Elite Care Adams - Hood

Based on observation, interview and record review, conducted during a site visit on 10/22/24, it was confirmed the facility failed to ensure the service plan was reflective of resident needs and ensure the implementation of services for 3 of 3 sampled residents (#s 1, 2 and 3). Findings include, but are not limited to:A review of Resident 1's service plan, dated 09/19/24, indicated:* Resident 1 resided in Adams House* Resident 1 was to be checked for incontinence management every two to three hours.During an observation between 5:50 am and 10:22 am on 10/22/24, Resident 1 was not checked or changed.A review of Resident 2's service plan dated 10/19/24, and a Temporary Service plan dated 09/20/24 indicated:* Resident 2 resided in Hood house.* Resident 2 was incontinent of bowel and bladder and care staff were to check Resident 2 every two to three hours and assist with incontinence care; and* Resident 2 had refused cares and when that occurred and Resident 2 became combative, staff were to leave him/her alone, re-attempt after sometime, and "call for a change of face."During an observation on 10/22/24, Resident 2 was toileted upon waking at 7:08 am. Resident 2 was not provided incontinence care again until 11:01 am. During an interview on 10/22/24, Staff 4 (UW) stated s/he was not able to toilet Resident 2 consistent with his/her service plan because Staff 4 was working alone and was cooking, serving and cleaning up breakfast from 8:00 am to 10:30 am. Staff 4 also stated Resident 2 was having a good day, but if s/he were to become aggressive, Staff 4 would have to call an administrator or other management to provide the change of face due to no other staff in the house.A review of Resident 3's service plan dated 09/27/24 revealed:*Resident 3 resided in Hood house.*Resident 3 required scheduled and as needed medications administered by the MT one time per day.During an interview on 10/22/24, Staff 4 (UW) stated Resident 3 did not have any daily medications.The findings were reviewed with and acknowledged by Staff 1 (Campus Director) and Staff 2 (Administrator) on 10/22/24.The facility failed to to ensure the service plans were reflective of residents needs and ensure the implementation of services.Verbal plan of correction: Facility will begin staffing two people in each house as soon as possible. They will begin recruitment immediately and will begin contacting agency until they can hire someone effective 10/22/24. They stated that was the last facility on campus with only 1 UW working in each house on a shift and the other houses have 2 UWs.

Based on observation, interview, and record review, conducted during a site visit on 10/22/24, it was confirmed the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident for 2 of 3 sampled residents (#s 1 and 2). Findings include, but are not limited to:Adams and Hood Houses were separate and distinct homes with no shared entrance, each consisting of two floors. A review of the posted staffing plan (undated) indicated the following:* Adams House - 6:00 am-6:00 pm: one Universal Worker (UW);* Hood House - 6:00 am-6:00 pm: one UW;* Adams House - 6:00 pm-6:00 am: one UW;* Hood House - 6:00 pm-6:00 am: one UW; and* Campus Float: 6:00 pm-6:00 am: one UW.1 UW were observed working in each house during night shift ending on 10/22/24 and day shift beginning on 10/22/24.A review of the facility's schedule for 10/16/24 through 10/22/24 revealed the facility regulary staffed only one UW per shift in each house.A review of Resident 1's service plan dated 09/19/24 and "Fire and Life Safety Education" dated 03/29/24 revealed:*Resident 1 resided in Adams House.*Resident 1 was to be checked for incontinence management every two to three hours; and*Resident 1 was a two-person transfer out of bed in the event of an emergency evacuation.During an observation between 5:50 am and 10:22 am on 10/22/24, Resident 1 was not checked for incontinence management.In an interview on 10/22/24, Staff 6 (UW) stated Resident 1 was a two-person transfer out of bed.A review of Resident 2's service plan dated 10/19/24, and a Temporary Service plan dated 09/20/24 indicated:*Resident resided in Hood House*Resident 2 was incontinent of bowel and bladder and care staff were to check Resident 2 every two to three hours and assist with incontinence care; and*Resident 2 had refused cares and when that occurred and Resident 2 became combative, staff were to leave him/her alone, reattempt after sometime, and "call for a change of face."During an observation on 10/22/24, Resident 2 was toileted upon waking at 7:08 am. Resident 2 was not provided incotinence care again until 11:01 am. During an interview on 10/22/24, Staff 4 (UW) stated s/he was not able to toilet Resident 2 consistent with his/her service plan because Staff 4 was working alone and was