WILLOWBROOK PLACE

1. Corrective Action Taken for Affected Staff:Staff #1 and Staff #2 were immediately removed from independent caregiving duties. Both staff completed full competency evaluations for all personal care tasks under direct observation by a designated supervisor. Staff #1 was reassigned to housekeeping until all competencies were completed. 2. Systemic Changes Implemented:A standardized Resident Care Assistant Competency Validation Checklist was implemented for all RCAs. No staff may be scheduled independently until all required competencies are documented and signed. 3. Measures to Prevent Recurrence:Staff Development Director will verify competency documentation before any staff member is added to the schedule. Supervisors will complete competency checks each time a new task is assigned, as required by regulation. 4. Monitoring:The Administrator or designee will audit 100% of new hire files weekly for 90 days, then monthly thereafter. Results will be reviewed during monthly QA meetings. Completion Date: 05/30/2026

Corrective Action Taken:Staff #1 was reassigned to housekeeping until fully trained and validated. Staff #3 was suspended pending investigation. Documentation audits were initiated immediately. Systemic Changes Implemented:All staff job descriptions were reviewed, updated, and reissued. Staff signed acknowledgments confirming understanding of their roles and scope of practice. The shift-to-shift verification form was reviewed with staff and staff signed acknowledgement of the shift-to-shift procedure. Measures to Prevent Recurrence:Supervisors will verify that staff are working within their assigned roles each shift. Staff will receive retraining on documentation expectations and care plan adherence. Monitoring:Random audits of 10% of shift documentation weekly for 12 weeks will be conducted. All shift-to-shift verification forms will be reviewed upon submission for 90 days, then weekly thereafter. Any discrepancies will result in corrective action. Completion Date: 05/30/2026What is the residence's plan to ensure staff are completing all tasks as required, and not just documenting completion?The residence will ensure staff are completing required tasks by implementing the following:Direct supervisory observation each shift to confirm that care tasks listed in the care plan are being performed as written. Real-time comparison of documentation to observed care, including spot checks of resident status, room conditions, and care outcomes. Shift-to-shift verification, already referenced in the POC: “The shift-to-shift verification form was reviewed with staff and staff signed acknowledgement of the shift-to-shift procedure.”Immediate corrective action when discrepancies are identified, consistent with the POC statement: “Any discrepancies will result in corrective action.”How will the residence ensure staff are providing resident care, as required?The residence will ensure staff provide required resident care by:Supervisors verifying that staff are working within their assigned roles each shift, as stated in the POC: “Supervisors will verify that staff are working within their assigned roles each shift.”Retraining staff on care plan adherence, ensuring they understand and follow individualized resident needs: “Staff will receive retraining on documentation expectations and care plan adherence.”Using the shift-to-shift verification form to confirm that required care tasks were completed and communicated. Conducting random audits of shift documentation, which helps identify gaps in care delivery: “Random audits of 10% of shift documentation weekly for 12 weeks will be conducted.”The monitoring plan must identify all of the following:Exactly how and what will be reviewed as part of the monitoring;The residence will review:Shift documentation for accuracy, completeness, and alignment with resident care plans. Shift-to-shift verification forms to ensure required tasks were completed and communicated. Direct observation findings, comparing observed care to documented care. Care plan adherence, ensuring staff actions match resident-specific requirements. The sample, representative of the facility census, included in the monitoring;A 10% sample of all shifts will be reviewed weekly. The sample will include all three shifts, weekdays and weekends, and a mix of staff roles (RCAs, QMAPs, etc.). Residents included in the review will represent varying care needs (ADL assistance, medication support, memory care, etc.). How often the monitoring will occur;Weekly review of 10% of shift documentation for at least 12 weeks (as stated in the POC). Daily review of shift-to-shift verification forms for the first 90 days, then weekly thereafter. How the monitoring will be documented;A Shift-to-Shift Verification Review Log. A Direct Observation Record completed by supervisors. All findings will be stored in the QA binder. Each entry will include date, shift, staff reviewed, findings, corrective actions, and follow-up. The total minimum length of time the monitoring will continue (a minimum of 3 months isrequired)Monitoring will continue for:120 days of documentation audits120 days of shift-to-shift form reviewHow the monitoring will be included in the QAPI process. All audit results will be reviewed during monthly QA meetings, consistent with the facility’s existing QA structure. Trends, deficiencies, and corrective actions will be documented in the QAPI dashboard. Persistent issues will trigger root cause analysis and additional staff training. QAPI will determine whether monitoring can be reduced, continued, or expanded.

