SUN VALLEY ASSISTED LIVING

TAG 0642 PLAN OF CORRECTION – DEMENTIA TRAININGThe facility will conduct re-training and update its training material to include training on residents that are affected with Dementia, including recognizing behavioral expressions and management techniques; how to effectively communicate to residents with dementia, or other conditions that impair communication; the role of and communication with external service providers. CORRECTIVE ACTIONThe staff will be trained on the above material immediately following the submittance of this plan of correction. The staff training checklist and training checklist and materials will also be updated to reflect the above subjects. Staff re-orientation and re-training is to be completed latest by October 30th 2024. Additionally, several additional subjects on the aforementioned training materials were introduced to the staff and the training on the subject matters are continuing for the next 3 months. The systemic changes that has taken place to ensure that new staff is thoroughly understood the needs of the residents as well as the day to day responsibilities such as recognizing behavioral expressions and how to effectively communicate to residents with dementia is to have the new staff do a minimum of 2 days of on the job training and orientation, in tandem with the existing staff (in accordance to the subjects of training on the training checklists). MONITORING & DOCUMENTATIONMonitoring on this plan of correction will be done as a part of the facility’s quarterly QAPI (QMS) internal audit, in which the administrator will review if staff are fully comprehend and implemented the training given on above subjects. Documentation of this POC will be done through updates on the internal audit the records as well as partially through monthly resident meeting notes where the residents are free to express and suggest service improvement or adjustment on above subjects. One of the methods on how the corrective action is monitored is by having the administrator to interview the staff on a day to day basis if there are any challenges on implementing the training material. Secondly, by having the administrator interviews the residents in terms of the day to day interactions with the staff and if the staff are able to meet their needs. The result of these monitoring is to be documented on the Staff performance review form and on the Resident council meeting note, specifically if there are input or grievance in regards to staff performance. The monitoring will continue for the next three months and adjusted accordingly if there are changes in residents needs and demographics. This plan of correction will be included as part of internal review in the facility’s QAPI when the facility conducted its quarterly internal audit and will be conducted for the next three months and onward.

Plan of Correction 0812 – Visitation Policy UpdateThe facility has corrected the error by revising its visitation policy to includes all the required elements from Chapter VII, Regulation 9.2 (A-H) in its visitation policy as follows:(B) To describe any restriction or limitation necessary to ensure the health and safety of residents, staff, or visitors and the reasons for such restriction or limitation (as explained below on section F, G & H)C) To be available for inspection at the request of the Department;(D) Be provided to residents and/or family members upon request; andE) To Include the right of each resident of an assisted living residence to have at least one visitor of the resident's choosing during their stay at the residence, unless restrictions or limitations under federal law or regulation, other state statute, or state or local public health order apply. This visitation right shall be exercised in accordance with the following:(1) A visitor to provide a compassionate care visit to alleviate the resident's physical or mental distress.(2) For a resident with a disability:(a) A visitor or support person, designated by the resident, orally or in writing, to support the resident during the course of their residency. The support person may visit the resident and may exercise the resident's visitation rights even when the resident is incapacitated or otherwise unable to communicate.(b) When the resident has not otherwise designated a support person and the resident is incapacitated or otherwise unable to communicate their wishes, an individual may provide an advance medical directive designating the individual as the resident's support person or another term indicating that the individual is authorized to exercise visitation rights on behalf of the resident.(F) The policies and procedures may impose limitations on visitation rights. During a period when the risk of transmission of a communicable disease is heightened, an assisted living residence may:1) Require visitors to enter the residence through a single, designated entrance;(2) Deny entrance to a visitor who has known symptoms of the communicable disease;(3) Require visitors to use medical masks, face-coverings, or other personal protective equipment while on the assisted living residence premises or in specific areas of the residence;(4) Require visitors to sign a document acknowledging(a) The risks of entering the residence while the risk of transmission of a communicable disease is heightened; and(b) That menacing and physical assaults on health-care workers and other employees of the residence will not be tolerated;(5) Require all visitors, before entering the residence, to be screened for symptoms of the communicable disease and deny entrance to any visitor who has symptoms of the communicable disease;(6) Require all visitors to the residence to be tested for the communicable disease and deny entry for those who have a positive test result; and(7) Restrict the movement of visitors within the residence, including restricting access to where immunocompromised or otherwise vulnerable populations are at greater risk of being harmed by a communicable disease.