cooking, serving and cleaning up breakfast from 8:00 am to 10:30 am. Staff 4 also stated Resident 2 was having a good day, but if s/he were to become aggressive, Staff 4 would have to call an administrator or other management to provide the "change of face" due to no other staff in facility being available.In an interview on 10/22/24, Staff 6 stated in the event of an emergency, s/he would have to call a neighboring facility or call management for assistance.During an interview on 10/22/24, Staff 4 stated in the event of an emergency, s/he would have to have call any management and/or help from other facilities on the campus. S/he further stated if there was a fire s/he would take the residents to the flagpole but s/he didn't know who specifically would monitor residents at the flagpole or in the house during an evacuation. During an interview on 10/22/24, Staff 2 (Administrator) stated the facility used to have a "float" on day shift who worked in both Adams and Hood houses, but their last day was 09/15/24. He further stated residents had eloped from the facility on 10/07/24 and 10/14/24.The findings were reviewed with and acknowledged by Staff 1 (Campus Director) and Staff 2 (Administrator) on 10/22/24.The facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident.Verbal plan of correction: Facility will begin staffing two people in each house as soon as possible. They will begin recruitment immediately and will begin contacting agency until they can hire someone effective 10/22/24. They stated that was the last facility with only 1 UW working in each house on a shift and the other houses have 2 UW.

Based on observation, interview, and record review, conducted during a site visit on 10/22/24, it was confirmed the facility failed to develop and maintain and Acuity-Based Staffing Tool (ABST) for 3 of 3 sampled residents (#s 1, 2, and 3). Findings include, but are not limited to:Adams and Hood Houses were separate and distinct homes with no shared entrance, each consisting of two floors. A review of the posted staffing plan (undated) indicated the following:* Adams House - 6:00 am-6:00 pm: one Universal Worker (UW);* Hood House - 6:00 am-6:00 pm: one UW;* Adams House - 6:00 pm-6:00 am: one UW;* Hood House - 6:00 pm-6:00 am: one UW; and* Campus Float: 6:00 pm-6:00 am: one UW.1 UW was observed working in each house during night shift ending on 10/22/24 and day shift beginning on 10/22/24. A review of Hood House's ABST revealed the need for the following care hours:Day (6:00 am - 6:00 pm): 10.38 hoursNight (6:00 pm - 6:00 am): 6.87 hoursAn observation of the morning meal in Hood house revealed breakfast service lasts from 8:00 am to 10:30 am which was cooked, served and cleaned up by a Universal Worker.Interviews on 10/22/24 with Staff 4 (UW) revealed UWs are responsible for preparing, serving and cleaning up the morning meal and serving and cleaning up the noon and evening meals between 6:00 am and 6:00 pm. Staff 4 stated the tasks take about five hours total. Staff 4 stated in the event of an emergency, s/he would have to have call any management and/or help from other facilities on the campus. S/he further stated if there was a fire s/he would take the residents to the flagpole but s/he doesn't know who specifically would monitor residents at the flagpole or in the house during an evacuation. A review of the Adams House's ABST revealed the need for the following care hours:Day (6:00 am - 6:00 pm): 10.63 hoursNight (6:00 pm - 6:00 am): 6.72 hoursAn observation of the morning meal on 10/22/24 revealed breakfast service lasts from 8:00 am to 10:30 am which was cooked, served and cleaned up by a Universal Worker.A review of the facility's schedule for 10/16/24 through 10/22/24 revealed the facility regularly scheduled only one UW in each house per shift.In an interview on 10/22/24, Staff 6 (UW) stated Resident 1, who resided in Adams house required the assistance of two people to transfer out of bed.A review of Resident 1's "Fire and Life Safety Education," dated 03/29/24, indicated the resident was a two-person transfer out of bed in the event of an emergency evacuation.In an interview on 10/22/24, Staff 6 stated in the event of an emergency, s/he would have to call a neighboring facility or administration for assistance.During an interview on 10/22/24, Staff 2 (Administrator) stated the facility used to have a "float" on day shift who worked in both Adams and Hood houses, but their last day was 09/15/24. He further stated residents had eloped from the facility on 10/07/24 and 10/14/24.In an interview on 10/22/24 at 7:07 am, Staff 7 (UW) stated s/he floated to all facilities on campus during night shift, minus the Specific Needs Contract building, and that s/he helped with resident care, showers, and the delivery of supplies and food. Staff 7 was not observed in the facility again after