Print Inspection: 4ZHB

The findings of the on-site investigation, conducted 06/01/23 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

bid:twice a day

CBG:capillary blood glucose or

blood sugar

cc:cubic centimeter

CG:caregiver

cm:centimeter

F:Fahrenheit

HH:Home Health

HS or hs:hour of sleep

LPN:Licensed Practical Nurse

MA:Medication Aide

MAR:Medication Administration

Record

MCCMemory Care Community

mg:milligram

ml:milliliter

O2 sats:oxygen saturation in the

blood

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

RN:Registered Nurse

SP:service plan

TAR:Treatment Administration

Record

tid:three times a day

Based on observation, interview and record review, it was confirmed that the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs for 1 of 1 sampled resident (#1). Findings include, but not limited to:

During the site visit on 06/01/23, the facility's posted staffing plan indicated the facility had the need for the following staff:

- Day: 2 MTs, 2 CGs;

- Swing: 2 MTs, 2 CGs; and

- Night: 1 MT, 1 CG.

A review of the facility's time cards for 05/26/23, 05/27/23 and 05/29/23 revealed on each of those days the facility only had 2 MTs and 1 CG working on day shift, instead of the posted 2 CGs for day shift.

Interviews with Staff 3 (CG) and Staff 4 (CG) confirmed there was only 1 CG working during day shift on 05/26/23, 05/27/23 and 05/29/23. Staff 3 and 4 stated they should respond to call lights within 5-10 minutes.

The facility's call light logs for 05/26/23, 05/27/23 and 05/29/23 revealed the following response times greater than 15 minutes.

- On 05/26/23, 29 minutes at 7:24 am;

- On 05/26/23, 45 minutes at 8:10 am,

- On 05/27/23, 17 minutes at 7:20am; and

- On 05/27/23, 20 miutes at 12:43pm.

On 06/01/23,  2 MTs and 2 CGs were observed working on day shift. Resident 1 was observed to engage their call light at 10:37 am and a staff member responded at 10:51am.

During an interview with resident 1, s/he stated "its not good when there is only 1 CG working."

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.

The findings were reviewed with and acknowledged by Staff 1 (Administrator) on 06/01/23.

Verbal plan of correction: Staff 1 will in-service RCCs on the facilites staffing policies and procedures within the next two weeks, and ensure they are responding promptly to staffing issues.

Based on observation, interview and record review, it was confirmed that the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs residents during a site visit on 06/01/23. Findings include, but not limited to:

During the site visit on 06/01/23, the facility's posted staffing plan indicated the facility had the need for the following staff:

- Day: 2 MTs, 2 CGs;

- Swing: 2 MTs, 2 CGs; and

- Night: 1 MT, 1 CG.

A review of the facility's time cards for 05/26/23, 05/27/23 and 05/29/23 revealed on each of those days the facility only had 2 MTs and 1 CG working on day shift, instead of the posted 2 CGs for day shift.

Interviews with Staff 3 (CG) and Staff 4 (CG) confirmed there was only 1 CG working during day shift on 05/26/23, 05/27/23 and 05/29/23. Staff 3 and 4 stated they should respond to call lights within 5-10 minutes.

The facility's call light logs for 05/26/23, 05/27/23 and 05/29/23 revealed the following response times greater than 15 minutes.

- On 05/26/23, 29 minutes at 7:24 am;

- On 05/26/23, 45 minutes at 8:10 am,

- On 05/27/23, 17 minutes at 7:20am; and

- On 05/27/23, 20 miutes at 12:43pm.

On 06/01/23,  2 MTs and 2 CGs were observed working on day shift. Resident 1 was observed to engage their call light at 10:37 am and a staff member responded at 10:51am.

During an interview with resident 1, s/he stated "its not good when there is only 1 CG working."

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.

The findings were reviewed with and acknowledged by Staff 1 (Administrator) on 06/01/23.

Verbal plan of correction: Staff 1 will in-service RCCs on the facilites staffing policies and procedures within the next two weeks, and ensure they are responding promptly to staffing issues.