The findings of the on-site investigation, conducted on 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

bid:twice a day

CBG:capillary blood glucose or

blood sugar

cc:cubic centimeter

CG:caregiver

cm:centimeter

F:Fahrenheit

HH:Home Health

HS or hs:hour of sleep

LPN:Licensed Practical Nurse

MA:Medication Aide

MAR:Medication Administration

Record

MCCMemory Care Community

mg:milligram

ml:milliliter

O2 sats:oxygen saturation in the

blood

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

RN:Registered Nurse

SP:service plan

TAR:Treatment Administration

Record

tid:three times a day

Based on interview and record review, conducted during a site visit on 09/22/23, it was determined the facility failed to provide a safe and home-like environment  for 1 of 1 sampled resident (#4) whose records were reviewed. Findings include, but are not limited to:

In separate interviews on 09/22/23, Staff 1 (Life Enrichment Director) and Staff 2 (Wellness Director) had both stated that Resident 4 was moved to the "assisted living" from the Memory Care (MC) due to another resident in the MC targeting him/her. S/he also stated Resident 4 was moved back to the MC after the other resident had passed away. Staff 2 stated they were unaware of how long the resident was in the "AL" and to his/her knowledge, staffing was not increased to during that time.

In a phone interview on 09/26/23, Staff 3 (ED) stated s/he was unaware if there was an assessment done or a new service plan put into place when the resident moved into the "AL".  S/he stated they would need to look through the documents.

There was no evidence to indicate an assessment or service plan was completed when Resident 4 moved into the AL from the MC in August 2022.

A review of progress notes dated August 2022 through April 2023, indicated Resident 4 was moved from the MC to AL on 08/30/22 and was moved back to the MC on 04/05/23.

A progress note dated 08/30/22 at 12:44pm indicated that the facility had spoke to Resident 4's family member about trialing a move to the AL side to separate the 2 residents and s/he liked the idea.

A progress note dated 02/15/23 at 3:30pm indicated a quarterly assessment was completed on 02/14/23 and that Resident 4 had very poor short-term memory and required frequent re-direction.

CS reviewed Resident 4's service plans dated 10/12/21 and 03/03/23 which indicated the following:

·"Resident not oriented to place or time"

·"Does not have the ability to use or manage a key"

·"Very poor short-term memory requiring frequent re-direction"

·"Often exit seeks which can cause others in MC to exit seek as well"

·"Wanders up and down hallways and will frequently ask where room is, for staff to show where the bathroom is, or when the next meal is"

·Both service plans indicated Resident 4's MC room number , even during the time s/he was living in the AL.

These findings were shared with Staff 2 and Staff 3 via email on 09/29/23.

It was determined the facility failed to provide a safe and home-like environment.

Verbal plan of correction: No plan of correction was provided

Based on interview and record review, conducted during a site visit on 09/22/23, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (#2) whose records were reviewed. Findings include, but not limited to:

Compliance Specialist reviewed Resident 2's Medication Administration Record (MAR), dated July 2023 through August 2023, and progress notes, doctor's orders, and incident form dated 08/05/23. The documents indicated between 07/23/23-07/29/23 and 08/03/23-08/05/23, Resident 1 was given half a dose of what was ordered for Lorazepam. This occurred 11 times before it was discovered.

Progress notes dated 07/03/23 indicated that Resident 1 did not receive his/her 8 pm Tramadol 50 mg tab as ordered. The MT only administered one tab instead of two tabs on 07/01/23-07/02/23.

In an interview, Staff 2 (Wellness Director) stated the pharmacy sent two medications, one for scheduled and one for PRN Lorazepam, at the same time and it was read wrong.

The findings were reviewed with and acknowledged by Staff 2 on 09/22/23.

It was confirmed the facility failed to carry out medication and treatment orders as prescribed.

Verbal plan of correction: Re-training has been done at MT meetings which occur monthly. Nurse went over the three checks with staff and reminders to check the orders. Facility started labeling the PRN Lorazepam so they don't get the two mixed up.

Based on interview and record review, conducted during a site visit on 09/22/23, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (#1). Findings include, but are not limited to:

A review of Resident 1's August 2023 Medication Administration Record (MAR) and progress notes indicated on 08/03/23 Resident 1 was given prior PRN Tylenol dose that was discontinued on 08/01/23. Compliance Specialist also reviewed faxes to his/her doctor and to APS dated 08/03/23 regarding the medication error.

In an interview, Staff 2 (Wellness Director) stated the medication had  "just got discontinued and changed to scheduled instead of PRN" and "the med tech didn't check on the computer before giving".

The findings were reviewed with and acknowledged by Staff 2 on 09/22/23.

It was confirmed the facility failed to carry out medication and treatment orders as prescribed.

Verbal plan of correction:

Re-training has been done at MT meetings which occur monthly. Nurse went over the three checks with staff and reminders to check the orders.

Based on interview and record review, conducted during a site visit on 09/22/23, it was determined the facility failed to make records available to the Department upon request. Findings include, but are not limited to:

In a phone interview on 09/26/23, Staff 3 (ED) stated they would look and see if there was an evaluation or service plan done when Resident 4 was moved from the MC to the AL, and would follow up with the Compliance Specialist (CS).

In a phone call on 09/27/23, Staff 3 stated s/he would send the documents by the next morning.

Compliance Specialist (CS) was not provided documentation of an assessment or service plan being completed in August 2022 when Resident 4 was moved from the MC to the AL during the onsite visit on 09/22/23.

In review of emails sent on 09/26/23, 09/27/23, and 09/29/23 to Staff 3 (ED), the CS requested records of assessments or service plan updates between August 2022 and March 2023 documenting how the facility would be providing the care needed for Resident 4 outside of the MC.  The CS did not receive the records as requested.

The findings were shared with Staff 2 (Wellness Director) and Staff 3 via email on 09/29/23.

It was determined the facility failed to make records available to the Department upon request.

Verbal plan of correction: No plan of correction was provided.