Print Inspection: P6W9

The findings of the on-site investigation, conducted 08/02/2023 through 08/03/2023, 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, conducted during a site visit on 08/02/23-08/03/23, it was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool (ABST). Findings include, but are not limited to:

A review of the ODHS ABST website on 08/01/2023 indicated this facility had 42 of 42 residents entered into the ABST. Twenty-one of the 42 residents were listed as requiring zero care hours.  

In an interview on 08/02/23, Staff 1 (Executive Director) stated the facility does use the ODHS ABST, and s/he had entered all of the residents into the tool but had not updated any of their information in it. S/he stated the RN, RCC and ED were intending to spend the next couple of days getting the information cleaned up, updated and corrected within the tool, but that it was not currently updated or accurate.

The facility failed to fully implement and update an Acuity Based Staffing Tool.

The findings of the investigation were reviewed with and acknowledged by Staff 1 on 08/03/23.

Verbal plan of correction:

The RCC, RN and ED had been working on 08/02/23and 08/03/23 on updating all of the information in the tool and correcting data entry errors. The ABST will be completed and up-to-date by the end of day 08/03/23.

Based on interview and record review, conducted during a site visit on 08/02/23-08/03/23, it was confirmed the facility failed to ensure if the direct care staff person's duties include the administration of medication or treatments, appropriate facility staff must document that they have observed and evaluated the individual's ability to perform safe medication and treatment administration unsupervised for 1 of 1 sampled staff members (# 7). Findings include, but are not limited to:

A review of Staff 7 (Med Tech) demonstrated competencies and staff list with hire dates indicated the following:

·Staff 7 was hired on 04/06/23 and demonstrated competencies were signed off as completed with RCC on 07/05/23.

A review of staff schedule, dated July 2023, indicated Staff 7 was working in the capacity of a Med Tech prior to completion of his/her demonstrated competencies.

In an interview on 08/03/23, Staff 1 (Executive Director) stated that when Staff 7 was hired there was a different RCC that worked at the facility and completed the training but failed to complete the paperwork.

The facility failed ensure if the direct care staff person's duties include the administration of medication or treatments, appropriate facility staff must document that they have observed and evaluated the individual's ability to perform safe medication and treatment administration unsupervised

The findings of the investigation were reviewed with and acknowledged by Staff 1 on 08/03/23.

Verbal plan of correction:

The facility has hired a new RCC and s/he is responsible for completing the paperwork and ensuring it is completed timely. All new staff are assigned a staff member to shadow and then are evaluated for competency. Since the RCC started s/he has reviewed staff files and has completed training and paperwork of all employees that did not have it completed already.

Based on interview and record review, conducted during a site visit on 08/02/23-08/03/23, it was confirmed the facility failed to provide meaningful activities that promote or help sustain the physical and emotional well-being of residents for 1 of 1 sampled resident (# 2). Findings include, but are not limited to:

In an interview on 08/03/23, Staff 1 (Executive Director) stated the activities portion in resident service plans are the individualized activity plans.

A review of Resident 2's service plan, dated 06/05/23, did not address the following:

·Physical abilities or limitations in participating in activities;

·Adaptations necessary for the resident to participate; and

·Identification of activities for behavioral interventions.

The facility failed to provide meaningful activities that promote or help sustain the physical and emotional well-being of residents.

The findings of the investigation were reviewed with and acknowledged by Staff 1 on 08/03/23.

Verbal plan of correction:

Each residents' service plan will be reviewed to ensure the activities portion is compliant with the rule. As the facility is in the process of migrating systems to Point Click Care Staff 1 will ensure that the information is current and accurate within their system as the migration occurs.