The findings of the on-site investigation, conducted 05/04/2023 and 05/05/2023 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.

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, it was determined the facility failed to ensure resident incidents were immediately reported to the local Seniors and People with Disability (SPD) office for 1 of 1 sampled residents (#2) who were reviewed. Findings include, but are not limited to:

A review of Resident 2's service plan, dated 12/14/22 and 03/23/23, indicated s/he requires the assistance of two staff members for transfers and ambulation, regular assistance with toileting, and total assistance with bathing.

A review of Resident 2's progress notes, dated 04/03/23 through 02/16/23, revealed an entry categorized as a "non-injury fall" on 03/29/23 (a CG) was assisting (Resident 2) with transferring without the assistance of a second staff member when the resident fell to the ground, hitting his/her head on the shower. CG called for a MT and the emergency medical technicians (EMTs) were "called to check the Resident 2 out. Resident refused to be sent out. No apparent injuries at this time. Resident requested something for [his/her] head pain."

A review of the facility's investigation, dated 03/30/23, indicated "abuse and neglect ruled out - resident was not alone_staff was there, resident's foot turned and caused resident to fall." There was no evidence to indicate this incident was reported to local Adult Protective Services (APS) or local SPD.

In an interview on 05/05/23, Staff 1 and Staff 6 stated this incident was not reported to APS. Staff 1 stated the reason for not reporting was because of a "gray area".

It was determined the facility failed to ensure resident incidents were immediately reproted to the local SPD office for 1 of 1 sampled resident incidents.

On 05/05/23, these findings were reviewed with and acknowledged by Staff 1 and Staff 6.

Plan of Correction:

Effective immediately, the Administrator will resume daily clinical meetings to review incident reports, determine what actions are required, and to review service plan updates and status.

a. Based on interview and record review, it was confirmed the facility failed to ensure the implementation of services for 1 of 1 sampled resident (#2). Findings include, but are not limited to:

A review of Resident 2's service plan, dated 12/14/22 and 03/23/23, indicated s/he required the assistance of two staff members for transfers and ambulation, regular assistance with toileting, and total assistance with bathing.

A review of Resident 2's progress notes, dated 04/03/23 through 02/16/23, indicated that on 03/29/23 (a CG) was assisting (Resident 2) with transferring without the assistance of a second staff member when the resident fell to the ground, hitting his/her head on the shower. CG called for an MT, and the emergency medical technicians (EMTs) were "called to check Resident 2 out. Resident refused to be sent out. No apparent injuries at this time. Resident requested something for [his/her] head pain."

In an interview on 05/04/23, Staff 1 (Administrator) stated s/he had transferred Resident 2 alone, the last time was approximately 3 months ago, and some day shift staff "may do so" alone.

The facility failed to ensure the implementation of resident's service plans for 1 of 1 sample resident when staff members transferred the resident without the assistance of a second staff member.

On 05/05/23, these findings were reviewed with and acknowledged by Staff 1 and Staff 6.

Plan of Correction:

Effective immediately, the Administrator and Resident Care Coordinator will orient all direct care staff to the residents' service plan and implement a signature sheet to ensure review and accountability.

Based on interview and record review, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled residents (#1) whose orders were reviewed. Findings include, but are not limited to:

In an interview on 05/04/2023 at 6:10 pm, Resident 1 stated "medications has been an ongoing issue" and there had been issues with his/her [mood stabilizing medication]. Resident 1 stated the powder treatment was believed to be discontinued but it wasn't and was approved to be self-administered.

A review of Resident 1's progress notes, dated December 2022 through April 2023, and  Medication Administration Records, dated January through April 2023, indicated there was no evidence the following medications had been administered:

*Medications used to treat mood, depression, migraines, and hypothyroidism were  missed 12 times in January.

*Medications used to treat mood and migraines were missed six times in February.

*Medications used to mood and migraines were missed seven times in March; and

*Medications used to treat mood and migraines were missed two times in April before Resident 1 left on vacation.

On 05/05/2023, Resident 1's physicians orders were reviewed and signed by his/her physician on 01/17/23 and 04/19/2023 which revealed the missed medications were ordered.

In an interview on 05/04/2023 at 7:17 pm, Staff  5 (MT) stated after reviewing Resident 1's medication history and cards was unable to explain why they would not have been administered.

In an interview on 05/05/2023 at 1:07 pm, Staff 1 (Administrator) and Staff 6 (RCC) were unable to explain why Resident 1's medication had not been administered.

It was confirmed the facility failed to carry out medication orders as prescribed.

On 05/05/2023 at 12:30 pm these findings were reviewed with and acknowledged by Staff 1 and Staff 6.

Plan of Correction:

Effective 05/06/2023, Staff 6 will require all MTs to generate daily missed medication reports before the end of shift and submit them to RCC to be reviewed daily with Staff 1 and RN at clinical huddles.

Based on interview and record review, it was confirmed the facility failed to fully implement an Acuity Based Staffing Tool (ABST). Findings include, but are not limited to:

In an interview on 05/04/23, Staff 1 (Administrator) stated the facility's ABST updated automatically when resident service plans were updated and confirmed multiple residents' service plans were overdue.

In an interview on 05/05/23, Staff 6 (RCC) stated service plans were updated before/upon move in, quarterly, and with a significant changes of condition. S/He had been working on updating 11 resident service plans that were overdue, but one had been updated on 05/04/23.

A review of the "Service Plans Due within 90 Days" report, dated 05/04/23, provided by Staff 1 indicated there were 11 residents' service plans that were overdue.

It was confirmed the facility failed to fully implement an Acuity Based Staffing Tool (ABST) for 11 identified residents whose service plans were overdue for their quarterly review.

On 05/05/23, these findings were reviewed with and acknowledged by Staff 1 and Staff 6.

Plan of Correction:

Within one week, the Resident Care Coordinator will ensure all out-of-date serivce plans will be updated adn entered into the facility's Service Planning/ABST system.