(8) If an assisted living residence requires that a visitor use a medical mask, face covering, or other personal protective equipment or to take a test for a communicable disease in order to visit a resident at the assisted living residence, nothing in these regulations:(a) Requires the residence allow a visitor to enter, if the required equipment or test is not available due to lack of supply;(b) Requires the residence to supply the required equipment or test to the visitor, or bear the cost of the equipment for the visitor; or(c) Precludes the health-care residence from supplying the required equipment or test to the visitor. G) The policies and procedures may impose additional limitations for the visitors of a resident with a communicable disease who is isolated. In this case, the residence may impose additional restrictions including:(1) Limiting visitation to essential caregivers who are helping to provide care to the resident;(2) Limiting visitation to one caregiver at a time per resident with a communicable disease;(3) Scheduling visitors to allow for adequate time for screening, education, and training of visitors and to comply with any limits on the number of visitors permitted in the isolated area at the time; and(4) Prohibiting the presence of visitors during aerosol-generating procedures or during collection of respiratory specimens.(H) Any limitations imposed shall be consistent with applicable federal law and regulation and other state statute. MONITORING & DOCUMENTATIONMonitoring on this plan of correction will be done as a part of the facility’s quarterly QAPI (QMS) internal audit, in which the administrator will review if the facility’s policies are current and updated based on the changes of regulations on Chapter 7. Documentation of this POC will be done through updates on the internal audit the records as well as partially through monthly resident meeting notes where the residents are free to express their concerns or suggestions on the subjects of visitation. One of the methods on how the corrective action is monitored is by having the administrator to interview the staff on a day to day basis if there are any challenges on implementing the policy. Secondly, by having the administrator interviews the residents in terms of the day to day implementation of the policy. The result of these monitoring is to be documented on the Resident council meeting note, specifically if there are input or grievance in regards to visitation policy. The monitoring will continue for the next three months and adjusted accordingly if there are changes in residents needs and demographics. This plan of correction will be included as part of internal review in the facility’s QAPI when the facility conducted its quarterly internal audit and will be conducted for the next three months and onward. The monitoring will continue for the next three months and adjusted accordingly if there are changes in the guiding regulations.

Plan of Corrections 0816 – Addition of Involuntary Discharge Policy The facility has corrected the error by adding involuntary discharge policy to the facility’s discharge policy. The added policy shall includes all the required elements from Chapter VII, Regulation 9.3 (A-I) as follows:INVOLUNTARY DISCHARGE9.3 The assisted living residence shall have an involuntary discharge grievance policy that complies with Section 25-27-104.3, C.R.S., and includes, at a minimum:(A) The individual designated by the assisted living residence to receive involuntary discharge grievances.(B) The ability for any of the persons the assisted living residence is required to notify in accordance with Part 11.16 to file a grievance challenging the involuntary discharge and/or reasons for the discharge with the individual designated in subpart(A), above, within 14 calendar days after written notice of the involuntary discharge is provided by the assisted living residence.(C) The ability for the resident, or other person allowed to file a grievance to receive assistance in preparing and filing a grievance without interference from the assisted living residence.(D) A requirement that grievances related to involuntary discharge be submitted to the individual designated by the facility in accordance with subpart (A) as follows:(1) In writing, or(2) Orally submitted to the individual designated in accordance with subpart (A), above. In the case of an oral submission, the assisted living residence shall ensure the individual submitting the grievance retains proof of the oral submission through a witness or other evidence.(a) If the grievance is orally submitted and witnessed, the assisted living residence shall ensure that the resident or other person filing the grievance has the witness's name and contact information, and shall keep that information as part of the grievance documentation.(E) A requirement that no later than 5 business days after the submission of a grievance in accordance with subpart(D), above, the individual designated by the assisted living residence to receive involuntary discharge grievances shall provide a response to the grievance as follows:(1) A written response shall be provided to the individuals required to receive notice in Part 11.16, the state long-term care ombudsman, and the designated local ombudsman.