Based on interview and record review, conducted during a site visit on 07/30/24, it was confirmed the facility failed to provide a daily program of social and recreational activities for 2 of 2 sampled residents (#s 1 and 2). Findings include, but are not limited to:

During an interview on 07/30/24, Staff 1 (Executive Director) indicated during the timeframe of the complaint the activities director had to go on leave for surgery. There had been no one covering for activities while s/he was out resulting in the facility canceling activities. Staff 4 (Activities Director) had been out for about 3 weeks. Staff 1 also indicated s/he had been working with Staff 4 to improve the activities program.

During separate interviews on 07/30/24, Residents 1 and Resident 2 indicated they do not attend activities at the facility because they are boring and not engaging.

A review of Staff 4's performance improvement notifications dated 01/05/24 and 07/15/24 indicated Staff 4 received a verbal and written warning for his/her inability to provide social and recreational activities for the residents.

A review of the activities calendar indicated the activities on 07/30/24 we as follows;

·10:00 AM- Morning exercise.

·11:00 AM-Corner Kitchen.

·12:00 PM- Lunchtime trivia.

·2:00 PM- Bingo.

·3:30 PM- Wii Games.

On 07/30/24, the findings were reviewed with and acknowledged by Staff 1.

It was determined the facility failed to provide a daily program of social and recreational activities.

Verbal plan of correction: Staff 1 will continue to work with Staff 4 to improve the activities program.

Based on interview and record review, conducted during a site visit on 07/30/24, it was confirmed the facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to:

In an interview on 07/30/24, Staff 1 (ED) indicated no knowledge of the average call light response time, however, indicated the standard was to answer within 5 minutes.

A review of call light history from 05/09/24 through 05/13/24 indicated 94 call light response times that exceeded 15 minutes and of those, 61 response times exceeded 20 minutes. The longest response time had been 50 minutes.

A review of call light history from 07/26/24 through 07/28/24 indicated 46 call light response times that exceeded 15 minutes and of those, 33 response times had exceeded 20 minutes. The longest response time had been 87 minutes.

It was confirmed the facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident.

On 07/30/24, the findings were reviewed with and acknowledged by Staff 1.

Verbal plan of correction: Staff 1 will start auditing call lights and have meetings with staff when call lights have exceeded regular response times.

Based on interview and record review, conducted during a site visit on 07/30/24, it was confirmed the facility failed to update an acuity-based staffing tool (ABST). Findings include, but are not limited to:

On 07/30/24, the facility's ABST was reviewed, and the staffing levels generated indicated the facility required three staff on day shift, two care staff on swing shift, and one care staff on night shift. There were 36 of 38 residents' profiles that had not been updated quarterly.

The posted staffing plan indicated the following staffing levels:

·Day shift: two caregivers and one med tech.

·Swing shift: two caregivers and one med tech.

·Night shift: one caregiver and one med tech.

In an interview on 07/30/24, Staff 1 (Executive Director) indicated the facility had been using the ODHS ABST. Staff acknowledged the residents who had not been updated quarterly.

It was confirmed the facility failed to update an acuity-based staffing tool.

On 07/30/24, the findings were reviewed with and acknowledged by Staff 1.

Based on interview and record review, conducted during a site visit on 07/30/24, it was confirmed the facility does not take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. Findings include, but are not limited to:

During an interview on 07/30/24, Staff 1 (ED) indicated the facility was 98 percent cleaned up of the bed bugs and will continue to have the pest control company to come out until there was no more trace of the bugs. S/he indicated the facility is working hard to eliminate this issue.

A review of the pest control invoices indicated the following:

·Invoices from 05/09/24 through 07/09/24 had indicated evidence of active bed bugs.

·On 07/09/24 pest control inspected rooms 202 through 204 and found no evidence of active bed bugs. Facility requested they look at rooms 205 and 213 where no current bed bugs had been found.

·On 07/16/24 and 07/23/24 pest control inspected rooms 202, 203, and 204. No activity of bed bugs had been indicated in rooms 202 or 204. In room 203 pest control found one single juvenile bed bug and removed the bug.

·It was determined the facility does take measures to prevent the entry of rodents, flies, mosquitoes, and other insects.

It was confirmed the facility does not take measures to prevent the entry of rodents, flies, mosquitoes, and other insects.

On 07/30/24, the findings were reviewed with and acknowledged by Staff 1.

Verbal plan of correction: The facility has a pest company coming out to treat the bed bugs and will continue the treatments until the facility and resident no longer has them.