Print Inspection: ZC3B

The findings of the change of ownership survey, conducted 11/27/23 through 11/29/23, 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.

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 first revisit to the re-licensure survey of 11/19/23, conducted 02/21/24 through 02/22/24, 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.

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 second revisit to the change of ownership survey of 11/29/23, conducted on 05/14/24 through 05/15/24, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 Home and Community Based Services Regulations.

Based on observation, interview, and record review, it was determined the facility failed to provide a safe and homelike environment for 1 of 1 sampled resident (#2) and one non-sampled resident. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 10/2023 with diagnoses including dementia, altered mental status and agitation.

Resident 2's move-in evaluation stated room lighting was a "behavior trigger" and the resident preferred the lights off during the day, when resting or sleeping.   

Resident 2 shared a room and bathroom with the non-sampled resident. Resident 2's head of bed was positioned next to the bathroom doorway.

Progress notes between 11/01/23 and 11/21/23 indicated verbal conflicts between Resident 2 and the non-sampled resident over lighting in the room and leaving the bathroom door open with the bathroom light on.

In an interview on 11/28/23, Resident 2 stated: "I've had arguments with my roommate about the room and bathroom lights turned on. She/he knows it bothers me and I believe she/he does it on purpose, it's been very frustrating."

A facility "Safety Event Report" on 11/28/23 indicated the non-sampled resident opened the bathroom door while Resident 2 was using the bathroom. Resident 2 was startled and shut the bathroom door on the non-sampled resident's fingers.

In an interview on 11/29/23 an non-sampled resident stated "I don't like my new roommate and we've yelled at each other. I spend more time sitting in the dining room."

On 11/29/23, surveyors observed Resident 2 sitting on the edge of the bed. The non-sampled resident exited the bathroom, leaving the bathroom door open and the bathroom light on. A verbal conflict ensued between the two residents. In response, the facility updated the  residents' service plans and placed a sign on the door "knock[ing] before entering if door closed."

The need to provide a safe and homelike environment for residents was discussed with Staff 1 (ED) and Staff 2 (Health Services Director) on 11/29/23. They acknowledged the findings.

1. Resident 2 moved to room 12A, a shared room. She moved  with all her personal belonging and furniture and will receive assistance in making her room is a home-like environment. Her service plan addressed her preferences in her room, including preferred lighting and having the lights turned off during the day when resting or sleeping.

2. The service plan will be reviewed quarterly at every care conference, and as needed, to ensure that a resident's preferences in her home are  addressed. The service plan will be updated with any new information from incident reports, care conferences, etc as to resident's preferences and/or identified environmental triggers to his behaviors.

3. This will be evaluated at least every quarter and as needed.

4.The administrator will be responsible for the corrections to be completed and monitored.

Based on observation, interview, and record review, it was determined the facility failed to provide a daily activity program of social and recreational activities based on individual and group interests, physical, mental and psychosocial needs, and created opportunities for active participation in the community. Findings include, but are not limited to:

During the survey, the MCC was home to 23 residents.

Random resident observations were made during the survey between 11/27/23 and 11/29/23. Review of the activity calendar and interviews with staff revealed the following:

a. The November 2023 Memory Care Activity Program calendar indicated the following activities would occur on 11/27/23:

* 11:00 am - Bingo; and

* 1:00 pm - Brain Teasers.

b. On 11/28/23, the activity calendar noted the following activities would occur:

* 9:00 am - Stretching;

* 10:00 am - Morning News;

* 11:00 am - Bowling;

* 1:00 pm - Walker/Chair exercise;

* 2:00 pm - Round Table Chat; and

* 3:00 pm - Puzzles.

c. On 11/29/23, the activity calendar noted the following activities would occur:

* 9:00 am - Stretching;

* 10:00 am - Morning News; and

* 11:00 am - Trivia.

The only facility led activity between 11/27/23 and 11/29/23 was Trivia on 11/29/23 at 10:15 am. Throughout the survey from 11/27/23 to 11/29/23, the other scheduled activities were not observed to take place. Residents were observed sitting in TV/dining room areas for long periods of time, sleeping, while a television played continuously, walked the halls, or remained in their rooms unengaged in individual and/or group activities.

