Rosewood Court Residential Care.

“Based on observations and interviews, 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 C240. See plan of correction for C240 OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by:”

“Based on observations and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner, and in accordance with the Food Sanitation Rules, OAR 333-150-000. include, but are not limited to: Observation of the main kitchen, dining room kitchenette, and activities kitchenette on 03/20/25 at 10:40 am through 2:00 pm revealed the following deficiencies: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on or underneath the following: * Interior and exterior of Convection ovens; * 2 oscillating and 1 box fans; * Floors in corners/edges: * Floors under and behind equipment; * Ledges around baseboards throughout kitchen area; * Industrial can opener and housing’ * Industrial mixer; * Walls in dish machine/ware washing room/area; * Utility carts; * Metal racks in walk in cooler; * Cooling fan cages and ceilings in walk in cooler; * Exterior of ice machine; * White wood shelving throughout kitchen; * Removable hood vents; * Interior of steamer; * Exterior of white bulk food bins; * Open stainless steel shelving storing pots and pans; * Reach in refrigerator in Activity kitchenette; * Interior of cabinets in Activity kitchenette; * Ceiling vent in Activity kitchenette; * Over the stove hood/fan in Activity kitchenette; and * Blender base in dining room kitchenette;. b. The following areas were found in need of repair: * Multiple edges of shelving in cabinets in dining room kitchenette and activity room kitchenette with exposed porous wood. * Large gaps in the wall under dish machine where pipes exit. * Large cracks in floor of walk in cooler. * Large gap between flooring and cove base in main kitchen area from freezer floor sinking. Multiple stainless steel wall panels damaged from shift in floor. * Freezer with build up of frost/ice; * Multiple areas in main kitchen flooring where seems are pulling apart leaving gaps for debris build up. Floor under feet of convection stove damaged from heat of stove. * Section of wall under soap dispenser with damage to dry wall. c. Muliple staff in main kitchen handling food or clean equipment without facial hair restraints. d. Muliple food items in Activity kitcheneete refrigerator were found open without open dates. e. Staff drinks were observed stored in the Activity refrigerator where resident food was stored. A staff drink was observed stored in the dining room kitchenette that did not have a lid or straw as required per code. f. Staff in the main kitchen were noted to be eating in the kitchen at a rolling cart that was next to clean equipment and had single service meal items on the cart. At approximately 1:30pm, Staff 2 (Dietary Manager) was informed of this observation and acknowledged that was not an approved/dedicated area for staff to eat. g. Meal service was observed in the dinning room. Puree texture of bread items was observed to be very runny and did not hold any shape on a fork. The food item ran thru the tine of the fork. Staff were not aware this texture was too thin for puree. When surveyor pointed out the thin texture the staff indicated that they would put it in bowls. Surveyor intervened and insisted the too thin meal item not be served until thickened appropriately. Staff 2 visualized the food product and agreed it was not at the correct food consistency for puree and had kitchen staff correct the item before served to residents. h. During meal service, multiple residents at each table were served their meals at alternate times than other residents at the same table. This left some residents sitting and waiting for their food while other residents at the table were eating their food. This led to one confused resident attempting to reach over and take another resident’s plate. This caused the other resident to be upset and yell at the other resident. After meal service staff 1 was interviewed at approximately 1pm and they acknowledged that all residents at one table should be served together before moving to serve other residents from another table. Surveyor observed this practice not followed for multiple tables/residents during lunch meal. Surveyor toured the main kitchen areas with Dietary manager (staff 2) who acknowledged areas in need of correction. Surveyor toured the Activity kitchenette with staff 1 (Administrator) who acknowledged the identified areas. At approximately 1:30 pm the surveyor reviewed the areas in need of cleaning, repair and practices with Staff 1 (Administrator) and they acknowledged the areas in need of correction. A: 1: All affected areas and equipment were immediately cleaned and sanitized by kitchen staff. 2: •Will implement a routine cleaning schedule covering all equipment and surfaces listed in the citation. • Equipment such as fans, mixers, and utility carts will be included in routine maintenance protocols. • Staff will receive training on food safety and sanitation procedures, with an emphasis on thorough cleaning under, behind, and above equipment. • The Activity and Dining Room kitchenettes were added to the facility-wide cleaning and inspection schedule. 3: Dietary Manager will review cleaning checklist for Responsible Staff Member(s) weekly x 4 and then monthly ongoing. 4: Dietary Manager is responsible to oversee the cleaning and maintenance of kitchen equipment. B. 1: Shelving will be repaired or replaced with sealed, non-porous materials to meet sanitary standards. Gaps in the wall under the dish machine will be sealed with appropriate wall patch and waterproof material. Damaged flooring, gap between flooring and cove base, and ice build-up in walk-in cooler will be repaired. Flooring under convection stove will be repaired or replaced. Wall under soap dispenser will be repaired. 2: Staff will be inserviced on notifying maintenance when repairs are needed. Maintenance will conduct routine kitchen inspections for repairs needed and review maintenance requests for kitchen repair needs and follow-up. 3: Kitchen audits will be conducted by the maintenance director or designee to include shelving, flooring, cabintetry, walls, and any other areas of disrepair monthly x 3 then quarterly x 3 to ensure compliance. 4: The Administrator will oversee the implementation of all corrective actions. Reports will be documented and reviewed during monthly safety meetings. Any new issues will trigger immediate investigation and timely follow-up. C-G: 1: Beard nets will be made readily available in the kitchen area. Signage reminding staff of PPE requirements will be posted near handwashing and entry points. All improperly labeled or undated food items or staff items were removed from the refrigerator immediately. Staff were directed to not consume food items in the kitchen and the cart and surrounding area were immediately sanitized. The pureed meal was withheld until the puréed food was modified to meet proper consistency standards. 2: Staff will be retrained on personal hygiene and grooming standards, including the mandatory use of facial hair restraints when handling food or clean equipment. Staff will receive refresher training on proper food storage and labeling procedures, including the importance of open dating to ensure food safety and prevent spoilage. Date label stickers and markers will be available in kitchenettes. Staff will be trained on the requirement that drink containers have a lid/straw. Signage placed at refrigerator indicating it is for resident food. Clear signage will be posted in the kitchen to remind staff that eating in food prep and storage areas is prohibited. All dietary staff will receive a refresher training on food texture standards. Visual guides will be posted in prep areas. 3: The Dietary Manager or Shift Supervisor will conduct daily checks ongoing to ensure all food handlers are in full compliance with PPE requirements and eating and drinking policies.The cook will perform ”

