Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation revisit conducted 10/21/24.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

a. Based on interview and record review, conducted during a site visit on 02/07/24 through 02/13/24, it was confirmed the facility failed to immediately notify the local Department office of an incident of abuse or suspected abuse for 1 of 1 sampled residents (#  29). Findings include, but are not limited to:

During an interview on 02/07/24, Staff 9 (MT) stated a caregiver had found Resident 29 and another resident unclothed in Resident 29's room on 01/29/24. S/he further stated Resident 29 complained of "pain in [his/her] bottom" and had since become fearful of the other resident who had been found in his/her room. Staff 9 stated s/he had created an incident report, interim service plan, and a progress note regarding the incident.

Progress notes for Resident 29, dated 01/29/24, indicated s/he was to be monitored for complaints of pain in his/her bottom.

During an interview on 02/07/24, Staff 8 (LPN) stated s/he had deleted the incident report and interim service plan as s/he "didn't think it was a real incident." S/he stated the facility had not reported the incident to the local Seniors and People with Disabilties (SPD) office.

During an interview on 02/07/24, Staff 1 (Executive Director) confirmed the facility had not reported the incident to the local SPD.

It was determined the facility failed to immediately notify the local Department office or the local AAA of any incident of abuse or suspected abuse.

The findings of the investigation were reviewed with and acknowledged by Staff 1, Staff 2 (Regional Operations Director) and Staff 3 (Campus Director) on 02/13/24.

A written plan of correction was requested in lieu of a verbal plan of correction.

b. Based on interview and record review, conducted during a site visit on 02/07/24 through 02/13/24 it was confirmed the facility failed to implement a policy for the referral of residents who may be victim of acute sexual assault examiner for 1 of 1 sampled residents (#29). Findings include, but are not limited to:

During an interview on 02/07/24, Staff 9 (MT) stated s/he had created an incident report and interim service plan regarding potential sexual abuse for an altercation involving Resident 29 and another resident on 01/29/24.

During an interview on 02/07/24, Staff 8 (LPN) stated s/he had deleted the incident and interim service plan for Resident 29 as s/he "did not think it was an incident."

The facility's Abuse, Neglect an Exploitation policy did not contain information regarding the referral of residents who may be the victim of acute sexual assault the the nearest trained sexual assualt examiner.

There was no documented evidence the facility had referred Resident 29 to a trained sexual assualt examiner within 86 hours of the incident according to rule.

It was determined the facility failed to implement a policy for the referral of residents who may be victims of acute sexual assault to the nearest trained sexual assault examiner for a potential sexual assault.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Administrator), Staff 2 (Regional Operations Director), and Staff 3 (Campus Director) on 02/13/24.

A written plan of correction was requested in lieu of verbal plans of correction.

1. Based on interview and record review, conducted during a site visit on 10/21/24, it was determined the facility developed and implemented a written policy that prohibits the falsification of records. Findings include, but are not limited to:

The facility had a written policy, undated, prohibiting the falsification of records by staff.

There was no documented evidence the facility had falsified records within 30 days of the site visit.

Staff 8 (Med Tech) stated s/he was unaware of any facility staff falsifying records, including MARs or progress notes.

Staff 3 (Regional Director of Operations) stated med techs received bi-weekly training.

It was determined the facility implemented a written policy prohibiting the falsification of records.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2 (Incoming Executive Director), Staff 3, and Staff 4 (Campus Director) on 10/21/24.

2. Based on interview and record review, conducted during a site visit on 10/21/24, it was determined the facility did implement a policy for the referral of residents who may be victim of acute sexual assault to the nearest trained sexual assault examiner. Findings include, but are not limited to:

During an interview on 10/21/24, Staff 1 (Executive Director) stated no instances of alleged acute sexual assault had occurred in the past 30 days.

A review of the facility's Abuse, Neglect an Exploitation Policy included guidance regarding the referral of residents who may be the victim of acute sexual assault to the nearest trained sexual assault examiner.