Corrective Action Taken:All current resident care plans were reviewed to ensure representative involvement. Representatives were contacted to confirm participation and provide input. Systemic Changes Implemented:The Care Plan Conference Form requiring signatures of all participants was reviewed and will be utilized for any care plan adjustments. Care plan meetings will occur at admission, bi-annually, and with any significant change. Measures to Prevent Recurrence:The administrator will be notified immediately by the Clinical Services Director when a new assessment is completed that adjusts a resident’s care plan. The administrator will schedule a Care Conference with the resident representative immediately upon notification of these changes. Care plans will not be finalized in the EHR until representative input is documented. Monitoring:The Clinical Services Director will audit 10 care plans monthly for 6 months. Completion Date: 05/30/2026Exactly how and what will be reviewed as part of the monitoring;The Clinical Services Director (CSD) will review:Care plans to verify that representative input is documented before finalization. Care Plan Conference Forms, ensuring all required signatures (resident, representative, staff) are present. “The Care Plan Conference Form requiring signatures of all participants was reviewed and will be utilized…”EHR care plan revision history, confirming no care plan was finalized without representative involvement. Communication logs (phone logs, emails, meeting notes) to confirm representatives were contacted and given the opportunity to participate. Assessment-to-care-plan workflow, ensuring that: “Care plans will not be finalized in the EHR until representative input is documented.”Each audit will check for:Representative notificationRepresentative participation or documented attemptsCompleted signaturesTimely scheduling of care conferencesAlignment between assessment changes and updated care plansThe sample, representative of the facility census, included in the monitoring;10 care plans per month, as stated in the POC. “The Clinical Services Director will audit 10 care plans monthly…”The sample will include:Residents from all care levels (independent, assisted, memory care). Residents with recent assessments, significant changes, or new admissions. A mix of residents with active representatives and those with limited or hard-to-reach representatives. This ensures the sample reflects the full resident population and care-planning needs. How often the monitoring will occur;Monthly audits, consistent with the POC. “Audit 10 care plans monthly…”Additional spot checks will occur whenever a new assessment triggers a care plan change. How the monitoring will be documented;A Care Plan Representative Involvement Audit Tool, capturing:Resident nameDate of assessmentDate representative was contactedMethod of contactRepresentative participation (yes/no)Signatures present on Care Plan Conference FormWhether the care plan was finalized only after representative inputCorrective actions takenAll completed audits will be stored in the QAPI binder and electronically in the facility’s shared drive. Documentation will include trends, deficiencies, and follow-up actions. The total minimum length of time the monitoring will continue (a minimum of 3 months isrequired)Monitoring will continue for 6 months: “Audit 10 care plans monthly for 6 months.”How the monitoring will be included in the QAPI process. Audit results will be reviewed during monthly QAPI meetings. The QAPI meetings will:Track trends in representative participationIdentify barriers (e.g., unreachable representatives, scheduling issues)Recommend corrective actions or policy adjustmentsDetermine whether additional staff training is neededPersistent issues will trigger a root cause analysis and targeted interventions. QAPI will determine when monitoring can be reduced or must be extended beyond 6 months.

Corrective Action Taken:All staff were retrained on Resident #2’s care plan requirements, including face-to-face safety checks and two-hour sleeping checks. Resident #2’s safety plan was updated to include enhanced monitoring. Systemic Changes Implemented:A new Safety Check Log requiring real-time documentation was implemented. Supervisors will verify completion of checks each shift. Measures to Prevent Recurrence:Residents with behavioral or fall-risk interventions now have highlighted alerts in the EHR and 24-hour binder. Monitoring:Daily review of safety check logs for 30 days, then weekly for 60 days. Completion Date: 04/30/2026Exactly how and what will be reviewed as part of the monitoring;The Administrator or designee will review:Safety Check Logs for accuracy, completeness, and real-time documentation. “A new Safety Check Log requiring real-time documentation was implemented.”Face-to-face safety checks and two-hour sleeping checks to ensure they were completed as required in Resident #2’s care plan. “All staff were retrained on Resident #2’s care plan requirements, including face-to-face safety checks and two-hour sleeping checks.”Supervisor verification records confirming that checks were completed each shift. “Supervisors will verify completion of checks each shift.”EHR alerts and 24-hour binder alerts for residents with behavioral or fall-risk interventions to ensure staff followed highlighted requirements. “Residents with behavioral or fall-risk interventions now have highlighted alerts in the EHR and 24-hour binder.”Each review will check for:Timeliness of checksMissing or late entriesConsistency between documentation and resident conditionSupervisor sign-offsAny deviations from the care plan or safety planThe sample, representative of the facility census, included in the monitoring;The monitoring sample will include:All residents with behavioral interventions, fall-risk interventions, or enhanced monitoring requirements, not only Resident #2. A mix of residents across all shifts, including nights, when safety checks are most critical. A minimum of 10% of all residents with safety-related care plan interventions reviewed weekly after the initial 30-day period. This ensures the sample reflects the facility’s overall risk profile and census. How often the monitoring will occur;Consistent with the POC:Daily review of all safety check logs for the first 30 days. Weekly review of safety check logs for the following 60 days. “Daily review of safety check logs for 30 days, then weekly for 60 days.”Additionally:Supervisors will continue shift-by-shift verification throughout the entire monitoring period. How the monitoring will be documented;Monitoring will be documented using:A Safety Check Audit Tool, capturing:Resident nameRequired check frequencyActual check timesStaff completing checksSupervisor verificationAny missed or late checksCorrective actions takenA Weekly Safety Monitoring Summary prepared by the Administrator or designee. All documentation will be stored in the QAPI binder and electronically in the facility’s shared drive. Each entry will include date, shift, findings, and follow-up. The total minimum length of time the monitoring will continue (a minimum of 3 months isrequired)Monitoring will continue for a total of 90 days, which exceeds the required minimum of 3 months. “Daily review… for 30 days, then weekly for 60 days.”How the monitoring will be included in the QAPI process. All audit findings will be reviewed during monthly QAPI meetings. QAPI will track:Missed or late safety checksTrends in staff complianceEffectiveness of the new Safety Check LogResident outcomes related to safety interventionsPersistent issues will trigger root cause analysis, additional staff training, or revisions to the safety plan process. QAPI will determine whether monitoring can be reduced after 90 days or must be extended.

