The findings of the desk review, conducted 06/15/23, 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, 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 desk audit on 06/15/2023, it was determined the facility failed to evaluate the resident's health, medical, behavioral or care needs within a reasonable time after the resident had been deemed ready for discharge for 1 of 1 sampled resident (# 1) whose records was reviewed. Findings include, but are not limited to:

In an interview on 06/15/23, Staff 1 (Administrator) stated Resident 1 was sent to the hospital after a resident-to-resident altercation and the family was informed that they would not be able to re-admit the resident to the facility without one-on-one care. Staff 1 further stated no one from the facility evaluated the resident when s/he was ready to discharge from the hospital and that no move-out notice was issued for Resident 1.

Resident 1's charting notes dated 09/01/22-10/01/22 were reviewed.

*A note entered on 09/30/22 indicated resident was involved in a resident-to-resident altercation, administrator advised staff to have resident sent to hospital to be evaluated, PCP and POA advised of incident.

*A note entered on 10/01/22 indicated hospital social worker was informed they would need to admit Resident 1 until the facility could find alternate placement for resident.

*A note entered on 10/01/22 indicated Resident 1 was ready for discharge from the hospital and the prospect of a one-on-one caregiver was discussed with family as well as the possibility of alternate placements, taking resident home with family or increasing resident medications. Family was informed without proper safety measures in place they would not be able to re-admit Resident 1 to the facility.

*A note entered on 10/01/22 indicated Resident 1's wife was looking for alternate placements for resident.

*A note entered on 10/01/22 indicated that a director for another community had an immediate opening and would be going to the hospital to evaluate Resident 1 for placement in their facility.

There was no evidence an involuntary move out notice was provided to the resident and no evaluation of the resident's health, medical, behavioral or care needs within a reasonable time, but no later than 24 hours after the resident has been deemed ready for discharge.

The facility failed to evaluate the resident ' s health, medical, behavioral or care needs within a reasonable time after the resident had been deemed ready for discharge.

The findings of the investigation were reviewed with and acknowledged by Staff 1 on 06/30/23.

Verbal Plan of Correction:

Facility owners and administrator have worked with marketing on how to evaluate incoming residents to ensure residents are a correct placement so that they do not end up in a similar situation with a failed placement of a resident.