(2) An oral explanation of the written response shall be provided to the resident and/or person filing the grievance, as appropriate.(3) The written response shall include the following statement regarding the filing of an appeal:"If the resident, or other person that submitted this grievance is dissatisfied with this response, they may file an appeal to the executive director of the Colorado Department of Public Health and Environment within 5 business days after receiving this written response. The appeal must include the original grievance, the original notice of involuntary discharge and supporting documentation given to the resident as part of that notification, and any additional information or documentation."(F) Acknowledgement that if the resident, the individual filing the grievance, or the assisted living residence is dissatisfied with the findings and recommendations of the Department related to an appeal, they may request a hearing conducted by the Department pursuant to Section 24-4-105, C.R.S.(G) A requirement that the assisted living residence not take any punitive or retaliatory action against a resident due to the resident filing a grievance or appeal pursuant to this Part.(H) A requirement that the assisted living residence continue to assist with planning a discharge or transfer of the resident while the grievance or appeal to the Department is pending.(I) A requirement that the resident be allowed to return to the assisted living residence if all of the following apply:(1) The stated reason for the involuntary discharge in the notice of involuntary discharge provided in accordance with Part 11.17 is nonpayment of monthly services or room and board,(2) The assisted living residence discharged the resident on or after the 31st day after the written notice of involuntary discharge was provided to the resident, and(3) The resident substantially complied with payments due to the residence, as determined through the grievance and appeal process. MONITORING & DOCUMENTATIONMonitoring on this plan of correction will be done as a part of the facility’s quarterly QAPI (QMS) internal audit, in which the administrator will review if the facility’s policies are current and updated based on the changes of regulations on Chapter 7. Documentation of this POC will be done through updates on the internal audit the records as well as partially through monthly resident meeting notes where the residents are free to express their concerns or suggestions on the subjects of discharge, voluntary or involuntary. One of the methods on how the corrective action is monitored is by having the administrator to review on case by case basis if there are any challenges on implementing the policy (when applicable). Secondly, by having the administrator interviews the residents in terms of the case by case implementation of the policy. The result of these monitoring is to be documented accordingly and on a case to case basis on the resident progress note, specifically if there are any reasons for the facility to enact the involuntary discharge policy towards its resident(s) .The monitoring will continue for the next three months and adjusted accordingly if there are changes in regulations and when there applicable situation(s) at the facility. This plan of correction will be included as part of internal review in the facility’s QAPI when the facility conducted its quarterly internal audit and will be conducted for the next three months and onward. The monitoring will continue for the next three months and adjusted accordingly if there are changes in the guiding regulations.

Plan of Corrections 0912 – Risk Assessments The facility has corrected the error by creating risk assessment forms related to natural and human-caused crises including, but not limited to, fire(s), gas explosion, power outages, tornado, flooding, and threatened or actual acts of violence to measure the preparedness of the facility as well as to assess the residents’ capacity in dealing with such event(s). In addition to the above, the facility had conducted risk assessments and preparedness review of the facility itself as well as assessing the current residents capacity in regards to dealing with hazards and preparedness measures related to natural and human-caused crises including, but not limited to, fire(s), gas explosion, power outages, tornado, flooding, and threatened or actual acts of violence 0n Oct 23, 2024. MONITORINGThe risk assessment for the hazards mentioned above including facility preparedness and residents evaluation will be a part of the facility's routine fire drill that is conducted on a once every other month basis. The evaluation activity will be a part of a checklist of routine drills monitored during the facility's QMP internal audit to assure that the review/assessments are dome timely and accurately. The monitoring will continue for the next three months and adjusted accordingly if there are changes in residents capacity as well as changes in the facility’s readiness. DOCUMENTATIONDocumentation of this POC will be done on created risks assessment forms and will be part of the routine drills file folder. The timely execution of this POC will be monitored through the quarterly QMS internal audit. This plan of correction will also be included as part of internal review in the facility’s QAPI when the facility conducted its quarterly internal audit and will be conducted for the next three months and onward.

