Print Inspection: QS21

The findings of the on-site investigation, conducted 11/28/23 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

bid:twice a day

CBG:capillary blood glucose or

blood sugar

cc:cubic centimeter

CG:caregiver

cm:centimeter

F:Fahrenheit

HH:Home Health

HS or hs:hour of sleep

LPN:Licensed Practical Nurse

MA:Medication Aide

MAR:Medication Administration

Record

MCCMemory Care Community

mg:milligram

ml:milliliter

O2 sats:oxygen saturation in the

blood

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

RN:Registered Nurse

SP:service plan

TAR:Treatment Administration

Record

tid:three times a day

Based on observation, interview and record review, conducted during a site visit on 11/28/23, it was confirmed the facility failed to fully implement and update an Acuity-Based Staffing Tool (ABST) for 1 of 2 sampled residents (#5). Findings include, but are not limited to:

1. During an interview Staff 1 (Executive Director), Staff 2 (Health Services Specialist) and Staff 3 (Assisted Living Director), stated the facility needed the following staff:

Day: 2 CGs, 1 MT;

Evening: 1.75 CGs, 1 MT; and

Night: 1 CG, 1 MT.

A review of the facility's ABST confirmed the need for that amount of staff.

One CG and one MT were observed working on day shift. Interviews with staff revealed a  CG had gone home at 10 am on 11/28/23.

2. Facility records revealed Resident 5 moved into the facility on 11/01/23. Resident 5 had not been entered into the facility's ABST as of 11/28/23.

The findings were reviewed with and acknowledged by Staff 1, Staff 2 and Staff 3 on 11/28/23.

The facility failed to staff to the level required and update the ABST.

Based on interview and record review, conducted during a site visit on 11/28/23, it confirmed the facility failed to ensure the implementation of services for 1 of 1 sampled resident (#2). Findings include, but are not limited to:

Resident 2 moved into the facility on 08/02/23. Resident 2 moved out of the facilty on 10/03/23 and was unable to be interviewed or observed.

Resident 2's service plan dated 08/02/23 stated "Staff will assist [Resident 2] with showers... 1x/week"

A review of Resident 2's progress notes dated 08/02/23 - 09/23/23 revealed:

*On 08/12/23 it was documented that "[s/he] has been requesting to have a shower and we are unable to do it safely until [s/he] has the proper equipment. [S/he] understands that and will wait until we can get what we need"; and

*On 08/22/23 it was documented "[home health occupational therapy] recommended shower 2x/wk. We will be able to provide it once DME arrive."

During a phone interview on 11/29/23 Staff 1 (Executive Director) stated that Resident 2 indicated s/he only wanted a shower 1x per week in his/her initial assessment. Staff 1 agreed that the resident was not given a shower per the service plan.

The findings were reviewed with Staff 1 by phone on 11/29/23.

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

Verbal plan of correction: Facility will ensure all necessary equipment has been delivered to the facility prior to the resident moving in. Staff are now documenting any showere refusals on new shower sheets.

Based on interview and record review, conducted during a site visit on 11/28/23, it was determined the facility failed to develop a service planning team that consists of the resident the resident's legal representative, if applicable, any person of the resident's choice for 1 of 1 sampled resident (#1). Findings include, but are not limited to:

During an interview on 11/28/23, Resident 1 stated his/her POA handles his/her service planning.

During a phone interview on 11/28/23 Witness 1 (Resident 1's POA) stated the facility recently included him in a service planning meeting but previously only notified him when there was an increase in cost.

Service plans for the last 12 months signed by Resident 1 and/or his/her POA were requested from the facility on 11/28/23. On 11/29/23 Staff 2 (Health Services Specialist) emailed a copy of Resident 1's service plan dated 01/16/23 which was only signed by Staff 2 with a Service Agreement as the last page, noting the cost which was signed by Witness 1 on 02/04/23.

No other service plans or documentation of Resident 1 or Witness 1 being included in the service planning team was provided.

The findings were reviewed with and acknowledged by phone with Staff 1 (Executive Director) on 12/01/23.

It was determined the facility failed to develop a service planning team that consists of the resident the resident's legal representative, if applicable, any person of the resident's choice.

Verbal plan of correction: ED stated the resident and POA will be scheduled for service planning meetings.

Based on interview and record review, conducted during a site visit on 11/28/23, it was confirmed the facility  failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (#4). Findings include, but are not limited to:

A review of Resident 4's December 2022 and January 2023 MAR revealed over 100 occasions in which a medication was not given or a treatment was not completed.

During an interview on 11/28/23, Staff 2 (Health Services Specialist) stated the facility had a lot of agency staff around December 2022 and January 2023 and had a lot of struggles. She said she was not surprised about medication and treatment problems at that time, but was not working in the facility.

The findings were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2, Staff 3 (Assisted Living Director) on 11/28/23.

The facility failed to carry out medication and treatment orders as prescribed.

Verbal plan of correction: MTs are now reaching out to pharmacy, faxing PCP if a medication was not delivered, and following-up about cycle-fill medications.  Weekly MT meetings are held to review new information, training material and answer questions. Assisted Living Director reviewed medication variance report daily and follow up with staff immediately to ensure documentation was completed and to ensure PCP was notified if a resident refused.

Based on observation, interview and record review, conducted during a site visit on 11/28/23, it was confirmed the facility failed to fully implement and update an Acuity-Based Staffing Tool (ABST) for 1 of 2 sampled residents (#5). Findings include, but are not limited to:

1. During an interview Staff 1 (Executive Director), Staff 2 (Health Services Specialist) and Staff 3 (Assisted Living Director), stated the facility needed the following staff:

Day: 2 CGs, 1 MT;

Evening: 1.75 CGs, 1 MT; and

Night: 1 CG, 1 MT.

A review of the facility's ABST confirmed the need for that amount of staff.

One CG and one MT were observed working on day shift. Interviews with staff revealed a  CG had gone home at 10 am on 11/28/23.

2. Facility records revealed Resident 5 moved into the facility on 11/01/23. Resident 5 had not been entered into the facility's ABST as of 11/28/23.

The findings were reviewed with and acknowledged by Staff 1, Staff 2 and Staff 3 on 11/28/23.

The facility failed to staff to the level required and update the ABST.

Based on observation, interview and record review, conducted during a site visit on 11/28/23, it was confirmed the facility failed to have a training program that included methods to determine competency of direct care staff through evaluation, observation, or written testing for 2 of 3 sampled staff (#s 5 and 6). Findings include, but are not limited to:

1. Staff 5 (MT) was observed working on the floor on day shift on 11/28/23. Staff 4 (CG) was the only CG working on day shift.

During an interview, Staff 4 stated that s/he called Staff 5 for help transferring residents who needed the assistance of two people and Staff 5 assisted.

During an interview, Resident 1 stated that Staff 5 had attempted to transfer him/her that morning but did not know how to remove the armrests for his/her wheelchair, and had to call Staff 4 to show him/her how to transfer Resident 1.

The facility was unable to provide any records that Staff 5 had been trained to perform any CG duties including transfers.

2. Staff 6 was observed working independently on the floor as a MT.

The facility was unable to provide any records that Staff 6 had been trained as a CG or a MT.

The findings were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2 (Health Services Specialist), Staff 3 (Assisted Living Director) on 11/28/23.

The facility failed to have a training program that included methods to determine competency of direct care staff through evaluation, observation, or written testing.

Verbal plan of correction: An audit was completed 11/20/23 through11/24/23 of staff training documents and lists of missed training documents were distributed to staff. ED and receptionist are over-seeing the completion of staff training records. All staff training documents will be updated and current by 12/15/23.