Failure to provide a daily activity program of social and recreational activities based on individual and group interests, physical, mental and psychosocial needs, and that created opportunities for active participation in the community was discussed with Staff 1 and Staff 2 (Health Services Director/RN) on 11/29/23. They acknowledged the findings.

1. An activity assessment will be completed Life Enrichment Director/ Health Services Director  for all residents, which will be used to create a resident-centered, individualized activity plan that include personal preferences in leisure activities and entertainment including, but not limited to group vs individual activities, indoor vs outdoor activities, favorite activities, moving vs stationary activities, etc. Each resident's activity plan will be reviewed during care conference to assess for any changes in preferences. The Life Enrichment Director will meet weekly with the Executive Director, RCC, and HSD to review planned activities for the week and how they meet the residents preferences. The Life Enrichment Director will make a plan in how to ensure that each activity in the calendar will be completed by the Life Enrichment Director, or in their absence, a designee.

Care staff will be required to read each resident's individual activity plan and will be trained to encourage, remind, and invite residents to the scheduled activities. Activity stations will be placed throughout the community that allow for residents to spontaneously and independently participate in an activity as desired. Examples of activity stations are a puzzle table, a tactile station, adult coloring books and color pencils, etc. Care staff will be trained to encourage and engage resident in one of the activity stations when they are roaming the halls or otherwise unengaged.

2.The Life Enrichment Director will be responsible for ensuring that all scheduled activities are put on as scheduled and will keep track of which residents participated. Caregivers are to encourage, remind, and invite all residents to participate in activities.

3.The completion of activities as scheduled will be evaluated weekly during the clinical meeting between the Life Enrichment Director, ED, RCC, and HSD.

4.The Executive Director and Life Enrichment Director  will be responsible for the corrections to be completed and monitored.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were available to staff, reviewed quarterly and were reflective of residents' current status and care needs and provided clear instruction to staff for 2 of 4 sampled residents (#s 1 and 4) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 06/2022 with diagnoses including Type II diabetes and heart failure.

Interviews with care staff and observations made during the survey revealed the service plan was not reflective of the resident's care needs and/or did not provided clear instruction in the following areas:

* Use of a hip abduction pillow; and

* Use of Hoyer lift for transfers.

The need to ensure service plans were reflective of the resident's current care needs and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 2 (Health Services Director/RN) on 11/29/23. The findings were acknowledged.

2.  Resident 1 was admitted to the facility in 07/2022. A review of the resident's clinical record showed the most current service plan was a quarterly plan, dated 10/19/23.

During the entrance interview on 11/27/23, facility staff reported service plans were stored in the "care plan binder" for direct care staff to review. Upon observation of the binder stored located on a cart in the unit corridor, the service plan for Resident 1 was dated 07/17/23.

During an interview on 11/29/23 with Staff 1 (ED) and Staff 2 (Health Services Director) the lack of a current service plan and the need to ensure the most current service plan was available to staff  was discussed. They acknowledged the findings.

1. Resident #1's service plan have been updated to include all required components and to accurately reflect their status, needs and preferences. Detailed caregiving instructions were provided. Updated service plans were printed and put in service plan binder for staff to review and sign.

Resident #4's updated service plan was printed and put in the service plan binder for the staff to review and sign.

2.To prevent recurrence, all service plans will be audited weekly by the RCC to reflect the resident's current care and provide clear direction to the staff. RCC will do a weekly audit on the service plan binder to ensure the most current service plan is available to the staff and that staff has read and signed that service plans have been reviewed.

Rotating service plan audits will be conducted monthly by RCC and Health Services Director for accuracy and to ensure that all staff are reading and signing that service plans have been reviewed.

3. This will be audited monthly by RCC and HSD during monthly audits of rotating service plans to ensure accuracy, availability of the most up-to-date service plan to staff, and each staff's signature on the most updated service plan showing that they have read and reviewed.

4. The Executive Director and Health Services  Director  will be responsible for the corrections to be completed and monitored.

