Print Inspection: ZD5W

Based on interview and record review, conducted during a site visit on 04/01/24 and 04/04/24, it was confirmed the facility failed to ensure resident records are kept for a minimum of three years after the resident is no longer in the facility. Findings include, but are not limited to:

In an interview on 04/01/24, Staff 1 (Executive Director) stated the facility had a change of ownership and management in October of 2023. S/he stated the records from the previous ownership are incomplete and what they do have is unorganized in boxes.

The facility was unable to provide documentation for several residents that were requested.

The facility did not ensure resident records were maintained during the transfer of ownership in October 2023.

The findings of the investigation were reviewed with and acknowledged by Staff 2 (Consultant), Staff 3 (Regional) and Staff 4 (Administrator) via phone call on 05/17/24.

Verbal Plan of Correction: The concierge was to spend a couple days a week to organize the archive room and label bankers boxes with names to make files easier to locate.

Based on observation and interview, conducted during a site visit on 04/01/24 and 04/04/24, it was confirmed the facility failed to provide three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables and ensure food is prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules). Findings include, but are not limited to:

On 04/01/24 at 12:03 Resident 10 was observed to be served a regular lunch, but with no meat as the other residents were observed to have. Resident was not observed to be offered the alternative taco soup that was available.

On 04/04/24 at 8:00 am Resident 10 was served a regular texture meal, but the breakfast sausage was observed to be withheld. No alternative protein was observed to be offered.

In an interview on 04/04/24 Staff 8 (Caregiver) stated s/he removed the meat from Resident 10's lunch because it was dry and tough and s/he didn't want Resident 10 to choke. S/he did not know how the resident would get protein.

On 04/04/24 at 7:08 am the kitchenette was observed. There was an open milk jug in the refrigerator with no lid and an open energy drink. There was cottage cheese, lettuce, cantaloupe and mandarin oranges in the food storage containers with no dates. Several individual servings of food in Styrofoam containers were unlabeled and undated. An open basket of leftover food with no lid and no date was also observed.

In an interview on 04/04/24, Staff 4 (Administrator) stated s/he was not sure when any of the food was put in the fridge and was unaware things should be labeled and dated.

The facility failed to provide three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables and ensure food is prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules).

The findings of the investigation were reviewed with and acknowledged by Staff 2 (Consultant), Staff 3 (Regional) and Staff 4 (Administrator) via phone call on 05/17/24.

Facility Verbal Plan of Correction - Administrator ensured fridge was to be deep cleaned, equipped with thermometer and temperature sheet. Care staff received instructions to label with open and discard dates. This was to be monitored by Administrator. A dietary binder with image of residents and dietary restriction had been created and would be available in kitchenette for staff.

Based on observation, interview and record review, conducted during a site visit on 04/01/24 and 04/04/24, it was confirmed the facility failed to be responsible for ensuring the implementation of services for 2 of 2 sampled residents (#'s 1 and 10). Findings include, but are not limited to:

a.Resident 1's service plan dated 02/08/24 indicated the following:

·In mobility/ambulation Resident 1 totally dependent on staff for all mobility needs. S/he was non-ambulatory. Staff were to escort him/her to/from meals, activities and his/her room.

·In Escorts moderate level of assistance. Resident 1 may required escorts and required an assistive device for mobility/ambulation.

·In Meal consumption Resident 1 required moderate assistance, cutting up of food, opening cartons/packages; may have needed encouragement to select menu items. Resident was on a regular diet.

·An Interim Service Plan for Resident 1 dated 01/18/24 indicated resident had a diet change to a puree diet with thin liquids and required assistance with providing meals.

In an interview on 04/01/24, Staff 8 (Caregiver) stated Resident 1 had a mechanical soft diet, and required full feeding assistance, because s/he was unable to feed him/herself. Resident required full assistance with transferring and escorts.

During the noon meal on 04/01/24 Resident 1 was observed to be fed a pureed meal.

At 9:10 am on 04/04/24 staff were observed to wake and transfer Resident 1 into his/her wheelchair and escort resident to dining room. S/he was left unattended in the dining room, breakfast had been served at 8:00 am and the food had been returned to the kitchen at 8:56 am.

