Countryside Living Memory Care

The findings of the kitchen inspection, conducted 06/12/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000 and OARs 411 Division 57 for Memory Care Communities.Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.

The findings of the first re-visit to the re-licensure survey of 06/12/24, conducted 07/25/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, Oregon Health Service Food Sanitation Rules OARs 333-150-0000 and OARs 411 Division 57 for Memory Care Communities.

Based on observation and interview, it was determined the facility failed to ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to:On 06/12/24 at 10:30 am, the facility kitchen was observed to need cleaning in the following areas: * Ceiling in dishwashing area above clean dishes - buildup of dust;* Wall behind spray hose and below dishrack shelf in dishwashing area - black matter buildup; * Wall behind stove/grill - grease drips; * Side and front of stove/grill and ledges on front of stove/grill - food drips and grease;* Frame of door to dining room - buildup of dust; * Ceiling vent/light cover/sprinkler head above steam table - dust build up; and* Wall near ceiling above fire alarm - dust build up.Improper food storage: * Bins containing dry food under prep counter and in dry storage did not have lids securely closed, creating a potential for cross contamination. The areas of concern were discussed with Staff 1 (Executive Chef) and Staff 2 (Executive Director) on 06/12/24. The findings were acknowledged.

Based on observation and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C240.

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes. This report reflects the findings of the complaint investigation conducted 11/09/2022. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified: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

Based on interview, record review and observation, it was confirmed the facility failed to keep in good repair all equipment necessary for the health, safety and comfort of residents. Findings include: During an unannounced site visit on 11/09/2022, Staff # 1 (S1) stated the boiler was broken and not working, but is now completely repaired. Staff #7 (S7) stated the boiler was shutting off throughout the day, but after a re-set, worked for a few hours. Staff #2 (S2) stated a repair company was called on 10/27/2022 the day the boiler was showing signs of failure. A review of a work order dated 10/27/2022 described parts being ordered on 10/28/2022 and labor being done to install parts to the boiler on 11/03/2022.On 11/01/2022, Compliance Specialist (CS) observed the boiler which included the items listed in the work order including blower motor kit and ignition electrodes newly installed. CS tested the water temperature in the kitchen and two bathrooms. Hot water was found in all three areas that were tested. The temperature gauge on the boiler reflected a temperature of 132 degrees Fahrenheit.Facility Plan of Correction: The facility called a repair service upon discovery of the failed boiler. The repair company had to order parts from and wait for delivery. In the meantime the facility ensured that all residents still had access to hot showers and hot water by bringing residents across the street to the other building. The kitchen was not affected by the boiler being out of commission.

The findings of the change in ownership survey, conducted 04/13/2022 through 04/14/2022, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily 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 first re-visit to the change of ownership survey of 04/14/22, conducted 07/06/22, 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 the OARs 411 Division 57 for Memory Care Communities.Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily 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 second re-visit to the re-licensure survey of 04/14/22, conducted 10/11/22 through 10/12/22, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 57 for Memory Care Communities.

Based on observation and interview, it was determined the facility failed to ensure reasonable precautions were exercised against any condition that could threaten the health, safety, or welfare of residents. Findings include, but are not limited to:Observations on 04/13/22 and 04/14/22 revealed the facility had installed wood planks on the lower half of interior hallways and several pillars throughout common areas. The wood had a rough surface with splinters protruding throughout, which posed a potential threat of injury to residents. The concern was shown to Staff 4 (Kitchen/Maintenance Manager) on 04/14/22 at 10:00 am, and discussed with Staff 1 (Executive Director) on 04/14/22 at 11:15 am. Both acknowledged the rough surface of the wood planks posed a potential threat of injury to residents. Staff 1 stated the problem would be corrected to ensure the wood retained a smooth surface.

Based on observation and interview, it was determined the facility failed to ensure reasonable precautions were exercised against any condition that could threaten the health, safety, or welfare of residents. This is a repeat citation. Findings include, but are not limited to:During a tour of the environment on 07/06/22, the wood planks on the lower half of the interior hallways and several pillars throughout common areas were noted to have an abrasive surface which posed a potential threat of injury to residents. The need to ensure reasonable precautions were exercised against any condition that could threaten the health, safety, or welfare of residents was discussed with Staff 1 (Administrator) on 07/06/22 and 07/07/22. Staff 1 acknowledged the findings and stated the wood surface would be refinished to prevent resident injury.

