Ciel Mc of Cedar Mill

• The Culinary Director (CD), Maintenance Director (MD), and Executive Director (ED) conducted a comprehensive walkthrough of all areas identified during the survey. The team completed a deep cleaning of food preparation areas, equipment, vents, and floors under equipment, as well as recaulked the dishwashing area.
• The CD removed and disposed of inoperable equipment.
• The CD transitioned to pasteurized eggs, which have been delivered and are now in use.
• The CD held a documented in-service training with the culinary team addressing cross-contamination prevention.
• The MD repaired chipped walls, baseboards, and tiles in the kitchen.
• The MD corrected refrigerator temperature concerns, ensuring the unit maintains temperatures below 42°F.
• The MD completed a thorough cleaning and sanitization of the ice machine.

2. The CD implemented cleaning logs for both the main kitchen and the Memory Care kitchenette, outlining daily and weekly cleaning tasks.
• The CD reviews these logs with the team daily and conducts a weekly sanitation walkthrough with the Sous Chef.
• The CD, Sous Chef, and Memory Care Director (MCD) perform a detailed sanitation walkthrough on the first Monday of each month.

3. Daily and weekly walkthroughs of the kitchen are conducted by the CD and Sous Chef.
• The CD, ED, and MD jointly conduct a monthly walkthrough of the kitchen, storage closets, dishwashing area, Memory Care kitchenette, and hallways to identify and correct any damaged or chipped surfaces.

4. The CD and Sous Chef oversee all daily cleaning responsibilities.
• A weekly sanitation audit is completed for the kitchen, storage areas, Memory Care kitchenette, and dishwashing area by the CD and Sous Chef.

• The CD, MD, Memory Care Director/ED conduct a monthly walkthrough of the physical kitchen including MC kitchenette- including walls, tiles, and baseboards, to ensure all areas are maintained in compliance.

• The Culinary Director (CD), Maintenance Director (MD), and Executive Director (ED) conducted a comprehensive walkthrough of all areas identified during the survey. The team completed a deep cleaning of food preparation areas, equipment, vents, and floors under equipment, as well as recaulked the dishwashing area.
• The CD removed and disposed of inoperable equipment.
• The CD transitioned to pasteurized eggs, which have been delivered and are now in use.
• The CD held a documented in-service training with the culinary team addressing cross-contamination prevention.
• The MD repaired chipped walls, baseboards, and tiles in the kitchen.
• The MD corrected refrigerator temperature concerns, ensuring the unit maintains temperatures below 42°F.
• The MD completed a thorough cleaning and sanitization of the ice machine.

2. The CD implemented cleaning logs for both the main kitchen and the Memory Care kitchenette, outlining daily and weekly cleaning tasks.
• The CD reviews these logs with the team daily and conducts a weekly sanitation walkthrough with the Sous Chef.
• The CD, Sous Chef, and Memory Care Director (MCD) perform a detailed sanitation walkthrough on the first Monday of each month.

3. Daily and weekly walkthroughs of the kitchen are conducted by the CD and Sous Chef.
• The CD, ED, and MD jointly conduct a monthly walkthrough of the kitchen, storage closets, dishwashing area, Memory Care kitchenette, and hallways to identify and correct any damaged or chipped surfaces.

4. The CD and Sous Chef oversee all daily cleaning responsibilities.
• A weekly sanitation audit is completed for the kitchen, storage areas, Memory Care kitchenette, and dishwashing area by the CD and Sous Chef.

• The CD, MD, Memory Care Director/ED conduct a monthly walkthrough of the physical kitchen including MC kitchenette- including walls, tiles, and baseboards, to ensure all areas are maintained in compliance

New TSP was placed for Resident 3 with more details on elopement behaviors. It will be added to the service plan at the next quarterly update. Care staff have been retrained to read and sign TSPs.On going training will occur from the Clinical team to ensure care staff are reading and signing the TSPs. The Health and Wellness Director will input all relevant TSPs to the service plan at each update (quarterly and as needed). Memory Care Director will check each service plan update to ensure that the relevant TSPs have been entered.Administrator will be responsible that the items above are completed and documented timely.