Corrective Action Taken:A new process for storing external provider notes (EPNs) was implemented. All available EPNs were re-requested from providers. Systemic Changes Implemented:A Care Plan Change Notification Procedure was implemented, including electronic communication alerts, binder updates, and shift huddle announcements. Measures to Prevent Recurrence:EPNs will be reviewed weekly by the Administrator and cross referenced with sign in logs to verify that all residents seen by a provider have a corresponding EPN in the binder. Administrator will follow up with providers for all missing EPNs. Monitoring:Weekly audits of EPNs and care plan updates for 90 days. Completion Date: 05/30/2026Please provide additional information regarding staff notification of care plan/support changes. To ensure all staff are consistently notified of care plan and support changes, the residence has strengthened and clarified its communication workflow. Building on the systemic changes already described in the POC: “A Care Plan Change Notification Procedure was implemented, including electronic communication alerts, binder updates, and shift huddle announcements.”The following additional details apply:Electronic Alerts: When a care plan or support need changes, the Clinical Services Director (CSD) immediately updates the EHR. The system generates an alert visible to all staff at login. 24-Hour Binder Updates: The CSD or designee updates the binder within 1 hour of any change. Updated pages are highlighted for quick identification. Shift Huddle Announcements: Supervisors announce all care plan/support changes at the beginning of each shift. Staff must verbally confirm understanding. Staff Acknowledgment: Staff sign a Care Plan Change Acknowledgment Log confirming they have reviewed and understand the updated information. Cross-Referencing With Provider Visits: “EPNs will be reviewed weekly by the Administrator and cross referenced with sign in logs to verify that all residents seen by a provider have a corresponding EPN in the binder.” This ensures staff are notified whenever an external provider visit results in a care plan change. These steps ensure that every care plan or support change is communicated through three channels (electronic, written, verbal) and verified through staff acknowledgment. Exactly how and what will be reviewed as part of the monitoring;The Administrator or designee will review:All care plan changes entered into the EHR during the audit period. Care Plan Change Notification Procedure compliance, including:Whether electronic alerts were generatedWhether the 24-hour binder was updatedWhether shift huddle announcements were documentedWhether staff signed the Care Plan Change Acknowledgment LogExternal Provider Notes (EPNs) to ensure they were received, filed, and incorporated into care plans. “A new process for storing external provider notes (EPNs) was implemented.”Cross-reference of provider sign-in logs with EPNs to ensure no care plan changes were missed. “Administrator will follow up with providers for all missing EPNs.”Each audit will check for timeliness, accuracy, and completeness of staff notification. The sample, representative of the facility census, included in the monitoring;The monitoring sample will include:All residents who had a care plan change during the audit period. All residents seen by external providers, as identified through sign-in logs. A minimum of 10% of all residents each week, even if no changes occurred, to ensure system-wide compliance. This ensures the sample reflects the full range of resident needs and provider interactions. How often the monitoring will occur;Weekly audits for the entire monitoring period, consistent with the POC: “Weekly audits of EPNs and care plan updates for 90 days.”How the monitoring will be documented;Monitoring will be documented using:A Care Plan Change Audit Tool, capturing:Resident nameType of changeDate/time of changeWhether electronic alerts were issuedWhether binder updates were completedWhether shift huddle announcements were documentedStaff acknowledgment signaturesWhether EPNs were received and filedAny discrepancies and corrective actionsA Weekly Information Management Summary Report prepared by the Administrator. All documentation will be stored in the QAPI binder and electronically in the facility’s shared drive. The total minimum length of time the monitoring will continue (a minimum of 3 months is required)Monitoring will continue for 90 days, which meets and exceeds the required minimum of 3 months. “Weekly audits… for 90 days.”How the monitoring will be included in the QAPI process. Audit results will be reviewed during monthly QAPI meetings. QAPI will track:Timeliness of staff notificationMissing or late EPNsTrends in communication failuresStaff compliance with acknowledgment requirementsPersistent issues will trigger:Root cause analysisAdditional staff trainingRevision of the Care Plan Change Notification ProcedureQAPI will determine whether monitoring should continue beyond 90 days.

