Health inspection·September 12, 2024

F 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide documentation by a physician regarding the basis of a resident's involuntary transfer/discharge, the specific resident needs that cannot be met, facility attempts to meet the resident needs, the service available at the receiving facility to meet the resident's needs and failed to allow a resident to return to the facility pending the appeal process for 1 (R8) of 4 residents reviewed for Involuntary Discharge in a sample of 8. Findings include: R8's face sheet documented an admission date of 1/31/23, a discharge date of 7/22/24, and diagnoses including: Alzheimer's disease, cognitive communication deficit, other specified persistent mood disorders, altered mental status, unspecified psychosis not due to a substance or know physiological condition. R8's 7/22/24 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 6, indicating R8 has severe cognitive impairment. R8's 7/22/24 MDS Section E documented physical behavioral symptoms directed toward others, verbal behavioral symptoms directed toward others, and other behavioral symptoms not directed toward others occurred 1 to 3 days. R8's 7/22/24 MDS also documented R8 had a behavior of rejecting care occurring 4 to 6 days, but less than daily. R8's Care Plan documented a 2/7/23 problem start date documenting in part . Category: Behavioral Symptoms . (R8) has a past history of trauma. He usually understands/ makes others understand him . he (R8) displays verbal/ physical behaviors during reflection of care (refusing showers, ADLs (Activities of Daily Living), changing clothes), when others enter his room, when redirecting, while experiencing visual hallucinations (spiders everywhere), delusional episodes (being bitten by spiders .). He misinterprets intentions of others . Delusional episodes and potential past history of trauma triggers physical verbal behaviors with others at times, along with loud behaviors of others . R8's Care Plan documents a Goal of . Resident will have a reduction in physical, verbal behaviors during rejection of care, delusional episodes, and providing redirection by next review . with a target date of 3/18/24. Documented Approaches include: Encourage to go for a walk to help de-escalate and encourage to vent feelings frustrations. Listen with empathy and offer emotional support dated 8/3/23. If resident becomes agitated during care, stop task and re-approach at a later time dated 7/8/24. R8's Care Plan documents an additional goal of . Resident will have a reduction in physical/ threatening behaviors directed toward others by next review . with a target date of 3/18/24. Documented approaches for this goal include: Encourage him (R8) to let staff assist in redirecting peers if wandering into his room dated 8/3/23 and Assist as tolerated to quieter area providing distraction from loud areas/ peers dated 10/24/23. R8's care plan did not document a problem, goals, or approaches regarding Page 1 of 9 146171 146171 09/12/2024 Manor Court of Carbondale 2940 W Westridge Place Carbondale, IL 62901

F 0622 R8's diagnosis of Alzheimer's disease or dementia. Level of Harm - Minimal harm or potential for actual harm R8's Behavioral Analysis dated 6/22/24 through 7/22/24 documents physical behavioral symptoms directed toward others occurred 10 times during this time period. Documented interventions attempted include redirect, one-on-one, return to room, given food/ fluids, activity, toilet, backrub, and position change. The section easily altered after each documented behavior and intervention documents and answer of no. The sections effect on resident and effect on others after each documented behavior and intervention is left blank. Residents Affected - Few On 9/6/24 at 9:20 AM, V19 (Certified Nursing Assistant/ CNA) said she was caring for R8 during the night shift from 7/5/24 to 7/6/24. V19 said on 7/6/24 around 1:30 AM she entered R8's room to check R8 for incontinence. V19 said R8 had a bowel movement and R8's bedding and clothing was soiled. V19 said she woke R8 up and told R8 he needed to get up so staff could clean him up and change his bedding. V19 said she turned her back and started pulling the sheets off the head of R8's bed when R8 grabbed her around the neck and started punching V19 in the head and pulling V19's hair. V19 said she jumped over R8's bed and was able to get out of R8's room. V19 said about 10 minutes later V19 and another staff reentered R8's room and finished cleaning R8 up and changing his bedding. V19 said R8 would have physical behaviors in his room with staff, but would have physical behaviors anywhere in the facility. V19 said there was no plan on what