Aprons have been purchased for clothing protection during meal service. Staff have been educated to utilize these at each meal. All staff will be retrained during monthly all staff meeting by the Health and Wellness Director on when to wash hands/change gloves during perineal care/care in the bathroom. Ongoing training and observation by supervisory team members will occur to insure compliance and appropriate Infection Control measures ongoing.Memory Care Director will observe bathroom cares monthly to ensure compliance. Memory Care Director to ensure there are aprons for meals. Health and Wellness Director will be responsible for scheduling/conducting training. Memory Care Director to supervise monthly audits.

Before giving a psychotropic medication as PRN, the Med Tech will document that they have tried all listed nonpharmacological interventions. Med Techs will be re-trained during a Med Tech meeting to ensure they are aware of where to document that the nonpharmacological interventions were completed. The Health and Wellness Director will evaluate this quarterly.Licensed Nursing staff, led by Health and Wellness Director will work to ensure compliance.

On 7/31/24 during survey, a third caregiver for NOC shift was added to the schedule, as well as an extra carestaff during day shift and a half shift for swing. A server is also being hired to ensure that every meal in Memory Care has a server present. The ODHS ABST will be utilized from now on to ensure appropriate staffing. Review of labor will occur at each service plan update by Administrator, Health and Wellness Director, and Resident Care Coordinator.Review and completion will be ongoing by Administrator or designee.

The community will be utilizing the ODHS ABST tool in place of their previous tool to ensure all 22 ADLs are individually addressed for each resident and the amount of staff time needed for each ADL.The service planning team, specifically the Health and Wellness Director, will update the ODHS ABST at each service plan update (quarterly and as needed for any change of condition and for the resident prior to move in when we enter their service plan for our team. It will also be reassessed at 30 days when we administer the service plan as well with any changes. The ABST will be updated at each service plan update.Administrator or desginee will be responsible for accuracy ongoing.

One fire drill per shift will be conducted and documented. Each drill will rotate which shift is is completed on. Additionally, all planned fire drills are to be communicated to the Memory Care Director to ensure compliance. Each fire drill conducted will involve evacuating or relocating residents. Assisted Living staff and Memory Care staff will only be used for their designated sections for fire drills.Monthly review of Life Safety requirements, specifically Fire Drills, to be conducted and documented by Maintenance Director.Fire drills will be conducted effective immediately and every other month following with documentation of any problems that occurred, evacuation time period, number of occupants that were evacuated and any comments relating to any resident that resisted or failed to participate in the drills.Administrator will be responsible for oversight of corrections and compliance ongoing.

The facility will review and comply with all regulations under OAR 411-054-0105.The facility will continue to conduct audits for each apartment on a weekly basis.The Memory Care Director will conduct weekly audits of the bathroom doors for each shared apartment to ensure we are in compliance. The Memory Care Director, Maintenance Director and the Executive Director will work closely together to ensure we are in compliance.

Maintenance Director to install a locking mechanism on the inside of shared bathroom doors to ensure privacy and dignity of the resident.Memory Care Director will ensure that the locks are still in place and not broken. If broken, the Memory Care Director will contact the Maintenance Director to fix the lock.Memory Care Director completes weekly room audits and will check the locks in each room once weekly.The Maintenance Director and the Memory Care Director will work together to ensure the locks are placed, and functioning on the shared bathroom doors. Maintenance Director to install a locking mechanism on the inside of shred bathroom doors to ensure privacy and dignity of the resident. Maintenance Director is currently getting several bids for door locks. Memory Care Director will ensure that the locks are still in place and not broken. If broken, the Memory Care Director will contact the Maintenance Director to fix the lock.Memory Care Director completes weekly room audits and will check the locks in each room once weekly. The Maintenance Director and the Memory Care Director will work together to ensure the locks are placed, and functioning on the shared bathrrom doors.

The Memory Care Director will document and give each resident a key to their lockable unit. The key will be placed in each residents closet on the wall. Upon move in for new residents, the Memory Care Director will offer a key to access to their lockable unit and document that it was given.Documentation will be kept in the service plan. The service plan is reviewed and updated quarterly and as needed The key documentation will be reviewed during each service plan review and update.The Memory Care Director and the service planning team will work together to ensure the correct documentation is in each service plan.

