The findings of the on-site investigation, conducted on 10/12/2023, 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
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 interview and record review, conducted during a site visit on 10/12/23, it was confirmed the facility failed to fully implement and update an acuity-based staffing tool (ABST) to determine appropriate staffing levels for the facility. Findings include, but are not limited to:
On 10/12/23, the facilities ABST was reviewed, and there were 49 residents' profiles that had not been updated quarterly.
The staffing levels generated indicated the facility required the following:
Day shift: 1 ½ MTs and 4 CGs;
Swing shift: 1 ½ MTs and 3 CGs; and
NOC shift: 1 MT and 1 CG.
A review of the posted staffing plan indicated for Day and Swing shift three CGs and one and a half MTs scheduled and on NOC shift one CG and one MT.
In an interview on 10/12/23, Staff 1 (Executive Director) stated the facility was using the ODHS ABST. S/he stated, "We take the med tech questions and separate them to know the number of med techs to schedule, then we have the remaining questions to know the number of caregivers to schedule. We are working on hiring, currently we are staffing three CGs and one and a half MT for day, two and a half CGs and one and a half MT for swing, and one CG and one MT for NOC shift. We are staffing higher than what our corporate office wants." Staff 1 stated,"I have a stack of service plans that I need to update into the ABST tool this week."
The findings were reviewed with and acknowledged by Staff 1 on 10/12/23.
It was confirmed the facility failed to fully implement and update an acuity-based staffing tool to determine appropriate staffing levels for the facility.