I. Based on interview and record review, conducted during a site visit on 02/07/24, 02/08/24 and 02/13/24, it was confirmed the facility failed to immediately notify the local Department office of any incident of abuse or suspected abuse for 1 of 1 sampled resident (#2) whose records were reviewed. Findings include, but are not limited to:

A review of the faciltiy's policy and procedure "Incident Report - State Reporting", dated 01/05/24, indicated "the community will follow state regulations in regards to reporting incidents that negatively affect or that threaten the life, health, or safety of any resident."

In an interview on 02/08/24, Staff 2 (Administrator) stated the process for reporting incidents of abuse or neglect must be done "within 24 hours", during that time an internal investigation is conducted, and the residents and staff are asked what happened. A report is submitted via email.

A review of Resident 2's records indicated s/he experienced an injury of unknown cause:

* Progress note, dated 04/24/23 at 12:12 pm, indicated resident had an "unwitnessed fall.... Resident stated [s/he] lost [his/her] balance.  Resident was checked for injuries and non were noted at the moment."

* Progress note, dated 04/25/23 at 9:07 pm, indicated no bruising had been witnessed by the writer.

* Progress note, dated 04/26/23 at 11:43 am, indicated "resident has had evident bruising on [his/her] face for the last couple of days."

* There was no evidence this facial bruising was investigated or reported to the Department or local AAA.

* Progress note, dated 06/19/23 at 12:00 pm, indicated "caregiver found resident on the floor on top of pillows and blankets near [his/her] bed.... nude..... Resident was unable to clearly state what had occurred."

* There was no evidence to indicate abuse or neglect had been ruled out or reported to the local Department office or local AAA.

Resident 2 was discharged from facility on 07/29/23.

On 02/13/24, these findings were reviewed with and acknowledged by Staff 2 and Staff 16 (BOM).

The facility failed to immediately notify the local Department office of any incident of abuse or suspected abuse.

Verbal Plan of Correction:

Within 24 hours, the identified incidents will be reported the local Department office or local AAA and within two weeks, Administrator will provide training with nurse, medication technicians, and resident care coordinator.

II. Based on interview and record review, conducted during a site visit on 02/07/24, 02/08/24 and 02/13/24, it was confirmed the facility failed to immediately notify the local Department office of any incident of abuse or suspected abuse for 3 of 3 sampled residents (#s 3, 4, and 6) whose records were reviewed. Findings include, but are not limited to:

A review of the faciltiy's policy and procedure "Incident Report - State Reporting", dated 01/05/24, inidcated "the community will follow state regulations in regards to reporting incidents that negatively affect or that threaten the life, health, or safety of any resident."

In an interview on 02/08/24, Staff 2 (Administrator) stated the process for reporting incidents of abuse or neglect must be done "within 24 hours", during that time an internal investigation was conducted and the residents and staff were asked what happened. A report was submitted via email.

A. A review of Resident 3's records indicated the following:

* Progress note, dated 12/30/23 at 05:47 am, indicated "Resident on alert on 12/29/23 for resident altercation with [Room #]. Resident slept okay."

* An Incident Report, dated 12/29/23, indicated Resident 6 walked into Resident 3's room and pulled the blanket that Resident 3 was laying on. Resident was then laying on his/her back with legs up. Paramedics were called due to resident possibly hitting his/her head when Resident 3 fell onto the floor.

* There was no evidence this incident was reported to the local Department or local AAA.

* Progress note, dated 01/27/24 at 11:29 am, indicated Resident 3 had an "unwitnessed fall". At 8:00 am the same morning, Resident 3 was found on the floor in another resident's room sleeping on his/her stomach with a stuffed animal under his/her head.

* Service plan, dated 12/04/23, indicated s/he was monitored for wellness "4 [times] per shift."

* The facility's investigation lacked any indication if the service plan was being followed at the time the resident was found in another resident' unit.

B. A review of Resident 4's records indicated the following:

* Progress note, dated 11/11/23 at 9:11 pm, indicated resident was placed on alert due to discoloration to his/her right arm, turning purple, and had pain when touched.

* A temporary service plan, dated 11/11/23, was implemented.

* An incident report, dated 11/11/23, indicated "Caregiver reported that resident has purple discoloration on [his/her] right arm."

* There was no evidence to indicate abuse or neglect had been ruled out or reported to the local Department office or local AAA.

