Print Inspection: 5QHN

Based on interview and record review, conducted during a site visit on 10/31/24, the facility's failure to comply with required staffing or staff training practices was substantiated for 1 of 1 sampled staff (#6). Findings include, but are not limited to:

Compliance Specialist reviewed training documents for Staff 6 (Universal worker) who was hired on 04/30/24. Records indicated there was no documented training on service plans, orientation to the residents, or documentation showing Staff 6 had successfully demonstrated satisfactory performance in any task assigned in order to work unsupervised.

In separate interviews, Staff 1 (ED) stated s/he had started working at the facility in August 2024 and was not aware of staff working without completed training. S/he stated staff were trained on reviewing service plans on their first day. Staff 1 stated Staff 6 was terminated/quit on 06/01/24.

Staff 6 reported s/he had started working with residents before having any training and was left alone in the house overnight without anyone to train them. "The next time I went in, there was someone there, but [s/he] left several times during the night for about half an hour at time" and "it made me very uncomfortable with not having any training in case soemthing were to happen to one of the residents".

The findings were reviewed with and acknowledged by Staff 1 on 10/31/24.

The facility's failure to comply with required staffing or staff training practices was substantiated.

Verbal plan of correction: Facility is now doing onboarding. Hiring/interviews are done every Tuesday and if offered a position, onboarding is scheduled right away. Every week on Thursday's LPNs teach medications, transfers, and first aid training. RCC is responsible for completing the competency check off after 3 days of training in the home.

Based on interview and record review, conducted during a site visit on 10/31/24, it was determined the facility failed to have a fully implemented and updated Acuity Based Staffing Tool (ABST). Findings include, but are not limited to:

A review of the facility's ABST and resident roster indicated all 89 residents were included in the tool and had a completed ABST evaluation. Not all resident ABST evaluations had been updated at least quarterly in the tool.

A review of the ABST indicated the following:

·Day shift: Willow 2.17, Redwood 1.93, Cedar 1.24, Birch 2.09, Aspen 1.96, Cascade 1.24, Diamond Peak 1.75, Mt Vernon 0.90, Mt Hood 1.70 staff needed.

·Swing shift: Willow 0.12, Redwood 1.40, Cedar 0.91, Birch 0.52, Aspen 1.07, Cascade 0.74, Diamond Peak 1.16, Mt Vernon 0.66, Mt Hood 1.16 staff needed.

·Nigh shift: Willow 1.12, Redwood 0.19, Cedar 0.19, Birch 1.10, Aspen 0.24, Cascade 0.35, Diamond Peak 0.66, Mt Vernon 0.16, Mt Hood 0.46 staff needed.

A review of the posted staffing plan and staffing schedules for 09/25/24 through 10/31/24 indicated the following:

·Day shift: two universal workers (for each home)

·Swing shift: two universal workers, one lead direct care staff (for each home)

·Night shift: one universal worker (for each home)

·The facility was not staffing per the posted staffing plan and tool.

·The facility had six residents requiring two-person assistance with transferring, rolling, or sit to stand and was only scheduling one staff in each home on night shift for Cedar, Diamond, Redwood, and Willow homes.

In an interview on 10/31/24, Staff 1 (Executive Director) stated the following:

·The facility was using the state ABST.

·The tool generated a 24-hour staffing plan.

·The tool was updated with service plan updates, new move-ins, and change of condition.

·The facility had floats and shift supervisors that could go around between the nine homes.

·The facility was calculating their ABST hours by dividing by twelve hours or taking an average, even though they had staff working eight hours and 4 hour shifts as well.

Findings were reviewed with and acknowledged by Staff 1 during phone call on 11/05/24.

It was confirmed the facility failed to have a fully implemented and updated ABST.

Based on interview and record review, conducted during a site visit on 10/31/24, it was determined the facility failed to have a fully implemented and updated Acuity Based Staffing Tool (ABST). Findings include, but are not limited to:

A review of the facility's ABST and resident roster indicated all 89 residents were included in the tool and had a completed ABST evaluation. Not all resident ABST evaluations had been updated at least quarterly in the tool.

A review of the ABST indicated the following:

·Day shift: Willow 2.17, Redwood 1.93, Cedar 1.24, Birch 2.09, Aspen 1.96, Cascade 1.24, Diamond Peak 1.75, Mt Vernon 0.90, Mt Hood 1.70 staff needed.

·Swing shift: Willow 0.12, Redwood 1.40, Cedar 0.91, Birch 0.52, Aspen 1.07, Cascade 0.74, Diamond Peak 1.16, Mt Vernon 0.66, Mt Hood 1.16 staff needed.

·Nigh shift: Willow 1.12, Redwood 0.19, Cedar 0.19, Birch 1.10, Aspen 0.24, Cascade 0.35, Diamond Peak 0.66, Mt Vernon 0.16, Mt Hood 0.46 staff needed.

A review of the posted staffing plan and staffing schedules for 09/25/24 through 10/31/24 indicated the following:

·Day shift: two universal workers (for each home)

·Swing shift: two universal workers, one lead direct care staff (for each home)

·Night shift: one universal worker (for each home)

·The facility was not staffing per the posted staffing plan and tool.

·The facility had six residents requiring two-person assistance with transferring, rolling, or sit to stand and was only scheduling one staff in each home on night shift for Cedar, Diamond, Redwood, and Willow homes.

In an interview on 10/31/24, Staff 1 (Executive Director) stated the following:

·The facility was using the state ABST.

·The tool generated a 24-hour staffing plan.

·The tool was updated with service plan updates, new move-ins, and change of condition.

·The facility had floats and shift supervisors that could go around between the nine homes.

·The facility was calculating their ABST hours by dividing by twelve hours or taking an average, even though they had staff working eight hours and 4 hour shifts as well.

Findings were reviewed with and acknowledged by Staff 1 during phone call on 11/05/24.

It was confirmed the facility failed to have a fully implemented and updated ABST.