“The findings of the kitchen inspection, conducted 03/21/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000. The findings of the kitchen inspection, conducted 03/21/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.”

“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 420 and C 513. 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 420 and C 513. See plan of correction for C420 and C513 See plan of correction for C420 and C513 There are no detail notes for this visit.”

“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 260 and C 270. 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 260 and C 270. See plan of correction of C260 and C270 See plan of correction of C260 and C270 There are no detail notes for this visit.”

“The findings of the re-licensure survey, conducted 02/26/24 through 02/28/24, 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 re-licensure survey, conducted 02/26/24 through 02/28/24, 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 re-visit survey to the re-licensure survey on 02/28/24, conducted 05/13/24 through 05/14/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 for Home and Community Based Services Regulations. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record 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 survey to the re-licensure survey on 02/28/24, conducted 05/13/24 through 05/14/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 for Home and Community Based Services Regulations. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record 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 survey to the re-licensure survey on 02/28/24, conducted 07/22/24, 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. The findings of the second re-visit survey to the re-licensure survey on 02/28/24, conducted 07/22/24, 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 ensure service plans were reflective of residents' needs and preferences, provided clear direction regarding the delivery of services, and/or services were implemented for 3 of 5 sampled residents (#s 3, 4 and 6) whose service plans were reviewed. 1. Resident 4 was admitted to the facility in 12/2023 with diagnoses including dementia and Parkinson's disease. a. Observations of the resident, interviews with staff, review of the 02/15/24 service plan, Temporary Service Plans dated 12/28/23 through 02/20/24, and current evaluations identified Resident 4's service plan was not reflective of his/her needs and preferences, lacked clear direction to staff, and/or was not implemented in the following areas: * Mobility and transfer assistance; * Mood and behaviors; * Toileting assistance; * Fall risk, history, and interventions; * Bathing assistance; * Glasses; * Dressing assistance; * Grooming and hygiene; * Pain: instructions for use of "rice pack"; * Dietary preferences and needs; * Skin breakdown risk and interventions; and * Weight loss history with interventions. b. The handwritten updates to the temporary service plans did not include the date or initials of the staff who made the changes to the service plan. On 02/28/24 at 11:06 am, the need to ensure service plans were reflective of the resident's needs and preferences, provided clear direction regarding the delivery of services, and that the services were implemented was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (RCC), Staff 7 (Regional Nurse Consultant), and Staff 8 (Regional Director of Operations). They acknowledged the findings. Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and preferences, provided clear direction regarding the delivery of services, and/or services were implemented for 3 of 5 sampled residents (#s 3, 4 and 6) whose service plans were reviewed.”