Corrective Action Taken:Final disposition for Former Resident #5 was obtained and added to the record. Providers were contacted to resend missing EPNs. Systemic Changes Implemented:A Resident Record Checklist was implemented for all admissions, discharges, and deaths. Measures to Prevent Recurrence:All external provider notes will be added to the EPN binder within 24 hours of receipt. Monitoring:Monthly audits of 20% of resident records for 6 months. Completion Date: 05/30/2026Exactly how and what will be reviewed as part of the monitoring;The Administrator or designee will review the following components of each selected resident record:Resident Record Checklist for completeness at admission, discharge, or death “A Resident Record Checklist was implemented for all admissions, discharges, and deaths.”External Provider Notes (EPNs) to ensure all notes have been received, filed, and entered into the record “Providers were contacted to resend missing EPNs.”Final disposition documentation for any resident who has discharged or expired “Final disposition for Former Resident #5 was obtained and added to the record.”Care plan updates, ensuring all required documents are present and filed in the correct sectionsTimeliness of documentation entry (within 24 hours of receipt, as stated in the POCD for EPNs) “All external provider notes will be added to the EPN binder within 24 hours of receipt.”Each audit will check for missing documents, incomplete sections, misfiled items, and delays in documentation. The sample, representative of the facility census, included in the monitoring;The monitoring sample will include:20% of all active resident records each month, as stated in the POCDA mix of residents who:Were recently admittedRecently dischargedRecently seen by external providersHave complex care plans or multiple providersAt least one record involving a discharge or death each month (if applicable), ensuring the checklist is being used consistentlyThis sample ensures representation across the full range of resident statuses and documentation types. How often the monitoring will occur;Monitoring will occur monthly, consistent with the POCD “Monthly audits of 20% of resident records for 6 months.”How the monitoring will be documented;Monitoring will be documented using:A Resident Record Audit Tool, which will include:Resident nameDate of reviewRequired documents present or missingConfirmation that EPNs were received and filedConfirmation that final disposition documentation is present (if applicable)Verification that the Resident Record Checklist was completedAny discrepancies foundCorrective actions takenA Monthly Resident Record Audit Summary, prepared by the Administrator or designeeAll documentation will be stored in the QAPI binder and electronically in the facility’s shared driveThe total minimum length of time the monitoring will continue (a minimum of 3 months is required)Monitoring will continue for 6 months. “Monthly audits… for 6 months.”How the monitoring will be included in the QAPI process. Audit results will be reviewed during monthly QAPI meetingsQAPI will track:Trends in missing or late documentationFrequency of missing EPNsCompliance with the Resident Record ChecklistTimeliness of final disposition documentationPersistent issues will trigger:Root cause analysisAdditional staff trainingRevision of the Resident Record Checklist or filing proceduresQAPI will determine whether monitoring should continue beyond 6 months based on trends and compliance levels

Corrective Action Taken:All current staff completed documented training on every resident’s care plan relevant to their duties. Systemic Changes Implemented:A Care Plan Training Log was implemented. New hires must complete care plan training before their first shift. Measures to Prevent Recurrence:Care plan updates now trigger mandatory staff retraining with sign-off. Monitoring:Weekly audits of training logs for 60 days, then monthly. Completion Date: 05/30/2026Exactly how and what will be reviewed as part of the monitoring;The Administrator or designee will review:Care Plan Training Logs to verify that all current staff have completed training on every resident’s care plan relevant to their duties. “A Care Plan Training Log was implemented.”New hire files to confirm care plan training was completed before the first shift, as required. “New hires must complete care plan training before their first shift.”Retraining documentation to ensure staff completed mandatory retraining after any care plan update. “Care plan updates now trigger mandatory staff retraining with sign-off.”EHR care plan update history to confirm that training occurred promptly after each change. Staff schedules to ensure no staff member is assigned to resident care before completing required training. Each audit will check for completeness, timeliness, accuracy, and proper staff sign-off. The sample, representative of the facility census, included in the monitoring;The monitoring sample will include:All staff whose duties involve resident care, including RCAs, QMAPs, and supervisors. All new hires during the monitoring period. All residents whose care plans were updated, ensuring staff training was completed for each update. A minimum of 20% of all staff files each month after the initial 60-day period. This ensures the sample reflects the full range of staff roles and resident care needs. How often the monitoring will occur;Consistent with the POCD:Weekly audits of training logs for the first 60 days. “Weekly audits of training logs for 60 days…”Monthly audits thereafter for the remainder of the monitoring period. “…then monthly.”How the monitoring will be documented;Monitoring will be documented using:A Care Plan Training Audit Tool, capturing:Staff nameDate of initial trainingDate of retraining (if applicable)Care plans coveredVerification that training occurred before first shift (for new hires)Verification that retraining occurred after care plan updatesAny discrepancies and corrective actionsA Monthly Training Compliance Summary prepared by the Administrator or designee. All documentation will be stored in the QAPI binder and electronically in the facility’s shared drive. The total minimum length of time the monitoring will continue (a minimum of 3 months is required)Monitoring will continue for a minimum of 3 months, but the facility’s plan already exceeds this requirement:60 days of weekly auditsFollowed by monthly audits “Weekly audits… for 60 days, then monthly.”This meets and exceeds the regulatory minimum. How the monitoring will be included in the QAPI process. Audit results will be reviewed during monthly QAPI meetings. QAPI will track:Staff compliance with initial and ongoing care plan trainingTimeliness of retraining after care plan updatesTrends in missed or late trainingImpact on resident outcomes and care qualityPersistent issues will trigger:Root cause analysisAdditional staff trainingRevision of the Care Plan Training Log or training proceduresQAPI will determine whether monitoring should continue beyond the initial period.