Based on interview and record review, it was determined the facility failed to conduct an investigation of an injury of unknown cause to rule-out abuse and report the injury as suspected abuse to the local Seniors and People with Disabilities (SPD) office, for 1 of 2 sampled residents (#3). Findings include, but are not limited to:Resident 3 was admitted to the facility in 12/2020 with a diagnosis of vascular dementia. Resident 3's service plan, temporary service plans and charting notes reviewed during the survey identified the following:* On 01/02/22, charting notes indicated the resident had a bruise on the left arm;* On 02/20/22, charting notes indicated the resident had a bruise to the right upper thigh with skin tear and bruising to right arm above wrist;* On 04/05/22, charting notes indicated the resident had a skin tear to left forearm. These incidents represented injuries of unknown cause.There was no documented evidence the facility immediately investigated these injuries to rule out abuse or neglect. The facility did not report the injuries to the local SPD office as suspected abuse or neglect.The need to ensure injuries of unknown cause were investigated promptly and reported if necessary was discussed with Staff 1 (Executive Director) and Staff 3 (Resident Care Coordinator). Staff 1 acknowledged there was no documented evidence the facility had investigated the injuries to rule out abuse. Verification the facility had reported the incidents to the local SPD office was received during the survey.
Based on interview and record review, it was determined the facility failed to thoroughly investigate incidents of abuse or suspected abuse and report to the local SPD if abuse was not reasonably ruled out for 1 of 2 sampled residents (#6). This is a repeat citation. Findings include, but are not limited to:Resident 6 was admitted to the facility in 05/2019 with diagnoses including Alzheimer's Disease.Review of the resident's 06/13/22 through 07/06/22 progress notes and incident investigations revealed that on 07/01/22, s/he was "smacked" by another resident.The facility investigation, dated 07/05/22, four days after the event, did not indicate if the event was witnessed, did not indicate measures that would be taken to prevent the reoccurrence of abuse, was not reviewed by the administrator, and was not reported to the local SPD office until after the survey team entered on 07/06/22.The need to immediately and thoroughly investigate incidents of abuse, report them to the local SPD, and take measures to prevent the reoccurrence of abuse was discussed with Staff 1 (Administrator) and Staff 2 (RCC) on 07/06/22. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and maintained in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:During a tour of the main kitchen located in the north building, on 04/11/22 at 10:30 am, it was determined the following areas were in need of cleaning or repair:* The flooring near the dishwashing area, food prep area, and around multiple floor drains were cracked or missing floor covering that exposed the subfloor underneath;* Multiple areas of the floor baseboards were pulling away from the wall and floor seams were separating where debris could accumulate; * Multiple floor drains had an accumulation of black and brown matter;* The metal grease trap door located on the floor (near the Hobart mixer) had a buildup of rust and was separating away from the floor, which rendered the floor in this area uncleanable;* The walls and shelving in the dishwashing area, next to the grill and underneath the service counter had a buildup of food debris and splattered food matter;* The wall behind the food prep table, wall mounted spice rack, and coffee cart had a buildup of brown matter and dust;* The Hobart (industrial) mixer, Vitamix blender, and multiple toasters had food particle buildup;* The ice machine had a side vent that was covered with dust and debris. The vent blew air directly on the Hobart mixer;* The faucet for the hand washing sink (located near the walk-in refrigerator), had a hole caused by corrosion;* The walk-in refrigerator vent had dust debris that blew directly on food storage areas;* Meat and other food items were stored on trays or bins on the floor in the walk in refrigerator;* Various meat products were piled into one bin, each at varied stages of thawing. The meat products were resting in a bloody water substance, and some products were not labeled, dated, or shelved to allow air circulation;* The walk-in freezer had food spillage build up on the floor;* A gray metal shelf that stored grains and dried goods had an accumulation of food matter buildup and rust, which rendered the surface uncleanable;* The grease trap on the grill was not working properly and caused a large amount of grease accumulation inside the oven and down the right side of the oven door;* The stove top, grill hood vents and wall behind the grill/stove had an accumulation of food and grease matter buildup;* The ceiling ventilation unit and surrounding ceiling above the steam table had an accumulation of dust and condensation that was dropping onto a stack of clean plates, plate warmer and the top of the steam table;* Ceiling and ceiling vent above coffee cart had an accumulation of dust buildup and rust;* Ceiling above ice machine had peeling paint and exposed sheet rock;* Ceiling light fixture (above ice machine) had a missing light fixture cover;* A stool in the kitchen had a ripped seat, rendering the surface uncleanable;* Brooms, dust pans and a mop bucket were not stored properly in a janitor's closet; and* The janitor's closet had black matter substance on the walls and was being used to store multiple empty boxes and milk jugs.On 04/11/22, at 11:30 am, the kitchen was toured and findings were discussed with Staff 4 (Kitchen/Maintenance Manager) and Staff 1 (Executive Director). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure resident move-in evaluations addressed all required elements for 1 of 1 sampled resident (#2) whose new move-in evaluation was reviewed. Findings include, but are not limited to:Resident 2 moved into the MCC in 03/2022. The new move-in evaluation failed to address the following elements:* Mental Health issues including: history of treatment and effective non-drug interventions;* Personality, including how a person copes with change or challenging situations; * Pain: pharmaceuticals and non-pharmaceutical interventions, including how a person expresses pain or discomfort; and * Environmental factors that impact the resident's behavior including: noise, lighting and room temperature.The need to ensure move-in evaluations included all required elements was discussed with Staff 1 (Executive Director) on 04/14/22. She acknowledged the findings. No further information was provided.

