The findings of the on-site investigation, conducted 09/21/23 through 09/22/23, 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.

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 observation, interview and record review, conducted during a site visit on 09/21/23 and 09/22/23, it was confirmed the facility failed to ensure implementation of services for 1 of 1 sampled resident (# 6). Findings include, but are not limited to:

On 09/21/23, Resident 6's room was observed resident recliner seat contained dark-brown staining.

Resident 6's service plan, dated 09/05/23, indicated s/he required total assistance for toileting three to four times per day and housekeeping to be done two times weekly. Resident 6's service plan also indicated resident was a 2-person transfer with gait belt and s/he requires total assistance at all meals and adaptive utensils.

During an interview on 09/22/23, Staff 8 (Housekeeping) stated housekeeping had not been done in  "Emerald"  house in at least a week, and s/he will find used incontinence briefs under resident beds or furniture.

During an interview on 09/22/23, Staff 9 (Caregiver) stated  how s/he and Staff 10 (Caregiver) transferred Resident 6 into his/her wheelchair. S/he stated each staff placed a hand in each armpit to lift resident out of bed.

On 09/22/23 at 11:14 am, two staff were observed to enter resident 6's room, incontinence care was performed and resident was dressed and transferred into his/her wheelchair without the use of a gait belt.

On 09/22/23 Resident 6 was observed in the dining room at 11:52 am with a plate of food and no adaptive utensils and no staff present providing assistance.

On 09/22/23 at 12:13 pm Staff 9 was observed providing feeding assistance to Resident 6.

It was determined the facility failed to ensure implementation of services.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director) on 09/22/23.

Verbal plan of correction: Staff 1 will review Resident 6's evaluation as s/he is a new admit to the facility and his/her initial assessment may no longer be accurate to his/her current care needs. Staff 1 will follow-up with staff regarding use of gait belt and ensure his/her service plan is updated and reflective of resident's needs.

Based on interview and record review, conducted during a site visit on 09/21/23 and 09/22/23, it was confirmed the facility failed to ensure implementation of services for 1 of 1 sampled resident (# 2). Findings include, but are not limited to:

Resident 2's service plan, dated 09/14/23, indicated s/he required total assistance for showers 3-4 times per week, and standby to total assistance for dressing.

During an interview on 09/22/23, Staff 3 (Med Tech) stated Resident 2 was scheduled for and received showers two times per week.

During an interview on 09/22/23, Staff 1 (Executive Director) stated Resident 2 should get two showers per week but is service planned for up to four a week if s/he asked for them.

On 09/22/23 staff were observed to assist Resident 2 with his/her shower. When staff assisted Resident 2 to the dining room after his/her shower, s/he was observed to be in the same clothing that s/he was wearing prior to his/her shower.

It was determined the facility failed to ensure implementation of services for bathing and dressing.

The findings of the investigation were reviewed with and acknowledged by Staff 1 on 09/22/23.

Verbal plan of correction: Staff 1 would adjust Resident 2's service plan to accurately reflect the services Resident 2 received and would work with the family to ensure changes were acceptable.