NOTE: IDR has been submitted to dispute this deficiency. ActionsStaff Development Director will audit of all current personnel files by January 24th to identify those staff members without CPR and First Aid training. Staff Development Director has scheduled First Aid and CPR training on February 17th and February 20th for all care staff who do not have current CPR and First Aid certificatesCopies of CPR and First Aid certificates will be kept in Personnel files in Staff Development Office and a separate binder in the Executive Director’s officeHow and what will be reviewedED binder containing CPR and First Aid Certificates will continue to be maintained and reviewed with SDD for accuracy. Clinical Staff Schedule will continued to be reviewed to ensure at least 1 staff member with CPR/FA certification is scheduled at all times. Sample included in monitoringMonitoring will cover all QMAPs and Care StaffHow often monitoring will occurED Binder will continue to be reviewed following each CPR/First Aid class held at community. How the monitoring will be documentedMonitoring will continued to be documented on SDD/ED Weekly Meeting notes. How long will monitoring continueMonitoring has been a permanent part of SDD/ED weekly meetings. How will monitoring be part of QAPI processMonitoring will be documented in the monthly QAPI (CQI) notes. ADDENDUM:What process is the agency putting in place to ensure new staff have CPR certification as required? With each clinical staff new hire, SDD and ED will review all certification. If new hire does not have CPR certification, SDD will schedule a new CPR class for all new hires needing certification. ED and SDD will review schedule monthly and with every call off to ensure that there is always a minimum of 1 staff member CPR/First Aid certified in the community.

NOTE: IDR has been submitted to dispute this deficiency. Actions ED will re-educate the Clinical Services Director and Asst. Clinical Services Director on Anthem Falls Reduction Plan and Fall Reduction Protocol by February 14, 2025. CSD or ACSD will continue to revise all care plans that are found to be missing individualized approaches necessary to address fall risks related to deficits in strength and balanceED and CSD or ACSD will continue to review Care Plans weekly for each resident who has sustained a fallED will continue to periodically review resident files to ensure that Fall Reduction Plan is followed for every fall, including but not limited to ensuring care plans are updated with individualized approaches necessary. How and what will be reviewedCare plans for each resident who hassustained fall in the last 3 months. Sample included in monitoringMonitoring will cover all residents with fallsHow often monitoring will occurMonitoring will take place after every documented fall. How the monitoring will be documentedED will monitor compliance with Fall Reduction Program using checklist for every step to be completed with every fall. How long will monitoring continueMonitoring is a permanent part of CSD/ED weekly meetings. How will monitoring be part of QAPI processMonitoring will continue to be documented in the monthly QAPI (CQI) notes. ADDENDUM:Has the care plan for Resident #2-4 been updated to address the individualized approach necessary to address falls risks? Yes, the care plans were updated as necessary in our electronic health record system. What is the agency's plan to train staff on updated care plans? Updated care plans and coordinating services are updated automatically through our electronic healthcare systems: ElderMark and Point of Care. Care Staff access specific service tasks at each shift through Point of Care on their electronic devices.

