The findings of the on-site investigation, conducted 02/10/25, 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, OARs 411 Division 57 for Memory Care Communities.

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 interview and record review, conducted during a site visit on 02/10/25, the facility's failure to carry out medication and treatment orders as prescribed was substantiated for 1 of 1 sampled resident (# 1). Findings include, but are not limited to:

A review of Resident 1's physician orders dated 04/10/24, MAR dated 04/01/24 - 04/30/24 and chart notes dated 12/16/23 - 07/15/24 which indicated the following:

·On 04/06/24 at 8:30 am [Resident 1] was placed on alert for receiving wrong medications. Resident 1 received midodrine, aspirin, and senna docusate. RN notified and PCP faxed;

·Resident 1 had PRN orders for senna plus for constipation, scheduled order for low dose aspirin for cardiac health, and no order for midodrine.

In an interview on 02/10/25, Staff 1 (Administrator) stated s/he recalled this occurrence, and the staff member involved no longer worked for the facility.

The facility's failure to carry out medication and treatment orders as prescribed was substantiated.

Findings were reviewed and acknowledged by Staff 1 on 02/10/25.

Facility Verbal Plan of Correction: The staff member was removed from the medication cart and was restricted to caregiving.

Based on interview and record review, conducted during a site visit on 02/10/25, the facility's failure to fully implement and update an acuity-based staffing tool was substantiated for 2 of 2 sampled residents (#s 3 and 4). Findings include, but are not limited to:

Resident 3's service plan dated 09/06/24 and ABST last updated 10/25/24, had not been updated in the last quarter.

Resident 4's service plan dated 08/28/24 and ABST last updated 10/25/24, had not been updated in the last quarter.

Four residents were listed on the resident roster and lived in the facility that were not entered into the ABST.

An unsampled resident moved into the facility on 02/03/25 and had an incomplete ABST profile on 02/10/25.

In an interview on 02/10/25, Staff 1 (Administrator) stated s/he had forgotten that resident ABST profiles needed to have at least one item updated and saved to reflect the quarterly update. S/he also stated s/he had started to update the unsampled residents ABST profile but had not gotten back to completing it.

A review of the facility's posted staffing plan indicated the following:

·Day Shift: ALF - 2 Med techs and 4 Caregivers, MCC - 1 Med tech and 4 caregivers;

·Swing Shift: ALF - 2 Med techs and 4 Caregivers, MCC - 1 Med tech and 4 caregivers; and

·Night Shift: ALF - 1 Med-tech and 2 Caregivers, MCC - 2 Caregivers.

A review of the facility staffing from 02/04/25 - 02/10/25 indicated the facility was not consistently staffed to the posted staffing plan.

The facility failed to adopt an acuity-based staffing tool to determine appropriate staffing levels.

The findings were reviewed with and acknowledged by Staff 1 on 02/10/25.