the interview.After multiple requests on and before 10/22/24, an ODHS-approved float waiver was not provided.A review of Resident 1's service plan, dated 09/19/24, and ABST profile revealed discrepancies in time for the following ADL:* Grooming.A review of Resident 2's service plan, dated 10/11/24, and ABST profile revealed discrepancies in time for the following ADLs:* Monitoring behavioral symptoms; and* Non-pharmacological interventions for behaviors.A review of Resident 3's service plan, dated 09/27/24, and ABST profile revealed discrepancies in time for the following ADL:* Monitoring behavioral conditions or symptoms.The findings were reviewed with and acknowledged by Staff 1 (Campus Director) and Staff 2 (Administrator) on 10/22/24.The facility failed to fully develop and maintain an Acuity-Based Staffing Tool.

Based on interview and record review, conducted during a site visit on 07/08/24, it was confirmed the facility failed to review the initial service plan within 30 days of move-in to ensure that any changes made to the plan accurately reflect the resident's needs and preferences for 1 of 1 sampled resident (#1). Findings include, but are not limited to:A review of the admission records for Resident 1 indicated a move-in date of 12/13/21. A review of the "30-Day Evaluation/Assessment" for Resident 1 indicated an assessment was completed approximately 53 days after move-in on 02/05/22. Resident 1's service plan was then updated on 02/18/22.The findings were reviewed with and acknowledged by Staff 1 (Campus Director) and Staff 2 (Administrator) on 07/08/24.The facility failed to review the initial service plan within 30 days of move-in to ensure that any changes made to the plan accurately reflect the resident's needs and preferences.Verbal Plan of Correction: The facility created a spreadsheet that is shared with management to track resident's due dates and their new system Point Click Care "triggers" due dates for service plans. These two systems provided a "double check system."

Based on observation, interview, and record review, conducted during a site visit on 07/08/24, it was confirmed the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to:CS observed the facility consisted of two separate, distinct buildings referred to as "Adams House" and "Hood House" with resident apartments on two separate floors.The facility's resident roster, dated 07/08/24, indicated the facility was home to 23 residents. A review of the posted staffing plan (undated) indicated the following: * Adams House - 6am-6pm: 1 Universal Worker* Hood House - 6am-6pm: 1 UW* Float 6am-6pm: 1 UW* Adams House - 6pm-6am: 1 UW* Hood House - 6pm-6am: 1 UW*Campus Float: 6pm-6am: 1 UWIn an interview, Staff 1 (Campus Director) and Staff 2 (Administrator) stated the following:* The facility had an approved waiver for a "float" between buildings.* The "float" was counted towards the staffing hours.On 07/08/24 at 4:00pm, the CS requested a copy of the approved waiver from Staff 1 and a second request was submitted via email on 07/10/24 at 10:46am to Staff 5 (CEO). The facility was unable to provide evidence of an approved waiver after repeated requests.In an interview, Witness 3 (Operations and Policy Analyst) stated the facility's "float" did not count towards the facility's required staffing hours.On 07/08/24, throughout the site visit, the Compliance Specialist (CS) observed the following: * There was one UW in each house.* No "float" staff were observed.In an interview, Resident 5 stated the following:* Only one staff member worked during the day.* Resident 3 required two staff members for transfers and incontinent care.* Wait times for help were often 30 minutes.A review of Resident 3's service plan, dated 06/25/24, stated that resident required the assistance of four staff members to evacuate the building in the event of an emergency.In an interview, Witness 1 (Outside Provider) stated the following:* It was hard to find staff.* Staff worked "between buildings."* S/He was instructed to call a phone number to request staff assistance.During the interview with Witness 1 at 11:28am, an unsampled resident wandered into Resident 2's room. The unsampled resident required redirection, which was done by the Compliance Specialist. Witness 1 stated s/he often had to redirect that unsampled resident because staff were hard to find.In an interview, Witness 2 (Outside Provider) stated the following:* It was hard to find staff.* Only one staff person worked in each building.* S/He was hired due to lack of staff available to care for Resident 3.The findings were reviewed with and acknowledged by Staff 1 and Staff 2 on 07/08/24.The facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident.Verbal Plan of Correction: Management will talk with the owner about the need for more staff and work to hire more staff.