Based on interview and record review, it was determined the facility failed to ensure all required elements were addressed in the move-in evaluation for 1 of 1 sampled resident (#5) recently admitted to the facility. This is a repeat citation. Findings include, but are not limited to:Resident 5 was admitted to the facility in 06/2022 with diagnoses including dementia and depression.The resident's move-in evaluation, dated 06/09/22, was reviewed. There was no documented evidence the following elements had been addressed prior to the resident being admitted to the facility:* Dental status;* Skin condition;* List of treatment: type, frequency, and level of assistance needed; and* Recent losses.In an interview on 07/06/22, the need to address all required elements in the move-in evaluation was discussed with Staff 1 (Administrator) and Staff 2 (RCC). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 1 of 3 sampled residents (#1) whose orders were reviewed. Findings include, but are not limited to:Resident 1 was admitted in 2020 with diagnoses which included insulin dependent diabetes. S/he had orders, dated 03/18/22, for Humalog sliding scale insulin to be given before meals and bedtime in varied amounts based on results of the CBGs (blood sugars).The MARs, reviewed from 03/19/22 - 04/13/22, revealed 54 occasions when the resident should have received sliding scale insulin, but none had been documented as given.Staff 2 (RN) was interviewed 04/13/22 at 2:00 pm. She reviewed the MARs and confirmed staff had not documented if the resident received sliding scale insulin as ordered. No further information was provided.

