The findings of the on-site investigation, conducted on 07/06/2023, 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, interview, and record review, conducted during a site visit on 07/06/23, it was confirmed the facility failed to ensure the implementation of services for 1 of 1 sampled resident (#1). Findings include, but not limited to:
During interviews on 07/06/23, Staff 1 (Executive Director) stated in June Resident 1's shower times had been changed because the resident preferred certain staff to assist with his/her showers. Resident 1 had been getting showers during day shift but the staff s/he liked worked swing shift. Before that change, Resident 1 would refuse the service or be moved to a different day or time because of his/her preference of staff. Staff 1 stated Resident 1s nail care had been an issue, and thought staff were not completing the task. On 06/05/23 Staff 1 added the task to Resident 1's MARs to ensure the completion of the service. Resident 1 stated s/he did not have issues with showers being provided but did about his/her nail care. S/he stated his/her family member would come and cut his/her nails because staff did not complete the task.
A review of Resident 1's shower sheets indicated the resident received two showers weekly apart from his/ her own refusals. A review of the MARs dated 06/01/23-06/30/23 indicated staff were to cut the residents fingernails every 15 per the service plan. The instructions were placed in the MARs on 06/05/23 and from there to the site visit on 07/06/23, Resident 1 had only gotten his/her nails clipped once on 06/17/23. Resident 1's Service Plan stated resident was to receive a shower and nail trimming two times a month.
On 07/06/23, CS observed Resident 1's fingernails were long. Resident 1 showed CS multiple areas where the resident had scratched due him/herself due to his/her nails not being cut regularly.
It was confirmed the facility failed to ensure the implementation of services for trimming Resident 1's nails.
On 07/06/23, the findings were reviewed with and acknowledged by Staff 1.
Verbal plan of correction: The facility has changed Resident 1's shower schedule to match his/her preferred staff members. Staff 1 added the nail trimming to residents MARs to ensure staff are cutting residents nails every 15 days.
Based on observation, interview, and record review, conducted during a site visit on 07/06/2023, it was confirmed the facility failed to take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. Findings include, but are not limited to:
During interviews on 07/06/23, Staff 1 (Executive Director) stated the facility had an ongoing issue with bed bugs that started in January 2023. Staff 1 identified a group of apartments that continued to be infested with the bed bugs, including apartments 201-204. 213, 215, and 224. S/he also stated they had reduced the bed bugs to only four rooms. Staff 2 (Housekeeper) stated the facility has had bed bugs since s/he started working there in October 2022. S/He stated the bed bugs were only down one hallway and had not extended to other areas of the facility.
A review of the pest control company, Sprague, invoices showed the company had been out to the facility multiple times since 01/05/2023. Sprague had returned once or twice a month since then to treat for bed bugs. The last time Sprague came to treat for bed bugs was 07/03/2023, reporting the facility still had bed bugs.
It was confirmed the facility failed to take measures to prevent the entry of rodents, flies, mosquitoes, and other insects.
On 07/06/23, the findings were reviewed with and acknowledged by Staff 1.
Verbal plan of correction: The facility will continue with the company Sprague pest control to keep treating the bed bugs. They also use the chemical diatomaceous earth to help stop the spread of the bugs and has staff spraying tea tree oil around their ankles before entering the room.