The findings of the on-site investigation, conducted 5/16/2023, 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.

Based on observation, interview and record review, it was confirmed that the facility failed to have policies and procedures in place to assure the prevention and appropriate response to any incident for 1 of 1 identified resident. Findings include, but are not limited to:

During a site visit on 05/16/23 Resident 1's service plan, Interim Service Plans (ISPs) and progress notes dated 03/15/23 through 05/16/23 were reviewed.

Progress notes and ISPs revealed that Resident 1 had several resident to resident altercations, falls and medication errors as follows:

*03/19/23: Resident 1 received the wrong dose of a narcotic medication six times.

*03/22/23: Resident 1 had a non-injury fall.

*03/28/23: Resident 1 had "seizure- like" activity.

*03/30/23: Resident 1 had a fall with injury [not specified].

*04/01/23: Resident 1 had a fall resulting in a laceration to his/her head and was sent to the hospital.

*04/04/23: Resident 1 was involved in a resident to resident altercation. ISP stated to keep Resident 1 separated from other resident.

*04/05/23: PCP putting in a referral for mental health.

*04/18/23: Resident involved in a resident to resident altercation. ISP stated to keep Resident 1 separated from other resident.

*04/27/23: Resident involved in a resident to resident altercation.

*04/30/23: Resident 1 was involved in a resident to resident altercation and was slapped by another resident. ISP states to keep Resident 1 away from other resident

*05/14/23: Resident 1 was involved in a resident to resident altercation. ISP states to keep resident separated from other resident.

During an interview on 05/16/23, Staff 1 (Administrator) stated they called a clinic or a home health provider who would not come to the facility because there was not enough business in Independence. They stated there was no documentation of this in the resident progress notes or anywhere. Staff 1 stated they tried to keep Resident 1 separated from residents that s/he had altercations with but was unable to explain what the facility did to prevent incidences. Staff 1 stated they had not reported any events to Adult Protective Services.

The facility failed to have policies and procedures in place to assure the prevention and appropriate response to any incident.

These findings were reviewed with and acknowledged by Staff 1 (Administrator), Staff 2 (RCC) and Staff 3 (RN) on 05/16/23.

Verbal plan of correction: CS provided ODHS abuse/neglect reporting and investigation guide. Facility to review and provide training to staff on 5/25/2023. Facility to review ISPs and document implemented and attempted interventions for behaviors and incidences.

Based on interview and record review, it was confirmed the facility failed to  implement a service plan that reflected the resident's needs for 1 of 1 identified resident. Findings include, but are not limited to:

During the site visit on 05/16/23 interviews were conducted with staff and resident records were reviewed.

Resident 1's "initial" service plan, dated 03/15/23, located in the service planning binder available to staff, described the resident behaviors as "shopping" and disrobing. No other behaviors were noted. A "30 day" service plan, also dated 03/15/23, was obtained from Staff 1 (Administrator). No changes were noted from the "initial" service plan. A review of the 23 Interim Service Plans (ISPs) available for Resident 1 revealed the following:

*04/04/23: Keep resident separated from [Resident] and watch for agitation and aggression.

*04/07/23: New medication Agitation, anxiety, confusion, diarrhea.

*04/18/23: Watch for aggression, try to keep resident away from [Resident]

*04/27/23: Resident to resident altercation: Monitor for signs of pain or discomfort and aggression.

*04/30/23: D/C [medication] increased behaviors mood changes

*04/30/23: resident to resident: resident was struck by another resident so keep away from [Resident] and monitor scratch on right chin.

*05/01/23: new order [medication]: adverse reactions drowsiness, behaviors, mood changes, delirium, anger.

*05/02/23: Increase in [medication]: behaviors, mood changes, aggression.

*05/14/23 : resident to resident altercation: keep separated from [Resident].

In an interview on 05/16/22, Staff 1 (Administrator) acknowledged Resident 1's service plan lacked details or instruction to staff on Resident's behaviors. S/he stated that a prior administrator had been working on it.

In an interview on 05/16/23 Staff 4 (MT) stated it would be helpful if they had access to a service plan with clear direction on how to manage this resident's aggression and other behaviors.

The facility failed to implement a service plan that was reflective of the resident's behaviors or provided clear staff instruction on interventions for the behaviors. Resident 1 was involved in multiple resident to resident altercations which resulted in injury to Resident 1 or to other residents in the facilty.

Verbal plan of correction: Staff 1 stated they will ensure that Resident 1's service plan is updated and available to staff by end of business day on 05/17/23.

Based on interview and record review it was confirmed the facility failed to have written, resident-specific parameters for PRN psychotropic medications and failed to have documented; non-pharmacological interventions with ineffective results prior to administration of PRN psychotropics for 1 of 1 identified resident. Findings include, but are not limited to:

During a site visit on 05/16/23 staff were interviewed and Resident 1's MAR was reviewed.

Resident 1's MAR for 03/15/23 through 05/16/23 revealed Resident 1 was given a PRN psychotropic medication 31 times without specific parameters and documented non-pharmacological interventions with ineffective results.

During an interview on 05/16/2023, Staff 4 (MT) stated they do not have to document interventions used prior to the administration of [medication] but that it is used as a last resort.

The facility failed to have written, resident-specific parameters for PRN psychotropic medications and failed to have documented; non-pharmacological interventions with ineffective results prior to the administration.

These findings were reviewed with and acknowledged by  Staff 1 (Administrator), Staff 2 (RCC) and Staff 3 (RN) on 05/16/23.

Verbal Plan of correction: Facility to update resident' s MAR with resident specific parameters for use of PRN psychotropics and attempted non-pharmacological interventions by end of day on 5/17/2023.

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

During a site visit on 05/16/23 observations were made, interviews were conducted with staff and resident records were reviewed for one sampled resident.

A review of the facility's ABST for Resident 1 revealed the profile was created on 04/03/23 and staff spend two minutes 21x/week re-directing due to cognitive impairment or dementia and two minutes 16x/week ensuring non-drug interventions for behaviors. Resident 1's service plan indicated that s/he moved in on 03/15/23.

During the site visit on 05/16/23 staff were observed re-directing or walking with resident for over 30 minutes.

During separate interviews Staff 4 (MT), Staff 5 (CG) and Staff 6 (CG) stated they spent at least 10 minutes an hour re-directing Resident 1 due to cognitive impairment and behaviors.

These findings were reviewed with and acknowledged by Staff 1 (Administator) Staff 2 (RCC) and Staff 3 (RN) on 05/16/23.

The facility failed to fully implement an ABST.

Verbal plan of correction: Facility to update ABST to be reflective of resident needs by end of day on 5/17/2023.