Based on interview and record review, it was determined the facility failed to ensure written, signed physician orders for all medications the facility was responsible to administer were documented in the resident's facility record for 2 of 3 sampled residents (#s 6 and 8) whose physician orders were reviewed. This is a repeat citation. Findings include, but are not limited to:1. Resident 6 was admitted to the facility in 05/2019 with diagnoses including Alzheimer's Disease.Review of the resident's 06/13/22 through 07/06/22 MAR and 02/22/21 signed physician orders revealed the following:There was no documented evidence the facility had an order to administer the following medications which were listed on the 06/13/22 through 07/06/22 MAR:* Aspirin (joint pain);* Cephalexin (antibiotic);* Estradiol (vaginal medication);* Memantine (Alzheimer's Disease);* Sertraline (depression);* Acetaminophen PRN (pain or fever);* Antac-Sim PRN (stomach upset);* Bisacodyl suppository PRN (constipation);* Docusate Sodium PRN (constipation);* Enema PRN (constipation);* Milk of Magnesia PRN (constipation); and* Phenazopyridine PRN (dysuria).The need to ensure written, signed physician orders for all medications the facility was responsible to administer were documented in the resident's facility record was discussed with Staff 1 (Administrator) and Staff 2 (RCC) on 07/06/22. They acknowledged the findings.2. Resident 8 was admitted to the facility in 10/04/21 with diagnoses including Alzheimer's Disease. The resident's 06/13/22 through 07/06/22 MAR was reviewed. There was no documented evidence of signed physician orders in the resident's facility record for the following medications which were listed on the MAR: * Atenolol (blood pressure);* Bisacodyl tablets (constipation);* Diclofenac gel (joint pain);* Donepezil (Alzheimer's Disease);* Escitalopram (depression);* Hydrochlorothiazide (edema);* Pantaprazole (GERD);* Quetiapine (Depression);* Spiriva inhaler (respiratory); * Symbicort inhaler (respiratory);* Acetaminophen PRN (pain);* Albuterol inhaler PRN (respiratory);* Antac-Sim PRN (stomach upset);* Biscacodyl suppository PRN (constipation);* Hydrocortizone cream PRN (rash);* Hydroxyzine pamoate PRN (anxiety);* Milk of Magnesia PRN (Constipation);* Oxycodone PRN (pain);* Polyethylene Glycol PRN (constipation);* Quetiapine PRN (Anxiety);* Sodium Phosphate enema PRN (constipation);* Trazadone PRN (insomnia); and* Aquaphor ointment (dry skin). The need to ensure written, signed physician orders for all medications the facility was responsible to administer were documented in the resident's facility record was discussed with Staff 1 (Administrator) and Staff 2 (RCC) on 07/06/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused to consent to orders for 1 of 1 sampled resident (#3) who had documented medication or treatment refusals. Findings include, but are not limited to:Resident 3 was admitted to the facility in 12/2020 with a diagnosis of vascular dementia. Resident 3's physician orders from admission, current physician orders dated 04/08/22 and MARs from 03/01/22 through 04/12/22 were reviewed and identified the following:Resident 3 had 19 documented refusals for the following prescribed medications or treatments:* Donepezil (for memory loss);* Verapamil ER (for hypertension);* Brushing teeth (for oral care);* Memantine HCL (for dementia);* Gabapentin (for pain);* Xarelto (prevention of blood clots);* Atrovastatin (for cholesterol);* Weekly blood pressure and heart rate;* Ferrous Sulfate (iron supplement);* Fluoxetine (for depression);* Folic acid (for supplement);* Furosemide (for hypertension);* Potassium Chloride ( for blood pressure); and* Senna (for bowel care);There was no documented evidence the facility notified Resident 3's physician of the refusals.The need to ensure a system is in place to notify physician's when a resident refuses consent to orders was discussed with Staff 1 (Executive Director) and Staff 3 (Resident Care Coordinator) on 04/13/22. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure the physician or other practitioner was notified when a resident refused consent to an order. This is a repeat citation. Findings include, but are not limited to: Resident 8 was admitted to the facility in 10/2021 with diagnoses including Alzheimer's Disease. Review of the 06/13/22 through 07/06/22 MAR and physician notifications revealed the physician was not notified of the following medication refusals: * 06/23/22, 06/28/22, 06/29/22 and 07/04/22 - Donepezil (Alzheimer's Disease), Diclofenac Sodium gel (pain) and Quetiapine (depression); and * 06/30/22 - Diclofenac Sodium gel. The need to ensure the physician was notified when the resident refused consent to an order was discussed with Staff 1 (Administrator) and Staff 2 (RCC) on 07/06/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include but are not limited to:Refer to C160, C231, C252, C303, C305, C510, C513, Z164 and Z173.