NOTE: IDR has been submitted to dispute this deficiency. ActionsTraining took place at All Staff Meeting on 12/19/24 @ 2 pm. For employees not in attendance at all staff meetings, further training will occur daily. The training will be presented by the Clinical Service Director, the Executive Director, or designee, until which time all staff have received training. All training conducted will provide opportunities for questions and clarifications as needed. Completion Date: January 2,2025. Effective 12/19/24: All staff will receive the Anthem Medical Emergencies Policy for their review and questions. In addition, the ED or designee will verbally communicate with all staff at each change of shift to ensure that staff are aware of the process to be followed in the event of a fall. Effective 12/19/24: The Medical Emergencies Policy will be posted in Medication Rooms in clear site for further staff review. Any staff who do not complete training upon first shift worked or by 1/2/25 will be removed from the schedule. Staff will be informed that failure to follow policy and procedure will result in discipline action up to and including termination. All new staff will be trained in the Medical Emergencies Policy and Protocol at time of hire. All training will be documented, and a sign-in sheet will be maintained in separate community file for this training. This file will be maintained in the Executive Director’s office and reviewed monthly for compliance. Per policy, Clinical Service Director is to be called for all medical emergencies. In the event the Clinical Services Director is not available, Executive Director will be notified. During this notification, either CSD or ED will specifically ask staff about resident pain. This process to be carried out for all incidents, indefinitely. Medical Emergencies Policy to be reviewed by VP of Clinical Services to remove word “Severe” from definition of pain. How and what will be reviewedSignature sheets for all Medical Emergencies Training will be compared to current staff roster. Sample included in monitoringAll staff will be included in the training processHow often monitoring will occurMonitoring of training will take place after every training session. How the monitoring will be documentedED will monitor compliance using the checklist for every step to be completed with every fall. How long will monitoring continueMonitoring will become a permanent part of CSD/ED weekly meetings. How will monitoring be part of QAPI processMonitoring will be documented in the monthly QAPI (CQI) notes. EMERGENCIES ANDMEDICAL NEEDSAnthem Memory Care Updated May 20, 2022POLICY: Medical EmergenciesThe resident will receive emergency medical care when needed to preventfurther injury or illness. Procedure 1. Caregivers immediately summon the community Clinical Services and/orExecutive Director and/or their immediate supervisor should a residentexhibit signs and symptoms of a medical emergency. 2. The Clinical Services Director or designee, determines the severity of thesituation. 3. The community summons emergency medical services by calling 911),when the resident exhibits signs and systems of distress and/oremergency condition. Examples include, but are not limited to:a. New onset of chest pain;b. Recurrent chest pain, unrelieved in 15 minutes by previouslyordered nitroglycerin given as ordered;c. Unconsciousness;d. Fall with deformity, severe pain or head injury;e. Uncontrolled bleeding;f. First time seizure;g. Recurring seizure which last for more than 1 minute;h. Sudden onset severe pain;i. Shortness of breath;j. Sudden lack of muscle control, ability to communicate, droopingfacial expression or other signs of stroke;k. Low blood sugar (according to physician order parameters, usuallyl. Excessively high blood sugar, according to physician orderparameters;m. Poisoning;n. Fever which is not lowering despite interventions and feverreducing agents;o. Choking;p. Psychiatric crisis. 4. A non-emergency transport is only used when the resident needs urgentbut non-emergency medical care, such as stitches, controlled bleeding,etc. 5. The Executive Director or designee, contacts the family/responsible party,as quickly as possible, once the resident is safely under the care of theparamedics. Unless instructed otherwise by the family/responsible party,this includes anytime, 24-hours a day. 6. The Community staff are not required to obtain permission from thefamily/responsible party before summoning emergency medical services. 7. A staff member remains with the resident until paramedics transport out ofthe community. 8. A copy of the current medication list, Face Sheet, and any POLST/DNRdocuments are given to the paramedics, along with the EmergencyIdentification Form. 9. The actual medications are retained in the community. 10. The staff person observing the transport out of the community will notewhat belongings are going with the resident, such as jewelry, dentures,prosthetic devices, etc. 11. A narrative chart entry is made in the resident’s chart regarding thecircumstances which led up to the call (Data), what care was provided bythe staff, including any first aid (Action), as well as the resident’s responseto the action (Response). 12. An Incident Report is completed. POLICY: FallsShould a resident experience a fall, staff will provide or arrange for necessaryemergency care, and will follow up with necessary service plan updates. Procedure 1. Should the resident have trauma resulting in deformity, exhibit any changein level of consciousness, received obvious head or significant trauma theClinical Services Director or designee, or caregivers summon emergencymedical services (call 911). 2. When a resident falls, caregivers are instructed to summon immediateassistance from the Clinical Services Director or their immediatesupervisor. 3. Caregivers do not move the resident, except to protect against furtherinjury, as in the case of a dangerous environment. 4. The physician is contacted for further instructions if the head was notinvolved in the fall and the resident is able to move all extremities.a. The Clinical Services Director instructs caregivers to provideappropriate care and frequent resident checks. Any change instatus is reported to the Clinical Services Director. 5. An incident report is completed. 6. The Clinical Services Director informs the physician of subsequent fallsand instability. Medical intervention, physical therapy, and/or gait analysisis arranged when Resident/Responsible Person remain a significant riskfor falls. 7. Ongoing falls may require relocation from the community. Fall Reduction PlanFalls are a major threat to the health and independence of older adults aged 65 and older. Each year in the United Sates, nearly one-third of older adults experience a fall. About one in ten falls among older adults results in a serious injury, such as a hip fracture or head injury that requires hospitalization. Inaddition to the physical and emotional pain, many people need to spend at least a year recovering in a long-term care facility. Purpose:To identify fall risk factors for each resident and to eliminate or minimize risk factors and falls. Policy:The community may utilize a multifaceted approach to a Fall Reduction program which may include:• Education of staff and residents about fall risk and fall reduction techniques• Evaluate each new resident’s fall risk factors upon move in• Evaluate each residents fall risk factors quarterly, with a fall event, and with a significant change in condition.• Tailored interventions to reduce as many identified fall risk factors as possible• Physical activity program that provides physical activity/exercise to improve leg strength and balance for all residents based upon each resident’s current health status and interest in participation.• Multi-disciplinary fall risk reduction approach that includes exercise, physical therapy, medication management, pain management, correction/improvement of impaired vision, and environmental modifications. Procedure:• At time of initial evaluation, discuss and review the fall reduction information packet anddisclosure form.• Complete a fall risk evaluation upon move in, following a fall event, annually and with a significant change of condition.o For any resident with a fall history or at high risk for falls, request a physical therapy evaluation for fall risk, gait testing and transfer safety.o Discuss with physician any health, vision, pain, behavioral or medication related fall risk issues that could be reduced or eliminated.o Update Service/Care plan to include resident-centric interventionso Identify those residents whose room is cluttered, discuss risks with resident/POA and document removal of clutter as agreed to by resident/POA.• Track and trend all falls individually and in aggregate (Using Eldermark Dashboard features)o Analyze falls for patternso Implement alternate interventions as applicable.• Implement routine/daily environmental-focused community walk-throughs to identify factorsthat could contribute to falls such as raised area of carpeting, uneven flooring, slippery surfaces, missing or loose handrails/grab bars. Anthem Memory Care Communities policy indicates that no employee, acting alone, will assist a fallen resident off the floor. ProcedureIf a resident has fallen, the following steps should be taken:1. Evaluate the resident to determine if severe pain exists and if he/she can move. The resident should not be moved if he/she has severe pain. Instead, emergency services should be summoned. 2. Determine if the resident is weight bearing and can assist staff members in getting up from the floor. 3. If the resident feels he/she can bear weight, two employees can provide standby assistance to help the resident get up from the floor. If possible, staff members should provide reassurance and calmly talk to residents throughout the process. 4. If the resident cannot assist and is unable to bear weight, make the resident as comfortable as possible and call emergency services. Offer pillows for support, blankets for comfort. 5. Stay with the resident at all times until emergency services arrive. 6. An Incident Report shall be fully completed in Eldermark. 7. Repeated falls by a resident will have follow-up to include a Fall Risk Analysis and progressive measures to help avoid future falls. 8. If resident falls and strikes their head, there is a risk for a closed-head injury and, therefore, need to be sent to ER or seen my MD for evaluation of the injury. If the resident/POA does not agree to sending the resident out for treatment per medical/nursing advice, the responsible party will read and sign a disclosure statement indicating their refusal to adhere to medical/nursing advice.