Staff 2 (consultant/ Interim Executive Director) was alerted to Resident 1 having not received breakfast and being left unattended in the dining room. Staff 2 stated s/he would ensure Resident 1 received breakfast.

b.Resident 10's service plan dated 02/20/24 indicated the following:

·In Transferring gait belt was listed and Resident 10 was total assistance for transfers. Resident required routine hands-on assistance with transfers and/or changes in position. Resident was to have 2 person staff assistance with transfers by hoyer. Resident was able to stand pivot for transfers from wheelchair to chair in common area. For stand pivot transfers, Resident 10 was to have 2 person staff assistance with use of gait belt.

·In Meal consumption Resident 10 required moderate assistance, cutting up food, opening cartons/packages; may have needed encouragement to select menu items. Resident may have needed staff assistance with reminders to eat as sometimes s/he forgot to continue eating during meals. Resident was on mechanical soft diet. General diet, thin liquids, mechanical soft texture. Staff was to assist with appropriate food choices.

·A Temporary Service Plan for Resident 10 dated 08/02/23 indicated resident had a diet change to mechanical soft food, with limited distractions and constant reminders to slow down.

A review of Resident 10's physician orders dated 11/16/23 did not indicate resident had an order for a modified diet.

In an interview on 04/01/24, Staff 6 (Caregiver) and Staff 8 (Caregiver) stated Resident 10 was not on a special diet, and s/he did not like mechanical soft food. Both staff were unsure of what Resident 10's service plan stated for dietary requirements. Staff 8 stated s/he removed the meat from Resident 10's lunch because it was dry and tough and s/he didn't want resident to choke. Both staff stated they always transfered the resident by lifting him/her up by the arms, from his/her wheelchair to his/her bed.

In an interview on 04/04/24, Staff 9 (Caregiver) and Staff 10 (Caregiver) stated they stated they usually transfered Resident 10 by grabbing under elbows and doing a stand pivot transfer from bed to wheelchair, because the facility was short staffed and it was faster than the hoyer. Neither staff was sure what the service plan indicated.

On 04/01/24 at 12:58 pm Staff 6, Staff 8 and Staff 9 were observed transferring Resident 10 by lifting up on his/her arms, not using a gait belt, from his/her wheelchair to his/her bed.

On 04/04/24 at 7:19 am Staff 9 and Staff 10 were observed transferring Resident 10 with a stand pivot transfer and grabbing under his/her elbows from his/her bed to wheelchair. No gait belt or hoyer was used.

On 04/01/24 at 12:03 Resident 10 was observed to be served a regular lunch, but with no meat as the other residents were observed to have. Resident was not observed to be offered the alternative taco soup that was available.

On 04/04/24 at 8:00 am Resident 10 was served a regular texture meal, but the breakfast sausage was observed to be withheld. No alternative protein was observed to be offered.

The facility failed to be responsible for ensuring the implementation of services.

The findings of the investigation were reviewed with and acknowledged by Staff 2 (Consultant), Staff 3 (Regional) and Staff 4 (Administrator) via phone call on 05/17/24.

Facility Verbal Plan of Correction: Facility leadership was updating service plans continually from move-in date and making updates when due quarterly, to make service plans person centered, and ensured family involvement.

Based on observation and interview, conducted during a site visit on 04/01/24 and 04/04/24, it was confirmed the facility failed to designate an individual to be the facility's "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. Findings include, but are not limited to:

In an interview on 05/17/24 Staff 4 (Administrator) stated s/he did not believe the facility has a designated "Infection Control Specialist".

On 04/01/24 at 12:43 pm Staff 9 (Caregiver) was observed to pull "clean dishes" off a cart full of dirty dishes and attempt to put them away. Compliance Specialist intervened and provided instruction that once dirty dishes were placed on a cart, for infection control purposes, all other dishes were now dirty.

On 04/04/24 after breakfast staff were observed putting dirty dishes on top shelf of rolling carts. The cart had a rack of clean glasses below and staff removed a "clean" glass to pour a new beverage into it for a resident. Compliance Specialist reminded staff that the dishes below were previously clean and this is an infection control problem.

On 04/04/24 at 7:19 am a staff members observed transferring and changing a resident. A staff members hair was observed to drag through the residents soiled chuck.

