Based on observation, interview, and record review, conducted during a site visit on 08/22/24 and 08/23/24, it was confirmed the facility failed to implement a service plan that reflects the residents' needs for 4 of 5 sampled residents (#s 1, 3, 4, and 5). Findings include, but are not limited to:

A review of Resident 1's service plan, dated 08/20/24, revealed the resident was to be checked and offered toileting assistance four times per shift.

During an observation from 5:57 pm to 9:01 pm, Resident 1 was not toileted.

A review of Resident 3's service plan dated 07/09/24 revealed Resident 3 was to receive assistance with their hearing aides, oral care and was to be assisted to the toilet every two to three hours.

During an observation on 08/22/24, Resident 3:

*was not wearing hearing aides;

*was assisted to bed by Staff 7 (Caregiver) without being provided assistance with oral care; and

*was changed into a new pull-up and was not offered to use the toilet before bed.

A review of Resident 4's service plan dated 06/13/24 revealed Resident 4 was to be checked every two to three hours for incontinence. Resident 4 was to receive a liquid regular diet. Resident 4's service plan did not state to mix all liquids together.

During an observation on 08/22/24 from 4:34 pm to 8:08 pm,  Resident 4 was observed in the common areas of the facility in a geri chair, and was not checked for or provided incontinence care. During the evening meal, Staff 7 was observed mixing four different liquids together including a vanilla protein drink and liquid dinner foods into a cup and feeding them to Resident 4.

A review of Resident 5's service plan dated 08/22/24 revealed Resident 5 had a private caregiver from 7:00 am to 5:00 pm five days/week and facility staff were to assist Resident 5 when the caregiver was not there.

During an observation on 08/23/24 at 6:16 am no staff were observed on the floor. Resident 5 was observed to self-propel into the hall and look both directions. Resident 5 then wheeled back into their room and transferred to the toilet. Resident 5 urinated and then self-transferred back to the wheelchair.

The facility failed to implement a service plan that reflected the residents' needs.

The findings were reviewed with and acknowledged by Staff 1 (Consultant/Executive Director) and Staff 2 (Regional Director of Operations).

Verbal Plan of Correction: An audit of service plans will be completed by next week and service plan updates will occur within 30 days of the 08/23/24 site visit.

Based on observation, interview, and record review, conducted during a site visit on 08/22/24 and 08/23/24, 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 4 of 5 sampled residents (#s 1, 3, 4 and 5). Findings include, but are not limited to:

An observation of the facility's posted staffing plan showed the following:

* Day: four direct care staff, one medication tech

* Evening: four direct care staff, one medication tech.

* Night: two direct care staff, one medication tech.

A review of the facility's ABST revealed the facility required the following staffing hours per shift:

* Day: 78.28 hours

* Evening: 64.4 hours

* Night: 23.5 hours.

In multiple observations throughout the site visit, the call light reader board never showed active call lights for the memory care residents.

In an observation on 08/22/24, Staff 4 (CG) called for transfer assistance at 8:17 pm, but no staff were available to assist because two staff were on lunch breaks, two staff were providing resident care in separate rooms, and the MT had to watch the floor on the other hall.

During an observation from 5:57 pm to 9:01 pm, Resident 1 was not toileted.

A review of Resident 1's service plan, dated 08/20/24, revealed the resident was to be checked and offered toileting assistance four times per shift.

A review of Resident 3's service plan dated 07/09/24 revealed Resident 3 was to receive assistance with their hearing aides, oral care and was to be assisted to the toilet every two to three hours.

During an observation on 08/22/24, Resident 3:

*was not wearing hearing aides;

*was assisted to bed by Staff 7 (Caregiver) without being provided assistance with oral care; and

*was changed into a new pull-up and was not offered to use the toilet before bed.

A review of Resident 4's service plan dated 06/13/24 revealed Resident 4 was to be checked every two to three hours for incontinence. Resident 4 was to receive a liquid regular diet. Resident 4's service plan did not state to mix all liquids together.

During an observation on 08/22/24 from 4:34 pm to 8:08 pm,  Resident 4 was observed in the common areas of the facility in a geri chair, and was not checked for or provided incontinence care. During the evening meal, Staff 7 was observed mixing four different liquids together including a vanilla protein drink and liquid dinner foods into a cup and feeding them to Resident 4. Resident 4 was later observed sleeping in a geri chair in the common area.

In an interview on 08/22/24, Staff 4 (CG) stated they were unable to take Resident 4 to bed because Staff 7 was on their break and Staff 4 had to stay with the residents in the common area.

A review of Resident 5's service plan dated 08/22/24 revealed Resident 5 had a private caregiver from 7:00 am to 5:00 pm five days/week and facility staff are to assist Resident 5 when the caregiver was not there.

During an observation on 08/23/24 at 6:16 am no staff were observed on the floor. Resident 5 was observed to self-propel into the hall and look both directions. Resident 5 then wheeled back into their room and transferred to the toilet. Resident 5 urinated and then self-transferred back to the wheelchair.

