Print Inspection: MSWX

The findings of the on-site investigation, conducted on 06/15/23 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

Notes on Abbreviations:

"The abbreviations listed above can be used in the report without identifying the abbreviation within the report itself.

"Residents will be identified by "Resident 1", "Resident 2" etc, do not abbreviate.

"Staff will be identified by "Staff 1", "Staff 2" etc. do not abbreviate.

"If you introduce an abbreviation in the report, make sure it is a word that has a standard abbreviation associated with it and that it needs to be abbreviated. You don't need to abbreviate a word that you only use once in a report.

Based on interview and record review, conducted during a site visit on 06/15/23, 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 1 of 1 sampled (#1). Findings include, but not limited to:

On 02/23/23, Witness 1 stated in the complaint, on 12/04/22 around 9:00 pm the pull cord in Resident 1's bathroom was pulled, no one came for almost 45 minutes.

In an interview on 06/15/23, Staff 1 stated the expectation for call light response time was less than15 minutes.

A review of Resident 1's call history on 12/04/22, indicated at 8:55 pm the call light went off in Resident 1's room and went unanswered for 46 minutes. An additional review of Resident 1 call history between 11/03/22-11/05/22, indicated 10 occurrences where the call light exceeded the 15-minute response time. Four times where the call light was not answered for over an hour.

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 06/15/23, the findings were reviewed with and acknowledged by Staff 1(Executive Director).

Verbal plan of correction: Staff 1 stated that this occurrence happened back in December 2022 and the call lights have improved since then.

Based on interview and record review, conducted during a site visit on 06/15/23, it was confirmed the facility failed to implement and update an acuity-based staffing tool (ABST). Findings include, but are not limited to:

On 06/15/23, the facility's ABST was reviewed, and the staffing levels generated indicated the facility required nine care staff on day shift, seven care staff on swing shift, and two care staff on night shift. There were 14 residents' profiles that had not been updated quarterly.

A review of the posted staffing plan indicated for day and swing shift there are to be four CG and one MT scheduled and on NOC shift there are to be two CG and one MT.

In an interview on 06/15/23, Staff 1 (Executive Director) stated the facility is using the ODHS ABST. S/He was unable to demonstrate how the hours were calculated to determine the facility's staffing levels. The facility is home to 45 residents. Staff 1 explained there are two wings of the building and on day and swing shift there are two CG on each wing and one shared MT. On NOC shift there are two CG with one on each wing and one shared MT. Staff 1 stated s/he does not know how to convert their staffing levels using the acuity-based staffing tool and the facility is staffing to what their corporate office tells them they are budgeted for.

The facility failed to implement and update an acuity-based staffing tool.

On 06/15/23, the findings were reviewed with and acknowledged by Staff 1.

Verbal plan of correction: CS showed Staff 1 how to calculate hours needed based on the ABST tool. Staff 1 will reach out to OPA and CAC for ABST to further understand the tool within the month.