The findings of the on-site investigation, conducted on 10/13/23, 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, OARs 411 Division 57 for Memory Care Communities.
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 10/13/23, it was confirmed the facility failed to immediately notify the local APD office, or the local AAA, of any incident of abuse or suspected abuse. Findings include, but are not limited to:
A review of 18 suspected abuse or unexplained injury reporting forms with an incident date of 01/22/23 revealed the missed medications were discovered on 01/24/23 and reported to APS on 01/30/23.
In an interview on 10/13/23, Staff 2 (RN) stated when the incidents occurred, s/he was new to the community and out in training for the week. S/he stated, "the med tech decided not to pass meds" and "I initiated the report". Staff 2 also stated that it took awhile to get ahold of the med tech and gather all the information once s/he had been informed of it.
The findings were reviewed and acknowledged with Staff 1 (Business Office Manager) and Staff 2 on 10/13/23.
It was determined the facility failed to immediately notify the local APD office, or the local AAA, of any incident of abuse or suspected abuse.
Verbal pan of correction: Facility had an all-staff meeting after the incident and informed staff. MT training was done by RN on what and when to report. Initiating chain of command with new management so staff are aware of who to report to. They also have an RCC designated to each cottage now.
Based on interview and record review, conducted during a site visit on 10/13/23, it was confirmed the facility failed to provide three daily nutritious meals and snacks for the residents. Findings include, but are not limited to:
In an interview on 10/13/23, Staff 4 (MT) stated Resident 1 gets fed in his/her room after the dining room is served first, and s/he was forgotten. S/he stated it was not something that occurred frequently, just the one time.
Resident 1's service plan dated 07/27/23 revealed the resident was nonverbal and was a total assist for eating. An incident report dated 09/26/23 indicated that Resident 1's dinner tray was found in the microwave between 8:30 pm-9:00 pm, and it wasn't until 9:45 pm that someone was able to feed him/her dinner.
The above information was shared with Staff 1 (Business Office Manager) on 10/13/23. S/he acknowledged the findings.
It was confirmed that the facility failed to provide three daily nutritious meals and snacks for the residents.
Verbal POC: The facility implemented meal attendance logs in order to ensure residents are getting their meals and snacks.
Based on interview and record review, conducted during a site visit on 10/13/23, it was confirmed the facility failed to ensure service plans were updated quarterly for 1 of 1 sampled resident (#4), whose service plans were reviewed. Findings include, but are not limited to:
Compliance Specialist reviewed Resident 4's service plans dated 05/18/22 and 02/20/23. There was no indication the facility had completed any other service plans between the two dates.
During an interview on 10/13/23 Staff 4 (MT) stated the RCC's did the quarterly updates. S/he stated they were not getting done in the past, but they are beginning to do them better.
The findings were shared with Staff 1 via email on 10/18/23.
It was confirmed the facility failed to ensure service plans were updated quarterly.
Verbal POC: Facility has been working on getting service plans updated with change of management/staff. RCC's and RN are making sure they are being updated quarterly.
Based on interview and record review, conducted during a site visit on 10/13/23, it was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool (ABST) for 2 of 3 sampled residents (#s 1 and 2). Findings include, but are not limited to:
In review of the facility's ABST and resident roster on 10/13/23, all 42 residents were listed on the ABST. The facility was using the ODHS tool and the posted staffing plan matched the ABST generated staffing. Resident 1's last edit date was on 03/07/23 and Resident 2's last edit date was on 03/29/23.
In a phone interview on 10/13/23, Staff 2 (RN) stated the prior ED was mostly responsible for updating the ABST, along with the RN and RCC. S/he stated they are working with the regional nurse to get that going.
On 10/18/23, findings were reviewed via email with Staff 1 (Business office Manager).
The facility failed to fully implement and update an ABST.