The findings of the on-site investigation, conducted 08/03/2023, 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.

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

Notes on Abbreviations:

"The abbreviations listed above can be used in the report without identifying the abbreviation within the report itself.

"Residents will be identified by "Resident 1", "Resident 2" etc, do not abbreviate.

"Staff will be identified by "Staff 1", "Staff 2" etc. do not abbreviate.

"If you introduce an abbreviation in the report, make sure it is a word that has a standard abbreviation associated with it and that it needs to be abbreviated. You don't need to abbreviate a word that you only use once in a report.

Based on observation and interview, during a site visit on 08/03/23, it was confirmed the facility failed to provide three daily nutritious, palatable meals seven days a week; and prepare and serve food according to food sanitation rules. Findings include, but are not limited to:

During an interview on 08/03/23, Resident 3 stated, "I am often given alternative options from what I have ordered. The kitchen does run out of food often and does not ask me what I would like instead, they just make that decision for you. It is not as bad in the dining room but is an issue when receiving room trays."  

During interviews on 08/03/23, staff stated the following:

·"Running out of food or changing the menu does happen often."

·The chef does change food items on the menu to use leftover or save money."  

·"The kitchen attempts to let residents know of the changes but not always to residents who receive meal trays."  

On 08/03/23, CS observed the following:

·No staff reusing dirty dishes or glasses.

·The dishes in the dining room to be clean with no stains or food particles.  

·The food being provided did not match the menu.

·Staff delivering meals did not explain menu changes to residents or look in the boxes to ensure the food provided matched what the resident's ordered.

·The quality of food to be inadequate. The dinner rolls were burnt.

it was confirmed the facility failed to provide three daily nutritious, palatable meals seven days a week.

On 08/03/23, the findings were reviewed with and acknowledged by Staff 1.

Verbal plan of correction: The facility will immediately talk with the kitchen to have the food be more consistent with the menu provided to the residents. They will work on a better way to communicate to the residents the menu changes.

Based on interview and record review, conducted during a site visit on 08/03/23, 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 1 of 1 sampled resident (#1). Findings include, but are not limited to:

During an interview on 08/03/23, Staff 1 (RN) stated, "the call light response time is 10 minutes." Staff 1 acknowledged the long response times on the call light report printed.

CS was unable to interview Resident 1 who no longer resided in the facility. In the original complaint a family member stated the following:

·On 4/20/23 - approx. 2:00 pm. Husband pushed call button for toilet assistance for wife. After 35 minutes, a family member had to help the wife to the bathroom. No staff ever came.

·On 4/21/23 - 7:06 am called for aid. It took 13 minutes for someone to respond. After dressing and toileting, the employee left resident seated at the sink - staff said s/he would be "right back." After waiting 15 minutes, husband moved wife to the living room.

A record review of the call light report from 04/20/23-04/23/23 showed occurrences where the response time exceeded 10 minutes. For Resident 1 the call light response times were as followed:

·On 04/20/23 at 1:59:08 PM - 26 minutes 19 seconds.

·On 04/21/23 at 07:59:18 AM- 18 minutes 44 seconds.

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

On 08/03/23, the findings were reviewed with and acknowledged by Staff 1.

Verbal plan of correction: The facility will run a report for call light response times every week and will continue to audit.

Based on interview and record review, conducted during a site visit on 08/03/23, it was confirmed the facility failed to implement and update an acuity-based staffing tool (ABST). Findings include, but are not limited to:

On 08/03/23, the facility's ABST was reviewed, and the staffing levels generated indicated the facility required five care staff on day shift, four care staff on swing shift, and one care staff on night shift. There were 44 of 50 residents' profiles that had not been updated quarterly.

A review of the posted staffing plan indicated day and swing shift were to have two CG's and two MT's scheduled, and on NOC shift one CG and one MT.

In an interview on 06/15/23, Staff 1 (RN) stated the facility is using the ODHS ABST. Staff 8 (RCC) stated, "I know the ED told me last week that we needed to update residents quarterly in the ABST. When [S/he] comes back to work we will be working on updating those."  

The facility failed to update an acuity-based staffing tool.

On 08/03/23, the findings were reviewed with and acknowledged by Staff 1.

Verbal plan of correction: Staff 8 stated Staff 9 (ED) was aware their tool has not been updated. Staff 9 will be working with Staff 8 to update their tool and look at their staffing numbers indicated in the tool once updated.