See plans for C 295, C 360, C 361 and C 420.

See plans for C 260 and C 330.

Life Enrichment Director will complete the activities evaluation for the two sampled residents. The Life Enrichment Director will use the activity evaluation to complete the individualized activity plan for each resident. Upon move in, the Life Enrichment Director will complete the resident activity evaluation and the individualized activity plan as well as all of the residents individualized activity evaluations updated and completed for Memory Care by 9/30/24. The Life Enrichment Director will post the information in a binder in the breakroom for all the staff to review. The Life Enrichment Director will review all the individualized activity plans every six months unless a resident experiences a significant chagne of condition which we will update with the residents abilities.The Memory Care Director or designee will be responsible to see that the corrections are completed.

1) Pasteurized Eggs: Director of Dining Services to order pasteurized eggs from our approved food purveyor; ; training our dining services team on the importance of using pasteurized eggs vs non pasteurized eggs, and potential health risk of food bourne illness to our residents. Administer inservice for the team which will be signed by person in charge and all employees that attend inservice.2) Meal Tray Covers- Interim AED to inservice our employees and memory care servers to cover food prior to delivery and talk cross contamination is and food safety. We will ensure plate covers/plastic wrap for all food being delivered to the residents apartments as well as any other food transported in/out of the kitchen. 3)Unrestrained Beard- Director of Dining Services/Person in charge to inservice all dining employees on hair restraints in kitchen working with food prep, cooking, dishes and how it can become physical contaminant. Dining team to sign inservice

Refer to C240

1. Administrative management team including Executive Director, department managers and Park Avenue Life Stye Management for Clinical and Operations Directors have reviewed, revised and updated all policies and procedures and intitiated trainings for all new and existing staff. Please see each citation for more information2. A change of administrator is in process to provide effective oversight including ensuring the quality of care and servces. An admininstrator and designee have submitted information for approval by DHS. Both are completing required Criminal Background checks and other state requirements including attendance of OHCA Administrator Training Class form 7.25.2022 to 7.29.2022 prior to completing the licensing exam. 3. Administrative management including community and management company leadership participate in weekly audit reporting with quality improvements.4. Administrator and/or designee.