staff should do when R8 became agitated. V19 said she had spoken with V17 (Memory Care Unit Coordinator) about staff needing a plan on what to do when R8 became agitated or R8 needing his medications changed. R8's Behavior and Mood Event dated 7/6/24 documented R8 had a physical behavior toward staff with possible contributing factors of ADL (Activities of Daily Living) care. R8's 7/6/24 Behavior and Mood Event documented a 2:00 AM progress note documenting in part . Resident displayed physical behavior towards staff member while performing care. Resident has been redirected and is currently in his bed resting . R8's Behavior and Mood Events dated 7/8/24 documented a physical behavior directed toward staff with possible contributing factors of ADL care documenting in part . punched staff in abdomen during shower assistance . On 9/6/24 at 10:10 AM, V21 (CNA) said she was caring for R8 on 7/21/24. V21 said R8 was wearing an incontinent brief and jogging pants. V21 said it was apparent R8 needed incontinence care. V21 said she assisted R8 back to R8's room for care and as soon as V21 shut the door R8 physically attacked her. V21 said R8 would get physically aggressive with staff with providing personal care since R8 was admitted to the facility. V21 said R8's physically aggressive behaviors had gotten worse and more intense toward the end of R8's stay. V21 said R8 was able to be redirected when he was in the common areas but was not able to be redirected when staff were providing care in his room or in the shower room. V21 said the only thing staff could do when R8 became aggressive during care was to stop the task, leave, and return later to try to finish care. R8's Behavior and Mood Event dated 7/21/24 documented a physical behavior directed towards others and rejection of care with a 1:50 AM progress note documenting in part . resident became agitated and had a physical behavior toward staff when staff was attempting to assist resident with changing soiled (disposable undergarment) and soiled clothing resident was redirected safety of peers and staff secured resident is resting in bed at this time [sic] . R8's 7/22/24 Progress Note at 8:30 AM documented in part . Resident refusing care from staff d/t 146171 Page 2 of 9 146171 09/12/2024 Manor Court of Carbondale 2940 W Westridge Place Carbondale, IL 62901

F 0622 Level of Harm - Minimal harm or potential for actual harm (due to) delusional behaviors (believing that they just want to see him naked). Multipule attempts were made. Still unsuccessful . R8's 7/22/24 Progress Note at 10:16 AM documented in part . Resident displayed physical behaviors during episodes of rejection of care. Task was stopped at this time and will re-approach . Residents Affected - Few On 9/6/24 at 10:38 AM, V22 (CNA) said R8's mood would change quickly and if R8 could not understand what you were telling him R8 would get upset. V22 said R8 would wander into other resident's room and urinate in the floor. V22 said R8 was able to be redirected when in the common areas but could not be redirected when assisting R8 with personal care. V22 said R8 would become very upset with staff and become agitated when staff would remove soiled clothing or linens from R8's room. V22 said R8 had less behaviors with female staff and R8's behaviors were worse at night. On 9/5/24 at 11:59 AM, V17 (Memory Care Unit Director) said R8 was very difficult. V17 said when R8 was first admitted to the facility R8 was seen by the psychiatric provider and had less behaviors and suddenly had an increase in severity of physical behaviors. V17 said R8 would get mad if anyone went into his room because he thought people were trying to steal from him. V17 said R8 would become violently aggressive very quickly when staff were trying to assist him with care. V17 said R8's Electronic Medical Record (EMR) documented when R8 had physical behaviors toward others but did not contain details of the physical behaviors in the progress notes because other facilities are unlikely to accept the resident if the facility wanted to transfer the resident. On 9/5/24 at 12:30 PM, V2 (Director of Nursing) said he would expect there to be detailed notes in the resident's progress notes pertaining to a resident's behavior. V2 said if there were no details in the resident's progress notes about what behaviors are being exhibited or if the interventions are effective, he was unsure how the resident's care plan would be updated. On 9/4/24 at 10:26 AM, V14 (Hospital Social Worker) said R8 had been discharged to the hospital from the facility due to R8 being combative and the facility not being able to meet R8's needs. V14 said during R8's hospital stay R8 did not exhibit any