C. A review of the facility's records indicated on 12/31/23 at 11:07 am, Resident 6 was in bed when skin discoloration around his/her right eye was found. The facility's investigation lacked any documented reasonable conclusion that the physical injury was not the result of abuse and was not reported to the local Department office or local AAA.

On 02/13/24, these findings were reviewed with and acknowledged by Staff 2 and Staff 16 (BOM).

The facility failed to immediately notify the local Department office of any incident of abuse or suspected abuse.

Verbal Plan of Correction:

Within 24 hours, the identified incidents would be reported the the local Department office or local AAA and within two weeks, Administrator did provide training with nurse, medication technicians, and resident care coordinator.

Based on interview and record review, conducted during a site visit on 02/07/24, 02/08/24 and 02/13/24, it was confirmed the facility failed ensure the implementation of services and failed to provide clear directions for 2 of 3 sampled residents (#s 4 and 5) whose records were reviewed. Findings include, but are not limited to:

On 02/13/24 at 8:17 am, the Compliance Specialist (CS) observed breakfast plates delivered to Resident 4 and Resident 5. Resident 4's plated meal was regular texture and Resident 5's plated meal was pureed.  

On 02/13/24 at 8:26 am, the Compliance Specialist (CS) observed posted in the kitchen of Cottage A, the facility's Residents' Dietary profile which indicated Resident 4 was on a regular textured diet with thin liquids and Resident 5 was on a controlled carb diet with pureed textures.

A review of Resident 4's records indicated the following:

* Service plan, dated 11/14/23, provided conflicting information. One area of the service plan indicated s/he was to receive a "regular NAS, regular texture [with] thin liquid" diet and another indicated the resident was to receive "regular diet" and "mechanical soft."

* A review of hospice provider notes, dated 01/31/24, indicated "nutritional concern: ...difficulty swallowing" and "nutrition diet type: mechanical soft".

On 12/13/24 at 8:39 am,  the CS stopped Staff 15 (CG) from feeding Resident 4 due to choking concerns and a new plate with the ordered diet type was provided.

A review of Resident 5's records indicated the following:

* Service Plan, dated 11/15/23, indicated in the area "Profile Overview" s/he was to receive "control carb, regular texture, thin liquids" diet.

* In the area of "nutrition" his/her service plan indicated resident was to receive "regular diet".

A review of Resident 5's signed physician orders, dated 10/28/23, indicated "diet- regular diet as tolerated".

A review of Resident 5's nursing assessment dated 12/05/2, indicated "diet and texture: puree." There were no written physician orders found for the pureed diet.

In an interview on 02/13/24 at 9:15 am, Staff 2 (Administrator) and Staff 17 (RN) confirmed the contradictory service plan directions.

It was confirmed the facility failed to ensure the implementation of services and failed to provide clear directions.

On 02/13/24, these findings were reviewed with and acknowledged by Staff 2 and Staff 16 (BOM).

Verbal Plan of Correction:

Effective immediately, the RCC and RN did conduct a quarterly evaluation and assessment for Resident 5, and by end of day the Administrator did audit and update the facility's posted Dietary Profile in the kitchen, and implement a three check process in which new orders received were entered by staff, doubled checked by the RCC, then the RN did conduct the final review.   

Based on interview and record review, conducted during a site visit on 02/07/24, 02/08/24 and 02/13/24, it was confirmed the facility failed to include a Service Planning Team (SPT) that consisted of the resident or the resident's legal representative for 3 of 3 sampled residents (#s 3, 4, and 5) whose records were reviewed. Findings include, but are not limited to:

A review of Resident 3, 4, and 5s' service plans, dated 12/04/23, 11/14/23, and 11/15/23 respectively, and progress notes, dated 11/01/23 through 02/13/24, lacked any indications these service plans were reviewed with the resident or his/her legal representative.

In an interview on 02/08/24 at approximately 3:15 pm, Staff 2 (Administrator) stated the RCC reviewed the service plan with the family at care conferences. The RCC would have the resident or legal representative sign the service plan during the meeting. When unable to meet in person the service plan was reviewed via telephone and documented.

Staff 2 was shown Resident 3, 4, and 5 s' service plans and confirmed the lack of resident or legal representative's signatures.

On 02/08/24, these findings were reviewed with and acknowledged by Staff 2 and Staff 16 (BOM).

Verbal Plan of Correction:

Within 30 days, the Administrator did review SPT requirements with the RCC and ensure the resident or legal representative are involved in the SPT.

