Print Inspection: IQMQ

The findings of the on-site investigation, conducted 09/13/23, 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 09/13/23 it was determined the facility failed to implement an acuity-based staffing tool (ABST)  for 2 of 3 sampled residents (#s 2 and 3). Findings include, but are not limited to:

A review of the facility's ABST indicated the facility uses the ODHS tool. A review of the facility's records indicated the facility census at the time of entry was 60 residents.  The ABST's "facility section details" printed and received at 12:19 pm indicated the first floor had 27 residents entered and the second floor had 28 residents entered for a total of 55 residents, and does not include 5 residents who moved in between 08/2023 and 09/2023.

A review of Resident 2's service plan and ABST indicated the following:

·Resident requires staff to set up for mouth care and no time was allotted in the ABST for personal hygiene.

·Resident requires transfer assistance in or out of bed or chair and no time was allotted in the ABST.

·Resident requires assistance with ambulation and no time was allotted in the ABST.

A review of Resident 3's service plan and ABST indicated the following:

·Resident requires staff to set up for mouth care and no time was allotted in the ABST for personal hygiene.

·Resident requires transfer assistance and no time was allotted in the ABST.

In an interview on 09/13/23, Staff 1 (Executive Director) stated the facility lumps services together so safety checks are designated in the service plan to be done with care and grooming and personal hygiene time are combined in the ABST under the grooming time. Also, transfer assistance would never be done by itself so the time to transfer a resident is combined with the care time that staff would provide. Staff 1 confirmed the facility had 60 residents currently and 1 resident moving in soon.

The facility failed to fully implement an acuity-based staffing tool that met regulations.

The findings of this investigation were reviewed with and acknowledged by Staff 1 on 09/13/2023.

Based on interview and record review, conducted during a site visit on 09/13/23 it was determined the facility failed to evaluate 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 for 1 of 1 sampled residents (# 2). Findings include, but are not limited to:

In an interview on 09/13/23, Staff 2 (Health Services Director) stated Resident 2 was in the ICU and not thought to make a recovery that would allow him/her to return to the facility. The resident did get well enough to possibly come back to the facility on hospice. The first conversation that was had with the discharge planner was on 08/25/23 stating resident was ready to be discharged, discharge planner left a voicemail on 08/27/23 and the resident was reassessed on 08/28/23 to return on 08/29/23 and have their hospice assessment done upon return.

A review of progress notes for Resident 2 indicated the following:

·08/25/23 there was a conversation with the care manager at the VA hospital.

·08/27/23 Staff 2 called to speak to care manager. Staff 2 will come to VA hospital tomorrow (08/28/23) to assess resident for re-admission.

·08/28/23 Staff 2 reassessed resident for re-admission.

·08/29/23 Resident 2 re-admitted to facility.

The facility failed to evaluate 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 findings of this investigation were reviewed with and acknowledged by Staff 1 on 09/13/2023.

Verbal Plan of Correction:

The nursing staff was unaware of the 24-hour response time, but moving forward between the 3 nursing staff members they will ensure that this deadline is met for all discharge evaluations.