Print Inspection: S3CQ

The findings of the on-site investigation, conducted 07/28/2023, 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.

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 observation, interview and record review, conducted during a site visit on 07/28/23, it was confirmed the facility failed to ensure the staff person who administers the medication must visually observed the resident take the medication for 1 of 1 sampled resident (# 5) whose chart was reviewed. Findings include, but are not limited to:

Resident 5's medical chart indicated s/he had a self-administration order from his/her physician.

A review of Resident 5's 07/2023 MAR indicated the resident was receiving his/her medications, the facility was documenting the administration of Resident 5's medications. Many medications on MAR were written with the note that they are supervised self-administration.

In separate interviews on 07/28/23, Staff 1 (Administrator), Staff 2 (Med Tech) and Staff 3 (Med Tech) stated staff set up medications for Resident 5 and deliver them to resident's room and leave them for resident to take, if the resident has not taken his/her medication the next time staff enter, then staff remind resident that s/he needs to take his/her medication.

In an interview on 07/28/2023, Staff 1 stated resident has had a self-administration order since they moved into the facility and the facility and resident came to an understanding that the facility would store and set-up residents medications and leave them for resident to take and provide reminders to take medications.

On 07/28/23 at 12pm, Staff 2 was observed to deliver medications to Resident 5 and leave medication cup on residents walker tray.

The facility failed to ensure that a resident that self-administers their medication has an approved physician order, has been evaluated to self-administer at least quarterly and keep prescriptions in their unit.

The findings of the investigation were reviewed with and acknowledged by Staff 1 on 08/01/2023.

Verbal Plan of Correction:

Staff 1 will be in contact with Resident 5's physician to get clarification on orders and request orders be corrected to leave at bedside as it is Resident 5's preference for facility to manage medications but leave them for resident to take. Staff 1 anticipates receiving clarification and updating Resident orders by the end of the week (08/04/2023).

Based on interview and record review, conducted during a site visit on 07/28/2023 it was determined the facility failed to implement an acuity-based staffing tool (ABST) that met the regulation for 3 of 3 sampled residents (#s 2, 3 and 4). Findings include, but are not limited to:

In an interview on 07/28/2023, Staff 1 (Administrator) stated the information from resident service plans feeds into the facility's ABST system which generates a staffing plan, and this is automatically updated whenever a service plan is updated.

A review of the facility's ABST indicated the tool failed to include all of the 22 required ADL components to include:

* Repositioning in bed or chair;

* Assisting with leisure activities; and

* Responding to call lights.

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

The findings of this investigation were reviewed with Staff 1. No additional information was provided.

Verbal plan of correction:

As stated by Staff 1  "Per my upper management, our communities are in process of working with Corrective Action on reviewing Brookdale ' s Acuity Based Staffing Tool. There have been multiple calls and communications with the Department and we are continuing to partner and evaluate our tool as well as where the 22 required elements are identified. As we work through our Acuity Based Staffing Tool (ABST) with the department, we will continue to staff using Brookdale's tool. We will continue to evaluate and modify our staffing needs through our resident assessment process to include upon move in, change of condition, or quarterly. "