reporting of changes of condition; and

* Conditions that require assessment, treatment, observations, and reporting.

The need to ensure newly hired staff demonstrated competency in all required areas within 30 days of hire was discussed with Staff 3 (Admin Assistant) on 02/17/22. She acknowledged the findings.

Completed full audit on all staff to assurre all new hire paperwork is completed, 30 day check ins are being completed on time.

Monthly Audit of employee records, QA tool will be utilized to assure compliance.

Monthly

ED will provide oversight.

Based on interview and record review, it was determined the facility failed to ensure 2 of 4 newly hired direct-care staff (#s 19 and 20) had demonstrated competency in all assigned job duties prior to independently providing resident services. This is a repeat citation. Findings include, but are not limited to:

Training records were reviewed on 07/19/22. The following deficiencies were identified:

1. Staff 20 (MT) was hired 07/05/22. The Med Tech Training Skills Checklist was signed by Staff 20 on 07/18/22 and had not been signed by the trainer. Staff 20 was observed independently passing medications on 07/18/22 and 07/19/22.

The survey team received a signed note on 07/19/22 from Staff 14 (ED) stating Staff 20 would not pass medications independently until the trainer had completed the Skills Checklist.

2. Staff 19 (MT) was hired 06/07/22. The Med Tech Training Skills Checklist was signed on 07/11/22 by Staff 19 and by a trainer on 07/19/22. Staff 19 was on the Staff Schedule 07/03, 07/04 and 07/10 as an independent Med Tech. Staff 19 was observed independently passing medications on 07/18/22.

The need to ensure all newly-hired staff demonstrated competency in all assigned job duties prior to independently providing resident services was discussed with Staff 14 (Executive Director) and Staff 16 (Resident Services Manager) on 07/19/22. They acknowledged the findings.

All staff who work independently will have demonstrated compentecy within 30 days of hire.  

Immediately following demonstrated compentecy on a particular task the trainer will sign off on the trainee's checklist

All staff records have been audited to assure compentencies are completed and current.  Skills checklist will be reviewed twice monthly  

Executive Director or designee will audit skills checklist monthly for compliance.

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

Refer to C 252 and C 262.

Refer to C252 and C262

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

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

The need to develop individualized service plans addressing residents' nutrition and hydration needs was discussed with Staff 3 (Admin Assistant) and Staff 12 (Operations Personal Support) on 02/17/22. They acknowledged the findings.

Full audit of all resident service plans to ensure they all have an individualized nutrition and hydration plan in place.

Service planning team will be implimented with ED, RN, other staff, family and the residents.

Initial, Quarterly and COC.

ED will provide oversight.

Based on observation, interview and record review, it was determined the facility failed to consistently provide meaningful activities for all residents that promoted or helped sustain the physical and emotional well-being of the resident, and failed to ensure an individualized activity plan was developed for each resident based on their activity evaluation, for 1 of 2 sampled residents (#1) whose service plans were reviewed. Findings include, but are not limited to:

Resident 1's service plan offered some information about the resident's interests, but the facility had not fully evaluated the resident's:

* Current abilities and skills;

* Emotional and social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for the resident to participate; and

* Activities that could be used as behavioral interventions, if necessary.

Observations on 02/16/22 and 02/17/22 showed multiple residents wandering the halls, one entering other resident's rooms and residents seated in the TV area for extended periods of time without consistent interaction or intervention from staff.

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

The need to ensure all residents had individualized activity plans developed and implemented to engage them in meaningful activities was discussed with Staff 2 (RN) on 02/16/22 and Staff 3 (Admin Assistant) on 02/17/22. They acknowledged the findings.

Refer to tag C262

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

The MCC was toured on 02/16/22 and 02/17/22. Resident rooms including, but not limited to 10, 11, 12, 14, 15, 16, 18, 20, 21, 22  and 23 lacked any means of identifying the room for the resident.

The need to ensure each resident room was identified to assist the resident in identifying their room was reviewed with Staff 3 (Admin Assistant) and Staff 12 (Operations Personal Support) on 02/17/22. They acknowledged the findings.

Mangagers are going to perform daily walk throughs. All resident name plates have been corrected. Facility will indivualize resident shadow box'.

Daily walk throughs from managers. Changing name plates as soon as a resident moves in or moves out. Notifying families before a resident moves in, to please assist with making a shadow box for their loved one.

Daily, with manager walk throughs.

ED will provide oversight.