combative behaviors. On 9/10/24 at 2:43 PM, V14 said she had spoken with V2 at the facility on 7/24/24 and was told R8 would not be allowed to return to the facility. On 9/10/24 at 2:15 PM, V15 (Ombudsman) said she had spoken with V14 when V14 was told R8 would not be allowed to return to the facility. V15 said she had contacted V16 (Family Member) to ask if V16 would like to appeal the involuntary discharge of R8 from the facility. V14 said she had filed for an appeal of the involuntary discharge. V14 said the facility had not let R8 return to the facility during the involuntary discharge appeal process. On 9/12/24 at 10:30 AM, V1 (Administrator) said R8 had an incident of violent physical behaviors on 7/6/24, 7/7/24, and 7/21/24. V1 said R8 was involuntarily discharged to the hospital acute psychiatric unit with the intention that R8 was not going to be permitted to return to the facility. On 9/12/24 at 10:37 AM, V2 (Director of Nursing) said when he called to give the hospital report on R8 V2 had expressed to the hospital R8 would not be permitted to return to the facility and would be arriving with the involuntary discharge documents. V2 said if the hospital acute psychiatric unit had called the facility after R8 had been treated and report R8 was not having any behaviors R8 would not have been permitted to return to the facility. 146171 Page 3 of 9 146171 09/12/2024 Manor Court of Carbondale 2940 W Westridge Place Carbondale, IL 62901

F 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R8's 7/22/24 Notice of Involuntary Transfer or Discharge and Opportunity for Hearing for Nursing Home Residents documented R8 had been emergency transferred or discharged from the facility due to the safety of individuals in the facility being endangered. R8's Illinois Department of Public Health State of Illinois Proof of Service documented in part . The undersigned certifies that true and correct copies of the attached Notice of prehearing conference and hearing were sent via email and/or Certified mail to: (R8), (V16), (V14), (V15), and (the facility's attorney). That said documents were sent from the Illinois Department of Public Health Office in [NAME], Illinois on the (8th) day of August 2024 . On 9/10/24 at 9:59 AM, V24 (Psychiatric Nurse Practitioner) said R8's physically aggressive behaviors had worsened and R8 needed an inpatient acute psychiatric care stay. V24 said she had adjusted R8's psychiatric medications to the best of her abilities but increasing R8's medications would have been worrisome of chemical restraint. V24 said she was aware of R8 being involuntarily discharged from the facility. V24 said it was the responsibility of the Medical Director to document why the facility was not able to meet the resident's needs and what the receiving facility would need to meet the resident's needs. On 9/10/24 at 10:46 AM and 9/12/24 at 2:35 PM, messages were left with V25's (Physician) office with no return phone call from V25. On 9/10/24 at 10:32 AM, V2 said R8's EMR did not contain any documentation by V25 (Physician) pertaining to why the facility could not meet R8's needs and what the receiving facility would need to do to meet R8's needs. R8's 7/1/24 through 7/31/24 Physician Order Report documented the following medication orders: 7/17/24 7/20/24 Depakote Sprinkles 125 mg (milligrams) 2 capsules by mouth 3 times daily, 7/21/24 - open ended Depakote Sprinkles 125 mg 1 capsule by mouth 3 times daily, 7/10/24 clonazepam 0.5 mg 1 tablet by mouth at bedtime, 5/2/24 Risperdal 12.5 mg intramuscular once a day on Wednesday every other week. R8's Physician Order Report did not document an order from V25 or V24 to discharge R8 or to refer R8 to inpatient psychiatric treatment. R8's hospital Medication Administration Record (MAR) documented an 8/8/24 order to start Remeron 15 mg by mouth at bedtime and an 8/11/24 order to start Zoloft 50 mg by mouth daily. R8's hospital record documented an 8/3/24 progress note documenting in part . (R8) is going to medical due to low response with spoken with, lack of caloric intake and hydration. (R8) appears to be experiencing failure to thrive. Poor (oral) intake staff is encouraging (R8) to sip water, juice, ice chips through straw with no success. (R8's) vital signs are within normal limits. (R8) skin tents on back of hand and lips and gums are furled. (R8's) hue is a pale ashen hue . The facility policy titled Skilled Special Care Unit Care and Treatment (revised 4/7/21) documents in part . Our Memory Care program is a Skilled Special Care Unit designated to meet the physical needs, emotional needs, and psychosocial well-being of individuals related to Alzheimer's disease/ dementia diagnosis . Staff are trained to expect the unexpected with emphasis on using proactive interventions designed to prevent behaviors from occurring and to recognize individual signs that a resident is in stress. Emphasis is placed on perceiving any behaviors as a means of communication by a resident and determining the trigger . The resident will be assessed through observations geared toward analysis of the resident's activity interests, cognitive and behavioral status . The care plan is 146171 Page 4 of 9 146171 09/12/2024 Manor Court of Carbondale 2940 W Westridge Place Carbondale, IL 62901

