Print Inspection: XJVD

The findings of the on-site investigation, conducted 05/17/2023 through 05/17/2023, 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, OARs 411 Division 57 for Memory Care Communities.

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

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 observation, interview, and record review, it was confirmed the facility failed to implement and update an acuity-based staffing tool (ABST). Findings include, but are not limited to:  

The facility's ABST was reviewed on 05/17/23 and discussed with Staff 1 who explained the tool they used is Eldermark. S/He showed CS their acuity tool to determine care staff needed but was unable to demonstrate how the hours were calculated to determine the facility's staffing levels. The tool did not address all 22 ADLs for each resident and the amount of staff time needed to provide care.   

In an interview on 05/17/23 at 10:45am, Staff 1 explained the facility staffing per shift, stating that there are two wings of the building. On day and swing shift there are six CG with three on each side of the building and one shared MT. On NOC shift there are two CG, one on each side of the building and one shared MT. Staff 1 stated that the facility has 13 residents who require the assistance of two staff persons for transfers.   

CS observed the posted staffing plan to have been created on 12/20/22. The posted staffing plan indicated that for day and swing shift to schedule three-to-four CG and one MT. On NOC shift there is one CG, one MT, and one universal worker.   

The facility failed to implement and update an acuity-based staffing tool that addressed all the 22 activities of daily living (ADLs) for each resident and the amount of staff time needed to provide care and, as a result, the facility's acuity-based staffing tool does not reflect the correct care time for each resident.   

On 05/17/23, the findings were reviewed with and acknowledged by Staff 1 (Executive Director).  

Verbal plan of correction: Not provided.