It was determined the facility did implement a policy for the referral of residents who may be victims of acute sexual assault to the nearest trained sexual assault examiner.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2 (Incoming Executive Director) Staff 3 (Regional Operations Director) and Staff 4 (Campus Director) on 10/21/24.

a. Based on observation, interview and record review, conducted during a site visit on 02/07/24 through 02/13/24, it was confirmed the facility failed to implement a written policy that prohibits the falsification of records. Findings include, but are not limited to:

On 02/08/24 at approximately 2:20 pm, a fire drill was observed taking place in the facility.

In an interview on 02/08/24, during the fire drill, Staff 1 (Executive Director) stated the fire drill was actually a fire drill for the adjoining Assisted Living Facility, not the Memory Care.

A record review of a fire drill checklist dated 02/08/24 indicated a fire drill took place at 2:20 pm in the memory care. The following information was documented on the Fire Drill checklist:

- The report indicated the number of participants evacuating was 55;

- The escape route used was "courtyard;" and

- There were 11 staff members listed on the drill as participants and at least one of those staff members was an employee of the Assisted Living Facility.

No residents or staff were observed evacuating the facility.

During an interview on 02/08/24, after the fire drill had been completed, Staff 1 stated "I don't know why he wrote that, no one evacuated."

It was determined the facility failed to implement a written policy that prohibits the falsification of records and falsified a document regarding a fire drill.

The findings of the investigation were reviewed with and acknowledged by Staff 1, Staff 2 ( Regional Support) and Staff 3 (Campus Director) On 02/13/24.

A written plan of correction was requested in lieu of verbal plans of correction.

b. Based on interview and record review, conducted during a site visit on 02/07/24 through 02/13/24, it was confirmed the facility failed to implement a written policy that prohibits the falsification of records for 1 of 1 sampled Resident (# 1). Findings include, but are not limited to the following:

Resident 1's MAR, dated 12/25/23, indicated Staff 7 (Med Room Manager) had signed off on his/her medications as administered.

In an interview on 02/13/24, Staff 7 stated the following:

- S/he did not work on 12/25/23;

- "I did not administer any meds on 12/25/23;"

- S/he was able to remotely access the facility's electronic MAR; and

- "Our computers weren't working, I signed them out [electronically] after [the medications] were popped so they wouldn't show up as missed."

It was determined Staff 7 falsified a MAR.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Administrator) Staff 2 ( Regional Operations Director) and Staff 3 (Campus Director) on 02/13/24.

A written plan of correction was requested in lieu of verbal plans of correction.

c. Based on interview and record review, conducted during a site visit on 02/07/24 through 02/13/24, it was confirmed the facility failed to ensure the preparation, completeness, accuracy, and preservation of resident records for 1 of 1 sampled resident (# 29). Findings include, but are not limited to:

During an interview on 02/07/24, Staff 9 (MT) stated s/he had created an incident report and interim service plan regarding potential sexual abuse for an altercation involving Resident 29 and another resident on 01/29/24.

During an interview on 02/07/24, Staff 8 (LPN) stated s/he had deleted the incident and interim service plan for Resident 29 as s/he  "did not think it was an incident."

There was not documented evidence of an incident report or temporary service plan for Resident 29 involving the alleged incident on 01/29/24.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2 (Regional Operations Director), and Staff 3 (Campus Director) on 02/13/24.

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

A written plan of correction was requested from the facility in lieu of a verbal plan of correction.

Based on observation, interview, and record review, conducted during a site visit on 10/21/24, it was determined the facility ensured the preparation, completeness, accuracy, and preservation of resident records for 3 of 3 sampled residents (#s 6, 11, and 14). Findings include, but are not limited to:

The facility was able to provide all resident records requested during the investigation.

Residents' 6 and 14's MARs, dated 10/01/24 through 10/21/24, matched the most recent 90-day review of their physician orders.

Current service plans for Residents' 6, 11, and 14, dated 08/01/24, 08/30/24, and 08/15/24, were reviewed and found to be accurate to residents' observed needs.

Staff 8 (Med Tech) stated s/he was unaware of any staff falsifying records.