“Based on interview and record review, it was determined the facility failed to ensure short-term changes of condition documented weekly progress noted until the condition resolved for 1 of 5 sampled residents (#4) who experienced short-term changes of condition. Findings include, but are not limited to: Resident 4 moved into the facility in 12/2023 with diagnoses including dementia and Parkinson's disease. Resident 4's 12/28/23 through 02/26/24 facility progress notes, incident reports, and Temporary Service Plans (TSPs) were reviewed and showed the following changes of condition: * 12/28/23: New admission to facility; * 12/28/23: Right knuckle and left arm skin impairment; * 01/12/24: Fall with re-injury to a left knee wound; * 01/14/24: Non-injury fall; * 01/15/24: Fall with head strike and left wrist skin tear; and * 02/05/24: New antidepressant medication ordered. There was no documented evidence the changes were monitored at least weekly through resolution. The need to ensure short-term changes of condition were monitored with weekly progress noted until resolution was reviewed with Staff 1 (Administrator), Staff 2 (RN), and Staff 3 (RCC) on 02/28/24. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to ensure short-term changes of condition documented weekly progress noted until the condition resolved for 1 of 5 sampled residents (#4) who experienced short-term changes of condition. Findings include, but are not limited to: Resident 4 moved into the facility in 12/2023 with diagnoses including dementia and Parkinson's disease. Resident 4's 12/28/23 through 02/26/24 facility progress notes, incident reports, and Temporary Service Plans (TSPs) were reviewed and showed the following changes of condition: * 12/28/23: New admission to facility; * 12/28/23: Right knuckle and left arm skin impairment; * 01/12/24: Fall with re-injury to a left knee wound; * 01/14/24: Non-injury fall; * 01/15/24: Fall with head strike and left wrist skin tear; and * 02/05/24: New antidepressant medication ordered. There was no documented evidence the changes were monitored at least weekly through resolution. The need to ensure short-term changes of condition were monitored with weekly progress noted until resolution was reviewed with Staff 1 (Administrator), Staff 2 (RN), and Staff 3 (RCC) on 02/28/24. They acknowledged the findings. 1.All of Resident # 4 TSP's have been resolved 2. All other resident's current TSP's will be reviewed and monitored weekly by DON or designee, until resolution. 3. TSPs will be audited weekly for three months by the IDT to ensure compliance is achieved. 4. The administrator or designee will be responsible to see that the corrections are completed. 1.All of Resident # 4 TSP's have been resolved 2. All other resident's current TSP's will be reviewed and monitored weekly by DON or designee, until resolution. 3. TSPs will be audited weekly for three months by the IDT to ensure compliance is achieved. 4. The administrator or designee will be responsible to see that the corrections are completed. There are no detail notes for this visit.”

“Based on interview and record review, it was determined the facility failed to include and document all required elements of fire drills, and to provide fire and life safety instruction to staff on alternate months, in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to: Review of facility records on 02/27/24 identified the following deficiencies: a. Documentation of fire drills failed to include the following required elements: * Escape routes used, including alternate routes; * Problems encountered, relating to residents who resisted or failed to participate; * Evacuation time-periods needed; and * Number of occupants evacuated. b. There was no documented evidence that fire and life safety instruction was provided to staff on alternating months. On 02/28/24, the need to document all required elements for fire drills and provide fire and life safety instruction to staff on alternate months, in accordance with the OFC, was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (RCC), Staff 7 (Regional Nurse Consultant), and Staff 8 (Regional Director of Operations). They acknowledged the findings. Based on interview and record review, it was determined the facility failed to include and document all required elements of fire drills, and to provide fire and life safety instruction to staff on alternate months, in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to: Review of facility records on 02/27/24 identified the following deficiencies: a. Documentation of fire drills failed to include the following required elements: * Escape routes used, including alternate routes; * Problems encountered, relating to residents who resisted or failed to participate; * Evacuation time-periods needed; and * Number of occupants evacuated. b. There was no documented evidence that fire and life safety instruction was provided to staff on alternating months. On 02/28/24, the need to document all required elements for fire drills and provide fire and life safety instruction to staff on alternate months, in accordance with the OFC, was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (RCC), Staff 7 (Regional Nurse Consultant), and Staff 8 (Regional Director of Operations). They acknowledged the findings.”

