The findings of the complaint (Intake #s 28247 and 28436) health survey conducted 2/25/21 through 3/10/21 are documented in this report. The survey was conducted to determine compliance with OAR 411- 85 through 89.
The sample was comprised of 3 current residents and 2 closed record. The facility had a census of 80 residents.
Abbreviations possibly used in this document:
ADL: activities of daily living
bid: twice a day
BIMS: Brief Interview for Mental Status
CAA: Care Area Assessment
CBG: capillary blood glucose or blood sugar
cm: centimeter
CMA: Certified Medication Aide
CNA: Certified Nursing Assistant
CPR: Cardiopulmonary Resuscitation
DNS: Director of Nursing Services
F: Fahrenheit
FRI: Facility Reported Incident
HS or hs: hour of sleep
LPN: Licensed Practical Nurse
MAR: Medication Administration Record
mcg: microgram
MDS: Minimum Data Set
mg: milligram
ml: milliliters
O2 sats: oxygen saturation in the blood
OT: Occupational Therapist
PCP: Primary Care Physician
PO: by mouth, orally
PRN: as needed
PT: Physical Therapist
RA: Restorative Aide
RAI: Resident Assessment Instrument
RD: Registered Dietitian
ROM: range of motion
RN: Registered Nurse
RNCM: Registered Nurse Care Manager
SA: State Agency
SLP: Speech Language Pathologist
TAR: Treatment Administration Record
tid: three times a day
UA: Urinary Analysis
The findings of the revisit complaint (Intake #s 28247 and 28436) health survey conducted 4/30/21 are documented in this report. The survey was conducted to determine compliance with OAR 411 - 85 through 89. For additional information refer to the Form CMS 2567 dated 4/30/21.
Abbreviations possibly used in this document:
ADL: activities of daily living
bid: twice a day
BIMS: Brief Interview for Mental Status
CAA: Care Area Assessment
CBG: capillary blood glucose or blood sugar
cm: centimeter
CMA: Certified Medication Aide
CNA: Certified Nursing Assistant
CPR: Cardiopulmonary Resuscitation
DNS: Director of Nursing Services
F: Fahrenheit
FRI: Facility Reported Incident
HS or hs: hour of sleep
LPN: Licensed Practical Nurse
MAR: Medication Administration Record
mcg: microgram
MDS: Minimum Data Set
mg: milligram
ml: milliliters
O2 sats: oxygen saturation in the blood
OT: Occupational Therapist
PCP: Primary Care Physician
PO: by mouth, orally
PRN: as needed
PT: Physical Therapist
RA: Restorative Aide
RAI: Resident Assessment Instrument
RD: Registered Dietitian
ROM: range of motion
RN: Registered Nurse
RNCM: Registered Nurse Care Manager
SA: State Agency
SLP: Speech Language Pathologist
TAR: Treatment Administration Record
tid: three times a day
UA: Urinary Analysis
UTI: Urinary Tract Infection
The findings of the complaint (Intake #s 28247 and 28436) health revisit survey conducted 6/1/21 are documented in this report. The facility was found to be in substantial compliance with OARs 411 - 85 through 89.
Based on interview and record review it was determined the facility failed to ensure a RN charge nurse was available for eight consecutive hours between day and evening shifts for 28 of 56 days reviewed for RN coverage. This placed residents at risk for lack of nursing assessments. Findings include:
A review of the facility's Direct Care Staff Daily Reports from 1/1/21 through 2/25/21 revealed the following number of days without a RN charge nurse on duty for eight consecutive hours between day and evening shifts:
-12 of 31 days reviewed for the month of 1/2021
-16 of 25 days reviewed in the month of 2/2021
On 2/10/21 at 3:45 PM Staff 1 (Administrator) acknowledged the lack of required RN coverage on the identified dates.
1. Ongoing recruitment and retentionwill continue for qualified RNs who meet OAR requirements to be hired.2. The facility has initiated agency staffing,to assist in meeting OARs minimum staffing ratios no less than 8 hours of RN per day during the day or evening shift.3. Staffing Coordinator/HR has initiated arecruitment and retention plan.4. The administrator/designee will completean audit of the DHS staffing form 5 times a week for three months to ensure the RN staffing ratios meet the OAR minimum staffing ratio for RN’s. Findings will be reviewed in the monthlyQAPI meeting and quarterly thereafter with action plans. Recruitment plans developed for trends, which were identified. This will continue until substantial compliance has been achieved.
Based on interview and record review it was determined the facility failed to ensure minimum CNA staffing ratios were maintained for 25 of 56 days reviewed for minimum CNA staffing. This placed residents at risk for delayed care. Findings include:
A review of the facility's Direct Care Staff Daily Reports from 1/31/21 through 2/25/21 revealed the following number of days when the required state minimum CNA staffing ratios were not met during day shift:
-13 of 31 days reviewed for the month of 1/2021.
-12 of 25 days reviewed for the month of 2/2021.
On 3/10/21 at 3:45 PM Staff 1 (Administrator) acknowledged the lack of CNAs on day shift for the identified number of days.
1. Ongoing recruitment and certification will continue for qualified nursing aids, who meet all requirements to be hired.2. The facility has initiated agency staffing, to assist in meeting minimum staffing ratios.3. Staffing Coordinator/HR has initiated arecruitment and retention plan.4. The administrator/designee will completean audit of the DHS staffing form 5 times a week for three months to ensure the C.N.A. staffing ratios meet the OAR minimum staffing ratio for C.N.A’s. Findings will be reviewed in the monthlyQAPI meeting and quarterly thereafter with action plans. Recruitment plans developed for trends, which were identified. This will continue until substantial compliance has been achieved.
Based on interview and record review it was determined the facility failed to ensure minimum CNA staffing ratios were maintained for 3 of 11 days reviewed for minimum CNA staffing. This placed residents at risk for delayed care. Findings include:
A review of the facility's Direct Care Staff Daily Reports from 4/19/21 through 4/29/21 revealed the required state minimum CNA staffing ratios were not met on the following days: 4/22/21 evening shift, 4/27/21 day shift and 4/29/21 evening shift.
On 4/30/21 at 1:09 PM Staff 1 (Administrator) acknowledged the three days when minimum CNA staffing ratios were not met.
1. Ongoing recruitment and certification will continue for qualified nursing aids, who meet all requirements to be hired. Avamere initiated union wage increases to help with recruiting certified nursing aides, including increased pick up bonus, and evening and NOC shift differential pay. 2. Continue process for sponsoring applicants to become certified nursing assistants. 3. Continue utilizing agency staffing to assist in meeting minimum staffing ratios and getting another contract with other agency.4. HR/Staffing to continue recruitment and retention plan.5. The administrator/designee to complete weekly audit of at least 5 DHS sheets for three months to ensure the C.N.A staffing ratios meet the OAR requirements. Findings will be reviewed quartely and thereafter until substantial compliance has been achieved.
