The findings of the on-site investigation, conducted 10/14/24, 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

Based on observation and interview, conducted during a site visit on 10/14/24, it was confirmed the facility failed to provide three daily nutritious, palatable meals with snack available seven days a week. Findings include, but are not limited to:

·At 8:16 am on 10/14/24, breakfast had just been served in Flower House, an unsampled residents eggs temped at 106 Fahrenheit;

·At 8:24 am on 10/14/24, pans covered with foil were sitting on the counter in the kitchenette of River House;

·At 8:40 am on 10/14/24, breakfast was served in River House and the temperature of the egg was taken at 117 Fahrenheit;

·At 10:50 am on 10/14/24, staff were observed getting Resident 7 out of bed for the morning, staff were overheard asking where Resident 7's breakfast was. Staff fed Resident 7 an applesauce for breakfast;

·At 12:11 pm lunch was delivered to the kitchenette in Mountain House. Staff were observed taking temperatures of the food which were as follows:

oStuffing - 119 Fahrenheit

oTurkey - 119 Fahrenheit

oBrussel sprouts - 120 Fahrenheit

oSoup - 140 Fahrenheit

·The food was not observed to be microwaved before being served to residents.

In interviews on 10/14/24, residents stated the following:

·The food was good, but cold;

·No one offered to reheat meals;

·Food was cold, s/he doesn't eat much and doesn't eat a lot of breakfast here;

·The food was basic, but usually cold, all meals were cold; and

·Occasionally s/he has had to ask staff to reheat the food.

In an interview on 10/14/24, Staff 8 (Caregiver) stated Resident 7 did not get breakfast and only received an applesauce.

The facility failed to provide three daily nutritious, palatable meals with snack available seven days a week.

The findings were reviewed with and acknowledged by Staff 2 (Regional Director of Operations) and Staff 3 (Director of Nursing) on 10/14/24.

Facility Plan of Correction:

All culinary staff were re-educated on temperature checks and recordings, flow of dishing to ensure food remains consistent temperature by the Culinary Services Director on 10/15/2024. Culinary Director or designee will review procedure and checklist/temp logs twice a week for four weeks, weekly for four weeks and then periodically for one month to maintain compliance.

Based on interview and record review, conducted during a site visit on 10/14/24, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (# 5). Findings include but not limited to the following:

A review of Resident 5's signed physician orders, dated 07/16/24, 07/01/24 - 07/31/24 MAR and Medication Error Report indicated the following:

·Risperidone (a psychotropic medication) 0.5 mg tab, take 1.5 tabs by mouth twice daily;

·MAR indicated Risperidone was given as prescribed; and

·On 07/21/24 - 07/25/24 Resident 5's 8:00 pm doses of Risperidone were given at the incorrect dosage, according to Medication Error Report.

In an interview on 10/14/24, Staff 5 (Med tech) stated s/he was aware there were issues with Resident 5's Risperidone dosage, but was unfamiliar with the details.

In an interview on 10/14/24, Staff 3 (Director of Nursing) stated s/he was the person that caught the medication error for Resident 5. Resident 5's Risperidone came in a 0.5 mg card and a 0.25 mg card and the full dose to be given was one from each card. During his/her audit s/he discovered multiple doses of the 0.25 mg had not been given.

The facility failed to carry out medication and treatment orders as prescribed.

The findings were reviewed with and acknowledged by Staff 2 (Regional Director of Operations) and Staff 3 on 10/14/24.

Facility Plan of Correction:

1.Clinical meeting will continue to be held Monday through Friday of each week. Mandatory Attendees are the Health Services Director, Continuous Quality Improvement nurse, ED. Other attendees that rotate via electronic methods are the Regional Director of Health Services, Regional Director of Operations, Vice President of Clinical Operations. During this meeting the med pass exception report and the med pass report are pulled daily (for 72 hours over the weekend when the meeting is on Monday). The Continuous Quality Improvement nurse or designee will follow up on any medications not available by calling the physician, pharmacy, or responsible party, and will provide an updated report to the regional and corporate team 5 days a week to track follow up on medication arrivals.

2.All med techs were to be re-educated by the Continuous Quality Improvement  nurse or designee by Tuesday October 22, 2024 on the medication re-ordering policy and process.

3.The Continuous Quality Improvement  nurse or designee was to complete weekly cart audits and follow up on identified items for four weeks, then every other week for four weeks, and monthly for one month or until substantial compliance is achieved. The Results of these audits will be reported at the monthly Continuous Quality Improvement  meeting.

