The findings of the on-site investigation, conducted 08/02/2023, 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 08/02/23, 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 for 1 of 1 sampled resident (#1). Findings include, but are not limited to:
CS was unable to interview Resident 1 who no longer resided in the facility.
During an interview on 08/02/23, Staff 1 (Executive Director) stated, "The call light response time is between 5-10 minutes." Staff 1 acknowledged the long response times on the call light report printed.
A record review of the call light report for Resident 1 from April 2023, showed occurrences where the response time exceeded 10 minutes. On 04/08/23 the response time was 20 minutes 39 seconds. On 04/25/23 the response time was 24 minutes 23 seconds.
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 08/02/23, the findings were reviewed with and acknowledged by Staff 1.
Verbal plan of correction: Staff 1 will continue to run reports for the call lights and having staff meetings if s/he sees a pattern that exceeds their timeframe.
Based on interview and record review, conducted during a site visit on 08/02/23, it was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool (ABST). Findings include, but are not limited to:
During an interview on 03/28/2023, Staff #1 (Executive Director) stated their ABST was the same tool they had been using provided by their home office, called the resident services summary report.
A review of the facility's ABST showed the tool did not have all 22 activities of daily living (ADL's) outlined individually for each resident and the amount of staff time needed to provide care. The facility's ABST had multiple ADLs grouped together in subcategories. The ABST stated on day and swing shift, 1 MT and 3 CG were required and on NOC shift, 1 MT and 2 CG were required.
On 08/02/23, the findings were reviewed with and acknowledged by Staff 1.
Verbal plan of correction: Staff 1 will contact the OPA and CAC for ABST to further understand the tool within the month.