Based on observation and interview, the facility failed to ensure the general building exterior was maintained clean and in good repair, and that there was locked storage for chemicals, maintenance equipment and yard tools. Findings include, but are not limited to:* A bottle of bleach was found in an unlocked shed;* Two containers of plant fertilizer were stored near the garden hose;* There were gaps and holes between the seams of the concrete which created a tripping hazard for residents;.* There were loose concrete stepping stones by one of the gate doors;* Gardening tools, one with rust on the handle, were unsecured on the patio;* A metal frame, multiple ladders and round tables were stored in the courtyard;* The laminate had partially peeled off of a particle board fence panel;* A wet, soiled doormat was in the grass outside an exit door;* The sheds had chipped paint, disintegrating wood, and rust on the hinges;* A wood trellis near a gate had chipped paint, was covered in moss, and some of the boards were disintegrating;* Multiple fixtures in the "sensory" garden and other decorative yard art pieces had chipped paint and/or rust; and* Four of the five loveseat swings were in need of repair:a. Several inches of plant matter had accumulated and covered the top of the awning of a black loveseat swing. A large, flowering vine had taken root and grown in the soil on top of the awning. The underside of the awning was covered in moss; there were places where the fabric had disintegrated. Rust had developed on the metal seat frame.b. A second black loveseat swing had mold growing on the seat and the awning was discolored.c. A wood loveseat swing had a missing bolt and was broken.d. A second wood loveseat swing awning was discolored, filled with water and dripping. There were areas where the finish had worn off of the wood. There was splintering of the wood on the rear of one of the seats. The seat cushions had rips and frayed fabric.The need to ensure the environment was maintained clean and in good repair was discussed with Staff 1 (Administrator), Staff 4 (Facilities Maintenance Director/Dining Services Director) and Staff 8 (Maintenance Assistant) on 07/06/22. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure the environment was maintained clean and in good repair. Findings include, but are not limited to:Observations of the facility made during survey revealed the following:* The dining room door frame had scraped paint in several areas;* A brown wing back upholstered chair in the dining room had an accumulation of dried food matter on the seat and arm rests. Closer inspection revealed numerous ants crawling on the chair;* Several dining chairs had scraped wood on the arms and legs. Additionally, dried food matter was visible on seats and backs;* A rust-colored leather chair in a small room off the dining room had an accumulation of dried food matter on the seat, arms and sides; and * Ceiling exhaust fans in several shared bathrooms had a layer of black dirt and dust. The surveyor toured the environment with Staff 4 (Kitchen/Maintenance Manager) on 04/14/22 at 10:00 am. He acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure the environment was maintained clean and in good repair. This is a repeat citation. Findings include, but are not limited to:Observations of the facility on 07/06/22 during the survey revealed the following:* Several dining chairs had scraped wood on the arms and legs;* Three wooden tables in the dining room had scraped paint; and* The wood hutch and television stand in the television room adjacent to the dining room had gouges, dings and chipped paint. The need to ensure the environment was maintained clean and in good repair was discussed with Staff 1 (Administrator) during a tour of the environment on 07/06/22. She acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C 160, C 231, C 240 and C 513.
Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:Refer to C160, C231, C510 and C513.

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C 252, C 303 and C 305.
Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:Refer to C252, C303 and C305.

Based on interview and record review, it was determined the facility failed to evaluate and develop individualized activity plans for 3 of 3 sampled residents (#s 1, 2, and 3) whose activity plans were reviewed. Findings include, but are not limited to:Resident 1, 2, and 3's records were reviewed during the survey. There was no documented evidence an activity evaluation had been completed and that their service plans had been individualized to reflect the following:* Current abilities and skills;* Emotional/social needs and patterns;* Adaptations needed to participate;* Identification of activities for behavioral interventions; and* There was no specific activity plan which detailed what, when, how and how often staff should offer and assist each resident with individualized activities.On 04/14/22, the lack of an activity evaluation and individualized activity plan was discussed with Staff 1 (Executive Director) and Staff 3 (Resident Care Coordinator). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to evaluate residents for activities and to develop individualized activity plans from the evaluations for 2 of 2 sampled residents (#s 6 and 7). This is a repeat citation. Findings include, but are not limited to:A review of the service plans for Residents 6 and 7, and an interview with Staff 1 (Administrator) on 07/06/22 revealed the following:1. There was no documented evidence the facility evaluated each resident to include the following elements related to activities:* Current abilities and skills;* Emotional and social needs and patterns;* Physical abilities and limitations; and* Identification of activities for behavioral interventions.2. There was no documented evidence individualized activity plans addressing what, when, how, and how often staff should offer and assist the resident with activities were developed and documented.The need to ensure the facility completed an activity evaluation addressing all required elements and developed an individualized activity plan based on the evaluation for each resident was discussed with Staff 1 (Administrator) and Staff 2 (RCC) on 07/06/22. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure furniture in the outdoor recreation area was of sufficient weight and design to prevent injury and not aid in elopement. Findings include, but are not limited to:On 04/14/22, a tour of the facility's outdoor area revealed the following: * The secured courtyard had several chairs which were easily moveable and not of sufficient weight and design to prevent injury and not aid in elopement.During a walk-through of the facility at 10:00 am on the same day, Staff 4 (Kitchen/Maintenance Manager) was shown the concern. He acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure the fence surrounding the perimeter of the outdoor recreation area was not less than six feet in height. This is a repeat citation. Findings include, but are not limited to: During a tour of the environment on 07/06/22, the perimeter fence in the secure outdoor recreation area was measured by Staff 8 (Maintenance Assistant) at the request of survey and found to be 5'7" in height. The need to ensure the fence surrounding the perimeter of the outdoor recreation area was not less than six feet in height was discussed with Staff 1 (Administrator) during a tour of the environment.