The findings of the on-site investigation, conducted 12/13/2023, 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 and interview, conducted during a site visit on 12/13/23, it was confirmed the facility failed to have the current staffing plan posted. Findings include, but are not limited to:
On 12/13/23, CS observed no posted staffing plan in buildings 910, 920, and 940. CS observed in building 950 there was an old staffing plan posted which did not reflect the facility's ABST generated staffing plan.
During an interview on 12/13/23, Staff 1 (ED) stated, "I removed the posted staffing plans back in August and did not replace them."
It was confirmed the facility failed to have a current staffing plan posted.
On 12/13/23, the findings were reviewed with and acknowledged by Staff 1.
Verbal plan of correction: Staff 1 will create and post the required posted staffing plan by the end of the day on 12/13/2023.
Based on observation, interview, and record review, during a site visit conducted on 12/13/23, it was confirmed the facility failed to have service plans readily available to staff. Findings include, but are not limited to:
During an interview on 12/13/23, Staff 1 (ED) acknowledged that not all residents current service plans had been added into the service plan binders and had not been readily available to all staff.
A review of the service plan binders matched with the resident roster indicated the service plan binder contained a service plan for all residents, but for ten of those residents, the most recent service plan was not available to staff.
On 12/13/23, CS observed on Staff 1's computer, all residents to have current quarterly service plans.
It was confirmed the facility failed to have a residents most recent service plans readily available to staff.
On 12/13/23, the findings were reviewed with and acknowledged by Staff 1.
Verbal plan of correction: The RCC will update the service plan binders to reflect all residents current service plans.
Based on interview and record review, conducted during a site visit on 12/13/23, 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:
In separate interviews on 12/13/23, staff members stated the following:
During an interview on 12/13/23, Staff 1 (ED) stated the facility currently staffed with the following:
A review of the call light log, dated 09/12/23, indicated 26 call light response times that had exceeded 20 minutes. 14 of those response times had exceeded 60 minutes.
A review of the CG and MT schedules, dated 08/01/23 through 10/31/23, indicated several open uncovered shifts.
A review of timecards, dated 08/14/23 and 09/12/23, indicated the facility was short staffed for swing and night shift.
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 12/13/23, the findings were reviewed with and acknowledged by Staff 1.
Verbal plan of correction: The facility has been hiring 3-6 people per month and will continue to hire. The facility had issues with their call light system that has been resolved.
Based on observation, interview, and record review, conducted during a site visit on 12/13/23, 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:
On 12/13/23, CS observed no posted staffing plan in buildings 910, 920, and 940. In building 950 posted was an old staffing plan which did not reflect the facility's ABST generated staffing plan.
During an interview on 12/13/23, Staff 1 (ED) stated the facility currently staffed with the following:
During separate interviews, Staff 2 (CG) and Staff 5 (MT) stated the facility had been short staffed, often pulling staff from one building to another. Staff 2 stated, "There are many open shifts on the schedule that do not get filled. When staff are scheduled, there are frequent call outs."
A review of the CG and MT schedules, dated 08/01/23 through 10/31/23, indicated several open shifts for every or every other day. The facility was not consistently staffing to the staffing hours generated in the ABST.
The facility's ABST indicated the following staffing levels are required to meet the scheduled needs of residents:
·Building 910 and 920 (assisted living):
oDay: 2 care staff in each building.
oSwing 2 care staff in each building.
oNight: 1 care staff in each building.
·Building 940 (memory care):
oDay: 3 care staff.
oSwing 2 care staff.
oNight: 1 care staff.
·Building 950 (memory care):
oDay: 2 care staff.
oSwing 1 care staff.
oNight: 1 care staff.
It was confirmed the facility failed to adopt an acuity-based staffing tool (ABST) to determine appropriate staffing levels for the facility.
On 12/13/23, the findings were reviewed with and acknowledged by Staff 1.