The findings of the on-site investigation, conducted 08/20/23 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

bid:twice a day

CBG:capillary blood glucose or

blood sugar

cc:cubic centimeter

CG:caregiver

cm:centimeter

F:Fahrenheit

HH:Home Health

HS or hs:hour of sleep

LPN:Licensed Practical Nurse

MA:Medication Aide

MAR:Medication Administration

Record

MCCMemory Care Community

mg:milligram

ml:milliliter

O2 sats:oxygen saturation in the

blood

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

RN:Registered Nurse

SP:service plan

TAR:Treatment Administration

Record

tid:three times a day

Based on observation, interview and record review, conducted during a site visit on 08/20/23, 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 1 of 4 sampled resident (# 1). Findings include, but not limited to:

A review of Resident 1's service plan dated 08/07/23 revealed Resident 1 lived on the second floor and required the assistance of 2 to 3 staff members for the following service plan areas:

*Mobility limitations;

*Evacuation;

*Transferring;

*Toilet checks; and

*Bathing.

During the site visit on 08/20/23, Staff 1 (MT) and Staff 2 (CG) were observed working on night shift.

A review of the facility's schedule for July 2023 and August 2023 revealed there were are consistently two people scheduled on night shift.

During an interview on 08/20/23, Staff 1 stated s/he had only transferred Resident 1 on one occasion, during his/her training and that three people were required. Staff 1 was unsure how or if they could transfer and/or evacuate Resident 1 if needed.

During an interview on 08/20/23, Staff 2 stated s/he had never transferred Resident 1.

The findings were reviewed with and acknowledged by Staff 1 and 2 on 08/21/23 and Staff 3 (RCC) and Staff 4 (Administrator) by phone on 08/21/23.

The facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of residents.

Verbal plan of correction: Staff 3 came in for the rest of night shift on 08/20/23. The RCC and Administrator will discuss their staffing plan on 08/21/23 and will conduct a training/demonstration to see if the two people who worked the night shift are able to safely transfer the resident without a third person. If not, they will adjust their staffing plan.