NOTE: IDR has been submitted to dispute this deficiency. Actions CSD or designee will re-train all staff on how and when to report bruises and/or any injury of unknown origin by February 14, 2025. CSD or designee will continue to investigate all reports of bruises or injuries of unknown origin within 48 hours of the initial report. Results of the investigation will be documented in the resident chart and communicated to Primary Care Physician and resident representative. ED and CSD or designee will continue to review reported injuries of unknown origin at weekly 1:1 meeting to ensure care plans are updated appropriately. How and what will be reviewedSignature sheets for all Training will be compared to current staff roster. All occurrences of injuries of unknown origin will be reviewed for compliance. Sample included in monitoringAll staff will be included in the training processHow often monitoring will occurMonitoring of training will take place after every training session and after every occurrence. How the monitoring will be documentedED will monitor compliance using the checklist for every step to be completed with every reported injury of unknown origin. How long will monitoring continueMonitoring will become a permanent part of CSD/ED weekly meetings. How will monitoring be part of QAPI processMonitoring will be documented in the monthly QAPI (CQI) notes. ADDENDUM:How will new staff be trained on MANE Requirements?Prior to training on the floor, all staff complete video training including a section titled "Understanding Abuse & Neglect."

NOTE: IDR has been submitted to dispute this deficiency. ActionsWandering:Each resident's care plan will continue to include a comprehensive description of their wandering patterns and known behavioral expressions. These care plans will be completed by CSD at admission and with change in condition. Care staff will notify CSD and ACSD of these changes using wisdom to act notices. Staff will be re-trained and guided on implementing these approaches to effectively manage and address the resident's specific behaviors. Continuous Independent Access to Individual Rooms:Each resident's care plan will continue to outline how each resident will have continuous independent access to their individual room within the secure environment. The plan will include measures to protect residents from unwanted visitation by other residents. Staff will be re-trained on these measures to ensure that residents' privacy and security are maintained. Staff Oversight, Monitoring, and Accompaniment:Each resident's care plan will continue to identify the type and level of staff oversight, monitoring, and accompaniment needed to meet the needs of the resident within the secure environment and secure outdoor area. The plan will outline specific strategies and protocols for staff to provide appropriate support and supervision to the resident. Personal Grooming and Hygiene Items:Each resident's care plan will continue to identify the personal grooming and hygiene items that are determined to be safe for the resident to have in their own possession for self-care. The plan will include details on how these items are stored to prevent unauthorized access by other residents, ensuring the residents’ safety and maintaining their dignity. Staff Education and Training:Staff members involved in the care of residents within the secure environment will continue to receive comprehensive education and training on the enhanced care plan requirements upon hire and ongoing as needed. Training will cover topics such as understanding wandering behaviors, implementing individualized approaches, protecting privacy, providing appropriate staff oversight and monitoring, and maintaining secure storage of personal grooming and hygiene items. Enhanced Resident Care plan will continue to be completed and reviewed by CSD upon admission, with change in condition, and/or annually. How and what will be reviewed3 care plans will be sampled and audited monthly and ongoing during QAPI meetingsSample included in monitoringAll staff will be included in the training processHow often monitoring will occurMonitoring will take place after every training session. How the monitoring will be documentedMonitoring will be documented in the monthly QAPI notes. How long will monitoring continueMonitoring will be ongoing from this date forward. How will monitoring be part of QAPI process3 care plans will be audited by QAPI committee to ensure they include wandering patterns, known behavior expressions, room access, staff oversight needed for safety, and what grooming items are safe to keep in residents' possession. ADDENDUM:Have the care plans been updated to include the following:(A) A description of the resident's wandering patterns and known behavioral expressions, along with individualized approaches to be implemented by staff to protect the resident and other residents with whom they have contact;(B) A description of how the resident will have continuous independent access to his or her individual room, along with the ALR's plan to protect the resident from unwanted visitation by other residents;(C) Identification of the type and level of staff oversight, monitoring, and/or accompaniment that the ALR deems necessary to meet the needs of the resident within the secure environment and secure outdoor area; and(D) Documentation describing the personal grooming and hygiene items that are determined safe for the resident to have in their own possession for self-care, and how those items are stored to prevent unauthorized access by other residents. Yes, if these issues apply to a resident, it is part of their care plan. How are staff being trained on the current and updated care plans?Updated care plans and coordinating services are updated automatically through our electronic healthcare systems: ElderMark and Point of Care. Care Staff access specific service tasks at each shift through Point of Care on their electronic devices. What is the plan to ensure individuals have continuous independent access to their bedrooms?Residents that are able to use keys for their bedrooms are given keys. If keys are lost, they are replaced. For those residents who cannot manage keys, their rooms are left open for them.