Plan of Correction 0914 – Updated 72 hour continuation of care policy & procedure. The Facility had corrected the error by updating written policy and procedure of continuation of care to all participants (residents) for at least 72 hours following any emergency. The facility had the policy on hand during the survey, however the current 72 hours emergency plans does not include elements of follow up plans in terms of the procedure of where to go and who to contact in such emergency. Therefore, the facility will update its current policy & procedure to include those elements as follows:A schematic plan of the building or portions thereof placed visibly in a central location and throughout the building, as needed, showing evacuation routes, smoke stop and fire doors, exit doors, and the location of fire extinguishers and fire alarm boxes; When to evacuate the premises and the procedure for doing so;A pre-determined means of communicating with residents, families, staff and other providers;A plan that ensures the availability of, or access to, emergency power for essential functions and all resident-required medical devices or auxiliary aids;Storage and preservation of medications; Assignment of specific tasks and responsibilities to the staff members on each shift including use of a triage system to assess the needs of the most vulnerable residents first;Protection and transfer of health information as needed to meet the care needs of residents; andProtection and transfer of health information as needed to meet the care needs of residents as needed to meet the care needs of the residents during emergencies. MONITORINGMonitoring on this plan of correction will be done as a part of the facility’s quarterly QAPI (QMS) internal audit, in which the administrator will review if the facility’s policies are current and updated based on the requirements of the regulations on Chapter 7. Documentation of this POC will be done through updates on the internal audit records, in which the administrator will check if the current policy and procedures are UpToDate. The monitoring will continue for the next three months and adjusted accordingly if there are changes in residents needs and demographics. This plan of correction will be included as part of internal review in the facility’s QAPI when the facility conducted its quarterly internal audit and will be conducted for the next three months and onward. The monitoring will continue for the next three months and adjusted accordingly if there are changes in the guiding regulations.

Plan of Correction 0920 – Updated Emergency PlansThe Facility had corrected the error by updating written policy and procedure of handling emergency situation as part of the continuation of care plans to all participants (residents) for at least 72 hours following any emergency. The facility’s procedure section had included the missing required sections as follows:a schematic plan of the building or portions thereof placed visibly in a central location and throughout the building, as needed, showing evacuation routes, smoke stop and fire doors, exit doors, and the location of fire extinguishers and fire alarm boxes; When to evacuate the premises and the procedure for doing so;A pre-determined means of communicating with residents, families, staff and other providers;A plan that ensures the availability of, or access to, emergency power for essential functions and all resident-required medical devices or auxiliary aids;Storage and preservation of medications; Assignment of specific tasks and responsibilities to the staff members on each shift including use of a triage system to assess the needs of the most vulnerable residents first;Protection and transfer of health information as needed to meet the care needs of residents; andProtection and transfer of health information as needed to meet the care needs of residents as needed to meet the care needs of the residents during emergenciesMONITORING & DOCUMENTATIONMonitoring on this plan of correction will be done as a part of the facility’s quarterly QAPI (QMS) internal audit, in which the administrator will review if the facility’s policies are current and updated based on the requirements of the regulations on Chapter 7. Documentation of this POC will be done through updates on the internal audit records, in which the administrator will check if the current policy and procedures are UpToDate. The monitoring will continue for the next three months and adjusted accordingly if there are changes in residents needs and demographics. This plan of correction will be included as part of internal review in the facility’s QAPI when the facility conducted its quarterly internal audit and will be conducted for the next three months and onward. The monitoring will continue for the next three months and adjusted accordingly if there are changes in the guiding regulations.