“Based on interview and record review, it was determined the facility failed to ensure their re-visit survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to Z 164. Based on interview and record review, it was determined the facility failed to ensure their re-visit survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to Z 164. See plan of correction Z-164 See plan of correction Z-164 There are no detail notes for this visit.”

“Based on observation and interview, it was determined the facility failed to ensure the environment was maintained in clean and good repair. Findings include, but are not limited to: Observations of the facility on 02/26/24 showed the following areas in need of cleaning or repair: * Multiple walls and door frames in resident hallways had scrapes and gouges; * Discoloration/stains on built-in wood bench in TV area; * Worn white discoloration on wood handrails through much of building; * Floor moldings/baseboards damaged or separated from wall in several areas; * Tears and damage to vinyl couch in sitting room; * Heavy gouges on wood piano and bench in activity room; and * Several pieces of wood furniture throughout the facility had scratches or gouges. On 02/28/24, the areas in need of cleaning or repair were shown to and discussed with Staff 1 (Administrator) and Staff 4 (Maintenance Director). They acknowledged the findings. Based on observation and interview, it was determined the facility failed to ensure the environment was maintained in clean and good repair. Findings include, but are not limited to: Observations of the facility on 02/26/24 showed the following areas in need of cleaning or repair: * Multiple walls and door frames in resident hallways had scrapes and gouges; * Discoloration/stains on built-in wood bench in TV area; * Worn white discoloration on wood handrails through much of building; * Floor moldings/baseboards damaged or separated from wall in several areas; * Tears and damage to vinyl couch in sitting room; * Heavy gouges on wood piano and bench in activity room; and * Several pieces of wood furniture throughout the facility had scratches or gouges. On 02/28/24, the areas in need of cleaning or repair were shown to and discussed with Staff 1 (Administrator) and Staff 4 (Maintenance Director). They acknowledged the findings. 1.Walls and door frame scrapes and gouges will be repaired by the maintenance director or designee.  Discoloration/Stains on built-in wood bench repaired. Handrails throughout the building will be re-stained by maintenance director or designee. Floor moldings and baseboard damages have been repaired.  Replacement furniture was ordered on February 9, 2024 and is expected to arrive and installed by May 17, 2024.  The piano will be evaluated and either repaired or replaced. 2.  Staff will be educated on notifying the maintenance team of maintenance needs and repairs. 3.  A monthly audit will be done by the administrator or designee  to ensure the facility is clean and in good repair. 4.  The administrator or designee will ensure that the corrections are completed and monitored. 1.Walls and door frame scrapes and gouges will be repaired by the maintenance director or designee.  Discoloration/Stains on built-in wood bench repaired. Handrails throughout the building will be re-stained by maintenance director or designee. Floor moldings and baseboard damages have been repaired.  Replacement furniture was ordered on February 9, 2024 and is expected to arrive and installed by May 17, 2024.  The piano will be evaluated and either repaired or replaced. 2.  Staff will be educated on notifying the maintenance team of maintenance needs and repairs. 3.  A monthly audit will be done by the administrator or designee  to ensure the facility is clean and in good repair. 4.  The administrator or designee will ensure that the corrections are completed and monitored. There are no detail notes for this visit.”