1. Fire and Emergency Evacuation Plan has been reviewed and updated. Evacuation equipment obained and is used in all staff evacuation trainings. All residents have been evaluated for ability and need for level and type of assistance to participate in drills and evacuations. All newly hired staff have been trainied prior to providing services (date or hire). Existing staff are being trained on fire drills and the newly updated Emergency Plan and Evacuation procedrures.2. & 3. Weekly reports for employees not in attendance for routine monthly training and drills will be sent to each department manager for follow up with employee. Reisdent Service Plans will reflect willingness and ability to participate in these events, on move in and review/re-evaluated every 90 days or before, if changes in a resident condition. 4. Department Managers and Administrator. Reasonable Precautions1. All new hires are completing the 2hr infection control. Any current staff that has not completed the 2 hour infection control will be completing this training.RN will be completing training on 8/25 with All Staff.2. Infection control training added to new hire orientation. 3. Training will be audited weekly for 12 weeks and audits will be reviewed by Quality Assurance Committee and recommedations made based on audit review. 4. Health and Wellness Director (RN) or designee Adequate Direct Care Staff:1. State provided acuity-based staffing tool updated by Memory care direcotr at https://ltcfacilityportal.oregon.gov and calculated the number of staff hours required to meet the scheduled and unscheduled needs of all residents in Memory Care:a. Extra staff employed by Cornell Landing were added to all shifts. Staff reeducated on the acuity guideline policy for all potential move-ins. The acuity guidelines require the interdisicplinary team to discuss the acuity of a resident prior to move-in and ensure that staffing levels and/or equipment available will meet the needs of the resident. 2.and 3. Staffing hours will be monitored on a monthly basis by the Resident Care Coordinator, the Health & Wellness Director, and the Memory Care Director. When alterations to staffing hours are required based on the above-mentioned procedure, a determination will be made to hire more staff or in the case of a short-term change in condition bring outside providers (i.e., hospice, home health, agency, etc.). 4. The Memory Care Director under the direction of the Executive Director and the Health and Wellness Director will make the determination to approve new move-ins, hire staff, and/or bring in outside providers. Emergency Evacuation Equipment: 1. The following evacuation equipment has been purchased: a. 4 Evac-chairs have been purchased and will be placed in the stair wells on each floor - two on the NE and 2 on the NW stairwells. b. Evacation blankets Have been purchased and will be kept in various locations throughout the building where staff can easily access them in the event of an emergency requiring their use (i.e., commercial laundry room in Memory Care, Storage closet on 4th floor, etc.). c. Maps and directions for exiting installed at every stairwell.2. Staff will receive monthly training in emergency and fire/life safety. The Maintenance Director will be responsible for ensuring equipment is located in the correct areas and in good working order.3. Inspections should be performed on equipment quarterly and after any trainings and/or actual evacuations to ensure equipment is not damaged, in need of repair and/or replacement. 4. The Maintenance Director will monitor quarterly. Universal Precautions for Infection Control: Hand Hygiene1. Staff have been trained to offer hand hygiene to residents before meals, after activities, and after toileting. The staff have been given training in the importance of hand hygiene before meals as a way to decrease risk cross contamination of germs from hands to food and ultimately into the mouth of residents as well as the risks associated with lack of hand hygiene for both residents and staff. Residents are invited to perform hand hygiene throughout the day using various methods including: a. Use of sink and soap b. Hand sanitizerc. Waterless soap that can be wiped with a cloth or paper toweld. Hand wipesProviding residents with multiple types of hand hygiene and increased opportunities to perform hand hygiene will make it easier for them to perform the process and diminish resistance (although residents are still encouraged to make their own decisions). 2. The systems will be updated in the following ways: a. Frequent in-person training on the importance of hand hygiene will occur regularly with staff. b. Simple signs inviting residents to wash their hands will be placed throughout Memory Care will be placed in highly visible areas. c. Increased monitoring of staff during activities like toileting and meals to ensure that residents are offered frequent hand hygiene as part of their daily routine. 3. This will be monitored daily1. The Memory Care Director, The Health and Wellness Director, the Assistance Health and Wellness Director, the Resident Care Coordinator with additional oversight and support from the Executive Director. Paper Towels:1. New dispenser placed by sink. Paper towels immediatetly filled. 2. Paper towel check added to housekeeping checklist to verify that paper towels are replaced when running low. back up rolls available for staff use. Staff educated on location.

1. Newly hired Activity Director (AD) has completed evaluations for residents identified during survey including ability, interest and need for any accomodations. Ongoing evaluations of all residents in progress: information for resident choices,preferences, abilities and accomodations are incorporated into their SP.2. AD will develop new Activity Schedules for regular postings. AD will keeps record of resident attendance and leve of participation in activittes. AD will follow up residents as needed to determine further interests and and accomodations needed. Life Loop system is being used.3. AD will generate weekly report to Administrator.4. Activities Director.

1. All residents identified during survey have been assessed and evaluations completed with updates and current information. 2. A tracking document /calender has been developed for use as tool to assist nurses and adminisrator to complete evauations for each recurring SP in advance of 90 days. Addional YARDI (electronic documentation) training has been provided for staff to complete documetnation thouroghly and on time. 3. Daily clinical stand up meetings with nurses and administrator will include review of current evaluations scheduled and completed. Initial evaluations will be completed with documentation prior to move in date for SP development and all staff to follow. New move in Evaluation and SP will be reviewd and updated with in 30 days. The timeliness of completing all evaluations will be reviewed monthly by the Quality Improvement Committee. 4. Administrator and/or designee

1. All residents indentified during the survey have been assessed, service plans have been reviewed and updated appropriately. 2. The tracking doucment tool will be utilized as describe in POC for C252 to assist nurses and administrtors to track due dates and time lines for all residents' SP 3. Daily clinical stand up will include list of SP coming due and the schedule for completing similar to C252 POC. Audits will be completed twice a month to determine. 4. Health and Wellness Director.