The facility failed to designate an individual to be the facility's "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks.

The findings of the investigation were reviewed with and acknowledged by Staff 2 (Consultant), Staff 3 (Regional) and Staff 4 (Administrator) via phone call on 05/17/24.

Verbal Plan of Correction: Inservice meeting on cross contamination was to be held and training packets were provided with infection control practices.

Based on observation, interview and record review, conducted during a site visit on 04/01/24 and 04/04/24, it was confirmed the facility administrator failed to be responsible for ensuring adequate professional oversight of the medication and treatment administration system. Findings include, but are not limited to:

On 04/01/24 at 12:58 pm a loose pill was observed in Resident 10's wheelchair. Staff 8 (Caregiver) was alerted to the presence of the medication.

Staff 8 asked Compliance Specialist what to do with the medication. Staff 8 was observed to throw the pill in residents trashcan.

In an interview on 04/01/24, Staff 11 (RCC) stated when staff find a loose pill s/he should take the medication to the med tech.

Resident 10's 04/01/24 - 04/30/24 and progress notes were reviewed on 04/04/24, there were no entries indicating resident did not receive a medication or that a loose pill was found in residents wheelchair.

See findings in C0303.

The facility administrator failed to be responsible for ensuring adequate professional oversight of the medication and treatment administration system.

The findings of the investigation were reviewed with and acknowledged by Staff 2 (Consultant), Staff 3 (Regional) and Staff 4 (Administrator) via phone call on 05/17/24.

Facility Verbal Plan of Correction: A daily clinical meeting was being held every morning to review alert charting, new orders, incidents, missed medications with the nurse, RCC and administrator. Multiple staff trainings had been completed with MT's and Caregivers. The next training to occur was to be focused on a process for found medications.

Based on interview and record review, conducted during a site visit on 04/01/24 and 04/04/24, it was confirmed that the facility failed to carry out medication orders as prescribed for 4 of 4 sampled residents (#'s 3, 7, 8, & 9). Findings include, but are not limited to:

a. A review of Resident 3's Physician Orders dated 01/01/24 indicated the following:

·Methadone 5mg with instructions to " take 0.5 tablet by mouth 2 times daily at 8am and 3pm scheduled for pain", scheduled for 8:00 am and 3:00 pm with an order date 12/29/23;

·Quetiapine 50mg with instructions to "take 1 tablet by mouth 2 times daily (morning and at 2pm)", scheduled for 8:00 am and 2:00 pm with an order date 10/06/23; and

·Tizanidine 4mg with instructions to "take 2 tablet by mouth every 8 hours every day at 6:00am, 2:00pm, 10:00pm", scheduled for 6:00 am, 2:00 pm and 10:00 pm with an order date 12/26/23.

A review of Resident 3's 01/2024 MAR indicated the following:

·On 01/01/24 3:00 pm Methadone HCI was marked as not administered;

·On 01/01/24 2:00 pm Quetiapine Fumarate was marked as not administered; and

·On 01/01/24 2:00 pm and 10:00 pm Tizanidine HCL were both marked as not administered.

Resident 3's Chart Notes in 01/2024 MAR indicated the following:

·On 01/01/24 3:00 pm Methadone HCI  " INVESTIGATION: MT states that s/he was outside of the hour before/after window therefor did not administer medication " ;

·On 01/01/24 2:00 pm Quetiapine Fumarate  " INVESTIGATION: MT states that s/he was outside of the hour before/after window therefor did not administer medication " ;

·On 01/01/24 2:00 pm  " INVESTIGATION: MT states that s/he was outside of the hour before/after window therefor did not administer medication " ; and

·On 01/01/24 10:00 pm Tizanidine HCL  " MEDICATION NOT ADMINISTERED. UNABLE TO CONFIRM WITH AGENCY LPN REASONING "

b.A review of Resident 7's 01/2024 MAR indicated the following:

·On 01/01/24 5:00 pm Memantine HCI was marked as not administered;

·On 01/01/24 5:00 pm Acetaminophen was marked as not administered; and

·On 01/01/24 5:00 pm Mirtazapine was marked as not administered.

