HEIDI'S CHATEAU

1. Description of how licensee will correct each identified deficiency: An Activities Assessment of all residents was conducted on 2/12/24, to determine current resident activity preferences. The February activity calendar was modified to better reflect those preferences from 2/13-29, as well as the March 2024 activity calendar. Future activity calendars will likewise be structured based on those assessments, as well as input from future Resident Council meetings and resident requests or suggestions. From now on, new residents will also complete an activity assessment after admission, with results also used to ensure resident preferences are reflected in the activity calendar. An assessment of the Activities Program will now be completed quarterly, based on resident satisfaction surveys completed by all or a representative sample of residents, plus daily participation records and Resident Council input. Investigation showed that, on the day of survey, the Activities Director was engaged on an emergency basis filling in for the facility cook, who had gotten ill the night before and was unable to work on the day of survey. The activities assistant was helping her, and the Executive Director did not designate or bring in a caregiver to oversee the activities for the day. Informal procedures for ensuring activity coverage were not effective that day. A written protocol addressing this issue, as well as the quarterly required activities program assessment, has been developed and implemented. The Activities Director has primary responsibility for ensuring implementation of the activities calendar. If the Activities Director is unable to personally implement the activities, she will contact the activities assistant and delegate that responsibility to her. If the activities assistant is not available to implement the activities, the Activities Director will contact the Executive Director; the Executive Director will then designate or bring in a caregiver to implement the day’s activities, and assist that caregiver with the activities as needed. 2. Description of how the licensee will monitor the corrective action to ensure each deficiency is remedied and will not reoccur: Compliance with the quarterly assessment requirement, and consistent oversight/implementation of the activities calendar, will be monitored by the QMP. Documentation reviewed will include resident participation in activities on a day-by-day basis, to ensure the efficacy of established procedures ensuring implementation of the activities calendar, particularly on days when the Activities Director has not been present or available (see Executive Director actions below). Compliance with the quarterly program assessment requirement, and adequacy of that assessment, will be monitored by QMP by review of the Activities Director’s written report of each assessment. For the next 30 days, the Executive Director will review and sign off on resident activity participation records weekly, in comparison with the published activity calendar. She will also take action to correct any deficiencies identified. The Executive Director will continue such review and sign-off at least monthly until the QMP determines compliance has been achieved and consistently maintained, but no less than a period of at least two QMP meetings. Any additional actions to achieve compliance will be identified and reviewed for effectiveness by the QMP at its meetings, documented in their minutes. 3. A completion date that shall be no longer than thirty (30) calendar days from the issuance of the deficiency list [2/7/24], unless otherwise required or approved by the Department. Target completion date: 4/15/24.

Description of how Heidi’s Chateau will correct the deficiency: Medication administration procedures were modified to require faxing a copy of the MAR reflecting refused medications to the resident’s provider, plus phone notification to the provider office, both actions documented in resident progress notes. Modified the ongoing weekly Medication Administration Record (MAR) audit to address the specific issue of medication refusal and required notifications. Executive Director tasked the QMAP Manager with instructing QMAP staff and implementing new procedures. Staff QMAPs were notified by the QMAP Manager on 1/30/23 of the new procedures for immediate implementation. Monitoring plan to ensure deficiency remedied and will not reoccur: All MARs reviewed weekly to note any incidents of refused medications, and to confirm documentation of required notifications. Any missed notifications are immediately made and documented, confirmed by the QMAP Manager, who also counsels the responsible QMAP regarding the requirement. Results of weekly MAR audit compiled and reviewed by the Executive Director at least monthly for the next three months, and quarterly thereafter as part of the ongoing Quality Management process (QMP). Appropriate disciplinary action will be initiated for any QMAP staff with repeated failures of required notification. Of note, monthly audit review to date has identified only one occurrence of a resident pattern of refusal. Provider was notified by fax and call in a timely manner, documented in the record, per procedure; provider talked with resident about need for medication, and resident now taking medication as ordered. Completion Date NMT 30 days after issuance of deficiency list (3/30): 4/30/23