The findings of the on-site investigation, conducted 08/15/23 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 08/15/23, it was confirmed the facility failed to carry out medication orders as prescribed for 1 of 1 sampled resident (# 11). Findings include, but are not limited to:

A review of Resident 11's July 2023 MAR and an incident investigation dated 07/23/23 revealed the following:

*Resident 11 had an order for Clonazepam .5 mg take one tablet by mouth two times a day.

*On 07/23/23 Resident 11 did not receive his/her morning dose of Clonazepam medication.

During an interview with Resident 11 on 08/15/23 s/he stated remembering not getting the medication a few weeks previously, and had notexperienced any side effects or negative outcomes.

The findings were reviewed with and acknowledged by Staff 1 (Administrator) on 08/15/23.

The facility failed to carry out medication orders as prescribed.

Verbal plan of Correction: The Administrator to confirm that follow up training was completed with MT. LPN began printing reports that showed any holes in the MARs for MT's to review and correct, which was reviewed at clinical meeting on Thursdays. LPN to move medication errors to top of dashboard, review daily, and complete review weekly with the Administrator.

Based on observation, interview and record review, conducted during a site visit on 08/15/23, it was confirmed the facility failed to fully implement an ABST for 2 of 2 sampled residents (#s 1 and 2). Findings include, but are not limited to:

A review of the facility's ABST for 08/15/23 revealed the following:

*The facility required 66.41 hours of direct care or 8.85 shifts; and

*Resident 1 and Resident 2's care needs were not completely entered into the ABST.

The facility's posted staffing plan revealed the following: stated:

Day shift: 3 MA, 5 Universal workers, not increased to reflect ABST direct care needs.

Eight direct care staff were observed working on day shift on 08/15/23.

During an interview on 08/15/23, Staff 1 (Administrator) stated the facility staffed nine care staff during the day. She further stated, they are not always able to do that and confirmed there were only eight care staff working that morning.

The facility failed to fully implement an ABST.

The findings were reviewed with and acknowledged by Staff 1 on 08/15/23.

Verbal plan of correction: The Administrator will update the posted staffing plan by end of day on 08/15/23. She will audit ABST by end of week, and will implement a rule that the new move-in checklist must be used and ABST must be completed prior to the resident moving into the facility.  The Administrator to meet with the RCC weekly and audit the facility's checklist for compliance.