In an interview on 08/23/24, Staff 11 (CG) stated the facility was short staffed for day shift on 08/23/24.

In an interview on 08/23/24, Staff 5 (CG) stated that the facility "always had a problem with staffing."

In an interview on 08/23/24, Staff 6 (CG) stated they believed the facility's day shift staffing plan was not enough staff "to provide fair and quality care to the residents."

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 were reviewed with and acknowledged by Staff 1 (Consultant/Executive Director) and Staff 2 (Regional Director of Operations) on 08/23/24.

Verbal Plan of Correction: The facility will use Avastaff (Avamere Agency) to staff to current ABST hours until they get all of the service plans and ABST up to date.

Based on observation, interview, and record review, conducted during a site visit on 08/22/24 and 08/23/24, it was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool. Findings include, but are not limited to:

In an interview, Staff 1 (Consultant/Executive Director) stated the following:

* The facility used the ODHS tool.

* S/he was not able to access the tool.

* The tool was "out of compliance."

* Multiple residents were missing from the tool.

* The tool was updated when changes to service plans occurred but not with admissions or changes of condition.

In an interview, Staff 2 (Resident Care Coordinator) stated the facility's posted staffing plan was what the facility "always used" and was based on a 1:7 staff member to resident ratio.

A review of the facility's ABST revealed the following:

* Two residents were missing from the tool.

* Seven residents' profiles, including sampled Residents 1 and Resident 2,  had not been updated in the last quarter.

* Day shift required 78.28 staffing hours.

* Evening shift required 64.4 staffing hours.

* Night shift required 23.5 staffing hours.

*Resident 3's ABST profile was not reflective of their current needs.

An observation of the facility's posted staffing plan showed the following:

* Day: four direct care staff, one medication tech.

* Evening: four direct care staff, one medication tech.

* Night: two direct care staff, one medication tech.

Observations of staff working during the site visit included:

* Thursday evening shift: 4 CG and 1 MT working. (37.5 hours);

* Thursday night shift  2 CG  and 1 MT (22.5 hours )

* Friday day shift:  3 CG, 1 MT + someone at 8 am (28.5 hours)

During the site visit the following unmet needs of residents were observed:

In an observation on 08/22/24, Staff 4 (CG) called for transfer assistance at 8:17 pm, but no staff were available to assist because two staff were on lunch breaks, two staff were providing resident care in separate rooms, and the MT had to watch the floor on the other hall.

A review of Resident 1's service plan, dated 08/20/24, revealed the resident was to be checked and offered toileting assistance four times per shift.

During an observation from 5:57 pm to 9:01 pm, Resident 1 was not toileted.

A review of Resident 3's service plan dated 07/09/24 revealed Resident 3 was to receive assistance with their hearing aides, oral care and was to be assisted to the toilet every two to three hours.

During an observation on 08/22/24, Resident 3:

*was not wearing hearing aides;

*was assisted to bed by Staff 7 (Caregiver) without being provided assistance with oral care; and

*was changed into a new pull-up and was not offered to use the toilet before bed.

A review of Resident 4's service plan dated 06/13/24 revealed Resident 4 was to be checked every two to three hours for incontinence. Resident 4 was to receive a liquid regular diet. Resident 4's service plan did not state to mix all liquids together.

During an observation on 08/22/24 from 4:34 pm to 8:08 pm,  Resident 4 was observed in the common areas of the facility in a geri chair, and was not checked for or provided incontinence care. During the evening meal, Staff 7 was observed mixing four different liquids together including a vanilla protein drink and liquid dinner foods into a cup and feeding them to Resident 4. Resident 4 was later observed sleeping in a geri chair in the common area.

In an interview on 08/22/24, Staff 4 (CG) stated they were unable to take Resident 4 to bed because Staff 7 was on their break and Staff 4 had to stay with the residents in the common area.

A review of Resident 5's service plan dated 08/22/24 revealed Resident 5 has a private caregiver from 7:00 am to 5:00 pm five days/week and facility staff are to assist Resident 5 when the caregiver was not there.

During an observation on 08/23/24 at 6:16 am no care staff were observed on the floor. Resident 5 was observed to self-propel into the hall and look both directions. Resident 5 then wheeled back into their room and transferred to the toilet. Resident 5 urinated and then self-transferred back to the wheelchair.

In an interview on 08/23/24, Staff 11 (CG) stated the facility was short staffed for day shift on 08/23/24.

In an interview on 08/23/24, Staff 5 (CG) stated that the facility "always had a problem with staffing."

In an interview on 08/23/24, Staff 6 (CG) stated they believed the facility's day shift staffing plan was not enough staff "to provide fair and quality care to the residents."

The facility failed to fully implement and update an Acuity-Based Staffing Tool.

The findings were reviewed with and acknowledged by Staff 1 and Staff 2 (Regional Director of Operations).