POC 1600 - MEDICATION ADMINISTRATION RECORDS TIMELY AND ACCURATE SIGNATORIES.(Cross-reference S1604)The facility has corrected the error by adopting the following oversight policies and procedures in regards of timely and accurate update of Medication Administration Records and adding onto the MAR sheet a legible list of the names of the persons utilizing the record for medication administration, along with each of their signatures and their initials. The systemic changes that will be implemented is that the administrator shall conduct an evaluation and inspection on all residents MAR book and individual resident's file at minimum twice a month (middle of the month and by the end of the month upon receipt of new MARs from health providers/pharmacy) to inspect whether all medications are administered in accordance to the dose, time and route as indicated by the prescriber and whether it has been signed by staff upon administration and whether all administration of the residents' medications are reflected on the MAR book accurately and that all of the orders for the most current residents' medications lists are available and complete. At the time of the above evaluation, the administrator shall also inspect the residents prescription records and ensure that the prescription records and medication shows on MARS are matched. MONITORING & DOCUMENTATIONMonitoring on this plan of correction will be done as a part of daily and weekly administrator visit as well as the facility’s quarterly QAPI (QMS) internal audit, in which the administrator will compare the medications on the MAR book and the med orders on the resident’s whether the book or the most recent signed medication summary are similar or not. Administrator will also update the MAR if there has been signatories discrepancy on the book to ensure that the MAR is up to date and that the administered medication records is accurate and signed on staff’s individual shift. Documentation of this POC will be done through updates on the MAR book as well as updates on the internal audit records during the quarterly QMS internal audit. This plan of correction will be included as part of internal review in the facility’s QAPI when the facility conducted its quarterly internal audit and will be conducted for the next three months and onward.

POC 1604 - TIMELY QUARTERLY INTERNAL AUDIT.(Cross-reference S1600)The facility has corrected the error by adopting the following oversight policies and procedures in regards of the quarterly internal audit. The method and systemic changes in which the procedure shall be implemented is by setting a reminder on the administrative calendar to ensure the timeliness of quarterly internal audit. Furthermore, the facility had conducted the internal audit on 10/17/24 to cover the internal audit that was missed on August 2024. MONITORING & DOCUMENTATIONMonitoring on this plan of correction will be done as a part of the facility’s quarterly QAPI (QMS) internal audit, in which the administrator will review if the facility’s internal audit documentations are current and updated based on the planned schedule. Documentation of this POC will be done through updates on the internal audit records, in which the administrator will check if the current internal audit documents are UpToDate. The monitoring will continue for the next three months and adjusted accordingly if there are changes in residents needs and demographics. This plan of correction will be included as part of internal review in the facility’s QAPI when the facility conducted its quarterly internal audit and will be conducted for the next three months and onward. The monitoring will continue for the next three months and adjusted accordingly if there are changes in the guiding regulations.

POC 1632 - MEDICATION HANDLING AND STORAGE.The facility has corrected the error by adopting the following oversight policies and procedures in regards of Medication handling and storage. The facility will re-trained staff members about medication handling such as not leaving medications and or medication storage unattended, if staff needs to leave the room for a period of time whether long or short, the staff needs to place the medication inside the medication cabinet. Furthermore, the administrator will enforce that all medications needs to be stored in locked cabinet at all times and all controlled medications re to be stored in a lockable safe box inside the lockable medication cabinet to ensure that the controlled meds are double locked. MONITORING & DOCUMENTATIONMonitoring on this plan of correction will be done as a part of daily and weekly administrator visit as well as the facility’s quarterly QAPI (QMS) internal audit, in which the administrator will observe and review how staff administer and handle medications given to residents. The observation will include review of the five rights practice on administering medication (Right person, right medication, right dose, right time and right route) as well as the proper handling of medication including not leaving medications unattended. One of the systemic changes that will be implemented following this POC is to adopt a regular training/reminder session on medication administration as part of the monthly training to staff. Documentation of this POC will be done through updates on the MAR book as well as updates on the internal audit records during the quarterly QMS internal audit, specifically the staff performance review section. This plan of correction will be included as part of internal review in the facility’s QAPI when the facility conducted its quarterly internal audit and will be conducted for the next three months and onward.

