The findings of the on-site investigation, conducted on 12/07/2023, 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

Based on interview and record review, conducted during a site visit on 12/07/23, 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:

During an interview on 12/07/23, Staff 1 (ED) and Staff 2 (MCC Administrator) explained the tool the facility used was SPA. Staff 1 stated residents received points for ADLs, those points were converted into minutes. To get the staffing numbers, s/he takes the total minutes and divide that by 60 (60 minutes in an hour), then divide that total number by 7.5 (amount of working hours in a shift) and that gave the number of staff needed for the building per day. Staff 1 was unable to explain how the tool determined individual staffing numbers for each shift. Staff 1 was unable to tell the CS how the point level was determined for ADLs and how that converted into minutes.

A review of the facility's ABST, on 12/07/23, indicated the following:

·A total of 3482.5 minutes of care and required 7.73 care staff needed per day.

·The tool addressed 17 of the required 22 ADLs. The missing ADLs included:

oAssisting with communication, assistive devices for hearing, vision, and speech.

oResponding to call lights.

oSafety checks, fall prevention.

oCompleting resident specific housekeeping or laundry services performed by care staff.

oProviding additional care services, such as smoking or pet care.

A review of the facility's posted staffing plan indicated on day and swing shift the facility scheduled one MT, two CG, and on NOC shift there is one MT and one CG.

The facility failed to update an acuity-based staffing tool that addressed all the 22 activities of daily living (ADLs) for each resident and the amount of staff time needed to provide care and, as a result, the facility's acuity-based staffing tool does not reflect the correct care time for each resident.

On 12/07/23, the findings were reviewed with and acknowledged by Staff 1 and Staff 2.