The findings of the complaint health survey (Intake # 26133) conducted 8/27/20 through 9/8/20 are documented in this report. The survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities.
The sample was comprised of 7 current residents and 2 discharged residents. The facility had a census of 35 residents.
Abbreviations possibly used in this document:
ADL: activities of daily living
bid: twice a day
BIMS: Brief Interview for Mental Status
CAA: Care Area Assessment
CBG: capillary blood glucose or
blood sugar
cm: centimeter
CMA: Certified Medication Aide
CNA: Certified Nursing Assistant
CPR: Cardiopulmonary Resuscitation
DNS: Director of Nursing Services
F: Fahrenheit
FRI: Facility Reported Incident
HS or hs: hour of sleep
LPN: Licensed Practical Nurse
MAR: Medication Administration
Record
mcg: microgram
MDS: Minimum Data Set
mg: milligram
ml: milliliters
O2 sats: oxygen saturation in the
blood
OT: Occupational Therapist
PCP: Primary Care Physician
PO: by mouth, orally
PRN: as needed
PT: Physical Therapist
RA: Restorative Aide
RAI: Resident Assessment
Instrument
RD: Registered Dietician
ROM: range of motion
RN: Registered Nurse
RNCM: Registered Nurse Care
Manager
SLP: Speech Language
Pathologist
TAR: Treatment Administration
Record
tid: three times a day
UA: Urinary Analysis
UTI: urinary tract infection
The findings of the health complaint revisit survey conducted (10/06/20 through 10/08/20) are documented in this report. The facility was found to be in substantial compliance with requirements for Long Term Care Facilities, 42 CFR Part 483.
Based on interview and record review it was determined the facility failed to ensure residents were involved in their plan of care for 1 of 3 sampled residents (#1) reviewed for care planning. This placed residents at risk for unmet needs. Findings include:
Resident 1 admitted to the facility in 2020 with diagnoses including pacemaker placement and was cognitively intact.
In an interview on 8/27/20 at 1:06 PM Resident 1 stated the facility did not include her/him in discussions regarding her/his care plan.
In an interview on 8/28/20 at 10:36 AM Staff 5 (SSD) stated there had not been a care plan meeting with Resident 1, but that it would have been a good idea.
A review of the medical record revealed the only documentation of Resident 1 being involved in a care meeting was a 7/31/20 SNF Initial Care Management Meeting.
In an interview on 9/4/20 at 11:04 AM Staff 5 stated the meeting referred to in the 7/31/20 SNF Initial Care Management Meeting form was a meet and greet, neither Resident 1's care plan nor the discharge plans were discussed in this meeting.
On 9/8/20 at 1:15 PM Staff 1 (Administrator) acknowledged there was no documentation Resident 1 was involved in her/his plan of care.
F553 Resident #1 has discharged The Administrator reviewed care plans that occurred over the last 30 days for resident participation, addressed concerns identified. The Administrator in-serviced the Social Services Director, RCMs on the requirement that residents are involved in their plan of care, ensuring that both the care plan and discharged plans are discussed in initial and ongoing care management meetings. The Administrator or Designee will audit care management meetings for resident participation compliance weekly x 3 weeks then monthly x 2 monthsThe Administrator or Designee will report the results of these audits to the facility monthly Quality Assurance meeting for 60 days or until substantial compliance has been achieved or sustained as determined by the committee.The Administrator is responsible to ensure compliance. Date of Compliance 9/22/20
Based on observation and interview it was determined the facility failed to ensure residents could independently exit the facility for 2 of 3 doors with keypads reviewed for safe environment. This placed residents at risk for loss of independence and lack of homelike environment. Findings include:
In an interview on 8/27/20 at 1:06 PM Resident 1 stated the doors to exit the facility required a key code and this was only posted at the front door that was currently out of order. Resident 1 stated to exit the facility residents must ask staff to open the door for them.
On 8/31/20 at 11:38 AM three exit doors were observed to require a key code. The door at the front of the building had a key code posted above the key pad, however this door was out of order. The two doors on the back side of the building required a key code to exit did not have a key code posted.
In an interview on 8/31/20 at 12:45 PM Staff 1 (Administrator) and Staff 16 (Maintenance Director) confirmed there were no key pad codes by two of the exit doors and to exit through those doors the residents needed to either have staff enter the code or in an emergency pull the fire alarm.
F584 Resident #1 has discharged Front Door Keypad was repaired September 8, 2020 by third party vendor. The Maintenance Director posted the key codes on the two doors backside of the building. The Administrator in-serviced the Maintenance Director on the requirement to ensure residents can independently exit the facility to promote independence and homelike environment. Maintenance Director or Designee will audit the exit doors for posted key code compliance weekly x 3 weeks then monthly x 2 months. The Maintenance Director or Designee will report the results of these audits to the facility monthly Quality Assurance meeting for 60 days or until substantial compliance has been achieved or sustained as determined by the committee.The Maintenance Director is responsible to ensure compliance. Date of Compliance 9/22/20
The findings of the complaint health survey (Intake # 26133) conducted 8/27/20 through 9/8/20 are documented in this report. The survey was conducted to determine compliance with OAR 411 Divisions 85 through 89. For additional information refer to the Form CMS 2567 dated 9/8/20.
The sample was comprised of 7 current residents and 2 closed records. The facility had a census of 35 residents.
Abbreviations possibly used in this document:
ADL: activities of daily living
bid: twice a day
BIMS: Brief Interview for Mental Status
CAA: Care Area Assessment
CBG: capillary blood glucose or
blood sugar
cm: centimeter
CMA: Certified Medication Aide
CNA: Certified Nursing Assistant
CPR: Cardiopulmonary Resuscitation
DNS: Director of Nursing Services
F: Fahrenheit
FRI: Facility Reported Incident
HS or hs: hour of sleep
LPN: Licensed Practical Nurse
MAR: Medication Administration
Record
mcg: microgram
MDS: Minimum Data Set
mg: milligram
ml: milliliters
O2 sats: oxygen saturation in the
blood
OT: Occupational Therapist
PCP: Primary Care Physician
PO: by mouth, orally
PRN: as needed
PT: Physical Therapist
RA: Restorative Aide
RAI: Resident Assessment
Instrument
RD: Registered Dietician
ROM: range of motion
RN: Registered Nurse
RNCM: Registered Nurse Care
Manager
SLP: Speech Language
Pathologist
TAR: Treatment Administration
Record
tid: three times a day
UA: Urinary Analysis
UTI: urinary tract infection
The findings of the health complaint revisit survey (Intake 26133) conducted 10/06/20 through 10/08/20 are documented in this report. The facility was found to be in substantial compliance with OAR 411 Divisions 85 through 89.
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OAR 411-085-0310 Resident's Rights: Generally
Refer to F553
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OAR 411-086-0149 Physical Environment
Refer to F584
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