The findings of the on-site investigation, conducted 10/06/2023, 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, during a site visit conducted on 10/06/23, it was confirmed the facility failed to implement and update an acuity-based staffing tool (ABST). Findings include, but are not limited to:

During an interview on 10/06/23, Staff 1 (ED) and Staff 2 (MC ED) indicated the tool the facility used was Frontier. Staff 1 stated, "To get the staffing numbers we take 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 them the number of staff needed for the building per day. Residents ALD's are broken down with individual points, those points are converted into minutes." Staff 1 was unable to explain what number of minutes correspond into the number of points. Staff 1 directed CS to speak with Staff 4 (Director of operations) to explain, Staff 4 did not provide additional understanding of how the points were turned into minutes. Staff 2 stated, "There are two two person transfers and one resident that needs one on one assistance."  

The facility's ABST was reviewed on 10/06/23, the tool had total minutes needed: 2976.5. Based on the calculation provided above, CS took 2976.5 divided by 60= 49.60 then divided that by 7.5= 6.61 care staff needed for the day. The posted staffing plan indicated on day and swing shift the facility scheduled one MT, three CG, and on NOC shift there was an MT and two CG.

The facility failed to implement and 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 07/17/23, the findings were reviewed with and acknowledged by Staff 2.