Based on observation, interview and record review, conducted during a site visit on 07/08/24, it was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool. Findings include, but are not limited to:CS observed the facility consisted of two separate, distinct buildings referred to as "Adams House" and "Hood House" with resident apartments on two separate floors.The facility's resident roster, dated 07/08/24, indicated the facility was home to 23 residents. In an interview, Staff 1 (Campus Director) and Staff 2 (Administrator) stated the facility used the ODHS Acuity Based Staffing Tool and employed Universal Workers (UW) who worked 12 hour shifts.A review of the posted staffing plan (undated) indicated the following: * Adams House - 6am-6pm: 1 Universal Worker* Hood House - 6am-6pm: 1 UW* Float 6am-6pm: 1 UW* Adams House - 6pm-6am: 1 UW* Hood House - 6pm-6am: 1 UW*Campus Float: 6pm-6am: 1 UWIn an interview, Staff 1 (Campus Director) and Staff 2 (Administrator) stated the following:* The facility had an approved waiver for a "float" between buildings.* The "float" was counted towards the staffing hours.On 07/08/24 at 4:00pm, the CS requested a copy of the approved waiver from Staff 1 and a second request was submited via email on 07/10/24 at 10:46am to Staff 5 (CEO). The facility was unable to provide evidence of an approved waiver after repeated requests.A review of the facility's Acuity Based Stafffing Tool (ABST) indicated the following:* All residents were entered into the tool.* The tool generated a staffing plan.* The total hours of care needed was 23.92 hours.* Five residents' profiles had not been updated in the last quarter.On 07/08/24, throughout the site visit, the Compliance Specialist (CS) observed the following: * There was one UW in each house.* No "float" staff were observed.* At 11:30am, a resident wandered into Resident 2's apartment. CS redirected the resident.* At 11:37am, the CS observed Staff 3 (UW) was sitting at the kitchen table located on the upper floor. There was no staff available on the lower floor to supervise or rediect the resident who wandered into Resident 2's apartment. In an interview at 11:30am, Witness 1 (Outside Provider) stated s/he had to redirect a male resident out of a female resident's room multiple times because it was difficult to find staff.In an interview, Resident 5 stated wait times for help were often 30 minutes.In an interview, Witness 2 (Outside Provider) stated the following:* It was hard to find staff.* On the morning of 07/08/24, s/he was unable to find staff.* A private caregiver was hired because of a lack of staff and lack of care for Resident 3.The findings were reviewed with and acknowledged by Staff 1 and Staff 2 on 07/08/24.The facility failed to fully implement an Acuity Based Staffing Tool.

The findings of the re-licensure survey, conducted 02/20/24 through 02/22/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day
The findings of the revisit to the re-licensure survey of 02/22/24, conducted on 05/13/24, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

2. Resident 2 moved into the facility in 11/2021 with diagnoses including dementia.Observations of the resident, interviews with staff, review of the 01/03/24 service plan, and Temporary Service Plans, dated 01/07/24 through 02/15/24, identified Resident 2's service plan was not reflective of the resident's care needs and lacked clear direction to staff in the following areas:* Diet status, vegetarian; and* Use of right eye prothesis.The need to ensure the service plans were reflective of the residents care needs and provided clear direction to staff was reviewed with Staff 1 (Administrator), Staff 4 (Health Consultant) and Staff 10 (Campus Manager) on 02/22/24. They acknowledged the findings.