“Based on interview and record review, it was determined the facility failed to evaluate and develop individualized activity plans for 4 of 5 sampled residents (#s 2, 3, 4 and 6) whose activity plans were reviewed. Findings include, but are not limited to: Residents 2, 3, 4 and 6's records were reviewed during the survey. There was no documented evidence an activity evaluation had been completed and the service plans individualized to reflect one or more of the following required components: * Residents' current preferences; * Abilities and skills; * Emotional/social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and * Identification of activities for behavioral interventions. There was no specific activity plan which detailed what, when, how and how often staff should offer and assist each resident with individualized activities. The need to evaluate and develop individualized activity plans, including all required components for each memory care resident was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (RCC), Staff 7 (Regional Nurse Consultant), and Staff 8 (Regional Director of Operations) on 02/28/24. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to evaluate and develop individualized activity plans for 4 of 5 sampled residents (#s 2, 3, 4 and 6) whose activity plans were reviewed. Findings include, but are not limited to: Residents 2, 3, 4 and 6's records were reviewed during the survey. There was no documented evidence an activity evaluation had been completed and the service plans individualized to reflect one or more of the following required components: * Residents' current preferences; * Abilities and skills; * Emotional/social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and * Identification of activities for behavioral interventions. There was no specific activity plan which detailed what, when, how and how often staff should offer and assist each resident with individualized activities. The need to evaluate and develop individualized activity plans, including all required components for each memory care resident was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (RCC), Staff 7 (Regional Nurse Consultant), and Staff 8 (Regional Director of Operations) on 02/28/24. They acknowledged the findings. 1.Resident 2,3,4 and 6 will have an activity evaluation completed and service plans individualized for their activitiy needs. 2.All other residents will be reviewed, by the activity director or designee, during their quarterly evaluation and their service plans individualized as needed. 3.Activity plans will be audited by administrator or designee monthly, times three months, then quarterly after that, on going. 4.  The activity director will be responsible to ensure that the corrections are completed and monitored ongoing. 1.Resident 2,3,4 and 6 will have an activity evaluation completed and service plans individualized for their activitiy needs. 2.All other residents will be reviewed, by the activity director or designee, during their quarterly evaluation and their service plans individualized as needed. 3.Activity plans will be audited by administrator or designee monthly, times three months, then quarterly after that, on going. 4.  The activity director will be responsible to ensure that the corrections are completed and monitored ongoing. Based on interview and record review, it was determined the facility failed to evaluate all required elements for activities and to develop an individualized activity plan from the evaluation for 3 of 3 sampled residents (#s 2, 7, and 8) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to: A review of the activity evaluation and service plan for Residents 2, 7, and 8 revealed the following: 1. The activity evaluations did not adequately address the following required elements: * Past and current interests; * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and * Activities that could be used as behavioral interventions. 2. There was no documented evidence individualized activity plans which addressed what, when, how, and how often staff should offer and assist the residents with activities, and which reflected the residents' activity preferences and needs, were developed from the activity evaluations. The need to ensure an activity evaluation addressing all required elements was completed for each resident and an individualized activity plan was developed from the evaluation was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (RCC), Staff 5 (Business Office Director), Staff 6 (Activity Director), and Staff 20 (Dining Services Manager) on 05/14/24. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to evaluate all required elements for activities and to develop an individualized activity plan from the evaluation for 3 of 3 sampled residents (#s 2, 7, and 8) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to: A review of the activity evaluation and service plan for Residents 2, 7, and 8 revealed the following:”

“Based on observation and interview, it was determined the facility failed to consistently ensure residents were not locked outside their rooms. Findings include, but are not limited to: During the survey, observations of resident rooms revealed they were locked from the outside, preventing residents from entering their rooms without assistance from staff. Caregiving staff each carried a key which could open all residents' rooms, and walkie-talkies were used to communicate when a resident's room needed to be unlocked. In an interview on 02/27/24, Staff 1 (Administrator) and Staff 3 (RCC) explained how the current system was designed for the purpose of preventing intrusive wandering on the MCC unit. On 02/28/24, the need to ensure residents were not locked outside their rooms was discussed with Staff 1, Staff 2 (RN), Staff 3, Staff 7 (Regional Nurse Consultant), and Staff 8 (Regional Director of Operations). They acknowledged the findings. Based on observation and interview, it was determined the facility failed to consistently ensure residents were not locked outside their rooms. Findings include, but are not limited to: During the survey, observations of resident rooms revealed they were locked from the outside, preventing residents from entering their rooms without assistance from staff. Caregiving staff each carried a key which could open all residents' rooms, and walkie-talkies were used to communicate when a resident's room needed to be unlocked. In an interview on 02/27/24, Staff 1 (Administrator) and Staff 3 (RCC) explained how the current system was designed for the purpose of preventing intrusive wandering on the MCC unit. On 02/28/24, the need to ensure residents were not locked outside their rooms was discussed with Staff 1, Staff 2 (RN), Staff 3, Staff 7 (Regional Nurse Consultant), and Staff 8 (Regional Director of Operations). They acknowledged the findings. 1.Staff will not lock residents doors preventing them from entering their rooms without assistance. 2. Staff were educated on the door locking policy 3. Administrator or designee will do a weekly audit x 4, then a monthly audit x 2, to ensure compliance. 4. The administrator will be responible to see that the corrections are completed and monitored. 1.Staff will not lock residents doors preventing them from entering their rooms without assistance. 2. Staff were educated on the door locking policy 3. Administrator or designee will do a weekly audit x 4, then a monthly audit x 2, to ensure compliance. 4. The administrator will be responible to see that the corrections are completed and monitored. There are no detail notes for this visit.”