4.The community was to complete a MAR to cart audit done by Omnicare pharmacy by 10/22/2024. The Continuous Quaility Improvement nurse or designee was to follow up with any recommendations made from this report within one week of receiving the report.

Based on interview and record review, conducted during a site visit on 10/14/24, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (# 1). Findings include but not limited to the following:

A review of Resident 1's signed admitting physician orders, dated 07/16/24, and 07/01/24 - 07/31/24 MAR indicated the following:

·Lidocaine 5% patch (for pain), with instructions to place 1 patch onto the skin daily, keep applied for 12 hours then remove for 12 hours. Medication had two refills remaining.

·On 07/24/24 and 07/25/24 Lidocaine patch was marked as medication not available.

In an interview on 10/14/24, Staff 3 (Director of Nursing) stated when Resident 1 moved-in to facility the facility pharmacy should have been set up to start auto-filling medications, but did not.

The facility failed to carry out medication and treatment orders as prescribed.

The findings were reviewed with and acknowledged by Staff 2 (Regional Director of Operations) and Staff 3 on 10/14/24.

Facility Plan of Correction:

1.Clinical meeting will continue to be held Monday through Friday of each week. Mandatory Attendees are the Health Services Director, Continuous Quality Improvement nurse, ED. Other attendees that rotate via electronic methods are the Regional Director of Health Services, Regional Director of Operations, Vice President of Clinical Operations. During this meeting the med pass exception report and the med pass report are pulled daily (for 72 hours over the weekend when the meeting is on Monday). The Continuous Quality Improvement nurse or designee will follow up on any medications not available by calling the physician, pharmacy, or responsible party, and will provide an updated report to the regional and corporate team 5 days a week to track follow up on medication arrivals.

2.All med techs were to be re-educated by the Continuous Quality Improvement  nurse or designee by Tuesday October 22, 2024 on the medication re-ordering policy and process.

3.The Continuous Quality Improvement  nurse or designee was to complete weekly cart audits and follow up on identified items for four weeks, then every other week for four weeks, and monthly for one month or until substantial compliance is achieved. The Results of these audits will be reported at the monthly Continuous Quality Improvement  meeting.

4.The community was to complete a MAR to cart audit done by Omnicare pharmacy by 10/22/2024. The Continuous Quaility Improvement nurse or designee was to follow up with any recommendations made from this report within one week of receiving the report.

Based on interview and record review, conducted during a site visit on 10/14/24, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (# 2). Findings include, but are not limited to:

A review of Resident 2's signed physician orders dated 06/03/24 and 07/01/24 - 07/31/24 MAR indicated the following:

·Quetiapine 25 mg tablet (Psychotropic medication), take 0.5 tablets (12.5 mg total) by mouth at bedtime; and

·On 07/24/24 and 07/25/24 the medication was marked as "Medication not available."

In an interview on 10/14/24, Staff 5 (Med Tech) stated staff are supposed to reorder medications when there are seven days remaining, but many med techs were newer and didn't know when to order. When a resident runs out of medications staff are to document "medication not available and medication ordered". Staff 5 was unsure if Resident 5's quetiapine had been reordered prior to him/her ordering it on 07/24/24.

The facility failed to carry out medication and treatment orders as prescribed.

The findings were reviewed with and acknowledged by Staff 2 (Regional Director of Operations) and Staff 3 on 10/14/24.

Facility Plan of Correction:

1.Clinical meeting will continue to be held Monday through Friday of each week. Mandatory Attendees are the Health Services Director, Continuous Quality Improvement nurse, ED. Other attendees that rotate via electronic methods are the Regional Director of Health Services, Regional Director of Operations, Vice President of Clinical Operations. During this meeting the med pass exception report and the med pass report are pulled daily (for 72 hours over the weekend when the meeting is on Monday). The Continuous Quality Improvement nurse or designee will follow up on any medications not available by calling the physician, pharmacy, or responsible party, and will provide an updated report to the regional and corporate team 5 days a week to track follow up on medication arrivals.

2.All med techs were to be re-educated by the Continuous Quality Improvement  nurse or designee by Tuesday October 22, 2024 on the medication re-ordering policy and process.

3.The Continuous Quality Improvement  nurse or designee was to complete weekly cart audits and follow up on identified items for four weeks, then every other week for four weeks, and monthly for one month or until substantial compliance is achieved. The Results of these audits will be reported at the monthly Continuous Quality Improvement  meeting.