POC 2510 – Rubbish and Garden area clean upThe deficiencies on the exterior part of the facility have been corrected, The disposable cup, and plastic bottle cap rings near the porch and other trash has been removed, the weeds along the backyard fence have been cleared and the rose bush in front of the house have been trimmed. MONITORING & DOCUMENTATIONMonitoring on this plan of correction will be done as a part of the facility’s quarterly QAPI (QMS) internal audit, in which the administrator will review the environmental portion of the audit and made sure that those sections of the room is cleaned regularly and properly. Several of the systemic changes that has been implemented to help the facility to make sure that the environmental and cleaning aspects of the premises are not overlooked are; Firstly, by enforcing the cleaning checklist for staff on duty. The checklist covers some of the requirements such as cleaning schedule for interior and exterior part of the facility. The method on how the monitoring will be implemented is on his weekly visit to the facility the administrator will check if the staff filled out the cleaning checklist, The administrator then will compare by doing a visual inspection if the items that are listed on the checklist has been cleaned satisfactorily. If the cleanliness is not satisfactory, then the administrator will try to find the cause (such as cleaning agents doesn’t work or surface needs to be repainted etc.) and find ways to resolve it. The monitoring will occur at least twice a week during the administrator visit. The plan of correction will be documented on the aforementioned cleaning checklist form as well as on the 3 monthly internal environmental audit form. The monitoring will continue for 3 months onward. DOCUMENTATIONDocumentation of this POC will be done through updates on the internal audit records during the quarterly QMS internal audit. This plan of correction will be included as part of internal review in the facility’s QAPI when the facility conducted its quarterly internal audit and will be conducted for the next three months and onward, however immediately after the survey the above POC will be done once a week during the administrator visit to the facility.

POC 2516 – Exterior maintenance and repairsThe deficiencies on the exterior part of the facility have been corrected. The uneven concrete block have been levelled by adding more sand underneath to even the surface level, the small cracked portion of the concrete on the front porch has been recemented. MONITORING & DOCUMENTATIONMonitoring on this plan of correction will be done as a part of the facility’s quarterly QAPI (QMS) internal audit, in which the administrator will review the environmental portion of the audit and made sure that the exterior and interior section of the facility is maintained properly and regularly. Several of the systemic changes that has been implemented to help the facility to make sure that the environmental and cleaning aspects of the premises are not overlooked are; Firstly, by enforcing the cleaning checklist for staff on duty. The checklist covers some of the requirements such as cleaning schedule for common areas and resident’s room, and cleaning schedule for exterior part of the building. As for the environmental condition, the staff have been trained to immediately report to the administrator if immediate repairs are needed or some aspects of the house need attention. The method on how the monitoring will be implemented is on his weekly visit to the facility the administrator will check if the staff filled out the cleaning checklist, The administrator then will compare by doing a visual inspection if the items that are listed on the checklist has been cleaned satisfactorily. If the cleanliness is not satisfactory, then the administrator will try to find the cause (such as cleaning agents doesn’t work or surface needs to be repainted etc.) and find ways to resolve it. The monitoring will occur at least twice a week during the administrator visit. The plan of correction will be documented on the aforementioned cleaning checklist form as well as on the 3 monthly internal environmental audit form. The monitoring will continue for 3 months onward. DOCUMENTATIONDocumentation of this POC will be done through updates on the internal audit records during the quarterly QMS internal audit. This plan of correction will be included as part of internal review in the facility’s QAPI when the facility conducted its quarterly internal audit and will be conducted for the next three months and onward, however immediately after the survey the above POC will be done once a week during the administrator visit to the facility.