1. The Health and Wellness Director or desingee to Contact designated family members along with residents to invite and attend scheduled Service Plan meetings. Service Planning Teams consist or Administrator or designee, Nurse and one other staff member (either Med Tech or caregiver familiar with the resident service needs) and the team will particiapte in each SP. Service Plan meetings and teams will be scheduled for two different days each week. 2. By setting up two reoccuring weekly meeting with advance notice to all participants will help to ensure team attendance and timley completion of SP. 3. Weekly as stated in 2 above.4. Administrator and/or designee.

1. Res #1. A care cooordination meeting plan is in process of completion for fall risk reduction and fall prevention interventions. Pharmacy will review medications that may be contributing fall risk. Physical Therapy and Nursing are completing assessments with person centered approach to interventions to include in the SP. Res #2 A care coordinaiton meeting is planned with Hospice to review the goals of care along with pharmacy review of medicaitons that may be contibuting to loss of appetite /weight loss. 2. A change of conditon system now includes training all staff on regulations for observing, reporting, monitoring and documenting any noticiable changes in a residents routine or overall conditon. Training on the mandatory use of tools is in process and inlcudes: STOP AND WATCH for cargivers and SBAR for Med Techs and Nurses. Alert charting and Temporary or other changes on the SP will be directed by nurses and communicated to health services staff. Nurse is on call for any questions or concerns regarding a resident potential change of condition. Documentation will follow in the progress notes inlcuidng reviewing effectviness of interventons and when a short term condtion has been resolved and wll be taken off ALERT. An ALERT White Board will be located in MEDROOMS with HIPPA protections for daily tracking at a glance and shift change reporting. 3. Nurses will follow up daily on STOP & Watch and review the ALERT Charting daily. Weekly clincal standup meetings will include review of all residents CoC on ALERT. 4. Nurses and Administrator.

1. Res#3 passed away on hospice care7/18/22.Res #2 is currently receiving hospice care and her Service Plan has been updated to reflect this singinficant change of condition.2.Nurses will follow up with in 24 hours of any potential change of condition with a nursing assessment and documentation in progress notes; either a temporary SP for a temporary change of conditon or a new SP for a significant change of conditon (such as the addition of hopsice serivces) or loss of previous functional ability. All accidents, injuries, emergency room encounters will be called to the nurse on call if nurse is not on duty at the time of the incident for timely notificaton and follow up directions for care staff. 3. Daily stand up meetings will include changes to service plans based on changes of resident conditions. any accidents injuries and emergency room visits along with resident changes of condtion.4. Health & Wellenss Director

1.All residents identified on survey have been assessed, reviewed and addressed by nurses with specific written and verbal instructions with Med Techs. Medical orders for time sensitve administration and other tasks related to accurate administrations such as Blood pressures, physical postioning, empty stomach or with food are incuded in the MAR. Policies and procedures have been reviewed and updated to include time frame for other medicaitons without time sensitivity that include time frames for Breakfast, Lunch, Dinner and Bedtime administration. If medical orders donoot prohibit resident preferences , these will be included on the SP along with time sensitive meds. All resident refusal have been faxed to prescribers.Oregon Care Partners traing on Role of the Med Tech and Safe Mediction Use for Older Adults has been scheduled for Med Techs and Administrator.2 & 3. Nurses will review all medical orders and ensure accuracy for time sensitive medicaions administered on time along with MT following the complete medical order and notification to prescriber for all refusals with reason why resident is refusing if known. Nurses will complete audits 2 times weekly for orders and administration accuarcy and follow up. Nurses will , track and report medication errors; and direct staff in the overall safety and well being of the resident in each occurance. 4. Nurses will track and audit weekly for 12 weeks and report monthly to Quality Improvement Committee which inlcudes the Administrtor.