It was determined the facility ensured the preparation, completeness, accuracy, and preservation of resident records.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2 (Incoming Executive Director), Staff 3 (Regional Director of Operations), and Staff 4 (Campus Director) on 10/21/24.

Based on interview and record review, conducted during a site visit on 02/07/24 through 02/13/24, it was confirmed the facility failed to immediately notify the local Department office of an incident of abuse or suspected abuse for 1 of 1 sampled residents (#  29). Findings include, but are not limited to:

During an interview on 02/07/24, Staff 9 (MT) stated a caregiver had found Resident 29 and another resident unclothed in Resident 29's room on 01/29/24. S/he further stated Resident 29 complained of "pain in [his/her] bottom" and had since become fearful of the other resident who had been found in his/her room. Staff 9 stated s/he had created an incident report, interim service plan, and a progress note regarding the incident.

Progress notes for Resident 29, dated 01/29/24, indicated s/he was to be monitored for complaints of pain in his/her bottom.

During an interview on 02/07/24, Staff 8 (LPN) stated s/he had deleted the incident report and interim service plan as s/he "didn't think it was a real incident." S/he stated the facility had not reported the incident to the local Seniors and People with Disabilities (SPD) office.

During an interview on 02/07/24, Staff 1 (Executive Director) confirmed the facility had not reported the incident to the local SPD.

It was determined the facility failed to immediately notify the local Department office or the local AAA of any incident of abuse or suspected abuse.

The findings of the investigation were reviewed with and acknowledged by Staff 1, Staff 2 (Regional Operations Director) and Staff 3 (Campus Director) on 02/13/24.

A written plan of correction was requested in lieu of a verbal plan of correction.

Based on interview and record review, conducted during a site visit on 10/22/24, it was determined the facility did immediately notify the local Department office of an incident of abuse or suspected abuse for 1 of 1 sampled resident (# 4). Findings include, but are not limited to:

A review of a facility self-report dated 10/07/24 and Incident Report dated 10/07/24, indicated Resident 4 was involved in an incident that occurred on 10/06/24 in which the facility could not rule out abuse or neglect. The incident was reported to the local Department office on 10/07/24.

During an interview on 10/21/24, Staff 1 (Executive Director) stated the facility had notified the local Department office of all incidents of abuse or suspected abuse when abuse and/or neglect could not be ruled out.

It was determined the facility did immediately notify the local Department office or the local AAA of any incident of abuse or suspected abuse.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2 (Incoming Executive Director) Staff 3 (Regional Operations Director) and Staff 4 (Campus Director) on 10/21/24.

Based on observation, interview, and record review, conducted during a site visit on 02/07/24 through 02/13/24, it was confirmed the facility failed to ensure the implementation of services for 1 of 1 sampled residents (# 15). Findings include, but are not limited to:

On 02/08/24, Resident 15 was observed to have bedraggled hair and was visibly unclean.

Resident 15 stated on 02/08/24 s/he had not been offered a shower in 3 weeks.

Resident 15's service plan, dated 11/22/23 indicated that s/he needs care staff to assist him with his showers two times per week on Tuesday and Saturday mornings.

During interviews with caregivers, it was shared caregivers were to fill out shower sheets when bathing residents and provide them to the Resident Care Coordinator.

There was no documented evidence indicating Resident 15 had received or refused a shower between 02/01/24 through 02/12/24.

It was determined the facility failed to provide twice a week showers for Resident 15.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Exceutive Director), Staff 2 (Regional Operations Director), and Staff 3 (Campus Director) on 02/13/24.

A written plan of correction was requested in lieu of verbal plans of correction.

Based on observation, interview, and record review, conducted during a site visit on 10/21/24, it was confirmed the facility had not ensured the implementation of services for 2 of 3 sampled residents (#s 3 and 14). Findings include, but are not limited to:

A review of Resident 14's service plan dated 08/15/24, indicated the following;

* Resident has a "SafeStraw" to use with drinking liquids for reducing nasal regurgitation.

* Resident required staff assistance with showering on Monday and Fridays.

On 10/21/24 at 12:33 pm, Compliance Specialist (CS) observed staff provided Resident 14 with his/her meal for lunch. CS observed staff provide a regular straw and not the "SafeStraw" for his/her liquid beverage.

