Based on interview and record review, conducted during a site visit from 05/21/24 to 05/22/24, it was determined that 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 4 of 4 sampled resident (#s 4, 7, 8 and 9). Findings include, but are not limited to:

During a joint interview on 05/21/24 with Staff 1 (Executive Director) and Staff 14 (Cook), they stated:

·Residents were required to use their call buttons to be assisted from the dining room when finished with their meals;  

·Staff were not allowed to press call buttons on behalf of residents; and

·Kitchen staff had observed residents waiting in the dining room for over 30 minutes for staff assistance.

Resident's 4, 7, 8, and 9's service plans indicated they were to receive assistance to and from meals.

Call light logs indicated:

·Resident 4's dated 07/01/23-07/31/23:

o2 call lights exceeded 10 minutes at Breakfast.

o3 call lights exceeded 10 minutes at Lunch.

·Resident 7's, dated 12/28/23-01/15/24:

o7 call lights exceeded 10 minutes at Breakfast.

o4 call lights exceeded 10 minutes at Lunch.

o1 call light exceeded 10 minutes at Dinner.

·Resident 8's, dated 07/01/23-07/22/23:

o1 call light exceeded 10 minutes at Breakfast.

o1 call light exceeded 10 minutes at Lunch.

o1 call light exceeded 10 minutes at Dinner.

·Resident 9's, dated 07/02/23-07/30/23:

o1 call light exceeded 10 minutes at Breakfast.

o1 call light exceeded 10 minutes at Lunch.

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.

The findings of the investigation were reviewed with and acknowledged by Staff 1 on 05/22/24.

Verbal Plan of Correction:

Staff 1 will continue to communicate to caregivers and medication technicians the importance of responding to call lights timely. Staff will utilize the Meal Attendance Tracking Form to monitor which residents require assistance after meals to ensure timely transfers from the dining room.