Based on observation, interview, and record review, it was determined the facility failed to ensure the service plan was reflective, readily available to staff, and services were implemented for 1 of 3 sampled residents (#2) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 2 moved into the facility in 11/2023 with diagnoses including dementia. The resident's service plan available to staff dated 11/21/23 and temporary service plans from 01/28/24 to 02/21/24 were reviewed, observations were made, and interviews were conducted.

a. The resident's service plan was not implemented in the following areas:

* Nail trimming; and

* Mechanical soft diet.

b. The resident's service plan was not reflective in the following areas:

* Wandering/elopement risk and instructions to staff;

* Roommate status;

* Preference for meals in room; and

* Sleep patterns.

c. During the entrance interview on 02/21/24, facility staff reported service plans and temporary service plans were stored in the "care plan binder" for direct care staff to review. Upon observation of the binder stored located on a cart in the unit corridor at 9:30 am on 02/21/24, the service plan for Resident 2 was dated 11/21/23. Two identical service plans dated 01/20/24 and 02/19/24 were provided by the facility at 1:00 pm on 02/22/24, but these were not available to staff at the time of survey entrance.

The need to ensure current service plans were reflective, available to staff, and implemented was discussed with Staff 1 (ED) on 02/22/24. She acknowledged the findings.

1. Resident #2's service plan have been updated to include all required components and to accurately reflect their status, needs and preferences. Detailed caregiving instructions were provided. Including nail trimming & diet restictions, wandering/elopment risks, roomate status, preference for meals in room and sleep patterns

Updated service plans were printed and put in service plan binder for staff to review and sign.

2. To prevent reoccurance all service plans will be audited weekly by Health Services Director/ Nurse to reflects the current care and provide clear direction to staff. HSD will update service plans with current care /alerts  as they occur.

HSD will do a weekly audit on the service plan binder to ensure the most current service plan is avialbe to staff.

RCC will do a weekly audit make sure that the service plans, alerts, and TSP's are signed and reviewed by the staff.

Service Plan audits will be conducted monthly by Health Services Director and ED for accuracy and to ensure that all staff are reading and signing that service plan have been reviewed.

3.This will be audited monthly by HSD and ED during monthly audits service plans to ensure accuracy, availability of the most up-to-date service plan to staff, and each staff's signature on the most updated service plan showing that they have read and reviewed.

4. The Executive Director and Health Services  Director  will be responsible for the corrections to be completed and monitored.

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. Findings include, but are not limited to:

1. Observations were made during the survey to determine adherence to universal precautions for infection control.

On 11/28/23, approximately 11:40 am, the surveyor obtained permission and observed Staff 4 (Care Associate/CG) and Staff 6 (Care Associate/CG) provide incontinence care to Resident 4.

During the observation, Staff 4 failed to change gloves after removing a soiled incontinent product and wiping urine from Resident 4's perineum. Staff 4 touched a bin to retrieve the resident's barrier cream and applied the barrier cream to the resident's bottom while wearing the same soiled gloves.

The need to ensure staff consistently used universal precautions was discussed with Staff 1 (ED) and Staff 2 (Health Services Director/RN) on 11/28/23. The findings were acknowledged.

2. Lunch service was observed on 11/28/23 and 11/29/23.

Staff were observed setting tables with napkins and silverware, serving meals and beverages, touching residents, removing dirty dishes and opening the kitchenette door without changing their gloves or performing hand washing.

The need to ensure universal precautions for infection control were exercised, including appropriate hand hygiene while serving meals to the residents, was discussed with Staff 1 (ED) and Staff 2 (Health Services Director) on 11/29/23. The findings were acknowledged.

Infection prevention control

1.All staff will be trained and educated on proper hand hygiene, infection control and glove use by Health Services Director/ infection control specialist. Training and education include these following components: standard precautions, infection control, hand hygiene, soiled linens and proper glove use for incontinent care/ toileting, and hand hygiene during dining services.

2.   Signs will be placed in specific caregiver areas such as the break room, bathroom, supply closet, dining room, etc to remind caregivers to wash and/or sanitize hands in between care, prior/to and during meal service, and as often as possible.

RCC/designated staff  will be responsible during meal services to remind care staff to abide by infection control protocols prior to/during meal times.

3. Durng monthly all staff meeting infection control protocols will be reviewed by HSD as a continued refreseher training for all staff.

4. The Executive Director and Health Services Director  will be responsible for the corrections to be completed and monitored.