During an interview on 10/21/24, an unsampled staff stated, "S/he does have a special straw, but it is hard for him/her to use, and I don't think s/he really likes it, so the staff doesn't always use it."

The facility shower schedule indicated Resident 14 was to receive showers on Sunday and Wednesday in the evening.

A review of Resident 14's Bluestep shower log system, from 09/21/24 through 10/21/24, indicated Resident 14 had not been provided two of their eight scheduled showers during the timeframe. There was no documentation of Resident 14 refusing shower assistance.

A review of Resident 3's service plan dated 10/11/24, indicated staff are to provided Resident 3 with shower assistance on Sunday and Wednesdays.

A review of the facility shower schedule indicated Resident 3 was to receive showers on Monday and Friday in the morning.

A review of Resident 3's Bluestep shower log system, from 09/21/24 through 10/21/24, indicated Resident 3 had not been provided six of the nine showers during the timeframe. There was no documentation of Resident 3 refusing shower assistance.

During an interview on 10/21/24, Staff 1 (Executive Director) indicated all residents showers and refusals are documented on the facility's Bluestep system.

During an interview on 10/21/24, Staff 16 (Caregiver) indicated showers are often missed.

It was confirmed the facility had not ensured the implementation of shower and assisted device services.

On 10/21/24, the findings were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2 (Incoming Executive Director), Staff 3 (Regional Operations Director) and Staff 4 (Campus Director).

Verbal plan of correction: The facility will review shower sheets daily during stand-up. LPN and Executive Director will ensure residents straw is used while providing his/her correct pureed diet.

Plan of correction for C 260-

1.) For resident 14 community requested and received a discontinue order for the safety straw for resident 14 as she would not use it. Service plan for resident 14 was updated to reflect this change. Resident 14 and 3 related to missing showers that were scheduled: community ensured that each resident had received a shower on shower days and educated staff on importance of documentation on shower given or refusal.                                                                                 2.)Educated staff on reading service plans and proper documentation. Managers do rounding daily to ensure staff are following and reading service plans to include shift huddles when changes to service plans occur. For any staff that may not be there for shift huddle there is also a 24 hour binder in each neighborhood with updated service plans for review.A shower book has been put in place for each neighborhood with the current shower schedule, blank shower sheets and a place for staff to put completed shower sheets updated with each change or new admission.             3.) Manager rounding completed twice daily and shift huddles in place.  Managers review documentation daily at stand up.  Clinical team meets weekly for IDT meeting to review upcoming service plans and to ensure changes are in place and communicated with staff.

4.)RCM/ED/LN will be responsible for making sure that service plans are being followed and that these new systems are effective and will schedule any training that is identified as needed.

Based on observation and interview, conducted during a site visit on 02/07/24 through 02/13/24, it was confirmed the facility failed to establish and maintain infection prevention and control protocols. Findings include, but are not limited to:

During an interview on 02/07/24, Staff 8 (LPN) stated the facility had COVID in the facility beginning on 02/01/24.

During a site visit on 02/07/24, it was observed the facility had signs posted on the entrance doors of the facility notifying that there was active COVID in the building as of 02/05/24. Staff 1 (Administrator) and Staff 6 (Caregiver) were observed not wearing a mask in the facility.

On 02/09/24, used personal protective equipment was observed overflowing from a garbage can and strewn across a chair in a common area.

There was no documented evidence the facilty had notified the Safety, Oversight and Quality unit until 02/07/24.

It was determined the facility failed to maintain infection prevention and control protocols.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Administrator), Staff 2 (Regional Operations Director), and Staff 3 (Campus Director) on 02/13/24.

A written plan of correction was requested in lieu of verbal plans of correction.

Based on observation, interview, and record review, conducted during a site visit on 10/21/24, it was determined the facility did establish and maintain infection prevention and control protocols. Findings include, but are not limited to:

On 10/21/24, the facility was observed to have storage with a surplus of infection prevention items including sanitary wipes, gloves, N-95 particulate respirators, masks, isolation gowns, disposable shoe covers and hand sanitizer.  

