The findings of the on-site investigation, conducted 09/01/2023 through 09/15/2023, 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.

Based on interview and record review, conducted during a site visit on 09/01/23, it was confirmed the facility failed to ensure medication and treatment orders were carried out as prescribed for 1 of 1 sampled resident (# 1) whose MAR was reviewed. Findings include, but are not limited to:

A review of Resident 1's progress notes, dated 01/2021, indicated on 01/12/21, Resident 1 was determined to no longer be safe to self-administer medications after an RN assessment and the physician was notified and requested prescriptions for Resident 1's medications. A second request was made the Resident 1's physician on 01/14/21.

A review of Resident 1's  MAR, dated 01/2021, indicated facility had created a MAR to begin facility administration on 01/23/21 with several medications denoted as "self-administration". Two of eight orders were not administered between 01/23/21 and 01/28/23. There was no evidence to indicate that eight of eight orders were administered between 01/12/23 and 01/23/21.

Progress notes, dated 01/26/21, indicated the Health and Wellness Director  "will talk with staff tomorrow about a plan"  in reference to facility administering Resident 1's medications.

In an interview on 09/01/23, Staff 1 (Administrator) stated s/he was did not know who Resident 1 was and was unaware of any concerns with Resident 1.

The facility failed to ensure physician orders were carried out as prescribed.

The findings of the investigation were reviewed with and acknowledged by Staff 1 on 09/15/23.

Verbal Plan of Correction

There is a new management team in the building to make sure this doesn't happen again. The Health and Wellness Director makes sure there are no changes to residents medication status' until the facility has received physician orders then s/he will fax Omnicare to either add a resident if s/he is going from self-medicating to facility management or to remove a resident if going from facility managing to self-medicating, then the Health and Wellness Director will update the residents care plan, print it and have all of the med techs review the information followed by the caregivers.

Based on interview and record review, conducted during a site visit on 09/01/23 it was determined the facility failed to implement an acuity-based staffing tool (ABST)  for 2 of 3 sampled residents (#s 2 and 3). Findings include, but are not limited to:

In an interview on 09/01/23, Staff 1 (Administrator) stated the facility uses ElderMark and there is a point value assigned that has a time allotted to it, and the facility currently staffs based on the number of residents and the point values for time.

A review of the facility's ABST indicated the tool failed to include all of the 22 required ADL components for the 3 sampled residents to include;

·If multiple staff are required to assist with transferring and completing tasks in previous question, how much additional time is needed.

·Providing treatments (e.g., skin care, wound care, antibiotic treatment.)

Resident 2 and 3s' ABST failed to address the following required ADL components:

·Providing non-drug interventions for pain management.

·Monitoring physical conditions or symptoms.

·Providing additional care service, such as smoking assistance or pet care.

Resident 3's ABST also failed to address the following required ADL component:

·Ensuring non-drug interventions for behaviors.

The facility failed to fully implement an acuity-based staffing tool that met regulations.

The findings of this investigation were reviewed with and acknowledged by Staff 1 on 09/15/23.