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. This is a repeat citation. Findings include, but are not limited to:

1. Lunch service was observed on 02/21/24 and 02/22/24.

Staff were observed setting tables with napkins and silverware, serving meals and beverages, touching residents, removing dirty dishes and opening the kitchenette door without changing their single-use gloves or performing hand hygiene in between.

The need to ensure universal precautions for infection control were exercised, including appropriate hand hygiene while serving meals to the residents, was discussed with Staff 1 (ED) on 02/22/24. She acknowledged the findings.

2. Observations of snack pass were made on 02/21/24 and 02/22/24.

Staff 10 was observed to don single-use gloves prior to handling the cart to pass out snacks. She was observed to touch the cart, the serving cups, knock on doors, touch door handles, feed residents, and go from room to room wearing the same pair of single-use gloves and without performing hand hygiene in between tasks.

The need to ensure universal precautions for infection control were exercised, including appropriate hand hygiene while serving snacks to the residents was discussed with Staff 1 (ED) on 02/22/24. She acknowledged the findings.

1. All staff will be re-trained and educated on proper hand hygiene, infection control and glove use by Health Services Director. Training will include standard precautions, infection control and hand hygiene during dining service and snack service.

2. Signs was placed in specific areas in the dining room,kitchen, hallways and specific caregiver areas like kitchen, breakroom and bathroom to remind caregivers to wash and /or sanitize hands between care, when entering and leaving resident room,  prior/to and during meal service.

Single use of gloves are no longer allowed in dining area on meal service or snack service delivery, unless the resident is on contact precautions.  

Hand sanitizers stations were added in the dining room, kitchen and hallways in between rooms for caregivers to use as they enter and leave the room . Also individual hand sanitizers are distributed to caregiver/staff so that they can use it between care/ service.

RCC/ HSD, AD and ED will be responsible during meal services to remind staff to abide by infection control during meal times and snack service.

3.During  monthly all staff meetings infection control protocols will be reviewed by HSD as a continued refreseher training for all staff.

4. The Executive Director and Health Services Director  will be responsible for the corrections to be completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure non-pharmacological interventions were attempted and documented to be ineffective prior to the administration of psychotropic medications for 1 of 1 sampled resident (#1) who was receiving PRN psychotropic medications. Findings include, but are not limited to:

Resident 1 moved into the facility in 07/2022 with diagnoses including vascular dementia with behavior disturbance.

Review of Resident 1's MAR, dated 11/01/23 through 11/27/23, and physician orders revealed the following:

Resident 1 was prescribed quietiapine, 12.5 mg daily as needed for severe agitation prior to wound care, and it was documented as administered to the resident on 11/25/23. The MAR included documentation the medication was administered for "agitation/anxiety".

The facility lacked documented evidence non-pharmacological interventions were attempted and were ineffective prior to administration of the medication.

In an interview on 11/29/23, Staff 5 (MT) confirmed the MAR and electronic system had a "note" space for staff to document non-pharmacological interventions attempted prior to administering the PRN medications, but there had been no information entered on the 11/25/23 administration.

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        On 11/29/23, the need to ensure non-pharmacological interventions were attempted and documented to be ineffective prior to the administration of PRN psychotropic medications was discussed with Staff 1 (ED) and Staff 2 (Health Services Director). They acknowledged the findings.

1.Health Services Director will complete a comprehensive MAR review for Resident #1 and all residents to ensure that resident specific parameters for use of PRN Psychoactive medications as well as adding a trigger for staff to document the resident specific non-pharmacological interventions attempted to be completed by 1-28-24.

Training will provided to all med techs on how to properly document the MAR non-pharmacological intervention attempted by 1-28-2023.

2.The system will be corrected so this violation will not happen again by:

a. Any new order for PRN psychoactive medication to treat mood or behavior issues will be reviewed by the Licensed Nurse through the triple check process.

b. The Licensed Nurse will ensure appropriate resident specific indicators for use are in place as well as non-pharm interventions staff should offer prior to using.

c. All active PRN psychoactive medications will be reviewed prior to quarterly physician orders sent for signature as well as with scheduled PRN medication audits.

3.This area will be evaluated on a quarterly basis prior to sending quarterly physician orders for signature, on a monthly basis with medication administration record audits and daily with triple check review if a new order is received.

On weekly clinicals HSD, ED, and RCC will be reviewing PRN Psychotropic use medications to ensure that non-pharmacological interventions were attempted prior to giving the medication.