During an interview on 10/21/24, Staff 4 (Campus Director) stated the facility had ordered supplies multiple times a month and ensured the infection control protocols were instated.

A review of supply invoices from Twin and Amazon Supplies dated 09/05/24, 10/03/24, 10/09/24, 10/18/24 indicated masks, gloves and pre-moistened wipes were ordered.

A review of the housekeeping schedule indicated residents were receiving housekeeping services consistently.

A review of training records for Staff 1 (Executive Director) indicated she had completed Infection Control Specialist Training for Community-Based Care on 11/04/23. Staff 2's (Incoming Executive Director)  training records indicated she had completed Infection Control Specialist Training for Community-Based Care on 09/27/24.

It was determined the facility did maintain infection prevention and control protocols.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2 (Incoming Executive Director) Staff 3 (Regional Operations Director) and Staff 4 (Campus Director) on 10/21/24.

Based on observation and interview, conducted during a site visit on 02/07/24 through 02/13/24, it was confirmed the facility failed to implement a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility for 1 of 1 sampled resident (# 1). Findings include, but are not limited to:

On 02/08/24, Resident 1's card of Trazodone 50mg (antipsychotic medication) was observed to be sitting on the medication room counter outside of the locked medication cart.

During an interview on 02/08/24, Staff 10 (MT) stated Resident 1's Trazodone had been discontinued on 02/05/24 and removed from the medication cart. S/he further stated staff kept discontinued medications on the counter until they were destroyed with the RN on Fridays.

During an interview on 02/09/24, Staff 11 (RN) stated "I expect narcotics to be destroyed right away, within 24 hours" and "they should absolutely not be left on the counter."

It was determined the facility failed to implement a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Administrator) Staff 2 ( Regional Operations Director) and Staff 3 (Campus Director) on 02/13/24.

A written plan of correction was requested in lieu of verbal plans of correction.

Based on observation, interview, and record review, conducted during a site visit on 10/21/24, it was confirmed the facility failed to implement a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility for 1 of 1 sampled resident (# 12). Findings include, but are not limited to:

The facility's narcotics log, with a most recent entry date of 10/20/24, indicated there was 22 ml of Lorazepam (anti-anxiety medication) remaining for Resident 12.

On 10/21/24, Resident 12's bottle of Lorazepam was observed to contain 20 ml of fluid.

On 10/21/24, Staff 8 (Med Tech) stated s/he believed the bottle had spilled and had reported the discrepancy to the nursing staff.

On 10/21/24, Staff 6 (LPN), Staff 7 (LPN), and Staff 5 (RN) stated they had no knowledge of the discrepancy.

There was no documented evidence the nursing staff had been notified of the discrepancy.

It was determined the facility failed to implement a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2 (Incoming Executive Director), Staff 3, and Staff 4 (Campus Director) on 10/21/24.

Verbal plan of correction: Facility reported the narcotics discrepancy to the local Seniors and People with Disabilities office on 10/21/24, completed an incident report, notified the resident's physician, and had begun to request the resident's physician to discontinue all bottled liquids in favor of single use doses.

Plan of correction C 302

1.) For Resident 12 narcotic discrepancy the narcotic count was fixed immediately by Regional LN and reported to APS the discrepancy. Training was provided to med techs about immediate report of narcotic discrepancy to LN/ED.                                             2.) The Medroom Manager will complete a weekly MAR/Narcotic audit each Wednesday and will review a sample of no less than 5 residents. The LN will review this audit each week with the Medroom Manager and ensure follow up.The Executive Director will review all audits during weekly quality assurance meetings.

3.) Weekly by LN and ED and each shift during narcotic count by the medtechs

4.) The LN will be responsible for making sure that the audit is done by the medroom manager each week and the LN will be responsible for reviewing audit. The Executive Director will be responsible for making sure that this is being followed and will review weekly.

Based on observation, interview, and record review conducted during a site visit on 02/07/24 through 02/13/24, it was confirmed the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident and left units unstaffed. Findings include, but are not limited to:

The facility's posted staffing plan indicated the facility requires the following minimums per shift, for 4 locked unit wings:

Day:       4 Caregivers, 1 Med Tech, (Mid-Shift Caregiver) 9 am - 6 pm.