See POC C 300C 303- Systems: Treatment orders1. Resident 2: RN immediately verified correct times were in place on MAR with note of time sensitive medication. Resident 4: RN immediately verified correct times were in place on MAR .RN completed 1:1 training with med tech that gave medication late.2. Med Tech meeting held 6/28/22 including training on approving medication as prescribed and administering time sensitive medications correctly.2 & 3. Nurses will review all medical orders and ensure accuracy for time sensitive medicaions administered on time along with MT following the complete medical order and notification to prescriber for all refusals with reason why resident is refusing if known. Nurses will complete audits 2 times weekly for orders and administration accuarcy and follow up. Nurses will , track and report medication errors; and direct staff in the overall safety and well being of the resident in each occurance. 4. Nurses will track and audit weekly for 12 weeks and report monthly to Quality Improvement Committee which inlcudes the Administrtor.

See POC C 300 Residents PCP has been notified of refusals. Policies and Procedures have been updated to include reporting every time a resident refuses. Med Techs have been instructed on P&P and will document on the electroinc MAR along with faxing the PCP.2. Health and Wellness Director or nurse designee will audit documenation of refusals weekly. Med Tech will include refusals and notficaitons in shift to shift reports.3. Health and Wellness Director will audit and report weekly for 12 weeks. Audits to be reviewed during monthly QA meeting.4. Health and Wellness Director and/or nurse designee.

1. Resident #1 MARS and SP has been updated with current allergies. 2. YARDI system has been updated to include and transfers this information to MAR. Med Techs will notify nurse if any MAR does not include specific notations for allergies including NKDA (No Known Drug Allergies) Allergies will be included on SP , MARS and will be reviewed every 90 days.3. MARs will be reviewed by nurses monthly to include allergies. 4. Health and Wellness Director and/or nurse designee.

1. Staffing with full time employees inlcudes the following: Day shift= 1 Med Tech + 3 caregivers.Swing shift= 1 Med Tech+3 cargvers Night Shift= 1 Med Tech + 2 caregivers. This represents dedicated staff in MC. 2. Acuity Based Staffing Tool used and updated monthly as needed to track resident care for scheduled and unscheduled needs and staffing will be adjusted as required.3. Monthly or as needed as residents' condition change and or new residents move in.4. Administrator.

1. Maintenance Manager has revised and updated the Emergency Disaster Plan and Fire drill procedures; conducted trainings and evacations with staff and residents; developed alternating monthly schedules for staff and resident trainings and drills. 2. Detailed documentation regarding each training and drill procedure along with attendance is in prgress. Details include but are not limited to evacuation routes,safety points outside the building, how many people participated; amount of time to evacauate etc., 3. While fire drills are not announced in advance, both veral (daily stand up meetings) and written reports will be provied to administrator for results of drills and trainings utilizing the information required including all required aspects.Sumary reports will be provided to Quality Improvement Committee.4. Maintenace Manager.

See POC C420Residents ability and type of assistance or equipment needed to evacuate has been evauated and included on their SP. Training for Residents on Fire and Life Safety Procedures.1. While each resident has advanced dementia, it is not prudent to review the emergency evacuation procedures with them on move-in. However, each resident will be included in routine evacuation and emergency drills. Each resident will also be evaluated on move in for what type of assistance may be needed to evacuate the building.2. Every other month during fire drill procedures, staff will follow SP to assist each resident as needed.3. SP will be reviewed every 90 days for assistance needed during fire drill to determine if there any changes.4. Health and Wellness Director or designee

1. Kitchen cleaning and repairsRsident rooms #118, #123, #1272. Weekly community rounding to be completed by department heads as assigned by administrator for 12 weeks. Weekly rounds will be audited by Administrator and/or designeed, identified issues to be addressed in a timely manner and reviewed monthly during QA meeting. 3. Weekly for 12 weeks and reviewed during monthly QA. QA committee will determine continued need for audits based on review of audtis. 4. Administrator and/or designee.