4. Executive Director, Health Services Director will be responsible to ensure the corrections are completed and monitored.

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 C260 and C295.

Refer to response for C260 and  C295

Based on observation and interview, it was determined the facility failed to provide a minimum of 80 square feet per resident exclusive of closets, vestibules and bathroom facilities, in apartments occupied by two residents. Findings include, but are not limited to:

During the survey, the following was noted:

* On 11/28/23 and 11/29/23, multiple sampled and non-sampled residents expressed a lack of adequate space in their units. Resident 2 stated his/her bed was positioned against the wall because there was "not enough room for his/her roommate to access the bathroom". An non-sampled resident stated the laundry hamper was "in the way, causing a risk of tripping" because "there is not enough room."; and

* Observations of resident rooms showed limited space for residents to access the bathroom and closet areas in some units, resulting in measurements taken of multiple resident units.

Resident rooms 4 and 5 in the Memory Care unit, had two residents living in each apartment. The living space was measured by two facility staff during the survey. Rooms 4 and 5 measured approximately 12 feet by 12 feet, or 144 total square feet.

Failure to provide each resident a minimum of 80 square feet of living space per resident was discussed with Staff 1 (ED) and Staff 2 (Health Service Director/RN) on 11/29/23 at 12:40 pm. The findings were acknowledged.

Resident Units

1. Residents in the following Rooms will be  moved to provide each resident a minimum of 80 sq feet of living space per resident.

Resident 2 was moved to a different room which is Rm 12 A

Residents at room 4 and 5 will be moved as follows:

a. Resident 5 A and B will be moving to Room 6A & B once room reconfiguration is completed.

b. Room 6B resident will be moving to single Room 5.

c. Resident 4A will be moving to room 1 shared room.

d. Resident 4B will remain in the single room 4.

2.The system will be corrected by keeping  a census sheet whichs specify which room is a single and double occupany. This will be used by the ED / Marketiing.

3.Monthly review of the census sheet by the ED.

4.Executive Director will be responsible to ensire the corrections are completed and monitored.

Based on observation and interview, it was determined the facility failed to ensure the dining area had the capacity to seat 100 percent of the residents and failed to provide lounge and activity areas for social and recreational use. Findings include, but are not limited to:

During the survey, the facility had a combined dining and activity area that included seven tables with the capacity to seat 19 residents. The current census at the facility was 23 residents and the memory care (upper floor) was licensed for a total capacity of 25 residents. Observations of meal service in the dining room on 11/27/23 through 11/29/23 showed residents having difficulty accessing space in the dining area to join in the meal and on 11/28/23, an non-sampled resident was escorted back to their room for a lunch meal as there was no space available to sit in the dining area.

In an interview on 11/29/23, Staff 1 (ED) acknowledged the inadequate space to seat all of the residents and stated they had been considering relocating some furniture to accommodate the residents' needs.

The need to ensure capacity to seat 100 percent of residents in the dining area and provide a lounge and activity space was discussed with Staff 1 and Staff 2 (Health Services Director) on 11/29/23. They acknowledged the findings.

Dining Area

1. Dining room will have a reconfiguration of tables and chairs. Piano will be transferred  downstairs in dining room to give more room for additional seating in the dining room. That would provide the capacity to seat 100 percent of the resident in the dining area.

Please see attached floor plans.

To correct the lack of lounge and activity area, the current ED office will transitioned to activity area and lounge for social and recreational use for the residents.

2. The system will be corrected by creating a lounge/ activity area for the resident for social and recreational use.

3. This area will be evaluated quarterly to ensure that 100 percent seating is avaialbe in dining room and activity area/ lounge is accessible to resident for social and recreational use.

4. Excutive Director will be responsible for the corrections to be completed and monitored.

Concerns were identified in the following areas and the facility was provided with technical assistance:

The setting needs to be integrated in and support the same degree of access to the greater community as people not receiving HCBS, including opportunities for individuals enrolled in or utilizing HCBS to: (B) Engage in greater community life.

Specifically related to key locked elevator doors that impeded resident access to all floors of the community when the RCF with endorsed memory care was operating solely as a memory care community in which all areas of the community were secured.