Swing:   4 Caregivers, 1 Med Tech

Night:     2 Caregivers, 1 Med Tech

Facility timecards, dated 11/19/23, indicated there had been two caregivers and one med tech on swing shift and one caregiver and one med tech on night shift.

During the site visit it was observed the facility would leave hallways between adjoining wings open during night shift so that one caregiver was responsible for two wings. Caregivers did not have a line of sight between adjoining wings.

During an interview on 02/07/24, Staff 9 (Caregiver) stated the following:

- The facility had eight two-person assists;

- Falls happened at night; and

- "Residents are passing away because not enough staff and no management in memory care."

During an interview on 02/07/24 Staff 4 (LPN) stated the facility had no two-person transfers.

During an interview on 02/08/24, Staff 1 (Executive Director) stated the facility had identified at least five two-person transfers, at least one in each locked wing, and that their service plans were being updated to reflect that.

It was determined the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident and left units unstaffed.

The findings of the investigation were reviewed with and acknowledged by Staff 1, Staff 2 (Regional Operations Director), and Staff 3 (Campus Director) on 02/13/24.

A written plan of correction was requested during the exit conference in lieu of a verbal plan of correction.

Based on observation, interview, and record review, conducted during a site visit on 10/21/24, it was determined the facility provided qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to:

The facility's posted staffing plan indicated for day and swing shifts, there were six Caregivers (CG) and two Med Techs (MT). For night shift, there were five CGs and one MT.

The facility staffing schedule, dated 10/01/24 through 10/31/24 indicated from 10/14/24 through 10/21/24, the facility staffed MTs according to their posted staffing plan 100% of the time and the facility staffed CGs according to their posted staffing plan 98% of the time.

On 10/21/24, during day and swing shifts, there were two MTs and six CGs working the floor.

Staff 16 (CG) stated the facility was staffed most of the time. S/He doesn't leave his/her hall until his/her relief shows up. S/He worked swing and night shift the other day because of call offs. Most of the staff stayed to cover the next shift if there were issues with coverage.

It was determined the facility provided qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident.

The preliminary findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2 (Incoming Executive Director), Staff 3 (Regional Director of Operations), and Staff 4 (Campus Director).

Based on interview and record review, conducted during a site visit on 02/07/24 through 02/13/24, it was confirmed the facility failed to fully implement and update and Acuity-Based Staffing Tool (ABST).  Findings include, but are not limited to:

During an interview on 02/07/24, Staff 6 (CG) stated there were eight two-person transfers between the four halls in the memory care.

During an interview on 02/07/24, Staff 4 (LPN) stated the facility did not have any two-person transfers.

A review of the facility's ABST on 02/07/24 indicated:

- The facility uses a tool called Acuity- Based Staffing Tool - Blue Step;

- Caregiving minutes are tallied for each ADL on service plans, then data is then placed into the facility's ABST; and

- No residents had caregiving minutes reflecting two-person transfer needs.

During an interview on 02/09/24, Staff 1 (Executive Director) stated the facility had identified five unsampled residents who required a two-person transfer assist.

It was determined the facility had not updated their ABST to reflect resident's acuity.

The findings of the investigation were reviewed with and acknowledged by Staff 1, Staff 2 (Regional Operations Director), and Staff 3 (Regional Operations Director) on 02/13/24.

A written plan of correction was requested during the exit conference in lieu of a verbal plan of correction.

Based on observation, interview, and record review, conducted during a site visit on 10/21/24, it was confirmed the facility failed to develop and maintain an acuity-based staffing tool (ABST) for 2 of 3 sampled residents (#s 3 and 14). Findings include, but are not limited to:

The facility implemented an ABST called Blue Step. It was not approved by the Department at the time of the investigation, but had been submitted for review. All residents were entered into the tool, Residents 3, 6, and 14's ABST were reviewed and updated at required times. Their respective service plans and ABST profiles accurately captured care needs and were reflected in the ABST evaluation. The facility's posted staffing time accounted for the total ABST care time and incorporated unscheduled needs, fire life safety, multi-person transfer and care, segregated areas, high acuity, behavioral needs, and universal worker task time. The facility was consistently staffing to the posted staffing plan.