Executive Director and/or Staff Development Director will audit each employee file for background checks for all personnel members and ensure that the results are properly documented in their personnel files over the next 30 days. In cases where background checks were not previously conducted, we will perform the required checks. Staff Development Director will be retrained on the steps required prior to hiring all employees. For the next 3 months prospective employee files will be audited for completion of all required background checks prior to hire. Completed audits will be documented on the audit tracker and reviewed by the ED at the weekly SDD and ED meetings. Ongoing a minimum of 2 employee files will be audited each month and results reviewed at the QAPI meeting each month.

Our staff has created a comprehensive roster of current residents, including their names and room locations. A diagram showing room locations will also be developed and updated at least monthly. Placement of Roster and Diagram: The roster of current residents and room location diagram will be placed in a readily accessible behind the front desk. This has been completed. All facility staff will be trained on the locations of the resident roster and room location diagram. Monthly audits will be completed by ED to ensure presence and accuracy of the resident roster and room location diagram

The Executive Director will retrain the Life Engagement Director on the required notices for planned resident engagement offerings and notifications of any changes. This training will occur within 30 days and documented on a training sign off sheet. Notices of planned resident engagement offerings will be created to inform residents, relatives, and the public about upcoming activities and events. These notices will include the date, time, location, and description of each offering. Notices will be posted in each neighborhood (West and East), which will be readily accessible to residents, relatives, and the public. The notices will be clearly visible and easily readable. Copies of all notices will be retained and accessible in the ED office for at least six months. LED and ED will review these postings weekly for 3 months to ensure compliance. The review will be documented in the weekly ED/LED meetings.

Immediate Training and Education: Training and education have been provided to all QMAPs and caregivers with a specific focus on infection control when preparing and administering medications and providing care. This training has been conducted to ensure that all staff are aware of best practices in hand hygiene, the proper use of personal protective equipment, medication preparation, and other relevant topics. Monthly training sessions will be completed with a strong emphasis on infection control and medication administration best practices, monthly training sessions will be held for all staff, including QMAPs and caregivers. These sessions will be conducted by qualified trainers with expertise in the field. Content of Monthly Training: Each monthly training session will cover a range of topics related to infection control, including but not limited to:Proper hand hygiene techniquesCorrect use of personal protective equipmentMedication preparation and administration proceduresNational and state regulations and guidelines for infection controlReporting of concerns and incidents related to infection control. We will maintain records of each monthly training session, including attendance, topics covered, and any questions or concerns raised by staff. This documentation will be reviewed regularly to ensure that all staff are receiving consistent and up-to-date training. CSD/ACSD/CSC will conduct monthly audits on QMAPs with a random sampling of 3 per month.

Executive Director and/or Staff Development Director will audit each employee file for background checks for all personnel members and ensure that the results are properly documented in their personnel files over the next 30 days. In cases where background checks were not previously conducted, we will perform the required checks. Staff Development Director will be retrained on the steps required prior to hiring all employees. For the next 3 months prospective employee files will be audited for completion of all required background checks prior to hire. Completed audits will be documented on the audit tracker and reviewed by the ED at the weekly SDD and ED meetings. Ongoing a minimum of 2 employee files will be audited each month and results reviewed at the QAPI meeting each month.

The Staff Development Director will conduct a thorough audit of all personnel files of permanent and agency staff to identify any missing orientation and training documentation and background check results. This review will be completed within the next 30 business days. For personnel files lacking the required documentation, we will collect the missing documentation. This will include obtaining copies of orientation and training certificates and any missing background check results. Orientation and Training that was missed will be provided within 30 days of finding the deficitate. Staff Development Director will be retrained on the steps required prior to hiring all employees or staffing an agency employee. All newly hired staff, including all agency staff will be promptly oriented and trained as part of our regular onboarding process prior to working on the floor. For the next 3 months prospective employee files will be audited for completion of all required background checks prior to hire. Completed audits will be documented on the audit tracker and reviewed by the ED at the weekly SDD and ED meetings. Ongoing a minimum of 2 employee files will be audited each month and results reviewed at the QAPI meeting each month.

Our staff has created a comprehensive roster of current residents, including their names and room locations. A diagram showing room locations will also be developed and updated at least monthly. Placement of Roster and Diagram: The roster of current residents and room location diagram will be placed in a readily accessible behind the front desk. This has been completed. All facility staff will be trained on the locations of the resident roster and room location diagram. Monthly and ongoing audits will be completed by ED to ensure presence and accuracy of the resident roster and room location diagram.