Print Inspection: 8M9Z

Based on observation, interview and record review, conducted during a site visit on 02/23/24, it was determined the facility failed to complete background checks as required for direct care staff for 2 of 5 sampled staff (#s 2, 3, 4, 5, and 6) Findings include, but are not limited to:

Document review on 02/23/24 of notices to BCU (Background Check Unit) for Staff 2 (CG), with hire date of 11/28/23, and Staff 3 (CG), with hire date of 01/03/24, were each missing a copy of BCU determination for working. Compliance Specialist (CS) observed paper trail indicated the background checks had been sent off but final determination was not listed in these 2 employee files. Staff 4 (CG) with a hire date of 11/28/23, Staff 5 (CG) with a hire date of 11/28/23, and Staff 6 (CG) with a hire date of 11/28/23 were listed and verified that each staff member was approved with a "Final Fitness Determination" and the position listed for each staff member.  BCU documentation was listed in each employee file for Staff 4, 5, and 6.

In an interview on 02/23/24 Staff 1 (Asst. Administrator) stated they were not aware of the missing  background checks. H/she stated if a staff member came back with a denial from BCU they are not hired.

The above information was shared and acknowledged by Staff 1 on 02/23/24.

Plan of Correction: Staff 1 immediately requested the final determinations for Staff 2 and Staff 3 in order to complete the employee files and was delegating the task of updating each employee file to double check that background checks were complete and in the files per OAR.  

Based on interview and record review, conducted during a site visit on 02/23/24, it was confirmed the facility failed to ensure residency agreements were in place for 5 of 6 sampled residents. (#1, 2, 3, 4, 5, and 6). Findings include, but are not limited to:

In an interview on 02/23/24, Staff 1 (Asst. Administrator) and Staff 2 (QA/Training) stated the facility will issue residency agreements upon move-in.

Documents reviewed on 02/23/24 revealed that Resident 1, with a move in date of 02/15/24 was the only resident to have a residency agreement in their binder. Resident 2 (move in date of 01/18/23),Resident 3 (move in date 09/22/23), Resident 4 (move in date 01/30/24), Resident 5 (move in date 01/25/24), and Resident 6 (move in date 02/08/24) residency agreements were not in their binders and staff were unable to locate them during site visit.

The above information was shared and acknowledged by Staff 1 on 02/23/24.

It was determined the facility failed to provide residency agreements and ensure  resident rights for living under a legally enforceable agreement.

Plan of correction: The facility will update residency agreements and update binders in the coming week (week of March 4).