4.The community was to complete a MAR to cart audit done by Omnicare pharmacy by 10/22/2024. The Continuous Quaility Improvement nurse or designee was to follow up with any recommendations made from this report within one week of receiving the report.

Based on observation, interview, and record review, conducted during a site visit on 10/14/24, the facility's failure to fully implement and update an acuity-based staffing tool (ABST) for 1 of 3 sampled resident (# 3) was substantiated. Findings include, but are not limited to:

The facility implemented the ODHS ABST. All residents had a completed ABST evaluation, the census was 46, all sampled residents' ABST profiles were reviewed and updated at required times, and 2 of 3 sampled residents (#s 1 and 2) service plans accurately captured care needs and were reflected in the ABST evaluation. Deficiencies identified were Resident 3's service plan and ABST evaluation which did not accurately capture his/her care needs, the posted staffing plan did not account for total ABST care time, and the care time did not include unscheduled needs, fire and life safety, segregated areas, high acuity, behavioral needs, or universal task time related to meal service in addition to ABST.

Staff 3 (Director of Nursing) stated s/he was responsible for updating the facility's ABST. S/He updated service plans and ABST quarterly, with a change of condition, when a resident had a new medication order, or were going on an alert. The census was 46. To calculate staffing by ABST, s/he compiled the total hours of care and divided that by 7.5 to determine staffing levels. Fire and life safety was not captured in the tool. Universal worker care time was calculated by adding time to resident laundry and housekeeping services.

The facility was divided into four distinct and separate communities referred to as "Houses." The four houses were "Flower," "Mountain," "Lighthouse," and "River."

The posted staffing plan indicated for day shift, there were two Med Techs (MTs) for all houses, two Caregivers (CGs) for each house, and one float CG who covered all houses. For swing shift, there were two MTs for all houses and two CGs for each house. For night shift, there was one MT for all houses, and one CG for each house.

On 10/14/24, during day shift, there were two MTs for all houses, two CGs in Flower, one CG in Mountain, two caregivers in Lighthouse, and one CG in River. During swing shift, there was one MT for all houses, two CGs in Flower, two CGs in Mountain, two CGs in Lighthouse, and one CG in River.

The facility's staffing schedule, dated 10/07/24 through 10/14/24, indicated there was one instance where the facility was not scheduling enough CGs, and eight instances where the facility was not scheduling enough MTs to match their posted staffing plan. Staffing schedules were requested, but the facility did not provide a staffing schedule for 10/11/24 for swing and night shift, or 10/13/24 for all shifts.

Staff 9 (CG) stated s/he was the only CG on day shift in the house s/he was assigned to.

Staff 10 (CG) stated s/he was the only CG working swing shift in the house s/he was assigned to, and was scheduled until 4:00 pm. At approximately 2:41 pm, no staff had come to check on Staff 10 or provided assistance to residents in that house.

Staff 11 (MT) stated s/he was the only MT working swing shift and was assigned to all houses.

Staff 12 (CG) stated there were not enough staff to care for everyone. There were five residents who required full assistance with eating and there were two CGs scheduled, so they are unable to feed all residents at once. Management didn't help or provide staff support. S/He believed the house s/he was assigned to needed three CGs.

Staff 6 (CG) stated on Mondays and Sundays s/he usually works a house by him/herself and management wouldn't assist.

Staff 4 (Business Office Manager) stated regarding staffing, s/he had openings for a MT. The facility did not have enough MTs. CGs are "perfectly staffed" if no one calls in, except for night shift. That was to schedule "bare minimum." If they needed to schedule an extra float, they could not. S/He staffs according to his/her staffing plan. Staff 3 updates the ABST to generate the posted staffing plan. The staffing plan for day shift was two CGs per house plus one CG float, and two MTs. For swing shift, there were two CGs per house and two MTs. For night shift, there was one CG per house and one MT.

Resident 1 was unavailable for interview.

During an interview regarding Resident 1's care needs, Staff 9 stated s/he needed help getting up in the morning. S/He had been sick lately and hadn't been out of his/her room much. S/He required the assistance of one staff member with getting dressed and toileting. Resident 1 could toilet him/herself but needed more help with the steps of toileting. Staff assisted more with reminders and cuing for next steps because s/he had increased confusion.

Resident 2 was unavailable for interview.

During interviews regarding Resident 2's care needs, Staff 6 and Staff 7 (CG) stated staff served his/her food and s/he would bring her meal trays out. S/He required one person standby assistance for showering. S/He was independent with dressing, grooming, and will check the activity calendar schedule his/herself and decide to go to activities. S/He was one of the more independent residents in the facility.