F 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few accessible to all (Memory Care Unit) staff and shall be utilized as a directive for all cares provided . As a resident requires more assistance, staff will communicate these needs with the Director of Memory Care to ensure changes are made to the resident's plan of care as needed The facility policy titled Transfer of a Resident (revised 1/11/23) documents in part . 5. Involuntary Discharge . Involuntary transfers will be initiated for reasons as specified by the Resident Contract. R8's admission Agreement dated 1/31/23 documents in section Q. Discharge The Facility may terminate the contract and discharge the Resident with a 30 day notice for any of the following reasons: The discharge is necessary for the resident's welfare and the resident's needs cannot be met in the Facility .The safety of individuals in the Facility is endangered. The health of individuals in the Facility would otherwise be endangered . 146171 Page 5 of 9 146171 09/12/2024 Manor Court of Carbondale 2940 W Westridge Place Carbondale, IL 62901

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review the facility failed to provide showers for dependent residents for 1 (R2) of 3 residents reviewed for Activities of Daily Living in a sample of 8. Residents Affected - Few The findings include: R2's Resident Face Sheet documents an admission date of 6/17/24 with diagnoses including acute respiratory failure with hypoxia, acute myocardial infarction, unspecified, Chronic Obstructive Pulmonary Disease, unspecified, unspecified open wound, left knee, initial encounter, systemic lupus erythematosus, unspecified, and Rheumatoid arthritis, unspecified. R2's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) score of 15 which indicates R2 is cognitively intact. The same MDS documents that for shower/baths, R2 requires substantial/maximum assistance-helper lifts or holds trunk or limbs and provides more than half the effort. R2's Care Plan documents a problem area of Resident Care Information dated 6/17/24. Documented approaches include bathing type: shower/whirlpool and bath days of Monday, Wednesday and Friday. On 9/5/24 at 10:00 am, R2's hair appeared to be greasy and to have not been washed. R2 said her hair had not been washed in a week or so and it really needs it. R2 said she has not had a shower in a while, said she has received mostly bed baths with moistened bath wipes. R2 said she would really like her hair washed. On 9/10/24 at 10:45 am, V1 (Administrator) said the CNA's (Certified Nurse Assistants) does the whirlpools baths. On 9/5/24 at 11:00 am, V2 (DON/Director of Nurses) said that the facility policy is that a resident receives one shower/bath a week, and they do schedule residents for 2 a week. V2 said it is his expectation that if a resident refuses a shower/bath, staff will go back and attempt again. R2's document labeled CNA Duties List dated 8/13/24 document that R2 received a shower on 8/27/24 and notes BB which indicates a bed bath. R2's Point of Care History in the electronic Health Record document that R2 refused a shower on 8/17/24. This indicates that R2 went 14 days without a shower/ bath. R2's Point of Care History documents R2's next shower/bath as 9/4/24 which indicates R2 went from 8/25/24 to 9/4/24 which indicates 9 days without a shower/bath. The facility's Personal Care of Residents policy (revised 12/02) documents Each Resident shall have at least one (1) complete bath and hair wash weekly and as many additional baths and hair washes as necessary for satisfactory personal hygiene. 146171 Page 6 of 9 146171 09/12/2024 Manor Court of Carbondale 2940 W Westridge Place Carbondale, IL 62901

