The findings of the on-site investigation, conducted on 06/22/2023, 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
Notes on Abbreviations:
"The abbreviations listed above can be used in the report without identifying the abbreviation within the report itself.
"Residents will be identified by "Resident 1", "Resident 2" etc, do not abbreviate.
"Staff will be identified by "Staff 1", "Staff 2" etc. do not abbreviate.
"If you introduce an abbreviation in the report, make sure it is a word that has a standard abbreviation associated with it and that it needs to be abbreviated. You don't need to abbreviate a word that you only use once in a report.
Based on interview and record review, during a site visit conducted on 06/22/23, it was confirmed the facility failed to have a service plan include a written description of who shall provide the services and what, when, how, and how often the services shall be provided, for 1 of 1 sampled resident (#1) whose service plan was reviewed. Findings include, but are not limited to:
A review of Resident 1's evaluation dated 03/03/23. stated that Resident 1 was a one person transfer for dressing and undressing and cleansing for toileting needs. However, Resident 1's service plan, dated 03/14/23, did not address whose responsibility it was to preform dressing and undressing assistance.
In an interview on 06/22/23, Staff 1 (Executive Director) and Staff 4 (Nurse) acknowledged that Resident 1's service plan did not reflect his/her evaluation and that the service plan was unclear whose responsibility it was to provide specific services.
It was confirmed the facility failed to have a service plan include a written description of who shall provide the services and what, when, how, and how often the services shall be provided.
On 06/22/23, the findings were reviewed with and acknowledged by Staff 1.
Verbal plan of correction: Staff 1 will have RCC re-evaluate residents service plan to match the evaluation so that her needs are clear to staff. This task is told to be completed by the end of the following week.
Based on observation, interview, and record review, during a site visit conducted on 06/22/23, 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. Findings include, but are not limited to:
In interviews on 06/22/23, staff stated the following,
·"The call light system does work; however, staff do not carry their iPad's that alert them when a call light is going off."
·"Call lights not being answered timely has been an ongoing issue at the facility that we are trying to address."
On 06/22/23, CS observed the following,
·12:22pm-Resident pulled cord by bedside.
·12:44pm-CS left Resident 1's room, sat outside his/her room to continue to wait for staff to respond. Multiple staff members around.
·1:00pm- Staff member went into Resident 1's room, however only assisted his/her roommate with services.
·1:22pm-Staff came back to Resident's room to ask if they would like assistance with using the restroom and turned off the call light.
·2:30pm-CS had Staff 3 (RCC) in a vacant room, test the system to ensure it worked. Staff 3 took iPad into the room and when s/he pulled the cord it did register to their call system.
A review of the call history for 06/22/23, showed that Resident 1's bedroom call light was pressed at 12:22pm with a response time of 57 minutes.
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.
On 06/22/23, the findings were reviewed with and acknowledged by Staff 1(Executive Director).
Verbal plan of correction: Staff 1 is aware of the ongoing issue and has already purchased mounts so that they can mount the IPads to the walls in each hallway. So, even if staff do not carry their IPads with them they will still be able to hear when they go off and be able to answer them timely.