Based on observation, interview, and record review, conducted during a site visit on 02/07/24, 02/08/24, and 02/13/24, it was determined the facility failed to implement an acuity based staffing tool for 2 of 3 sampled residents (#s 4 and 5) whose records were reviewed. Findings include, but are not limited to:

In an interview on 02/08/24 at 3:15 pm, Staff 2 (Administrator) stated the following:

* There were 52 residents that called this facility home.

* Staffing levels were determined after a service plan was reviewed and entered into their Acuity Based Staffing Tool.

* If there were changes to residents' needs, the ABST was updated.

* The clinician team met one time a week to review resident acuity.

* Facility was currently using the ODHS ABST.

* Staffing levels were calculated by identifying the day of the week with the highest acuity time and dividing by 7.5 for each shift.  

In separate interviews on 02/08/24, Staff 9 (CG) and Staff 18 (RCC/MT) stated the following:

* It took a total of 10 minutes to transfer Resident 4 and Resident 5 out of bed.

* It took a total of 15-20 minutes to provide feeding assistance to Resident 4 and Resident 5.

* It took a total of 5-8 minutes to transfer Resident 5 out of bed and 5-7 minutes to transfer Resident 4 out of bed.

A review of the facility's ABST with Staff 2, indicated  the following:

* All residents were entered.

* A staffing plan was generated per day per shift.

* There were 22 distinct ADLs listed in the ABST.

a. A review of Resident 4's records, their ABST profile and observation of the resident indicated the following;

* Resident 4's Service Plan, dated 11/14/23, indicated s/he required total staff assistance with ADLs. Two staff members were required for ADLs including transfers, dressing, toileting.

* The ABST was not refletive of Resident 4's two-person-assist status.

*  Resident 4's ABST indicated six minutes was spent on assisting resident with eating and two minutes was spent transferring the resident in/out of bed or a chair.

* On 02/13/24, at 6:40 am, Staff 14 and Staff 15 provided dresssing and toileting assistance.

* At 6:46 am through 6:52 am, Staff 14 and Staff 15 provided assistance with transfer from bed to chair.

* Staff 15 provided feeding assistance that took a total of 45 minutes and 56 seconds.

b. A review of Resident 5's records, their ABST profile, and observation of the resident indicated the following;

* Resident 5's Service Plan, dated 11/15/23, indicated s/he required total staff assistance with ADLs, and assistance of two staff members for ADLs including transfers, dressing, toileting.

* The ABST was not refletive of Resident 5's two-person-assist status.

* Resident 5's ABST indicated seven minutes was spent on assisting resident with eating and four minutes was spent transferring the resident in/out of bed or a chair.

* On 02/13/24, at 6:24 am, Staff 14 and Staff 15 provided toileting assistance.

* At 6:30 am through 6:37 am, Staff 14 and Staff 15 provided assistance with transfer from bed to chair.

* Staff 14 provided feeding assistance that took a total of 36 minutes and 29 seconds.

The facility failed to implement an acuity based staffing tool.

On 02/13/24, these findings were reviewed with and acknowledged by Staff 2 (Administrator) and Staff 16 (BOM).

Based on interview and record review, conducted during a site visit on 02/07/24, 02/08/24, and 02/13/24, it was determined the facility failed to ensure 4 of 4 sample staff (#s 7, 9, 13, and 21) who records were reviewed completed pre-service dementia training; and the facility failed to ensure 2 of 3 sampled direct care staff (#s 9 and 21) had completed required training within 30 days of hire. Findings include, but are not limited to:

A review of training records for Staff 7 (CG) hired on 11/09/22, Staff 9 (CG) hired on 08/02/23, Staff 13 (Activity Coordinator) hired on 08/02/23, and Staff 21 (CG) hired on 11/06/23, lacked documented training in one or more of the following required topics:

* Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: Identify and address pain.

* Environmental factors that are important to resident ' s well-being (e.g., noise, staff interactions, lighting, room temperature, etc.);

* Family support and the role the family may have in the care of the resident; and

* The use of supportive devices with restraining qualities in memory care communities.

A review of training records for direct care staff for Staff 7 (CG) hired on 11/09/22, Staff 9 (CG) hired on 08/02/23, and Staff 21 (CG) hired on 11/06/23, lacked documented training in the following required topic:

* Changes associated with normal aging.

It was determined the facility failed to ensure staff members completed pre-service dementia training and the facility failed to ensure direct care staff had completed required training within 30 days of hire.

On 02/13/24, these findings were reviewed with and acknowledged by Staff 2 (Administrator) and Staff 16 (BOM).

