Print Inspection: 5W6G

The findings of the on-site investigation, conducted 05/15/24 to 05/16/24, 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

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 05/15/24 and 05/16/24, it was determined the facility failed to immediately notify the local Department office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. Findings include, but are not limited to:

Staff 1 (Executive Director) provided a "Suspected Abuse or Unexplained Injury Reporting" form regarding an incident that occurred on 05/22/23 for Resident 2.

A review of Central Access Management (CAM) revealed APS was not notified of the incident until 05/25/23.

Staff 1 provided a "Suspected Abuse or Unexplained Injury Reporting" form regarding an incident that occurred on 04/09/24 for an unsampled resident.

A review of CAMs revealed Adult Protective Services (APS) was not notified of the incident until 04/22/24.

Staff 1 provided a "Suspected Abuse or Unexplained Injury Reporting" form regarding an incident that occurred on 05/10/24 for Resident 1.

A review of CAMs revealed APS was not notified of the incident until 05/15/24.

During an interview , Staff 1 stated they reported incidents to APS after conducting their internal investigations.

The findings were reviewed with Staff 1 and Staff 2 on 05/16/24.

The facility failed to immediately notify the local Department office, or the local AAA, of any incident of abuse or suspected abuse.

Verbal Plan of Correction: Management will report incidents moving forward within 24 hrs before or concurrently with internal investigations.

Based on interview and record review, conducted during a site visit on 5/15/24 and 5/16/24, it was confirmed the facility failed to include a written description in service plans of who shall provide the services and what, when, how, and how often the services shall be provided for 2 of 3 sampled residents (#s 1 and 3). Findings include but are not limited to:

A review of Resident 1's service plan, dated 04/29/24, indicated the following:

* Resident 1 was incontinent and required 2 two-staff members to assist with brief changes and peri care.

* The service plan did not include how often resident was to receive incontinence assistance.

A review of Resident 3's service plan, dated 03/26/24, indicated the following:

* Resident 3 was incontinent and required 2 two-staff members to assist with escort to and from toilet, brief changes, and peri care.

* The service plan did not include how often resident was to receive incontinence and toileting assistance.

The findings were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 2 (RN).

The facility failed to include a written description in service plans of who shall provide the services and what, when, how, and how often the services shall be provided.

Verbal Plan of Correction: Within two weeks, management will update resident service plans to reflect details of frequency (i.e. toileting and hydration).

Based on record review and interview, conducted during a site visit on 05/15/24 and 05/16/24, it was determined the facility failed to fully implement and update an acuity-based staffing tool. Findings include, but are not limited to:

In an interview on 05/16/24, Staff 1 (Executive Director) stated the following:

* The facility is using the ODHS tool;

* Staff 1 updates the tool upon admission, within 30 days, quarterly, and with changes of conditions.

On 05/16/24, a review of the facility's ABST "Export All Data" report revealed profiles had not be updated within the last quarter for Resident 4, Resident 5, and Resident 6.

In an interview 05/16/24, Staff 1 and Staff 2 (RN) confirmed these three residents' profiles had not been updated within the last quarter.

The facility's posed staffing plan showed the facility used Universal Workers (UW) and indicated the following:

* Day: five UWs;

* Eve: five UWs; and

* Night: three UWs.

A review of the facilty's Staffing Schedule for May 2024 indicated the facility consistently scheduled to their posted staffing plan.

Observations of day and evening shift staffing showed the facility was staffing to the levels required by the facility's ABST.

Observations of residents did not reveal any missed needs.

The findings were reviewed with and acknowledged by Staff 1 and Staff 2 on 05/16/24.

The facility failed to fully implement and update an acuity-based staffing tool.

Based on observation, interview, and record review, conducted during a site visit on 05/15/24 and 05/16/24, it was confirmed  the facility failed to ensure an individualized nurtrition and hydration plan was developed for 3 of 3 sampled residents (#s1, 2, and 3). Findings include but are not limited to:

A review of Resident 1's service plan, dated 03/25/24, indicated the following:

*Resident is independent with eating tasks;

*Staff to prepare and serve all snacks;

*There was no frequency specified related to snack and hydration; and

*There were no resident-specific details regarding preferences for drinks or snacks.

A review of Resident 2's service plan, dated 04/30/24, indicated the following:

*Resident can eat on his/her own but needs staff assistance at times;

*Staff are to encourage food consumption and fluids;

*There was no frequency specified related to snack and hydration; and

*There were no resident-specific details regarding preferences for drinks or snacks.

A review of Resident 3's service plan, dated 03/29/24, indicated the following:

*Resident is independent with eating tasks;

*Staff to prepare and serve all snacks;

*There was no frequency specified related to snack and hydration; and

*There were no resident-specific details regarding preferences for drinks or snacks.

On 05/15/24 and 05/16/24, the following were observed:

*A hydration cart was in the dining room;

*Residents were all served the same drink; and

*Residents were given the same snacks.

The findings were reviewed with an acknowledged by Staff 1 (Executive Director) and Staff 2 (RN) on 05/16/24.

The facility failed to ensure an individualized nurtrition and hydration plan was developed and included in the service plan.

Verbal Plan of Correction: Management will be providing education on the implementation of resident-specific snack and hydration programs within two weeks.

Based on interview, observation, and record review, conducted during a site visit on 05/15/24 and 05/16/24, it was confirmed the facility failed to provide a daily program of social and recreational activities that are based upon individual and group interests, physical, mental, and psychosocial needs, and creates opportunities for active participation in the community at large. Findings include, but are not limited to:

A review of the facility's activity schedule, dated 05/15/24, indicated the following:

* "Hammer Paint Craft;"

* "Hammer Away Day;"

* Morning stretch;

* Group Karaoke;

* Daily Chronicles;

* Bingo; and

* An animated movie.

On 05/15/24, the Compliance Specialists did not observe any of the scheduled activities occurred.

A review of the facility's activity schedule, dated 05/16/24, indicated the following:

* "What's all the Racket Day!"

* Daily Chronicles;

* Racketball;

* Wheel of Fortune; and

* An animated movie.

During observation on 05/16/24 at 1:18 pm, only bingo was observed to occur with four residents in attendance. No other activities were observed.

In an interview on 05/16/24, Staff 4 (Activities Director ) stated s/he used a company-provided activity website to create the facility's activity calendar and did not include residents' individualized activity plans.

The findings were reviewed with an acknowledged by Staff 1 (Executive Director) and Staff 2 (RN) on 05/16/24.

The facility failed to provide a daily program of social and recreational activities that are based upon individual and group interests, physical, mental, and psychosocial needs, and creates opportunities for active participation in the community at large.

Verbal Plan of Correction: Within three weeks, management will train activities person in using the resident evaluations which will transfer into the service plan to then provide an activities program that is based on resident-specific interests.