Print Inspection: QXW3

The findings of the on-site investigation, conducted 06/28/23 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

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 interview and record review, conducted during a site visit on 06/28/23,  it was confirmed the facility failed to ensure the implementation of services per resident service plan for 1 of 1 sampled resident (#1). Findings include, but not limited to:

Resident 1's current service plan noted the following:

* "I require complete transfer assist, or use of hoyer or other lift aid";

* "1 person(s) required for this task"; and

* "[Resident] requires the assistance of 2-3 or more staff or a mechanical lift which is not available at the community."

During an interview on 06/28/23, Staff 4 (Medication Technician/Caregiver) stated Resident 1 required assistance from two or three care staff for transfers. Staff 4 indicated it is very difficult to transfer him/her sometimes. Staff 3 RCC Assistant and 5 (RCC) stated their care planning platform auto-populated "1 person is required" for each task and they were unable to change that selection to include more than one staff.

The findings were reviewed with and acknowledged by Staff 2 (Executive Director) on 06/28/23.

The facility failed to ensure the implementation of services per resident service plan.

Facility plan of correction: Staff 2 will reach out to the facilities home office to contact ECP (Care Planning Platform) to change the auto-populated "1 person assistance" selection and allow for accurate reflection of needs.

Based on observation, interview and record review, conducted during a site visit on 06/28/23, it was confirmed the facility failed to have awake qualified direct care staff sufficient in number to meet the scheduled and unscheduled needs of residents for 1 of 1 sampled resident (# 1). Findings include, but not limited to:

Resident 1's current service plan noted Resident 1 required the assistance of two to three or more staff for transfers.

The facility's schedule for 06/01/23 through 06/30/23 revealed only one MT and one CG are scheduled on night shift.

During an interview on 06/28/23, Staff 4 (MT/CG) stated, Resident 1 required two to three people for transfers. Staff 4 further stated  Resident 1 often had to wait 30 or more minutes for help because staff need to find another caregiver to help transfer.

During an observation and interview with Resident 1, s/he stated it often took longer than 20 minutes for help and it was  especially difficult when s/he was left on the toilet. Resident 1 engaged his/her pendant for assistance at 2:10 PM and staff responded to the pendant at 2:27 PM (17 minutes) on 06/28/23.

Call light logs revealed at least 40 instances when Resident 1 waited more than 15 minutes for assistance between 06/01/23 and 06/28/23. Six of those instances were longer than 30 minutes.

The findings were reviewed with and acknowledged by Staff 2 (Executive Director) on 06/28/23.

It was confirmed the facility failed to have awake qualified direct care staff sufficient in number to meet the scheduled and unscheduled needs of residents.

Verbal plan of correction: Staff 2(Executive Director) will review the facilities ABST by end of day on 06/28/23, and include two residents who were not yet entered into BAST. Facility had just hired three new caregivers and continues to hire more staff. Executive Director stated, they will add a half shift to their night shift and an additional person to their swing shift within two weeks. Staff 2 will add people to day shift as able and will audit call light response times weekly beginning 06/30/23.

Based on observation, interview and record review, conducted during a site visit on 06/28/23,  it was confirmed the facility failed to fully implement and update an Acuity-Based Staffing Tool (ABST). Findings include, but not limited to:

Two Caregivers and two Medication Technicians were observed working during day shift on 06/28/23.

A review of the facility's ABST revealed the need for 46.95 hours of care on day shift. Additionally, two unsampled residents  were not included in the facility's ABST.

During an interview on 06/28/23, Staff 2 (Executive Director) agreed the facility's current staffing plan was not consistent with the facility's ABST.

The findings were reviewed with and acknowledged by Staff 2 on 06/28/23.

Verbal plan of correction: Staff 2 will review facility's ABST by end of day on 06/28/23 and include two residents who were not yet entered into the ABST. Staff 2 had just hired three new caregivers and will continue to hire more staff. Executive Director stated they will add a half shift to their night shift and an additional person to their swing shift within two weeks. Staff 2 will add people to day shift as able and will audit call light response times weekly beginning 06/30/23.