Resident 3 was unavailable for interview.

During an interview regarding Resident 3's care needs, Staff 12 (CG) stated s/he was mostly independent. Staff were standby assistance with showers, cleaned his/her laundry, and changed his/her bed sheets. Resident 3 was independent with transferring, dressing, toileting, and ambulation. S/He changed his/her own brief, removed his/her trash, and left it outside the room for staff to pick up. Resident 3 had behavioral challenges "almost every day," and s/he didn't like when other residents were in his/her way, in his/her space, or trying to open his/her room. S/He was hard of hearing and didn't like when staff changed the music or tv channel. Staff tried to anticipate his/her triggers and they had to regularly intervene and redirect Resident 3.

Resident 3's ABST evaluation, updated 07/31/24, and Service Plan, dated 07/30/24, revealed the following discrepancies:

-ABST evaluation had time allotted for personal hygiene and mouth care. The service plan indicated s/he was independent with oral care;

-ABST evaluation had time allotted for assisting with leisure activities. The service plan indicated s/he was independent with needs;

-ABST evaluation had time allotted for dressing and undressing. The service plan does not mention the resident requires dressing assistance; and

-ABST evaluation had time spent on nail care and brushing hair. The service plan states nail care was being provided by an outside provider.

It was determined the facility's failure to fully implement and update an ABST for Resident 3 was substantiated.

The findings of the investigation were reviewed with and acknowledged by Staff 2 (Regional Director of Operations) and Staff 3 on 10/14/24.

Based on observation, interview, and record review, conducted during a site visit on 10/14/24, the facility's failure to fully implement and update an acuity-based staffing tool (ABST) for 1 of 3 sampled resident (# 3) was substantiated. Findings include, but are not limited to:

The facility implemented the ODHS ABST. All residents had a completed ABST evaluation, the census was 46, all sampled residents' ABST profiles were reviewed and updated at required times, and 2 of 3 sampled residents (#s 1 and 2) service plans accurately captured care needs and were reflected in the ABST evaluation. Deficiencies identified were Resident 3's service plan and ABST evaluation which did not accurately capture his/her care needs, the posted staffing plan did not account for total ABST care time, and the care time did not include unscheduled needs, fire and life safety, segregated areas, high acuity, behavioral needs, or universal task time related to meal service in addition to ABST.

Staff 3 (Director of Nursing) stated s/he was responsible for updating the facility's ABST. S/He updated service plans and ABST quarterly, with a change of condition, when a resident had a new medication order, or were going on an alert. The census was 46. To calculate staffing by ABST, s/he compiled the total hours of care and divided that by 7.5 to determine staffing levels. Fire and life safety was not captured in the tool. Universal worker care time was calculated by adding time to resident laundry and housekeeping services.

The facility was divided into four distinct and separate communities referred to as "Houses." The four houses were "Flower," "Mountain," "Lighthouse," and "River."

The posted staffing plan indicated for day shift, there were two Med Techs (MTs) for all houses, two Caregivers (CGs) for each house, and one float CG who covered all houses. For swing shift, there were two MTs for all houses and two CGs for each house. For night shift, there was one MT for all houses, and one CG for each house.

On 10/14/24, during day shift, there were two MTs for all houses, two CGs in Flower, one CG in Mountain, two caregivers in Lighthouse, and one CG in River. During swing shift, there was one MT for all houses, two CGs in Flower, two CGs in Mountain, two CGs in Lighthouse, and one CG in River.

The facility's staffing schedule, dated 10/07/24 through 10/14/24, indicated there was one instance where the facility was not scheduling enough CGs, and eight instances where the facility was not scheduling enough MTs to match their posted staffing plan. Staffing schedules were requested, but the facility did not provide a staffing schedule for 10/11/24 for swing and night shift, or 10/13/24 for all shifts.

Staff 9 (CG) stated s/he was the only CG on day shift in the house s/he was assigned to.

Staff 10 (CG) stated s/he was the only CG working swing shift in the house s/he was assigned to, and was scheduled until 4:00 pm. At approximately 2:41 pm, no staff had come to check on Staff 10 or provided assistance to residents in that house.

Staff 11 (MT) stated s/he was the only MT working swing shift and was assigned to all houses.