The facility's posted staffing plan indicated for day and swing shifts, there were six Caregivers (CGs) and two Med Techs (MTs). For night shift, there were five CGs and one MT.

The facility staffing schedule, dated 10/01/24 through 10/31/24 indicated from 10/14/24 through 10/21/24, the facility staffed MTs according to their posted staffing plan 100% of the time and the facility staffed CGs according to their posted staffing plan 98% of the time.

On 10/21/24, during day and swing shifts, there were two MTs, and six CGs working the floor.

Staff 16 (CG) stated the facility was staffed most of the time. S/He doesn't leave his/her hall until his/her relief shows up. S/He worked swing and night shift the other day because of call offs. Most of the staff stayed to cover the next shift if there were issues with coverage.

During an interview regarding Resident 3's care needs, Staff 12 stated s/he required standby assistance for showers and required the assistance of two staff members. S/He required the assistance of two staff members for toileting and changing briefs. With transferring, Resident 3 sometimes required two staff members, but s/he could stand up on his/her own and assisted with care. S/He required assistance with eating for the entire meal and was on a cut up diet. Before, Resident 3 was on a regular diet, but was choking on food.

During an interview regarding Resident 6's care needs, Staff 11 stated in the morning, care staff changed his/her briefs and provided cleaning care for him/her. Resident 6 sometimes required the assistance of two staff members. S/He could stand on his/her own and could assist with his/her care. Normally one staff member helped him/her with transferring. If s/he had a "bad day" and his/her legs were weak, two staff members helped with transferring. Hospice bathed Resident 6, but facility staff cleaned him/her if s/he had a toileting accident. When there was an emergency needing medication, they called hospice. Otherwise, facility MTs administered medication to Resident 6.

During an interview regarding Resident 14's care needs, Staff 11 (CG) stated at 6:00 am, care staff changed his/her briefs and clothing, when they showered Resident 14, s/he required the assistance of two staff members, s/he required the assistance of two staff members to transfer, and required assistance with eating. Resident 14 was on a pureed diet, and MTs administered his/her medications.

Residents scheduled and unscheduled needs were not being consistently met for 2 of 3 sampled residents (#s 3 and 14). Residents 3 and 14 were missing scheduled showers.

The facility's shower schedule (undated) indicated Resident 3 was to receive showers twice weekly on Sundays and Wednesdays and Resident 14 was to receive showers twice weekly on Mondays and Fridays.

Resident 3's shower sheets indicated s/he received three showers between 09/21/24 and 10/20/24.

Resident 14's shower sheets indicated s/he received six showers between 09/23/24 and 10/14/24.

Residents 3, 6, and 14 were not available for interview.

It was confirmed the facility failed to develop and maintain an ABST for Residents 3 and 14.

The preliminary findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2 (Incoming Executive Director), Staff 3 (Regional Director of Operations), and Staff 4 (Campus Director).

Plan of correction for C 361- The Proprietary ABST has been submitted to the department for approval it was submitted in August of 2024 and we are awaiting the approval.

1.) Community reviewed ABST for resident 3 and 14 to ensure for accuracy.

2.)The plan of correction for TAG 260 will be followed to show that the needs of the residents are being met. Community Management ensures that staffing is above ABST by 1-2 staff members to ensure scheduled and unscheduled needs of the residents are being met.

3.)Staffing is being monitored daily to ensure that we are staffing to ABST and above to meet needs. The ABST will be updated per the rule, before resident move in, at 30 day evaluation, quarterly and with any change of condition.

4.)RCM/MRM/ED monitor the schedule to ensure staff in place to meet need.The Executive Director will ensure that the ABST has been updated as needed during weekly IDT meetings and after each change of condition and will review staffing per the ABST report that is generated in bluestep and will continue to staff to mandated staffing levels and follow the restrictions on admissions.