Print Inspection: 2V12

The findings of the on-site investigation, conducted on 10/24/2023, 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, 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, during a site visit conducted on 10/24/23, it was confirmed the facility failed to ensure the staff person who administed the medication visually observed the resident take the medication for 1 of 1 sampled resident (#1). Findings include, but not limited to:

A review of the facility self-report, dated 08/30/23, confirmed staff had not observed Resident 1 take his/her Quietiapine, and they had provided the resident with an extra dose of the medication.

During an interview on 10/24/23, Staff 1 (ED) confirmed that on 08/30/23 staff had not observed Resident 1 take their medication and had provided the resident with an extra dose of Quietiapine.

It was confirmed the facility failed to ensure that the staff person who administered the medication visually observed the resident take the medication.

On 10/24/23, the findings were reviewed with and acknowledged by Staff 1.

Verbal plan of correction: Staff 1 did verbally coach the med tech to remind him/her to visibly observe resident take medication and went over medication errors. The community self-reported medication error to APS, completed an Incident Report, ISP's, placed resident on Alert Charting.

Based on interview and record review, during a site visit conducted on 10/24/23, it was confirmed the facility failed to carry out medication orders as prescribed for 1 of 1 sampled resident (#1). Findings include, but not limited to:

A review of the facility self-report dated 08/30/23, confirmed Resident 1 had been given two doses of the PRN medication Quietiapine.

A review of the physician order dated 08/16/23 indicated Resident 1 was to receive one tablet of Quietiapine by mouth daily at breakfast, lunch, and dinner.  

During an interview on 10/24/23, Staff 1 (ED) confirmed Resident 1 had been given a double dose of his/her medication.

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

On 10/24/23, the findings were reviewed with and acknowledged by Staff 1.

Verbal plan of correction: Staff 1 did verbally coach the med tech to remind him/her to visibly observe resident take medication and went over medication errors. The community self-reported medication error to APS, completed an Incident Report, ISP's, placed resident on Alert Charting.

Based on interview and record review, conducted during a site visit on 10/24/23, it was confirmed the facility failed to adopt an acuity-based staffing tool (ABST) to determine appropriate staffing levels for the facility. Findings include, but are not limited to:

A review of the resident roster indicated the facility was home to 14 residents. A review of the facility's ABST indicated 12 residents were entered into the tool. Eight of those residents had not been updated quarterly or upon move-in.

In an interview on 10/24/23, Staff 1 (ED) stated, "There are two new residents who had not been added into the ABST tool. One resident moved in on 09/22/23 and the second resident moved in on 10/03/23."

It was confirmed the facility failed to adopt an acuity-based staffing tool (ABST) to determine appropriate staffing levels for the facility.

On 10/24/23, the findings were reviewed with and acknowledged by Staff 1.

Based on interview and record review it was confirmed the facility failed to provide records to the Department upon request. Findings include:

Compliance Specialist (CS) requested documentation on 01/18/24 from the facility for an investigation conducted on 10/24/23 and did not receive them. Reviewed email request dated 01/18/24 following up on the request for documentation still needed to Staff #1 (S1). The facility did not provide the documentation requested. On 01/25/24 CS informed S1 about documentation not being provided upon request.

Plan Of Correction: Not provided.