Staff 12 (CG) stated there were not enough staff to care for everyone. There were five residents who required full assistance with eating and there were two CGs scheduled, so they are unable to feed all residents at once. Management didn't help or provide staff support. S/He believed the house s/he was assigned to needed three CGs.

Staff 6 (CG) stated on Mondays and Sundays s/he usually works a house by him/herself and management wouldn't assist.

Staff 4 (Business Office Manager) stated regarding staffing, s/he had openings for a MT. The facility did not have enough MTs. CGs are "perfectly staffed" if no one calls in, except for night shift. That was to schedule "bare minimum." If they needed to schedule an extra float, they could not. S/He staffs according to his/her staffing plan. Staff 3 updates the ABST to generate the posted staffing plan. The staffing plan for day shift was two CGs per house plus one CG float, and two MTs. For swing shift, there were two CGs per house and two MTs. For night shift, there was one CG per house and one MT.

Resident 1 was unavailable for interview.

During an interview regarding Resident 1's care needs, Staff 9 stated s/he needed help getting up in the morning. S/He had been sick lately and hadn't been out of his/her room much. S/He required the assistance of one staff member with getting dressed and toileting. Resident 1 could toilet him/herself but needed more help with the steps of toileting. Staff assisted more with reminders and cuing for next steps because s/he had increased confusion.

Resident 2 was unavailable for interview.

During interviews regarding Resident 2's care needs, Staff 6 and Staff 7 (CG) stated staff served his/her food and s/he would bring her meal trays out. S/He required one person standby assistance for showering. S/He was independent with dressing, grooming, and will check the activity calendar schedule his/herself and decide to go to activities. S/He was one of the more independent residents in the facility.

Resident 3 was unavailable for interview.

During an interview regarding Resident 3's care needs, Staff 12 (CG) stated s/he was mostly independent. Staff were standby assistance with showers, cleaned his/her laundry, and changed his/her bed sheets. Resident 3 was independent with transferring, dressing, toileting, and ambulation. S/He changed his/her own brief, removed his/her trash, and left it outside the room for staff to pick up. Resident 3 had behavioral challenges "almost every day," and s/he didn't like when other residents were in his/her way, in his/her space, or trying to open his/her room. S/He was hard of hearing and didn't like when staff changed the music or tv channel. Staff tried to anticipate his/her triggers and they had to regularly intervene and redirect Resident 3.

Resident 3's ABST evaluation, updated 07/31/24, and Service Plan, dated 07/30/24, revealed the following discrepancies:

-ABST evaluation had time allotted for personal hygiene and mouth care. The service plan indicated s/he was independent with oral care;

-ABST evaluation had time allotted for assisting with leisure activities. The service plan indicated s/he was independent with needs;

-ABST evaluation had time allotted for dressing and undressing. The service plan does not mention the resident requires dressing assistance; and

-ABST evaluation had time spent on nail care and brushing hair. The service plan states nail care was being provided by an outside provider.

It was determined the facility's failure to fully implement and update an ABST for Resident 3 was substantiated.

The findings of the investigation were reviewed with and acknowledged by Staff 2 (Regional Director of Operations) and Staff 3 on 10/14/24.

Based on observation, interview, and record review, conducted during a site visit on 10/14/24, the facility's failure to fully implement and update an acuity-based staffing tool (ABST) for 1 of 3 sampled resident (# 3) was substantiated. Findings include, but are not limited to:

The facility implemented the ODHS ABST. All residents had a completed ABST evaluation, the census was 46, all sampled residents' ABST profiles were reviewed and updated at required times, and 2 of 3 sampled residents (#s 1 and 2) service plans accurately captured care needs and were reflected in the ABST evaluation. Deficiencies identified were Resident 3's service plan and ABST evaluation which did not accurately capture his/her care needs, the posted staffing plan did not account for total ABST care time, and the care time did not include unscheduled needs, fire and life safety, segregated areas, high acuity, behavioral needs, or universal task time related to meal service in addition to ABST.

Staff 3 (Director of Nursing) stated s/he was responsible for updating the facility's ABST. S/He updated service plans and ABST quarterly, with a change of condition, when a resident had a new medication order, or were going on an alert. The census was 46. To calculate staffing by ABST, s/he compiled the total hours of care and divided that by 7.5 to determine staffing levels. Fire and life safety was not captured in the tool. Universal worker care time was calculated by adding time to resident laundry and housekeeping services.

The facility was divided into four distinct and separate communities referred to as "Houses." The four houses were "Flower," "Mountain," "Lighthouse," and "River."

