Print Inspection: 8ERW

The findings of the on-site investigation, conducted 09/17/24 through 09/18/24 are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 and Division 57 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, conducted during a site visit on 03/18/25, the facility's failure to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident was substantiated for 2 of 2 sampled residents (#s 4 and 5). Findings include, but are not limited to:

The facility's posted staffing plan was:

Day shift: two med techs and two caregivers;

Evening shift: two med techs and two caregivers; and

Night shift: one med tech and one caregiver.

The facility's staff schedule, dated 06/30/23 through 07/13/23, indicated 52 shifts where the facility did not schedule to their posted staffing plan.

Call light logs for resident's 4 and 5, dated 07/03/23 through 07/10/23, indicated four instances of call lights longer than 15 minutes.

Staff 6 (Resident Care Coordinator) stated call lights were supposed to be answered within seven minutes.

Resident 5 stated s/he waited 15 to 20 minutes for calls "on a good day," and had been left in the restroom so long his/her legs fell asleep.

It was determined 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 of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 2 (Regional Director of Operations).

Based on interview and record review, conducted during a site visit on 03/18/25, the facility's failure to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident was substantiated for 1 of 1 sampled resident (# 6). Findings include, but are not limited to:

The facility's posted staffing plan indicated:

Day shift: two med techs and two caregivers;

Evening shift: two med techs and two caregivers; and

Night shift: one med tech and one caregiver.

The facility's staff schedule, dated 02/11/24 through 02/17/24, indicated 12 shifts where the facility did not schedule to their posted staffing plan.

Call light logs for Resident 6, dated 02/11/24 through 02/18/24, indicated six instances of call lights longer than 15 minutes.

Staff 6 (Resident Care Coordinator) stated call lights were supposed to be answered within seven minutes.

Resident 6 was unavailable for interview.

It was determined 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 of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 2 (Regional Director of Operations).

Based on interview and record review, conducted during a site visit on 03/18/25, the facility's failure to fully implement and update an acuity-based staffing tool (ABST) was substantiated. Findings include, but are not limited to:

The facility's census was 44.

24 out of 44 residents were not updated quarterly as required.

Staff 6 (Resident Care Coordinator) stated s/he was behind on updating the facility's ABST.

It was determined the facility's failure to implement and update an ABST was substantiated.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 2 (Regional Director of Operations).