Based on observation, interview, and record review, it was determined the facility failed to ensure service plans provided clear direction regarding the delivery of services, including a written description of who shall provide the services and what, when, how, and how often the services shall be provided, and/or was implemented for 2 of 3 sampled residents (#s 1 and 2) whose service plans were reviewed. The following was identified:1. Resident 1 admitted to the facility in 01/2024 with diagnosis including dementia. Observations of the resident, interviews with staff, review of the 02/11/24 service plan, Temporary Service Plans dated 01/18/24 through 02/15/24 and current evaluation identified Resident 1's service plan lacked clear direction to staff and/or was not implemented in the following areas:* Safety checks related to: falls, diagnoses of dementia, disorientation, wandering, inability to use the facility provided call system, and frequent independent walks on facility grounds; * Use of GPS tracing device (JioTracker); * Resident specific activities to decrease risk for potential elopement; and* Bathing assistance, four times weekly.The need to ensure the service plans provided clear instruction to staff and was implemented was reviewed with Staff 1 (Administrator), Staff 3 (RN) and Staff 4 (Health Consultant) on 02/22/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to conduct and record fire drills every other month according to the Oregon Fire Code (OFC) and failed to provide fire and life safety instruction to staff on alternate months. Findings include, but are not limited to: Fire drill records were reviewed from 08/2023 through 01/2024, on 02/21/24. Fire drill records reviewed within the look back period were dated 11/28/23 and 01/31/24. The following was identified: a. Fire drills were not conducted every other month or at different times of day. A fire drill conducted on 11/28/23 was not audible, and one or both lacked documentation of the following information:* Escape route used; * Problems encountered and comments relating to residents who resisted or failed to participate in the drills;* Number of occupants evacuated; and* Alternate exit routes to react to varying potential fire origin points.b. Fire and life safety instruction was not provided to staff on alternating months between 08/2023 through 01/2024. The fire and life safety instruction reviewed revealed the following:* 10/27/23 training on how to use a fire extinguisher;* 11/28/23 training on how to use a fire extinguisher; and* 12/21/23 training on how to use a med sled.c. There was no documented evidence the facility made an effort to identify residents who were unwilling or failed to participate in fire drills and/or make changes to ensure the evacuation standard was met. In an interview on 02/22/24 at approximately 11:30 am, Staff 1 (Administrator) stated the facility had recently identified the same areas and since has initiated a new system.The need to ensure fire drills, and fire and life safety training was provided and documented as required was reviewed with Staff 1, Staff 3 (RN), and Staff 4 (Health Consultant). They acknowledged the findings.

The findings of the re-licensure survey, conducted 1/19/21 through 1/20/21 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day
The findings of the first re-visit to the re-licensure survey of 1/20/21, conducted 4/7/21 through 4/8/21, are documented in this report. It was determined the facility was in compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

Based on observation, interview and record review, it was determined the facility failed to ensure staff followed food handling practices in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:Observations of the kitchen, freezers and food temperature logs on 1/10/21 revealed:*Potentially hazardous food (eggs, chicken and fish) temperatures were not monitored consistently, and hot foods were documented to be less than 135 degrees upon serving; and*Multiple refrigerators and freezers lacked a thermometer to monitor temperatures.The need to ensure safe food handling practices are followed was discussed with Staff 1 (Director of Operations) and Staff 2 (Administrator) on 1/20/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure the initial evaluation contained all required elements and addressed sufficient information to develop an initial service plan, for 1 of 1 sampled resident (# 2) who was recently admitted to the facility. Findings include, but are not limited to:Resident 4 was admitted to the facility in May 2020. Review of the new move in evaluation revealed the following required elements were not documented as being addressed:* Personality, including how the person copes with change or challenging situations; * Indicators of nursing needs; * Complex medication regimen; * Drug use; and * Environmental factors that impact the resident's behavior, including noise, lighting, room temperature. The need to ensure all required elements are addressed in the initial evaluation was discussed with Staff 1 (Director of Operations) and Staff 2 (Administrator) on 1/20/21. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of the residents' current care needs and provided clear direction to staff regarding the delivery of services for 1 of 2 sampled residents (# 2) whose service plans were reviewed. Findings include, but are not limited to:Resident 2's 10/18/20 service plan, temporary service plans and "Change in Service Plan" documents were reviewed and were not reflective of the resident's current needs and/or did not provide clear direction to staff relating to the following care areas:* How the facility sets up transportation;* What services hospice provides; * Pressure alarm;* Effective non-drug interventions for anxiety and depression;* How often care staff were to check on the resident; and* Ability to consistently use the call light. The need to ensure service plans were reflective and gave clear direction to care giving staff was discussed on 1/20/21 with Staff 1 (Director of Operations) and Staff 2 (Administrator). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed and all orders were documented in the resident's record for 1 of 1 sampled resident (# 2) whose orders were reviewed. Findings include, but are not limited to:Resident 2's January 1 through 19, 2021 MARs and current physician orders were reviewed during the survey. a. There was no documented evidence the facility had orders to administer the following medications:* Docusate sodium 250 mg twice a day; and* Refresh Tears eye drops administered twice a day and PRN. b. Resident 2 had physician orders for Miralax to be administered once a day. The facility did not give the resident the medication on 1/18 and 1/19/21 and documented, "med not available." The need to ensure the facility followed physician orders and had signed orders in the resident's record was discussed with Staff 1 (Director of Operations) and Staff 2 (Administrator) on 1/20/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure the resident's MAR included resident specific parameters and instructions for PRN medications for 1 of 1 sampled resident (# 2) whose MARs were reviewed. Findings include, but are not limited to:Resident 2's 1/1/21 through 1/19/21 MAR was reviewed and revealed the following:The resident had PRN bowel medications including Milk of Magnesia, fleet glycerin suppository and an enema. The parameters lacked clear instruction to unlicensed staff relating to the Milk of Magnesia and the suppository.The need to ensure MARs included specific parameters and instruction to unlicensed staff was discussed with Staff 1 (Director of Operations) and Staff 2 (Administrator) on 1/20/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 newly hired staff (#s 6 and 9) had documented demonstration of competency in all required areas within 30 days of hire. Findings include, but are not limited to:Review of the facility's training records on 1/20/21 indicated the following:Staff 6 (CG) hired 3/10/20, Staff 9 (CG) hired 10/19/20 lacked documented evidence of competency for all required components within the first 30 days of hire for topics including: * Providing assistance with the activities of daily living;* Changes associated with normal aging;* Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition;* Conditions that require assessment, treatment, observation and reporting; and * General food safety, serving and sanitation.Staff 9 also lacked documented evidence of First Aid certification and abdominal thrust training. The need to document demonstrated competency in job duties within 30 days of hire and complete First Aid and abdominal thrust training was discussed with Staff 1 (Director of Operations) and Staff 2 (Administrator) on 1/20/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to have documented evidence the required 12 hours of annual in-service training including the dementia care training was completed for 2 of 2 long-term staff (#s 5 and 11) whose training records were reviewed. Findings include, but are not limited to:The annual in-service training records were reviewed for Staff 5 (CG), hired 7/15/19 and Staff 11 (CG), hired 12/7/19, on 1/20/21. There was no documented evidence Staff 5 and 11 received 12 hours of annual in-service related to provisions of care and chronic diseases in the facility population and dementia training. Annual in-service training was discussed with Staff 1 (Director of Operations) and Staff 2 (Administrator) on 1/20/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure fire and life safety instruction to staff was provided on alternate months of fire drills. Findings include, but are not limited to:Fire and life safety records were reviewed from 6/17/20 to 12/29/20 on 1/20/21. There was no documented evidence the facility was providing fire and life safety instruction to all staff on the alternating months of fire drills.The requirements fire and life safety instruction for staff were reviewed with Staff 1 (Director of Operations) and Staff 2 (Administrator) on 1/20/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure documentation of key evaluations were in the residents' charts and whether or not the residents had a key was documented in their service plan for 2 of 2 residents sampled (#s 1 and 2)Findings include but are not limited to: The resident's service plans and evaluations were reviewed during the survey. On 1/20/21, staff identified both Resident 1 and 2 as having keys to their units. Resident 1 also self-administered his/her medications. There was no documented evidence of key evaluations nor was it reflected in either one of the residents' service plans. The need to ensure all residents' were evaluated for their ability to manage a key to their units and the information was included on their service plans was discussed with Staff 1 (Director of Operations) and Staff 2 (Administrator) on 1/20/21. They acknowledged the findings.