The posted staffing plan indicated for day shift, there were two Med Techs (MTs) for all houses, two Caregivers (CGs) for each house, and one float CG who covered all houses. For swing shift, there were two MTs for all houses and two CGs for each house. For night shift, there was one MT for all houses, and one CG for each house.

On 10/14/24, during day shift, there were two MTs for all houses, two CGs in Flower, one CG in Mountain, two caregivers in Lighthouse, and one CG in River. During swing shift, there was one MT for all houses, two CGs in Flower, two CGs in Mountain, two CGs in Lighthouse, and one CG in River.

The facility's staffing schedule, dated 10/07/24 through 10/14/24, indicated there was one instance where the facility was not scheduling enough CGs, and eight instances where the facility was not scheduling enough MTs to match their posted staffing plan. Staffing schedules were requested, but the facility did not provide a staffing schedule for 10/11/24 for swing and night shift, or 10/13/24 for all shifts.

Staff 9 (CG) stated s/he was the only CG on day shift in the house s/he was assigned to.

Staff 10 (CG) stated s/he was the only CG working swing shift in the house s/he was assigned to, and was scheduled until 4:00 pm. At approximately 2:41 pm, no staff had come to check on Staff 10 or provided assistance to residents in that house.

Staff 11 (MT) stated s/he was the only MT working swing shift and was assigned to all houses.

Staff 12 (CG) stated there were not enough staff to care for everyone. There were five residents who required full assistance with eating and there were two CGs scheduled, so they are unable to feed all residents at once. Management didn't help or provide staff support. S/He believed the house s/he was assigned to needed three CGs.

Staff 6 (CG) stated on Mondays and Sundays s/he usually works a house by him/herself and management wouldn't assist.

Staff 4 (Business Office Manager) stated regarding staffing, s/he had openings for a MT. The facility did not have enough MTs. CGs are "perfectly staffed" if no one calls in, except for night shift. That was to schedule "bare minimum." If they needed to schedule an extra float, they could not. S/He staffs according to his/her staffing plan. Staff 3 updates the ABST to generate the posted staffing plan. The staffing plan for day shift was two CGs per house plus one CG float, and two MTs. For swing shift, there were two CGs per house and two MTs. For night shift, there was one CG per house and one MT.

Resident 1 was unavailable for interview.

During an interview regarding Resident 1's care needs, Staff 9 stated s/he needed help getting up in the morning. S/He had been sick lately and hadn't been out of his/her room much. S/He required the assistance of one staff member with getting dressed and toileting. Resident 1 could toilet him/herself but needed more help with the steps of toileting. Staff assisted more with reminders and cuing for next steps because s/he had increased confusion.

Resident 2 was unavailable for interview.

During interviews regarding Resident 2's care needs, Staff 6 and Staff 7 (CG) stated staff served his/her food and s/he would bring her meal trays out. S/He required one person standby assistance for showering. S/He was independent with dressing, grooming, and will check the activity calendar schedule his/herself and decide to go to activities. S/He was one of the more independent residents in the facility.

Resident 3 was unavailable for interview.

During an interview regarding Resident 3's care needs, Staff 12 (CG) stated s/he was mostly independent. Staff were standby assistance with showers, cleaned his/her laundry, and changed his/her bed sheets. Resident 3 was independent with transferring, dressing, toileting, and ambulation. S/He changed his/her own brief, removed his/her trash, and left it outside the room for staff to pick up. Resident 3 had behavioral challenges "almost every day," and s/he didn't like when other residents were in his/her way, in his/her space, or trying to open his/her room. S/He was hard of hearing and didn't like when staff changed the music or tv channel. Staff tried to anticipate his/her triggers and they had to regularly intervene and redirect Resident 3.

Resident 3's ABST evaluation, updated 07/31/24, and Service Plan, dated 07/30/24, revealed the following discrepancies:

-ABST evaluation had time allotted for personal hygiene and mouth care. The service plan indicated s/he was independent with oral care;

-ABST evaluation had time allotted for assisting with leisure activities. The service plan indicated s/he was independent with needs;

-ABST evaluation had time allotted for dressing and undressing. The service plan does not mention the resident requires dressing assistance; and

-ABST evaluation had time spent on nail care and brushing hair. The service plan states nail care was being provided by an outside provider.

It was determined the facility's failure to fully implement and update an ABST for Resident 3 was substantiated.

The findings of the investigation were reviewed with and acknowledged by Staff 2 (Regional Director of Operations) and Staff 3 on 10/14/24.