F 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to re-assess and implement progressive individualized interventions for increased occurrences of combative behaviors for 1 (R8) of 3 residents reviewed for dementia care in the sample of 8. Residents Affected - Few Findings include: R8's face sheet documented an admission date of 1/31/23, a discharge date of 7/22/24, and diagnoses including: Alzheimer's disease, cognitive communication deficit, other specified persistent mood disorders, altered mental status, unspecified psychosis not due to a substance or known physiological condition. R8's 7/22/24 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 6, indicating R8 has severe cognitive impairment. R8's 7/22/24 MDS Section E documented physical behavioral symptoms directed toward others, verbal behavioral symptoms directed toward others, and other behavioral symptoms not directed toward others occurred 1 to 3 days. R8's 7/22/24 MDS also documented R8 had a behavior of rejecting care occurring 4 to 6 days, but less than daily. R8's Care Plan documented a 2/7/23 problem start date documenting in part . Category: Behavioral Symptoms . (R8) has a past history of trauma. He usually understands/ makes others understand him . he (R8) displays verbal/ physical behaviors during refection of care (refusing showers, ADLs (Activities of Daily Living), changing clothes), when others enter his room, when redirecting, while experiencing visual hallucinations (spiders everywhere), delusional episodes (being bitten by spiders .). He misinterprets intentions of others . Delusional episodes and potential past history of trauma triggers physical verbal behaviors with others at times, along with loud behaviors of others . R8's Care Plan documents a Goal of . Resident will have a reduction in physical, verbal behaviors during rejection of care, delusional episodes, and providing redirection by next review . with a target date of 3/18/24. Documented Approaches include: Encourage to go for a walk to help de-escalate and encourage to vent feelings frustrations. Listen with empathy and offer emotional support dated 8/3/23. If resident becomes agitated during care, stop task and re-approach at a later time dated 7/8/24. R8's Care Plan documents an additional goal of . Resident will have a reduction in physical/ threatening behaviors directed toward others by next review . with a target date of 3/18/24. Documented approaches for this goal include: Encourage him (R8) to let staff assist in redirecting peers if wandering into his room dated 8/3/23 and Assist as tolerated to quieter area providing distraction from loud areas/ peers dated 10/24/23. R8's care plan did not document a problem, goals, or approaches regarding R8's diagnosis of Alzheimer's disease or dementia. R8's Behavioral Analysis dated 6/22/24 through 7/22/24 documents physical behavioral symptoms directed toward others occurred 10 times during this time period. Documented interventions attempted include redirect, one-on-one, return to room, given food/ fluids, activity, toilet, backrub, and position change. The section easily altered after each documented behavior and intervention documents and answer of no. The sections effect on resident and effect on others after each documented behavior and intervention is left blank. On 9/6/24 at 9:20 AM, V19 (Certified Nursing Assistant/ CNA) said she was caring for R8 during the night shift from 7/5/24 to 7/6/24. V19 said on 7/6/24 around 1:30 AM she entered R8's room to check R8 for incontinence. V19 said R8 had a bowel movement and R8's bedding and clothing was soiled. V19 146171 Page 7 of 9 146171 09/12/2024 Manor Court of Carbondale 2940 W Westridge Place Carbondale, IL 62901

F 0744 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few said she woke R8 up and told R8 he needed to get up so staff could clean him up and change his bedding. V19 said she turned her back and started pulling the sheets off the head of R8's bed when R8 grabbed her around the neck and started punching V19 in the head and pulling V19's hair. V19 said she jumped over R8's bed and was able to get out of R8's room. V19 said about 10 minutes later V19 and another staff reentered R8's room and finished cleaning R8 up and changing his bedding. V19 said R8 would have physical behaviors in his room with staff, but would have physical behaviors anywhere in the facility. V19 said there was no plan on what staff should do when R8 became agitated. V19 said she had spoken with V17 (Memory Care Unit Coordinator) about staff needing a plan on what to do when R8 became agitated or R8 needing his medications changed. R8's 7/6/24 Behavior and Mood Event documented R8 had a physical behavior toward staff with possible contributing factors of ADL care. R8's 7/6/24 Behavior and Mood Event documented a 2:00 AM progress note documenting in part . Resident displayed physical behavior towards staff member while preforming care. Resident has been redirected and is currently in his bed resting . R8's 7/8/24 Behavior and Mood Event documented a physical behavior directed toward staff with possible contributing factors of