The findings of the on-site investigation, conducted 07/26/2023, 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 observation and interview, during a site visit conducted on 07/26/23, it was confirmed the facility does not ensure the implementation of services for 1 of 1 sampled resident (#1). Findings include, but not limited to.
A review of Resident 1's service plan dated, 06/05/23, and Resident 1's wakeup schedule for June and July 2023, indicated the following:
"The service plan stated Resident 1 required staff to wake him/her up daily between 6:15 am and 6:30 am.
"The wakeup schedules had three occurrences where the resident was awoken past the timeframe listed in the service plan.
"The wakeup schedules showed staff woke the resident up at 6:40 am on 05/21/23 and 06/25/23. On 05/23/23 staff woke the resident up at 7:00 am.
During an interview on 07/26/23, Staff 2 (Caregiver) stated s/he woke Resident 1 up on time today. S/he confirmed s/he was the one scheduled to wake the resident up on 06/25/23, but there were only two staff working at the time. The other staff member was assisting a different resident at the time staff were to wake up Resident 1. Resident 1 needed two staff members in his/her room when providing services.
On 07/26/23, CS made three attempts to interview Resident 1 who was not in the facility during the site visit.
It was confirmed the facility does not ensure the implementation of services.
On 07/26/23, the findings were reviewed with and acknowledged by Staff 1 (Administrative Assistant).
Verbal plan of correction: Staff 1 stated the facility will remind staff of Resident 1's wakeup time and will follow according to the service plan.
Based on interview and record review, conducted during a site visit on 07/26/23, it was confirmed the facility failed to implement and update an acuity-based staffing tool (ABST). Findings include, but are not limited to:
On 07/26/23, the facility's ABST was reviewed. There were 41 resident's profiles, out of 47 residents, that had not been updated quarterly.
In an interview on 07/26/23, Staff 1 (Administrative Assistant) stated the facility was using the ODHS ABST. Staff 1 acknowledged the residents hadn't been updated in the tool.
The facility failed to update an acuity-based staffing tool.
On 07/26/23, the findings were reviewed with and acknowledged by Staff 1.
Verbal plan of correction: Staff 1 will contact the OPA and CAC for ABST to further understand the tool within the month.