The findings of the on-site investigation, conducted 09/13/23 through 09/15/23, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

Abbreviations possibly used in this document:

ADL:activities of daily living

CBG:capillary blood glucose or blood sugar

CG:caregiver

CS: Compliance Specialist

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MT:            Medication Tech

MAR:Medication Administration Record

MCC:Memory Care Community

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

RCC:Resident Care Coordinator

RN:Registered Nurse

Based on interview and record review, conducted during a site visit on 09/13/23, it was confirmed the facility falsified records requested by the Department. Findings include, but are not limited to:

a.

During an interview, 09/13/23, Staff 2 (LPN) stated s/he had given Staff 3 (Med Tech) training documents to sign 10 days prior to the site visit.

During an interview, Staff 3 stated Staff 2 had given him/her the training documents to sign that day.

The unsigned caregiving training documents were observed and photographed by Complaint Specialist on Staff 3's desk at 12:12 pm.

At 2:50 pm the same documents were again reviewed, signed by Staff 3, and backdated to 10/12/22.

The above findings were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 2 on 09/15/23.

It was determined the facility falsified records requested by the Department.

Verbal plan of correction: Training packets to be signed at time of training beginning immediately. LPN and RCC responsible for training. ED will oversee process.

b.

Based on interview and record review, conducted during a site visit on 09/13/23 and 09/15/23, it was confirmed the facility failed to ensure the accuracy and preservation of records for 1 of 1 sampled resident (# 1). Findings include, but are not limited to:

Resident 1 returned to the facility from a nursing facility on 09/20/22. The facility was unable to provide the discharge orders from the nursing facility when requested by the Department.

Resident 1's MAR, dated 9/01/22 through 10/31/22, indicated s/he did not receive Lasix from 09/20/23 until 10/28/22.

A transcription of a phone call, dated 10/25/22, from Resident 1's PCP indicated Staff 8 (MT) stated Resident 1  "is receiving [Lasix] daily".

Progress notes for Resident 1, dated 10/26/22, indicated Staff 2 (LPN)  " Questioned as to why [s/he] was no longer on Lasix. Upon investigation found orders in chart that were not processed appropriately. Sent [prescription] to pharmacy and started Lasix, notified PCP via voicemail as well as fax. "

The facility was unable to provide the fax to Resident 1's PCP on 10/26/23 when requested by the Department.

Progress notes for Resident 1, dated 10/28/22, indicated the facility received Resident 1's Lasix on 10/28/22.

During an interview, 09/15/23, Staff 2 stated  "started Lasix"  as written on Resident 1's progress notes "meant" that the process to acquire and administer Resident 1's medication had begun.

The above findings were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 2 on 09/15/23.

It was determined the facility failed to ensure accuracy and preservation of resident records.

Verbal plan of correction: LPN and RCC to review chart notes and double check one another's work to ensure accuracy. ED to review daily reports in progress notes, alerts and documentation and pass it on to LPN. Daily clinical meetings to begin immediately with LPN/RCC/ED on alert charting.

Based on interview and record review, conducted during a site visit on 09/13/23 and 09/15/23, it was confirmed the facility failed to provide sufficient care staff to meet the scheduled and unscheduled needs of residents. Findings include, but are not limited to:

A review of the facility's staffing plan indicated there was to be one caregiver and one med tech on shift for day, swing, and night shift.

A review of staff time sheets, 01/23/23-01/30/23, indicated:

-One direct care staff worked 01/23/23 swing shift.

-One direct care staff worked 01/24/23 swing shift.

-No direct care staff worked 01/25/23 swing shift.

-One direct care staff worked 01/25/23 night shift.

-One direct care staff worked 01/26/23 swing shift.

-One direct care staff worked 01/27/23 swing shift.

-No direct care staff worked 01/28/23 day shift.

-No direct care staff worked 01/28/23 swing shift.

-One direct care staff worked 01/29/23 day shift.

-One direct care staff worked 01/29/23 swing shift.

-One direct care staff worked 01/30/23 swing shift.

During an interview, 09/15/23, Staff 2 (LPN) stated s/he had worked 80+ hour weeks over that period covering shifts.

The facility was unable to provide a record of Staff 2 working in the capacity of direct-care staff as opposed to an ancillary staff member.

During an interview, 09/13/23, Staff 3 (Med Tech) stated staffing had been an issue  "around 9 months ago".

Call light records were unable to be reviewed for that period as the facility had since replaced their call light system and the previous one had been removed.

Resident 1 was unable to be interviewed as s/he is no longer residing in the facility.

The above findings were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 2 on 09/15/23.

It was determined the facility failed to provide sufficient care staff to meet the scheduled and unscheduled needs of residents.

Verbal plan of correction: Facility has replaced direct care staff who have quit, are currently fully staffed and are currently interviewing to replace staff who have recently given notice. Facility now has an RCC who is able to fill the role of direct-care staff in the event of an absence. Facility will no longer count ancillary staff as direct-care staff.

Based on interview and record review, conducted during a site visit on 09/13/23 and 09/15/23, it was confirmed the facility failed to have a training program that includes methods to determine competency of direct care for 2 of 3 sampled staff (#s 5 and 6). Findings include, but are not limited to:

During an interview, 09/13/23, Staff 3 (Med Tech) stated training procedures had drastically changed since s/he started working for the facility, and due to high turnover caregivers and med techs were regularly expected to perform the full duties of their job within a few days of being hired.

The facility was unable to provide competency checklists for Staff 5 (Med Tech) and Staff 6 (Caregiver).

The above findings were reviewed with and acknowledged by Staff 1 (Executive Director) on 09/13/23.

It was determined the facility failed to determine competency of direct care when training staff.

Verbal plan of correction: Facility to immediately begin an audit of staff training records and re-train staff as necessary. Audit has begun as of 09/15/23.

Based on observation and interview, conducted during a site visit on 09/13/23, it was confirmed the facility failed to keep interior surfaces in good repair for 1 of 1 sampled resident (# 3). Findings include, but are not limited to:

On 09/13/23 a hole approximately six to eight inches across was observed in Resident 3's drywall where the interior doorknob at the entrance to the unit had impacted the wall. Additionally, there were scratches and gouges throughout the apartment at levels where Resident 3's electric wheelchair had impacted surfaces.

During an interview, 09/13/23, Resident 3 stated the hole had been there for some time because s/he had trouble controlling his/her electric wheelchair. S/he stated maintenance had been notified and that s/he had expressed a desire for installation of a method to stop or slow the door from shutting.

During an interview, 09/13/23, Staff 2 (LPN) confirmed the hole in Resident 3's wall had been present for a while, and further stated it hadn't been fixed because Resident 3 would slam the door into the wall again anyway.

During an interview, 09/13/23, Staff 1 (Executive Director) stated the facility's maintenance person had been terminated the morning of 09/13/23.

The above findings were reviewed with and acknowledged by Staff 1 and Staff 2 on 09/13/23 and 09/15/23.

It was determined the facility to keep interior surfaces in good repair.

Verbal plan of correction: Facility to fix the walls of resident's apartment within 30 days of 09/13/23.