POC 0882 – CRITICAL INCIDENT REPORTINGThe facility had corrected the error by revising the policy and procedure of reportable occurrence, the facility will update its policies and procedures with the inclusion of critical incident reporting. The P & P will cover the following topic and training materials for staff:In the event an injury of high level of severity, staff should take immediate and necessary actions to provide appropriate medical care and immediately prepare a critical incident report. The seriousness of the event that leads to reasonable suspicion establishes two time limits for reporting:Serious Bodily Injury* - 2 Hour LimitAll Others*^ - Within 24 HourThe reporting timeline is based on clock time, not business hours. After business hours, on weekend sand holidays, the report continues to be forwarded to the department. The report must go to the department and local law enforcement. An individual (facility employee) may report per policy a reasonable suspicion of a crime to the facility administrator (provided an individual has clear assurance the administrator is reporting it), who will then coordinate reporting to the department and local law enforcement as required. The facility may not retaliate against any individual that reports a crime. Either of the above timelines also requires a thorough investigation and the investigative findings forwarded in a report to the department within 24 hours. As part of the injury investigation, the following questions are to be part of the investigations:The extent of the injuryThe location of the injury (The injury is located in area not generally vulnerable to trauma)The numbers of injuries observed at particular point of timeThe incidence of injuries over a period of timeMONITORING & DOCUMENTATIONMonitoring on this plan of correction will be done as a part of the facility’s quarterly QAPI (QMS) internal audit, in which the administrator will review if staff are fully comprehend and implemented the training given on above subjects, on the policy and procedure portion of this POC, monitoring on this plan of correction will be done as a part of the facility’s quarterly QAPI (QMS) internal audit, in which the administrator will review if the P& P documents are updated and completed accordingly to the department’s requirement. Documentation of this POC will be done through updates on the internal audit the records during the quarterly QMS internal audit. This plan of correction will be included as part of internal review in the facility’s QAPI when the facility conducted its quarterly internal audit and will be conducted for the next three months and onward.

POC 0926 - MEDICATION ADMINISTRATION RECORDS TIMELY & ACCURATE SIGNATORIES .The facility has corrected the error by adopting the following oversight policies and procedures in regards of timely and accurate update of Medication Administration Records and adding onto the MAR sheet a legible list of the names of the persons utilizing the record for medication administration, along with each of their signatures and their initialsThe systemic changes that will be implemented is that the administrator shall conduct an evaluation and inspection on all residents MAR book and individual resident's file at minimum twice a month (middle of the month and by the end of the month upon receipt of new MARs from health providers/pharmacy) to inspect whether all medications are administered in accordance to the dose, time and route as indicated by the prescriber and whether it has been signed by staff upon administration and whether all administration of the residents' medications are reflected on the MAR book accuratelyand that all of the orders for the most current residents' medications lists are available and complete. At the time of the above evaluation, the administrator shall also inspect the residents prescription records and ensure that the prescription records and medication shows on MARS are matched. MONITORING & DOCUMENTATIONMonitoring on this plan of correction will be done as a part of daily and weekly administrator visit as well as the facility’s quarterly QAPI (QMS) internal audit, in which the administrator will compare the medications on the MAR book and the med orders on the resident’s whether the book or the most recent signed medication summary are similar or not. Administrator will also update the MAR if there has been signatories discrepancy on the book to ensure that the MAR is up to date and that the administered medication records is accurate and signed on staff’s individual shift. Documentation of this POC will be done through updates on the MAR book as well as updates on the internal audit records during the quarterly QMS internal audit. This plan of correction will be included as part of internal review in the facility’s QAPI when the facility conducted its quarterly internal audit and will be conducted for the next three months and onward.