Verbal Plan of Correction:

Within 30 days, the Administrator or Business Office Manager will audit current staff's training records to ensure all required training are completed.

Based on observation, interviews, and record review, conducted during a site visit on 02/07/24, 02/08/24 and 02/13/24, it was confirmed the facility failed to provide a call system that connects resident units to the care staff center or staff pagers. Findings include, but are not limited to:

On 02/07/24, the Compliance Specialists observed this facility had three separate and distinct buildings referred to as Alpine Cottage A, Beachwood Cottage B, and Ponderosa Cottage C.

On 02/07/24 at 12:45 pm, in an interview, Staff 1 (Community Resource Director) and Staff 5 (RCC) stated the following:

* There were two pull cords available to residents- one in the bathroom and one near the head of resident's bed.  Call pendants are also available for residents.

* When activated the signal registered on the care staff's iPod.

* The caregiver used a magnet to deactivate the call. Each caregiver must carry an iPod.

* The facility's expectation for staff's call light response time is 15 minutes.

* Staff carry walkie-talkies to communicate when a call light was activated.

* There were no current call lights that were known to be broken, but when wall cords' batteries get low it will "beep".

* There was a time "approximately end of 2023", the vendor had to get involved due to internet was not connecting to current pendants and new pendants were on back order and not available until summer.  

On 02/07/24, the Compliance Specialists observed the following:

* When a call light was activated a light on the wall mount is red

* In Cottage C, at 2:08 pm, the front public-accessible restroom's wall mounted cord did not work.

* In Cottage A, between 3:20 pm and 3:45 pm, the wall mounted pull cords did not work in a bathroom in the common area near apartment 8.

* Apartment 8's bathroom wall mounted pull cord did not work.

* Both of apartment 6's bedsidewall mounted pull cords did not work.  While at apartment 6, two direct care staff members were requested to check their iPods. It was confirmed the signal was received for the bathroom, but a direct care staff member's iPod was set to the wrong building.

* Apartment 1's bedside cord did not work.

* In Cottage B, between 4:23 pm and 4:40 pm, the wall mounted pull cords were pulled in apartment 10. The bathroom's wall mount was activated but no signal was received.

*Apartment 5's wall mounted pull cord in the bathroom did not work.

On 02/07/24, these findings were reviewed with and acknowledged by Staff 1 and Staff 2 (Administrator).

The facility failed to provide a call system that connects resident units to the care staff center or staff pagers.

Verbal Plan of Correction:

Within 24 hours, the facility Administrator or designee, will conduct an audit by going room to room, comparing with their vendor app, and will increase frequency of checks on residents with non-working call lights.

On 02/08/24, the facility provided the Compliance Specialists the facility's Emergency Call Station Monthly Inspection form, dated 02/08/24, as verification the call system was tested and those lights that did not work were repaired with a battery replacement.

Based on interview and record review, conducted during a site visit on 02/07/24, 02/08/24, and 02/13/24, it was determined the facility failed to ensure 4 of 4 sample staff (#s 7, 9, 13, and 21) who records were reviewed completed pre-service dementia training; and the facility failed to ensure 2 of 3 sampled direct care staff (#s 9 and 21) had completed required training within 30 days of hire. Findings include, but are not limited to:

A review of training records for Staff 7 (CG) hired on 11/09/22, Staff 9 (CG) hired on 08/02/23, Staff 13 (Activity Coordinator) hired on 08/02/23, and Staff 21 (CG) hired on 11/06/23, lacked documented training in one or more of the following required topics:

* Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: Identify and address pain.

* Environmental factors that are important to resident ' s well-being (e.g., noise, staff interactions, lighting, room temperature, etc.);

* Family support and the role the family may have in the care of the resident; and

* The use of supportive devices with restraining qualities in memory care communities.

A review of training records for direct care staff for Staff 7 (CG) hired on 11/09/22, Staff 9 (CG) hired on 08/02/23, and Staff 21 (CG) hired on 11/06/23, lacked documented training in the following required topic:

* Changes associated with normal aging.

It was determined the facility failed to ensure staff members completed pre-service dementia training and the facility failed to ensure direct care staff had completed required training within 30 days of hire.

On 02/13/24, these findings were reviewed with and acknowledged by Staff 2 (Administrator) and Staff 16 (BOM).

Verbal Plan of Correction:

Within 30 days, the Administrator or Business Office Manager will audit current staff's training records to ensure all required training are completed.