1. Laundry policy and procdure had been updated to include how to handle soiled laundry, when to use the flushing sink and how to ensure detergent dispensers are kept filled and are operated properly. Laundry needs will be included on Resident Service Plans and indicate staff using disenfecting procedures during laundry cleaning. 2. All new and existing staff are scheduled to complete two hour infecion control training via Oregon Care Partners. Staff meetings scheduled to review and demonstrate updated P&P on Laundry disenfecting, how to obtain detergent refills and activate the disinfectant. How and when to use flushing sink and treat soiled laundry before placing in the machines. Instructions will also be posted in laundry rooms for easy reference and reminders. 3. Weekly observation with report to Admnistrator.4. Maintenance Director.

Refer to C 150, C160, C242, C360, C420, C422, C 513 and C530. Trai

1. Staff # 8 and #9 have completed all required training including 2 hour infection control and 6 hour Pre Service Dementia. Staff # 7 and #18 have completed 16 hours of annual training on required topics including2. Audits have been completed on all staff to identify what training was completed and when it has been completed. Results of these audits and training requirements outstanding will be reviewed with each employee with expectated dates of completion. Documentation with competencies will be collected and organized in each employee file. Trackkng documents for each required training topic and date completed will be kept in real time. Pre-service trainng will be completed prior to scheduled work with residents. Review of resident service plans and training for any special needs identified on residnets service plan will be included for direct care staff traininng. A list of required trainigs will be developed and provided each employee with deadline completion dates. Annual hours of inservice trainig for 16 hours will be developed inb advanced and provided to each employeeand wil be posted in the department in advance. 3. Weekly audits will be conducted on new employees and existing staf trainings for 12 weeks. Talent Acquistion Director will track and coordinate with Department Managers. Audits to be reviewed monthly during QA meeting. 4. Administrator and/or designee.

See POC C252, C260, C270, C280, C300, C305, C310.

1. Resident 1 and 3 service plans have been updated with each residents food and fluid preferences. Res #3 weight loss has been re-evaluated with updated intervenitons on the SP . Weekly weights as ordered for residents with signficant weight loss will be obtained and reviewed by nurse for further interventions as indicated. Monthly weights to be obtained for residents without weekly needs.2.Routine daily hydration rounds will be ocnducted by care staff. In between each meal, 6-8 ounce fluids of choice will be encouraged. Consumption will be noted and reported to nurse if any swallowing difficulty or lack of intake.Care staff will collect each residents food preference; assist them to complete their menu selections and provide information to include on their SP.3. Weekly aduits of weights to be completed by Health and Wellness Director for 12 weeks. Audits to be reviewed monthly during QA. 4. Administrator and/or designee.

See POC C 242 1.Evauatons have been completed for Residents 1, 2, 3 , 4 for current abilities and skills, emotional and social needs and patterns, physical abilities and limtiations, and adaptions need for each to partiicpate in activities they prefer. Challenging behaviors are identified and root cause analysis is used to identify possible triggers for behaviors. These have been included in the updates service plans for staff to follow. Redirections and engaging residents in mantaining routines is included in updated service plans for challenging behaviors. 2. Staff training on challenging beaviors is in progress inlcuding possble triggers. On going use of reporting tools including STOP AND WATCH and SBAR to provide accuate and timely information for nurse to follow up with TSP for Behavioral Interventions and or additonal interventions is progressing.3.Daily shift reports will include bevahioral interventions. Health and Wellness Director will evaluate effectivenss and document weekly or more often as needed. Nurse will report in daily stand up meetings. 4. Adminstrator.

1. Resident passed away on Hospice care 7/18/22.2. All care staff have been trained on various challenging behaviors; how to approach residents; and report to RN for further evaluation and development of TSP or new Service Plan depending on change of condtion. All residents new to MC will be evaluated and service planned for increased anxiety, exit seeking and wandering due to MC new environmnent and progressive brain disease process. Nurse consultant providing on going reviews and feedback for development of evaluations and service plans to address emotional needs and behaviors.3. Every 90 days or more often as needed.4. Health & Wellness Director

1. All residents have their rooms identified on the hallway wall adjacent to their door. A shodow box with resident identified items are depicted in the shadow box. The font size for their name is being enalrged for easier visualization. 2. On the day of move in- each resident's shadow box and name for room identification will be completed and placed near their door.3. On every new resident 's date of move in.4. Activity Director.