Print Inspection: I5DO

The findings of the on-site investigation, conducted 10/18/23 through 10/19/23 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, conducted during a site visit from 10/18/23 to 10/19/23,  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 for 2 of 2 sampled residents (#s 6 and 7). Findings include, but are not limited to:

The facility's posted staffing plan indicated the need for the following staff:

RCF:

Day: 3 CG, 2 MT;

Evening: 2 CG, 2 MT; and

Night: 2 CG, 1 MT.

Memory Care:

Day: 2 CG, 1 MT;

Evening: 2 CG, 1 MT; and

Night, 1 CG, 1 MT.

2 MT and 1 CG were observed working in the RCF portion on the facility on day shift 10/19/23.

A review of the facility's staff schedules for October 2023 revealed the facility is not consistently staffed to their posted staffing plan.

During an observation and interview on 10/19/23, Resident 6 waited 52 minutes for a response to his/her call light.

A review of Resident 6's call light logs for the prior 30 days revealed at least 11 other incidences when s/he waited over 25 minutes for his/her call light to be answered.

During an interview on 10/19/23, Resident 6 stated sometimes s/he has to wait so long to get assistance that s/he soils his/herself before staff arrive.

A review of Resident 7's call light logs for the prior 30 days revealed at least 4 occasions when s/he waited over 25 minutes for a call light to be answered.

During an interview on 10/18/23, the Compliance Specialist was notified of an incident on night shift in June 2023 when a single staff member was working in the locked memory care portion of the facility and the building's smoke alarms went off, causing the exit doors to remain unlocked. Staff 5 stated that all residents were woken up and that s/he was left to care for all memory care residents alone, and was unable to monitor both exit doors at the same time. One exit door leads to the street.

The findings were reviewed with and acknowlegded by Staff 1 (Executive Director) and Staff 12 (RN).

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.

Verbal plan of correction: Staffing had been a focus since new ED started. They have a brand new RCC, 10/19/23 was her first day shadowing. Hiring is ongoing. They have updated job postings, offering sign-on bonus and referral bonus. The facility just hired two new caregivers that will start training on the floor that week and just hired another CG the morning of 10/19/23. ED emailed a sister facility to see if they have anyone who needed extra hours. They had a couple people out on leave.

Based on interview and record review, conducted during a site visit from 10/18/23 to 10/19/23, it was confirmed the facility failed to ensure that staff have sufficient communication and language skills. Findings include, but are not limited to:

During the site visit on 10/19/23, Compliance Specialist attempted to interview Staff 6 (CG) who was unable to understand and answer the questions asked in English.

An incident investigation dated 10/09/23 stated "Appears to be a language barrier [with Staff 6] as evidence by interviewer need to repeat and explain questions."

The findings were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 12 (RN) on 10/19/23.

It was confirmed the facility failed to ensure that staff have sufficient communication and language skills.

Verbal plan of correction: During hiring process now they do their best to verify that individuals speak and understand English. RN now responsible for interviewing care staff. Former RCC spoke Spanish and would interview staff in Spanish if needed and hire them. Facility stated they would implement oversight of Spanish-speaking staff to ensure they were able to communicate with residents and would review facility's tuition-reimbursement program if staff want to take English classes.