Resident 7's Chart Notes in 01/2024 MAR indicated the following:

·On 01/01/24 5:00 pm Memantine HCI "MEDICATION WAS NOT ADMINISTERED: PER MT, S/HE WAS OUTSIDE OF THE HOUR BEFORE/AFTER WINDOW, THEREFORE DID NOT ADMINISTER THE MEDICATION";

·On 01/01/24 5:00 pm Acetaminophen "MEDICATION WAS NOT ADMINISTERED: PER MT, S/HE WAS OUTSIDE OF THE HOUR BEFORE/AFTER WINDOW, THEREFORE DID NOT ADMINISTER THE MEDICATION"; and

·On 01/01/24 5:00 pm Mirtazapine "MEDICATION WAS NOT ADMINISTERED: PER MT, S/HE WAS OUTSIDE OF THE HOUR BEFORE/AFTER WINDOW, THEREFORE DID NOT ADMINISTER THE MEDICATION".

c. A review of Resident 8's physician orders dated 01/01/24 indicated the following:

·Levothyroxine 75MCG with instructions to take  " 1 tablet by mouth for hypothyroidism "  scheduled at 5:00 am with an order date 12/21/23.

A review of Resident 8's 01/2024 MAR indicated the following:

·On 01/02/24 5:00 am Levothyroxine sodium was marked as not administered.

Resident 8's Chart Notes in 01/2024 MAR indicated the following:

·On 01/02/24 5:00 am Levothyroxine sodium "MEDICATION NOT ADMINISTERED. UNABLE TO CONFIRM REASONING WITH AGENCY LPN".

d.A review of Resident 9's physician orders dated 01/01/24 indicated the following:

·Famotidine 20mg with instructions to take "1 tablet by mouth twice daily" scheduled for 8:00 am and 5:00 pm, with an order date 06/23/23.

·Melatonin 5mg with instructions to take "1 tablet by mouth every evening" scheduled for 5:00 pm, with an order date 11/28/23.

A review of Resident 9's 01/2024 MAR indicated the following:

·On 01/01/24 5:00 pm Apixaban was marked as not administered;

·On 01/01/24 5:00 pm Donepezil Hydrochloride was marked as not administered;

·On 01/01/24 5:00 pm Famotidine was marked as not administered;

·On 01/01/24 5:00 pm Melatonin was marked as not administered; and

·On 01/01/24 5:00 pm Tamsulosin HCI was marked as not administered.

Resident 9's Chart Notes in 01/2024 MAR indicated the following:

·On 01/01/24 5:00 pm Apixaban "MEDICATION WAS NOT ADMINSITER; PER MT, S/HE WAS OUTSIDE OF THE HOUR BEFORE/AFTER WINDOW, THEREFORE DID NOT ASMINISTER THE MEDICATION";

·On 01/01/24 5:00 pm Donepezil Hydrochloride "MEDICATION WAS NOT ADMINSITER; PER MT, S/HE WAS OUTSIDE OF THE HOUR BEFORE/AFTER WINDOW, THEREFORE DID NOT ASMINISTER THE MEDICATION";

·On 01/01/24 5:00 pm Famotidine "MEDICATION WAS NOT ADMINSITER; PER MT, S/HE WAS OUTSIDE OF THE HOUR BEFORE/AFTER WINDOW, THEREFORE DID NOT ASMINISTER THE MEDICATION";

·On 01/01/24 5:00 pm Melatonin "MEDICATION WAS NOT ADMINSITER; PER MT, S/HE WAS OUTSIDE OF THE HOUR BEFORE/AFTER WINDOW, THEREFORE DID NOT ASMINISTER THE MEDICATION"; and

·On 01/01/24 5:00 pm Tamsulosin HCI "MEDICATION WAS NOT ADMINSITER; PER MT, S/HE WAS OUTSIDE OF THE HOUR BEFORE/AFTER WINDOW, THEREFORE DID NOT ASMINISTER THE MEDICATION".

In an interview on 04/04/24 Staff 4 (Administrator) stated a lot of medication errors had occurred.

The facility failed to carry out medication orders as prescribed.

The findings of the investigation were reviewed with and acknowledged by Staff 2 (Consultant), Staff 3 (Regional) and Staff 4 (Administrator) via phone call on 05/17/24.

