Print Inspection: FC96

The findings of the on-site investigation, conducted on 09/28/23, 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

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 09/22/23, it was confirmed the facility failed to develop and implement effective methods of responding to and resolving resident complaints. Findings include, but not limited to:

The facility's grievance policy stated:  "all grievances or complaints shall be documented on the Grievance Report form, including investigation results and efforts to address the issue."  It also indicated the person filing the complaint would receive a report of the findings and resolution.

Compliance Specialist reviewed the "Resident Grievance" log. The log contained six between March 20th, 2023-August 29th, 2023. The log did not include all investigation results and efforts to address the issues.

In an interview on 09/28/23, Staff 1 (Wellness Director) stated the grievance binder was located at the front desk but was not used. S/he stated that residents will come to him/her or the ED with concerns at the front. The ED meets with the resident council, and they have town hall meetings monthly. S/he was unsure if the person filing the complaint received a report of the findings.

In an interview on 09/28/23, Residents 3, 4, and 5 all stated there is no follow up to complaints. Resident 3 stated there was meetings once per month and the same concerns were brought up. Resident 4 stated they had asked for staff to come to his/her room to talk about his/her complaints and they did not come up.

The findings were reviewed with and acknowledged by Staff 1 on 09/28/23.

It was confirmed the facility failed to develop and implement effective methods of responding to and resolving resident complaints.

Verbal plan of correction: Wellness director and ED will go over the grievance policy and there will be training at the stand-up meetings and next all staff on reporting, documenting, and following up on grievances.

Based on observation, interview, and record review, conducted during a site visit on 09/22/23, it was confirmed the facility failed to ensure the implementation of services for 2 of 2 sampled residents (#s 4 and 5). Findings include, but not limited to:

On 09/28/23, compliance specialist (CS) observed the following in Resident 4 and Resident 5's apartment and bathrooms:

·Dark rings and mold around the toilet bowl;

·Trash full;

·Debris on the floors (papers, crumbs, dust);

·Dark rings around the sink and shower drains; and

·Dirty dishes in the sink.

In interviews on 09/28/23, Resident 4 and Resident 5 both stated they had not seen housekeeping in weeks, and they did not know what day they were supposed to come. Resident 4 stated s/he bought their own vacuum to clean with. Resident 5 stated staff had not been assisting him/her with weekly showers.

In review of the housekeeping checklist for the week of 09/18/23 it was confirmed housekeeping had not cleaned Residents 4 and 5's rooms. On 09/28/23, CS reviewed the housekeeping log for the week of 09/23/23 and Residents 4 and 5 still had not received housekeeping.

Resident 5's service plan, dated 08/30/23, indicated the resident required assistance with bathing weekly. The only completed shower sheets for Resident 5 for September 2023 were dated 09/24/23 and 09/09/23.

The findings were reviewed with and acknowledged by Staff 1 on 09/28/23.

It was confirmed the facility failed to ensure the implementation of services.

Verbal plan of correction: Wellness director has implemented new task sheets that started this week (9/25/23), which includes showers and laundry for the residents. The RCC and staffing coordinator will be auditing weekly and will follow up with staff. There will be a Care Partner meeting on 10/4/23 to go over this process and documentation. HK schedule to be followed and ensure that weekly housekeeping is getting done if the HK is out.

Based on interview and record review, conducted during a site visit on 09/22/23, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (#5). Findings include, but not limited to:

Compliance Specialist reviewed Resident 5's May 2023 Medication Administration Record (MAR) and orders which indicated the following medications were not administered as ordered:

"05/04/23 Potassium Chl ER 20MEQ M-Tab " out of this medication. On order "

"05/07/23 Fluticasone 50m cg "bottle was empty, put on order"

"05/09/23 Fluticasone 50m cg "not delivered yet"

"05/11/23 Trelegy Ellipta 200-62.5-25m cg "med not in yet"

"05/11/23 Atorvastatin 10mg Tab "Med not here from pharmacy"

"05/15/23 Melatonin 3mg Tab "med not here"

"05/15/23 Allopurinol 100mg Tab "not in stock"

"05/15/23 Trelegy Ellipta 200-62.5-25m cg "not available"

"05/15/23 Cefdinir 300mg Cap "out of med"

"05/16/23 Cyanocobalamin 1000mcg/ml vial "product evaporated"

"05/17/23 Furosemide 20mg Tab "out of stock"

"05/18/23 Furosemide 20mg Tab "Satellite order from pharmacy, will give upon delivery"

During an interview on 09/28/23, Resident 5 stated medications were not always ordered timely.

The findings were reviewed with and acknowledged by Staff 1 on 09/28/23.

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

Verbal plan of correction: There have been multiple MT meetings since May 2023. Re-training done on re-ordering meds, some MT were pulled and there has been new staff. RCC is doing more audits weekly.