Print Inspection: 0PWJ

The findings of the on-site investigation, conducted 06/27/23 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

RCM: Resident Care Manager

RN:Registered Nurse

Based on observation, interview, and record review, conducted during a site visit on 06/27/23, it was confirmed the facility failed to fully implement an Acuity Based Staffing Tool (ABST). Findings include, but are not limited to:

In an interview on 06/27/23, Staff 1 (Administrator) and Staff 2 (RCM) stated the facility had not adopted an ABST. Staff stated there are to be three caregivers (CG) and one medication aide (MA) on day and swing shift, and two CGs and one MA on night shift.

On 06/27/23, it was observed the facility was staffed with three CGs and one MA on day shift.

There was no documented evidence the facility was using an ABST that would determine a staffing plan reflective to meet the 24-hour scheduled and unscheduled needs of residents.

On 06/27/23, these findings were reviewed with and acknolwedged by Staff 1 and Staff 2. Staff 1 stated the owner had a log-in but never sent it to the facility.

The facility failed to adopt and fully implement an Acuity Based Staffing Tool (ABST).

Verbal Plan of Correction:

Effective immediately, the Administrator will enter all resident acuity information into the ODHS ABST and estimates it will be completed by end of day 06/28/23.