Facility Verbal Plan of Correction: A daily clinical meeting was being held every morning to review alert charting, new orders, incidents, missed medications with the nurse, RCC and administrator. Multiple staff trainings had been completed with MT's and Caregivers. The next training to occur was to be focused on a process for found medications.

Based on interview and record review, conducted during a site visit on 04/01/24 and 04/04/24, it was confirmed that the facility failed to carry out medication orders as prescribed for 5 of 5 sampled residents (#'s 2, 8, 11, 12, and 13). Findings include, but are not limited to:

A review of Resident 2's March 2024 MAR indicated the following on 03/23/24:

·8:00 am Acetaminophen recorded as "NA";

·12:00 pm Acetaminophen recorded with a dash mark and no initials;

·8:00 am Amlodipine Besylate recorded with a dash mark and no initials;

·12:00 pm Diclofenac Sodium recorded with a dash mark and no initials;

·8:00 am Docusate Sodium recorded as "NA";

·8:00 am Metoprolol Succinate recorded with a dash mark and no initials;

·7:30 am Pantoprazole Sodium recorded as "Med Aide Unavailable";

·8:00 am Blood Pressure was not recorded; and

·8:00 am Pulse was not recorded

A review of Facility self-reported missed medication list for Resident 2 on 03/23/24 indicated the following missed medication:

·Vitamin B12, Clopidogrel, Folic Acid, Atorvastatin and Vitamin C.

A review of Resident 8's March 2024 MAR indicated the following on 03/23/24:

·8:00 am Citalopram Hydrobromide recorded as not given due to "Medication reordered and will be on tonight's delivery";

·8:00 am Lidocaine recorded as "Given late"; and

·9:00 am Daily Weight recorded with a dash mark and no initials.

A review of Facility self-reported missed medication list for Resident 8 on 03/23/24 indicated the following missed medication:

·Acetaminophen, Cephalexin, Ferrous Sulfate, Citalopram, Lidocaine patch, ergocalciferol, magnesium oxide, memantine, multivitamin, nystatin, pantoprazole, and polyethylene glycol.

A review of Resident 11's March 2024 MAR indicated the following on 03/23/24:

·12:00 pm Turmeric Complex 500 mg recorded with a dash mark and no initials.

A review of Facility self-reported missed medication list for Resident 11 on 03/23/24 indicated the following missed medication:

·Acetaminophen, Amlodipine Besylate, aspirin, calcium carbonate, folic acid, metoprolol tartrate, potassium chloride, prevagen, turmeric and Vitamin B1.

A review of Resident 12's March 2024 MAR indicated the following on 03/23/24:

·8:00 am Lidocaine 4% patch recorded with a dash mark and no initials.

A review of Facility self-reported missed medication list for Resident 12 on 03/23/24 indicated the following missed medication:

·Aspirin, Cholecalciferol, Folic Acid, Lidocaine patch, Magnesium, Metoprolol, Omeprazole, Polyethylene glycol, Vitamin B1, Vitamin B12 and Vitamin D3.

A review of facility self-reported medication error dated 03/23/24 indicated the following:

·An agency LPN was working as a med tech on 03/23/24;

·The LPN did not pass the 8:00 am medications to multiple residents and medications had been pre-popped and mixed with 12:00 pm medications;

·At 3:30 pm medications were still waiting to be passed;

·Agency LPN came on shift at 9:30 am and RCC oriented agency staff to the charting system and medication room and cart.

·At 9:30 am 5 or 6 residents sill needed their medications.

In an interview on 04/04/24 Staff 4 (Administrator) stated a lot of medication errors had occured.

The facility failed to carry out medication orders as prescribed.

The findings of the investigation were reviewed with and acknowledged by Staff 2 (Consultant), Staff 3 (Regional) and Staff 4 (Administrator) via phone call on 05/17/24.

Facility Verbal Plan of Correction: A daily clinical meeting was being held every morning to review alert charting, new orders, incidents, missed medications with the nurse, RCC and administrator. Multiple staff trainings had been completed with MT's and Caregivers. The next training to occur was to be focused on a process for found medications.

