- Date
- 9/17/2024
- Report number
- CALMS - 00077549
- Type
- Licensing Violation
- Level
- 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Findings
- Violation 1: Staffing for scheduled and unscheduled needs.
STATEMENT OF FACTS: 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. The facility must staff above ABST time.
CONCLUSION OF LAW: The facility’s failure to provide qualified awake care staff is a violation of the following OARs: 411-054-0070(1)
Violation 2: Acuity-based staffing tool.
STATEMENT OF FACTS: Facilities must select and implement an acuity-based staffing tool (ABST) that is technology-based for determining appropriate staffing levels. Individual resident needs and care elements must be the primary consideration when developing and maintaining an ABST.
CONCLUSION OF LAW: The facility’s failure to fully implement and update an ABST is a violation of the following OARs: 411-054-0037(1)
Violation 3: Staffing training and competencies.
STATEMENT OF FACTS: The facility failed to have a training program that includes methods to determine competency of direct care staff. 1 of 12 caregivers whose documentation was reviewed, had documentation of demonstration of competencies in areas of caregiving.
CONCLUSION OF LAW: The facility’s failure to properly train and determine competencies is a violation of the following OARs: 411-054-0070(2)(a)
Violation 4: Resident services.
STATEMENT OF FACTS: Based on observation and record review, a resident who had orders for a mechanical soft diet due to a diagnosis of aspiration, was observed to be given an uncut porkchop for lunch, which put the resident at risk for aspiration.
CONCLUSION OF LAW: The facility’s failure to provide modified special diets is a violation of the following OARs: 411-054-0030(1)(a)(A)
Violation 5: Facility operation.
STATEMENT OF FACTS: The licensee failed to be responsible for the operation of the facility and the quality of the services rendered in the facility as demonstrated during the licensing investigation.
- Sanction
- ALFNR25-00178 $0 fine assessed