Concerns were identified in the following areas and the facility was provided with technical assistance:

H1512 - Optimize Settings: Independence, Activities:

(1) Residential and non-residential HCB settings must have all of the following qualities: (d) The setting optimizes, but does not regiment, individual initiative, autonomy, self-direction, and independence in making life choices including, but not limited to, daily activities, physical environment, and with whom to interact.

Refer to H 1501

Concerns were identified in the following areas and the facility was provided with technical assistance:

H1515 - Physical Setting: Individual Accessible:

(2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (b) The setting is physically accessible to an individual. Refer to 1501

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 C200, C242, C515 and C522.

Refer to response C 200, C242, C515 and C522

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 C260, C295 and C330.

Please refer to C260, C295, and C330

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. This is a repeat citation. Findings include, but are not limited to:

Refer to C260 and C295.

Refer to response for C260 and C295

Based on observation, interview, and record review, it was determined the facility failed to evaluate each resident for activities and develop an individualized activity plan for each resident based on the activity evaluation for 2 of 4 sampled residents (#s 1 and 4) whose activity plans were reviewed. Findings include, but are not limited to:

1. Resident 4 moved to the memory care facility in 06/2022 with diagnoses including Alzheimer's disease.

During the survey, Resident 4 was observed needing assistance and encouragement from staff to initiate, attend, and participate in activities. The facility did not offer group activities.

The activity section of Resident 4's current service plans were reviewed. Though there was some information about the resident's past or current interests, the facility had not fully evaluated the residents':

* Current abilities and skills;

* Emotional and social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for participation; and

* Activities that could be used as behavioral interventions.

There was no specific activity plan which detailed what, when, how and how often staff should offer and assist the residents with individualized activities. There were no instructions for providing activities for residents who did not participate in group activities.

The need to develop individualized activity plans which were based on a thorough evaluation of the resident's interests, abilities and needs was discussed with Staff 1 (ED) and Staff 2 (Health Services Director/RN) on 11/29/23. The findings were acknowledged.

2. Resident 1 moved to the memory care facility in 07/2022 with diagnoses including vascular dementia with behavioral disturbance. Resident 1's service plan offered some information about the residents' historical interests, however, the facility had not fully evaluated the resident's current abilities and activity needs, including:

* Emotional and social needs;

* Physical abilities and limitations;

* Adaptations necessary for the resident and

* Activities that could be used for behavioral interventions.  

There was no specific activity plan that detailed what, when, how and how often staff should offer and assist the resident with individualized activities s/he would benefit from.

On 11/29/23 the need to ensure the facility evaluated each resident and provided an individualized activity plan for each resident was discussed with Staff 1 (ED), Staff 2 (Health Services Director) and Staff 3 (Activities Director) who acknowledged the findings.

1. An activity assessment will be completed Life Enrichment Director/ Health Services Director  for  all residents, which will be used to create a resident-centered, individualized activity plan that include personal preferences in leisure activities and entertainment including, but not limited to group vs individual activities, indoor vs outdoor activities, favorite activities, moving vs stationary activities, etc. Each resident's activity plan will be reviewed during care conference to assess for any changes in preferences. The Life Enrichment Director will meet weekly with the Executive Director, RCC, and HSD to review planned activities for the week and how they meet the residents preferences. The Life Enrichment Director will make a plan in how to ensure that each activity in the calendar will be completed by the Life Enrichment Director, or in their absence, a designee.

Care staff will be required to read each resident's individual activity plan and will be trained to encourage, remind, and invite residents to the scheduled activities. Activity stations will be placed throughout the community that allow for residents to spontaneously and independently participate in an activity as desired. Examples of activity stations are a puzzle table, a tactile station, adult coloring books and color pencils, etc. Care staff will be trained to encourage and engage resident in one of the activity stations when they are roaming the halls or otherwise unengaged.

2.The Life Enrichment Director will be responsible for ensuring that all scheduled activities are put on as scheduled and will keep track of which residents participated. Caregivers are to encourage, remind, and invite all residents to participate in activities.

3.The completion of activities as scheduled will be evaluated weekly during the clinical meeting between the Life Enrichment Director, ED, RCC, and HSD.

4.The Executive Director and Life Enrichment Director  will be responsible for the corrections to be completed and monitored.