ADL care documenting in part . punched staff in abdomen during shower assistance . On 9/6/24 at 10:10 AM, V21 (CNA) said she was caring for R8 on 7/21/24. V21 said R8 was wearing an incontinent brief and jogging pants. V21 said it was apparent R8 needed incontinence care. V21 said she assisted R8 back to R8's room for care and as soon as V21 shut the door R8 physically attacked her. V21 said R8 would get physically aggressive with staff with providing personal care since R8 was admitted to the facility. V21 said R8's physically aggressive behaviors had gotten worse and more intense toward the end of R8's stay. V21 said R8 was able to be redirected when he was in the common areas but was not able to be redirected when staff were providing care in his room or in the shower room. V21 said the only thing staff could do when R8 became aggressive during care was to stop the task, leave, and return later to try to finish care. R8's 7/21/24 Behavior and Mood Event documented a physical behavior directed towards others and rejection of care with a 1:50 AM progress note documenting in part . resident became agitated and had a physical behavior toward staff when staff was attempting to assist resident with changing soiled depends and soiled clothing resident was redirected safety of peers and staff secured resident is resting in bed at this time [sic] . R8's 7/22/24 progress note at 8:30 AM documented in part . Resident refusing care from staff d/t (due to) delusional behaviors (believing that they just want to see him naked). Multipule attempts were made. Still unsuccessful . R8's 7/22/24 progress note at 10:16 AM documented in part . Resident displayed physical behaviors during episodes of rejection of care. Task was stopped at this time and will re-approach . On 9/6/24 at 10:38 AM, V22 (CNA) said R8's mood would change quickly and if R8 could not understand what you were telling him R8 would get upset. V22 said R8 would wander into other resident's room and urinate in the floor. V22 said R8 was able to be redirected when in the common areas but could not be redirected when assisting R8 with personal care. V22 said R8 would become very upset with staff and become agitated when staff would remove soiled clothing or linens from R8's room. V22 said R8 had less behaviors with female staff and R8's behaviors were worse at night. 146171 Page 8 of 9 146171 09/12/2024 Manor Court of Carbondale 2940 W Westridge Place Carbondale, IL 62901

F 0744 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 9/5/24 at 11:59 AM, V17 said R8 was very difficult. V17 said when R8 was first admitted to the facility R8 was seen by psychiatric provider and had less behaviors and suddenly had an increase in severity of physical behaviors. V17 said R8 would get mad if anyone went into his room because he thought people were trying to steal from him. V17 said R8 would become violently aggressive very quickly when staff were trying to assist him with care. V17 said that R8's Electronic Medical Record (EMR) documented when R8 had physical behaviors toward others but did not contain details of the physical behaviors in the progress notes because other facilities are unlikely to accept the resident if the facility wanted to transfer the resident. On 9/5/24 at 12:30 PM, V2 (Director of Nursing) said he would expect there to be detailed notes in the resident's progress notes pertaining to a resident's behavior. V2 said if there were no details in the resident's progress notes about what behaviors are being exhibited or if the interventions are effective, he was unsure how the resident's care plan would be updated. The facility's revised 4/7/21 Skilled Special Care Unit Care and Treatment policy documented in part . Our Memory Care program is a Skilled Special Care Unit designated to meet the physical needs, emotional needs, and psychosocial well-being of individuals related to Alzheimer's disease/ dementia diagnosis . Staff are trained to expect the unexpected with emphasis on using proactive interventions designed to prevent behaviors from occurring and to recognize individual signs that a resident is in stress. Emphasis is placed on perceiving any behaviors as a means of communication be a resident and determining the trigger . The resident will be assessed through observations geared toward analysis of the residents activity interests, cognitive and behavioral status . The care plan is accessible to all (Memory Care Unit) staff and shall be utilized as a directive for all cares provided . As a resident requires more assistance, staff will communicate these needs with the Director of Memory Care to ensure changes are made to the resident's plan of care as needed 146171 Page 9 of 9