Print Inspection: ENLW

The findings of the on-site investigation, conducted 12/13/2023, 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 and interview, conducted during a site visit on 12/13/23, it was confirmed the facility failed to have the current staffing plan posted. Findings include, but are not limited to:

On 12/13/23, CS observed no posted staffing plan in buildings 910, 920, and 940. CS observed in building 950 there was an old staffing plan posted which did not reflect the facility's ABST generated staffing plan.

During an interview on 12/13/23, Staff 1 (ED) stated, "I removed the posted staffing plans back in August and did not replace them."  

It was confirmed the facility failed to have a current staffing plan posted.

On 12/13/23, the findings were reviewed with and acknowledged by Staff 1.

Verbal plan of correction: Staff 1 will create and post the required posted staffing plan by the end of the day on 12/13/2023.

Based on observation, interview, and record review, during a site visit conducted on 12/13/23, it was confirmed the facility failed to have service plans readily available to staff. Findings include, but are not limited to:

During an interview on 12/13/23, Staff 1 (ED) acknowledged that not all residents current service plans had been added into the service plan binders and had not been readily available to all staff.

A review of the service plan binders matched with the resident roster indicated the service plan binder contained a service plan for all residents, but for ten of those residents, the most recent service plan was not available to staff.

On 12/13/23, CS observed on Staff 1's computer, all residents to have current quarterly service plans.

It was confirmed the facility failed to have a residents most recent service plans readily available to staff.

On 12/13/23, the findings were reviewed with and acknowledged by Staff 1.

Verbal plan of correction: The RCC will update the service plan binders to reflect all residents current service plans.

Based on interview and record review, conducted during a site visit on 12/13/23, 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. Findings include, but are not limited to:

In separate interviews on 12/13/23, staff members stated the following:

• "The call light system was down for about a week resulting in call lights not having been answered."  
• "Call lights not being answered timely has been an ongoing issue at the facility."
• "Multiple staff call out to their shifts and their shifts are not covered."  
• "Staff have to work through their lunches due to not having enough staff on the floor."  
• "Staff are often asked to float from one building to another."   
• "Resident needs have been missed, such as showers and timely toileting needs."  
• " There are no staffing plans posted in any building at the moment. "  

During an interview on 12/13/23, Staff 1 (ED) stated the facility currently staffed with the following:

• Buildings 910 and 920 are each staffed with one CG and one MT on day, swing, and night shifts, and the night shift MT oversees all four buildings.
• Buildings 940 and 950 are each staffed with two CGs and one MT on day and swing shift; and one CG and one MT who oversees all four buildings at once on night shift.

A review of the call light log, dated 09/12/23, indicated 26 call light response times that had exceeded 20 minutes. 14 of those response times had exceeded 60 minutes.

A review of the CG and MT schedules, dated 08/01/23 through 10/31/23, indicated several open uncovered shifts.

A review of timecards, dated 08/14/23 and 09/12/23, indicated the facility was short staffed for swing and night shift.

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.

On 12/13/23, the findings were reviewed with and acknowledged by Staff 1.

Verbal plan of correction: The facility has been hiring 3-6 people per month and will continue to hire. The facility had issues with their call light system that has been resolved.

Based on observation, interview, and record review, conducted during a site visit on 12/13/23, it was confirmed the facility failed to adopt an acuity-based staffing tool (ABST) to determine appropriate staffing levels for the facility. Findings include, but are not limited to:

On 12/13/23, CS observed no posted staffing plan in buildings 910, 920, and 940. In building 950 posted was an old staffing plan which did not reflect the facility's ABST generated staffing plan.

During an interview on 12/13/23, Staff 1 (ED) stated the facility currently staffed with the following:

• Buildings 910 and 920 are each staffed with one CG and one MT on day, swing, and night shifts, and the night shift MT oversees all four buildings.
• Buildings 940 and 950 are each staffed with two CGs and one MT on day and swing shift; and one CG and one MT who oversees all four buildings at once on night shift.

During separate interviews, Staff 2 (CG) and Staff 5 (MT) stated the facility had been short staffed, often pulling staff from one building to another. Staff 2 stated, "There are many open shifts on the schedule that do not get filled. When staff are scheduled, there are frequent call outs."  

A review of the CG and MT schedules, dated 08/01/23 through 10/31/23, indicated several open shifts for every or every other day. The facility was not consistently staffing to the staffing hours generated in the ABST.

The facility's ABST indicated the following staffing levels are required to meet the scheduled needs of residents:

·Building 910 and 920 (assisted living):

oDay: 2 care staff in each building.

oSwing 2 care staff in each building.

oNight: 1 care staff in each building.

·Building 940 (memory care):

oDay: 3 care staff.

oSwing 2 care staff.

oNight: 1 care staff.

·Building 950 (memory care):

oDay: 2 care staff.

oSwing 1 care staff.

oNight: 1 care staff.

It was confirmed the facility failed to adopt an acuity-based staffing tool (ABST) to determine appropriate staffing levels for the facility.

On 12/13/23, the findings were reviewed with and acknowledged by Staff 1.