Print Inspection: 06DF

The findings of the on-site investigation, conducted 07/06/23, 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

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 observation, interview and record review, during a site visit conducted on 07/06/23, 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 3 of 3 sampled residents (#S 1, 2, and 3). Findings include, but not limited to:

During the site visit, two caregivers and one medication technician were observed working on day shift. One caregiver and one medication technician were observed working on evening shift.

The facility's posted staffing plan noted the following:

Day shift: one medication aid, one caregiver;

Evening shift: one medication aide, one caregiver; and

Night shift: one medication technician.

Resident 1, Resident 2 and Resident 3's current service plans were reviewed and revealed the residents required the assistance of two people for transfers. Resident 3 required full assistance for meals.

In a phone interview on 07/07/23, Staff 5 (Interim Executive Director) stated their goal staffing is one MT and 2 CG for day and swing shift.

During interview on 07/06/23, Witness 1 (Spouse of Resident 1) stated on 06/24/23, S/he was in the facility visiting his/her spouse for the evening and only one person was working in the memory care. Witness 1 stated S/he "worked" that evening and helped pass resident meal trays and also cleaned up a tray that another resident had spilled on the floor.

A review of the facility's task charting revealed no tasks were documented as completed for evening shift on 06/24/23 for the 3 sampled residents.

During an interview on 07/07/23, Staff 2 (CG) stated S/he had worked as the only caregiver on the floor for both the memory care and the assisted living on evening shift 06/12/23. Staff 2 further stated, they were unable to obtainother care staff and had a dietary employee help transfer Resident 1 because S/he required the assistance of two people for transfers.

In an interview on 07/06/23, Staff 3 (MT) and Staff 4 (CG) stated, they needed one MT and 2 CG on evening shift because of the three residents who require assistance from two people for transfers and care. They stated that no one was available to help residents or watch the floor if they are helping one of those residents when two care staff were working.

The findings were reviewed with and acknowledged by Staff 1 (Administrator) on 07/06/23.

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

Verbal plan of correction: Staff 1 has contacted their sister facility to create a staffing pool. She had requested scheduling software, applicationss  and to create a staffing coordinator position, but those were denied by the home office. Staff 1 will coordinate with the business office manager to create a posting for available positions and move forward with recruitment.

Based on observation, interview and record review, during a onsite visit conducted on 06/07/23, it was confirmed the facility failed to fully implement an Acuity-Based Staffing Tool (ABST) for 3 of 3 sampled residents (#S 1, 2, and 3). Findings include, but not limited to:

During the onsite visit, two caregivers and one medication technician were observed working on day shift. One caregiver and one medication technician were observed working on evening shift.

The facility's posted staffing plan noted the following:

Day shift: one medication aid, one caregiver;

Evening shift: one medication aid, one caregiver; and

Night shift: one medication technician.

Service plans were reviewed for Resident 1, Resident 2 and Resident 3 which revealed all three require the assistance of two people for transfers. Evaluations for the three residents were provided electronically by Staff 5 (Interim Executive Director) on 07/07/23, and revealed 1 of 3 evaluations had not been completed in the last 90 days.

In an email received on 07/07/23, Staff 5 stated, "... the evaluations are what our acuity based staffing tool pulls from as well as what generates our service plans." In a phone interview on 07/07/23, Staff 5 stated their goal staffing was one MT and 2 CG for days and swing shift.

During an interview on 07/06/23, Witness 1 (spouse of Resident 1) stated on 06/24/23 s/he was in the facility visiting his/her spouse for the evening and only one person was working in the memory care. Witness 1 stated s/he "worked" that evening and helped pass resident meal trays and also cleaned up a tray that another resident had spilled on the floor.

During an interview on 07/07/23, Staff 2 (CG) stated s/he had worked as the only caregiver on the floor for both the memory care and the assisted living on evening shift 06/12/23.  S/he was unable to locate any other care staff working and had a dietary employee help transfer Resident 1 because s/he required the assistance of two people for transfers.

A review of the facility's task charting revealed that no tasks were documented as completed for evening shift on 06/24/23 for 3 of 3 sampled residents.

In an joint interview on 06/07/23, Staff 3 (MT) and Staff 4 (CG) stated they needed one MT and 2 CG on evening shift because of the three residents who require assistance from two people for transfers and care. They stated no one was available to help residents or watch the floor if they are helping one of those residents.

A review of the facility's ABST titled "Planned Time Staffing Report" did not include residents' names. It could not be verified that facility's residents and 22 ADLs were included in the ABST.

The findings were reviewed with Staff 1 (Administrator) on 07/06/23.

It was confirmed the facility failed to fully implement and update an Acuity-Based Staffing Tool (ABST).

Verbal plan of correction: Staff 1 would contact the regional and home office to do an audit and update of scheduled tasks within 24 hours because she was unsure their ABST was accurate and reflective of needs. Staff 5 stated he had already begun an audit of all service plans for accuracy.

Based on interview and record review, conducted during a site visit on 07/06/23,  it was confirmed the facility failed to keep all equipment in good repair. Findings include, but not limited to:

In an interview on 07/06/23 Staff 1 (Administrator) stated the facility's elevator did  not work for some time several months ago. She stated Resident 3's family member complained because Resident 3's spouse was unable to visit him/her as s/he was unable to use the stairs due to the need of a walker.

A review of an email correspondence dated 02/18/23 to the facility's Business Office Manager revealed the family member of Resident 3 contacted the facility about the elevator has stopped working on 02/09/23 and was still not operational. A response to this email on 02/19/23 stated the facility was having supply chain problems with their vendor and that the facility's home office would assist.

A review of maintenance logs from Kone Corporation revealed the elevator was fixed and working on 2/21/23.

It was confirmed the facility failed to keep all equipment in good repair.

The findings were reviewed with and acknowledged by Staff 1 on 07/06/23.

Verbal plan of correction: This issue has been resolved and the elevator is now operational.