POC 1350 – Outdoor Area maintenance, 72 hours continuous care & Access to food & beverages. 1. Plan of Correction for Rubbish and Garden area clean upThe deficiencies on the exterior part of the facility have been corrected, The disposable cup, and plastic bottle cap rings near the porch and other trash has been removed, the weeds along the backyard fence have been cleared and the rose bush in front of the house have been trimmed. MONITORING & DOCUMENTATIONMonitoring on this plan of correction will be done as a part of the facility’s quarterly QAPI (QMS) internal audit, in which the administrator will review the environmental portion of the audit and made sure that those sections of the room is cleaned regularly and properly. Several of the systemic changes that has been implemented to help the facility to make sure that the environmental and cleaning aspects of the premises are not overlooked are; Firstly, by enforcing the cleaning checklist for staff on duty. The checklist covers some of the requirements such as cleaning schedule for interior and exterior part of the facility. The method on how the monitoring will be implemented is on his weekly visit to the facility the administrator will check if the staff filled out the cleaning checklist, The administrator then will compare by doing a visual inspection if the items that are listed on the checklist has been cleaned satisfactorily. If the cleanliness is not satisfactory, then the administrator will try to find the cause (such as cleaning agents doesn’t work or surface needs to be repainted etc.) and find ways to resolve it. The monitoring will occur at least twice a week during the administrator visit. The plan of correction will be documented on the aforementioned cleaning checklist form as well as on the 3 monthly internal environmental audit form. The monitoring will continue for 3 months onward. DOCUMENTATIONDocumentation of this POC will be done through updates on the internal audit records during the quarterly QMS internal audit. This plan of correction will be included as part of internal review in the facility’s QAPI when the facility conducted its quarterly internal audit and will be conducted for the next three months and onward, however immediately after the survey the above POC will be done once a week during the administrator visit to the facility. 2. Plan of Correction for Updated 72 hour continuation of care policy & procedure. The Facility had corrected the error by updating written policy and procedure of continuation of care to all participants (residents) for at least 72 hours following any emergency. The facility had the policy on hand during the survey, however the current 72 hours emergency plans does not include elements of follow up plans in terms of the procedure of where to go and who to contact in such emergency. Therefore, the facility will update its current policy & procedure to include the following elements:a schematic plan of the building or portions thereof placed visibly in a central location and throughout the building, as needed, showing evacuation routes, smoke stop and fire doors, exit doors, and the location of fire extinguishers and fire alarm boxes; When to evacuate the premises and the procedure for doing so;A pre-determined means of communicating with residents, families, staff and other providers;A plan that ensures the availability of, or access to, emergency power for essential functions and all resident-required medical devices or auxiliary aids;Storage and preservation of medications; Assignment of specific tasks and responsibilities to the staff members on each shift including use of a triage system to assess the needs of the most vulnerable residents first;Protection and transfer of health information as needed to meet the care needs of residents; andProtection and transfer of health information as needed to meet the care needs of residents as needed to meet the care needs of the residents during emergenciesMONITORING & DOCUMENTATIONMonitoring on this plan of correction will be done as a part of the facility’s quarterly QAPI (QMS) internal audit, in which the administrator will review if the facility’s policies are current and updated based on the requirements of the regulations on Chapter 7. Documentation of this POC will be done through updates on the internal audit records, in which the administrator will check if the current policy and procedures are UpToDate. The monitoring will continue for the next three months and adjusted accordingly if there are changes in residents needs and demographics. This plan of correction will be included as part of internal review in the facility’s QAPI when the facility conducted its quarterly internal audit and will be conducted for the next three months and onward. The monitoring will continue for the next three months and adjusted accordingly if there are changes in the guiding regulations. 3. POC FOR FOOD AND DRINKS AVAILABILITY AND ACCESSIBILITYThe Facility had corrected the deficiency by providing an accessible snack & beverage storage located in the kitchen pantry and fridge accessible by the residents. The availability of snacks & beverage has been communicated with the current resident, and the resident now knew where to access the food. The type of snacks that is provided had been communicated and agreed to with the resident through resident meeting on 10/17/2024One of the changes that the facility has implemented is to have the staff fill-up the snack cabinets & beverage containers on a regular time interval. The scheduled interval is communicated to the residents so residents knows when snacks cabinets will be refill and therefor accessible to the residents. MONITORING & DOCUMENTATIONMonitoring on this plan of correction will be done as a part of quarterly residents’ meeting as well as the facility’s quarterly QAPI (QMS) internal audit, in which the administrator will review if provided snacks are meeting the needs of the residents..Documentation of this POC will be done through updates on the internal audit the records as well as partially through monthly resident meeting notes where the residents are free to express and suggest service improvement or adjustment on above subjects. This plan of correction will be included as part of internal review in the facility’s QAPI when the facility conducted its quarterly internal audit and will be conducted for the next three months and onward.