The findings of the on-site investigation, conducted on 10/19/2023, 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, OARs 411 Division 57 for Memory Care Communities.
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
Notes on Abbreviations:
"The abbreviations listed above can be used in the report without identifying the abbreviation within the report itself.
"Residents will be identified by "Resident 1", "Resident 2" etc, do not abbreviate.
"Staff will be identified by "Staff 1", "Staff 2" etc. do not abbreviate.
"If you introduce an abbreviation in the report, make sure it is a word that has a standard abbreviation associated with it and that it needs to be abbreviated. You don't need to abbreviate a word that you only use once in a report.
Based on observation, interview, and record review, during a site visit conducted on 10/19/23, 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 10/19/23, Staff 1 (RCC) and Staff 6 (Executive Director) stated, "The facility has been short staffed on swing shift, it is an ongoing issue we are aware of and have been trying to work on. "Staff 2 (RCC) stated, "The memory care has 48 residents, with at least 10 two person transfers." Staff 6 stated, "Two kitchen staff members who used to be caregivers have been often filling in."
A review of timecards and the labor distribution report for 08/05/23 indicated the facility was staffed lower than required. A review of the staff schedule for August and September 2023 indicated on 08/05/23 staff scheduled did not match timecards. The shower schedule indicated Resident 4 was to receive showers on Sundays during day shift. A review of the shower sheets indicated Resident 4 did not receive a shower until Wednesday 10/18/23.
On 10/19/23, CS observed one MT four CG's, (one who was in training), and one treatment aid. CS observed Resident 4 to have recently showered, however his/ her nails were unclean with debris embedded.
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 10/19/23, the findings were reviewed with and acknowledged by Staff 1.
Verbal plan of correction: The facility is aware they are short staffed on swing shift and have been continuously trying to hire. Have interviews lined up for the following week.
Based on interview and record review, conducted during a site visit on 10/19/23, 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 10/19/23, Staff 1 (RCC) stated, "The facility has been short staffed on swing shift, it is an ongoing issue we are aware of and have been trying to work on." Staff 2 (RCC) stated, "The memory care has 48 residents, with at least 10 two person transfers."
During a phone interview on 10/20/23, Staff 6 (Executive Director) stated the facility was using the ODHS ABST and acknowledged the facility had not been staffing to the hours indicated in the tool for swing shift.
On 10/19/23, the facility's ABST was reviewed, and the staffing levels generated indicated the facility required six care staff on day shift, five care staff on swing shift, and two care staff on night shift. There were 30 residents' profiles that had not been updated quarterly.
A review of the posted staffing plan indicated four CG's and one MT was to be scheduled, and one MT and one GC for night shift. The posted staffing plan did not match the current facility staffing.
It was confirmed the facility failed to adopt an acuity-based staffing tool (ABST) to determine appropriate staffing levels for the facility.
On 10/19/23, the findings were reviewed with and acknowledged by Staff 1.