The findings of the on-site investigation, conducted on 11/13/2023, 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 11/13/23, it was confirmed the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to:

On 11/13/23, CS observed one MT, two CG's, and one activities personnel working the floor. CS observed Resident 1's bed unmade, and their commode had not been emptied.

During an interview on 11/13/23, Staff 1 (ED) stated, "There are to be four CG and two MT for day and swing shift and two CG and one MT for night shift. I often work on the floor."

In separate interviews, staff members stated the following:

• "There are three CG and one MT working today. The activities personnel are acting as a caregiver today, s/he often does."
• "There are 12 two-person transfers, three use hoyers, and one uses a sit to stand."
• "We are not able to run the call lights response report, we audit them manually each morning."  
• "The call light response time should be two minutes, no later than five."  
• "The resident's showers have been a point of concern for the facility."  

During an interview on 11/13/23, Resident 1 stated the following;

• "One night I needed to use the restroom and pulled my call light, staff did not come in time, I ended up having an accident."
• "I pulled my call light this morning and waited 45 minutes. When the staff came, they explained that due to assisting other residents, I had not pulled my cord fast enough. Meaning that there was a line of residents also waiting for assistance."
• "Staff this morning was supposed to make my bed, they didn't."
• "Staff should also be emptying my commode which is full and that hasn't happened."  "

Resident 2 no longer resided in the facility. CS was unable to interview resident.

A review of the shower schedules, dated November 2023, indicated multiple showers missed and staff signed off showers had been given for dates that had not happened yet.

A review of the posted staffing plan stated the facility for day and swing shift had one MT and three CG's and on night shift had one MT and two CG's.

A review of the staff schedule, dated 09/01/23 through 11/13/23, indicated the facility was consistently staffing lower than the ABST. During the day of the site visit on 11/13/23, the facility had been short staffed.

It was confirmed the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident.

On 11/13/23, the findings were reviewed with and acknowledged by Staff 1.

Verbal plan of correction: Staff 1 had done an in-service with staff on 11/09/23 where discussion of the shower schedule was discussed. Staff 1 stated the facility has in-service meetings twice a month, the next meeting will be on 11/27/23. In the next meeting s/he will reiterate the shower sign off sheet and will have staff sit with their eyes closed for two minutes as an example of their call light response time and how long two minutes could be. Staff 1 had not addressed the issue that the facility was understaffed.

Based on interview and record review, conducted during a site visit on 11/13/23, it was confirmed the facility failed to adopt an acuity-based staffing tool (ABST) to determine appropriate staffing levels for the facility. Findings include, but are not limited to:

In separate interviews on 11/13/23, Staff 1 (Executive Director) stated the facility is using the ODHS ABST. S/He was unable to demonstrate how the hours were calculated to determine the facility's staffing levels. The facility was home to 51 residents. Staff 2 (RN) stated, "There are 12 two-person transfers, three use hoyers, and one uses a sit to stand." Staff 3 (MT) stated, "There are three CG and one MT. The activities personal is filling in as a CG today, s/he often does."  

A review of the facility's ABST indicated the facility required six care staff on day shift; four care staff on swing shift; and two care staff on night shift. There were 21 residents' profiles that had not been updated quarterly.

A review of the posted staffing plan indicated for day and swing shift there are to be three CG and one MT and on NOC shift there are to be two CG and one MT.

A review of the shower schedule, dated November 2023, indicated multiple showers missed and staff signed off showers had been given for dates that had not happened yet.

A review of the staff schedule, dated 09/01/23 through 11/13/23, indicated the facility was consistently staffing lower than the ABST.

It was confirmed the facility failed to adopt an acuity-based staffing tool (ABST) to determine appropriate staffing levels for the facility.

On 11/13/23, the findings were reviewed with and acknowledged by Staff 1.