Based on observation, interview and record review, conducted during a site visit on 04/01/24 and 04/04/24, it was confirmed the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to:

On 04/04/24 the transition from night shift to day shift was observed. At 6:00 am two of four night shift staff left before day shift staff arrived to relieve them. The facility was staffed under the posted staffing plan until approximately 6:20 am.

On 04/04/24 at 7:56 am three staff were observed to leave the facility to bring the breakfast meal carts from the kitchen (in the attached Assisted Living Facility). At 8:56 am three staff were observed leaving the facility to bring the food carts back to the kitchen, leaving the memory care staffed below the posted staffing plan.

In an interview on 04/04/24, Staff 5 (Caregiver) stated s/he has had to work by him/herself in the recent past with staff from the Assisted living facility assisting.

In an interview on 04/04/24 Staff 9 (Caregiver) and Staff 10 (Caregiver) stated they usually transfered Resident 10 by stand pivot because they were short staffed and it was faster than using his/her hoyer.

Posted staffing plan was reviewed which indicated:

·Day: 1 med tech, 3 caregivers

·Swing: 1 med tech, 3 caregivers

·Noc: 1 med tech, 2 caregivers

A review of 03/01/24 - 03/31/24 schedule indicated both 03/29/24 and 03/30/24 were short staffed per the posted staffing plan.

A review of timecards for 03/29/24 and 03/30/24 confirmed the facility was not staffed to the posted staffing plan.

The facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident.

The findings of the investigation were reviewed with and acknowledged by Staff 2 (Consultant), Staff 3 (Regional) and Staff 4 (Administrator) via phone call on 05/17/24.

Facility Verbal Plan of Correction: Facility leadership investigated staff leaving the facility short staff immediately. Administrator will ensure scheduling to staffing plan and ensure coverage on floor until coverage is found. Adminsitrator spoke to care staff and discussed in clinical about not leaving the facility unattended.

Based on observation, interview and record review, conducted during a site visit on 04/01/24 and 04/04/24, it was confirmed the facility failed to fully implement an Acuity Based Staffing Tool (ABST). Findings include, but are not limited to:

In an interview on 04/01/24, Staff 1 (Executive Director), Staff 2 (Consultant/ Interim Executive Director) stated the facility used the Oregon Department of Human Service tool and that Staff 1, Staff 2, and Staff 4 (Administrator) had all been updating the information. Staff 2 stated s/he did not update the ABST last week, but it was updated the Sunday before.

A review of the ABST and the resident roster indicated there had been three new admissions, admit dates of 03/22/24, 03/26/24 and 04/01/24, that were not entered into the ABST.

The facility failed to fully implement an ABST.

The findings of the investigation were reviewed via phone call with and acknowledged by Staff 2 (Consultant), Staff 3 (Regional) and Staff 4 (Administrator) on 05/17/24.

Based on observation, interview and record review, conducted during a site visit on 04/01/24 and 04/04/24, it was confirmed that the facility failed to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned for 3 of 3 sampled staff (#'s 5, 6, and 7). Findings include, but are not limited to:

Demonstrated competencies were requested for Staff 5, 6 and 7, and no demonstrated competencies were available or provided for 3 of 3 sampled staff.

In an interview on 04/04/24, Staff 5 (Caregiver) stated s/he did not recall completing a checklist, signing a checklist or having a trainer sign off on a checklist for training.

At 12:58 pm on 04/01/24 three staff members were observed to lift Resident 10 by his/her arms out of his/her wheelchair without the use of a gait belt or other safe techniques and put the resident in his/her bed.

In an interview on 04/01/24, Staff 6(Caregiver) and Staff 8 (Caregiver) stated they always transfered the resident the way Compliance Specialist observed.

The facility failed to verify direct care staff have demonstrated satisfactory performance in any duty they are assigned.

The findings of the investigation were reviewed with and acknowledged by Staff 2 (Consultant), Staff 3 (Regional) and Staff 4 (Administrator) via phone call on 05/17/24.

Verbal Plan of Correction: Staff 2 and Staff 4 were to redo all training packets for care staff, gait belt training for all staff had occurred and they were in the process of ensuring all service plans were reflective of needs. Competency checks were to be done and a lead caregiver had been appointed to review for completeness.